IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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O 


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1.0 


I.I 


1.25 


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25 

1^    12.2 

12.0 


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Hiotographic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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Ci^ 


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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notas/Notas  tachniquaa  at  bibiiographiquas 


Tha  Inatituta  haa  attamptad  to  obtain  tha  baat 
original  copy  available  for  filming.  Faaturaa  of  thia 
copy  which  may  ba  bibliographically  unique, 
which  may  alter  any  of  the  imagea  in  tha 
reproduction,  or  which  may  aignificantly  change 
the  uauai  method  of  filming,  are  checked  below. 


D 


n 


D 
D 


D 


n 


Coloured  covers/ 
Couverture  de  couieur 


I      I    Covers  damaged/ 


Couverture  endommagAe 


Covers  restored  and/or  laminated/ 
Couverture  restaurAe  et/ou  peilicuite 


I      I    Cover  title  missing/ 


Le  titre  de  couverture  manque 


I      I    Coloured  meps/ 


Cartes  gAographiques  en  couieur 


/I    Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couieur  (i.e.  autre  que  bleue  ou  noire) 


I      I    Coloured  plates  and/or  illustrations/ 


Planches  et/ou  illustrations  an  couieur 

Bound  with  other  material/ 
Relit  avec  d'autras  documents 

Tight  binding  may  causa  shadows  or  distortion 
along  interior  margin/ 

La  rellure  serrte  paut  causer  de  I'ombre  ou  de  la 
distortion  la  long  da  la  marge  intAriaura 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  lilmlng/ 
11  se  peut  que  certainas  pages  blanches  ajouttas 
lors  d'une  rastauration  apparaissent  dans  la  taxte, 
mais,  lorsqua  cela  6tait  possible,  ces  pages  n'ont 
pas  At  A  filmeas. 

Additional  comments:/ 
Commentaires  supplAmantairas: 


L'institut  a  microfilm*  le  meilleur  exempiaira 
qu'il  iui  a  AtA  poaaibia  de  ae  procurer.  Lea  dAtaiia 
de  cet  exempiaira  qui  sent  paut-Atra  uniquaa  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dana  la  mAthoda  normala  de  filmage 
aont  indiquAs  ci-dessous. 


r~~|   Coloured  pages/ 


Pages  de  couieur 

Pages  damaged/ 
Pagea  endommagAea 


□   Pages  restored  and/or  laminated/ 
Pages  restaurAes  et/ou  pelliculAes 


Pages  discoloured,  stained  or  foxed/ 
Pages  dAcolorAes,  tachetAes  ou  piquAes 


I      I   Pages  detached/ 


Pages  dAtachAes 

Showthroughy 
Transparence 

Quality  of  prir 

Quality  inAgala  de  I'impression 

includes  supplementary  materii 
Comprend  du  matAriai  supplAmentaira 

Only  edition  available/ 
Seule  Mition  disponibii 


rri  Showthrough/ 

|~~1  Quality  of  print  varies/ 

r~~|  includes  supplementary  material/ 

I — I  Only  edition  available/ 


n 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissuaa,  etc.,  have  been  ref limed  to 
ensure  the  best  possible  image/ 
Lea  pagea  totalament  ou  partieliemant 
obscurcies  par  un  feuillet  d'errata.  une  palure, 
etc.,  ont  M  fiimAes  A  nouveau  da  fagon  A 
obtenir  la  mailleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ca  document  est  film6  au  taux  de  reduction  indiquA  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

7 

12X 

16X 

20X 

24X 

2tX 

32X 

ails 

du 

)difi«r 

une 

nage 


The  copy  filmed,  here  has  been  reproduced  thanits 
to  the  generosity  of: 

National  Library  of  Canada 


The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  iceeplng  with  the 
filming  contract  specifications. 


L'exemplaire  filmd  fut  reproduit  grfice  d  la 
g6n6rosit6  de: 

Bibliothdque  nationale  du  Canada 


Les  images  suivantes  ont  6t6  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettet6  de  l'exemplaire  filmd,  et  en 
conformity  avec  les  conditions  du  contrat  de 
fitmage. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  priiirid  or  illustrated  impres- 
sion, or  the  back  co^'er  wi>en  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


Les  exempiaires  originaux  dont  la  couverture  en 
piapier  est  imprimis  sont  fiim^s  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
dernidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  oxemplaires 
originaux  sont  film6s  en  commenpant  par  la 
premidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dernidre  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ^-  (meaning  "CON- 
TINUED ").  or  the  symbol  V  (mearting  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Un  des  symboles  suivants  apparaitra  sur  la 
dernidre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  — ►signifie  "A  SUIVRE",  le 
symbole  V  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  dtre 
film6s  d  des  taux  de  reduction  diff6rents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  clichd,  il  est  fiimd  d  partir 
de  I'angle  sup6rieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  n^cessaire.  Les  diagrammes  suivants 
illustrent  la  m^thode. 


rata 
o 


>elure. 


3 


32X 


1 

2 

3 

1  2  3 

4  5  6 


THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE 


DESIGNED  FOR    THE   USE  OF  PRACTITIONERS 
AND  STUDENTS  OF  MEDICINE 


BY 

WILLIAM   OSLER,   M.  D. 

Fellow  of  the  Royal  Society  ;   Fellow  of  the  Roval  ColleKC  of  Physicians 

London  ;   Pmfessorof  Medicine  in  the  Johns  Hopkins  University  and  ' ' 

Physician-in-chief  to  the  Johns    Hopkins    Hospital,    Baltimore- 

formerly    Professor   of    the    Institutes    of    Medicine,    McGiU 

University,  Montreal ;  and  Professor  of  Clinical  Medicine 

in  the  University  of  Pennsylvania,  Philadelphia 


THIRD   EDITION 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1900 


2  V  6 1  4  2 


1 


t'oi'YKKiHT,   IWl'J,    isiir>,   IHW, 
By   1).   Al'l'MCTON    AM.  roMPANY. 


TO    TIIK 

ilU'inorn  of  inn  (fciulicro: 

WILLIAM    AKTIIL'li  .lOIINSON, 
ritiKsr  oi'  TIIK  rAitisii  oy  wiihikn,  uniaiuo. 

.lAMKS    H()\KLL. 

<)I'  'I'lIK  'I'OUKN'ro   HCIKMM,   1(1'    MIOIHilNK,    ANI>  DK   'I'lllC 
IINIVKItsriV    i>l'    ritlNIIN     COM.IIOI,,     irdlDNIO. 

UOHKirr    I'ALMKIi    HOWARD, 
DKAN  1)1'   iiiK  MioDKAi,  KAcii/jv   ani)  i'Uoi-i:hsou  <)|.   mkojcin;;, 

MCdII.I,    tINIVKUSITY,    MONTUKAI.. 


/ 


^ 


K 


yet 
till 
ii(l( 
lilx 
wli 
tlic 

J^ei 
Fe^ 
do 
Kni 
nil 
Dk 
Ne 
tro] 
Pn( 

Dia 
P,lo 
The 
ail  i 

1U0( 

mei 


wlii 
not 
bact 
mat 


PKEFACn^  TO   THE   TIIIIU)    EDITION. 


At  the  present  rate  of  pron;ross  in  all  (lopartmcnts,  a  text-hook  six 
ycarfl  old  needs  a  very  tliorouf^h  revision.  In  the  second  edition,  isKucd 
three  years  ajjjo,  many  corrections  were  niade  and  nincli  now  matter  was 
added.  Tlie  j)resent  edition  has  heen  wli(»lly  recast.  With  their  wonted 
liheraHty  the  puhlisliers  have  fiirnislied  a  new  font  of  type  and  a  some- 
what eidarged  pa<ife  so  that  the  a(hlitions  liave  not  materially  increased 
the  size  of  the  volume.     A  paper  of  better  (juality  has  also  been  used. 

The  f(»llowin<i;  articles  liave  been  rewritten  or  are  new :  Vaccination, 
13eri-JJeri,  The  Bul)onic  Plajjjno,  ( "(  rebro-spinal  bY'ver,  Pneumonia,  Malta 
Fever,  Yellow  Fever,  r)en*i;ue,  Intluenza,  Leprosy,  Glandular  Fever,  The 
(lonorrlueal  Infection,  (Jancer  of  the  Stoniach,  The  Gastric  Neuroses, 
Enteroptosis,  The  Cirrhoses  of  the  Liver,  Jaundice,  The  Diseases  of  the 
l>ile-passages,  Diseases  of  the  Pancreas,  Diseases  of  the  Thymus  (iland. 
Diseases  of  the  Spleen,  Lymphatism,  Addison's  Disease,  Encephalitis, 
Neurasthenia,  Erythro-melalgia,  aiul  many  shorter  articles,  as  Hyper- 
trophic Stenosis  of  the  Pylorus,  Ether  Pneumonia,  Anoesthesia  Paralysis, 
Pneumaturia,  Albumosuria,  etc. 

Into  the  sections  on  Typhoid  Fever,  Tuberculosis,  Rheumatic  Fever, 
Diabetes,  Gout,  Arthritis  Deformans,  Parasitic  Diseases,  Diseases  of  the 
Mlood,  Heart,  Lun^s,  and  Kidneys,  much  new  matter  has  been  incorporated. 
The  section  on  Diseases  of  the  Nervous  System  has  been  rearrange<l,  and 
an  attempt  has  been  made  to  group  the  dis'  ises  in  accordance  with  the 
modern  conceptions  of  the  anatomy  and  functions  of  the  parts. 

I  have  in  all  sections  tried  to  maintain  the  thoroughly  practical  char- 
acter of  the  work,  as  a  guide  in  diagnosis,  symj)tomatology,  and  treat- 
ment. 

I  have  again  to  thank  many  friends  for  much  valuable  help,  without 
which  the  revision  would  have  been  very  incomplete.  Dr.  Flexner  has 
not  only  given  me  great  assistance  in  connection  with  the  pathology  and 
bacteriology,  but  has  enabled  me  to  utilize  for  the  present  edition  much 
material  from  the  records  of  the  pathological  department  of  my  colleague 


vi 


I'KKFACK   TO   TIIK   TIIIIU)    KIHTION. 


Dr.  Wt'Icli.  Dr.  II  M.  riioiuiiH  and  Dr.  L.  I".  IliirkiM*  Imve  ^ivvii  iiiucli 
tiiiiu  and  invaiiiiil)lL>  lid])  in  tlio  reviHioii  of  tliu  section  on  DiscascH  uf  tlio 
NiTNons  S}'8ttMii.  To  the  tornier  1  owe  tlu;  e.\ct'llent  rearrangcnnunt  of 
the  Hnlijects  in  tliirt  section. 

To  my  associate  in  the  chair  of  medicine,  Dr.  Thayer,  and  to  my  aa- 
sistnnts,  Drs.  Fntcher  and  MeCrae,  1  am  nnder  many  oMigations.  Dr. 
Jii\  iiij>,(»od,  the  associate  in  ])athology,  by  whoso  nntimely  death*  the 
.Johns  Hopkins  Medical  School  has  snifered  a  grievons  loss,  wuh  most 
kind  in  fnrnisjiing  facts  from  the  post-mortem  records  of  the  ho8])ital. 

Dr.  Frank  It.  Smith  has  very  kindly  seen  the  edition  through  the 
press,  and  I  have  again  to  thank  my  secretary,  Miss  IJ.  ().  Ilumpton,  for 
the  preparation  of  the  index. 

And  not  least,  since  their  liberal  encouragement  has  uiiidi!  the  revi- 
sion ])ossil»le,  1  have  to  thaidv  my  brethren  on  both  sides  of  the  Atlantic 
for  their  kind  reception  of  the  previous  editions. 
July  .v,  /.s','/,s'. 


ill)  Wiia  uiio  of  llio  victims  in  tlic  Bouryogno  disaster. 


K'vc'ii  imich 

<t')lK'H  of  tin  I 

iigomont,  of 


1(1  to  my  a  a- 
itioiirt.  Di'. 
death"-  tlio 
B,  was  most 
lio8])itul. 
Iir()U<,'li  (ho 
iiiiptoii,  for 

0  the  revi- 
lie  Athintic! 


CONTENTS. 


SI'KCIKIC 


SECTION   I. 
INFHCTIOUS  DISEASES, 


T.  Tyi.l.oid  l'\'vcr 
II.  Typhus  F.'vcr. 

III.  Uc'liii)siiij,'  Fever 

IV.  Siiiiill-pox 
X'arinjii  Vi'i'ii 

lla'iii'irrliaKil'  Simill-pox 

N'lirioloid      .         .        .       , 
Viicci;iiiv  (Cow-pox)— ViKiciiiatinn 
Varicell.'i  (Cliicketi-pox)  . 
Searlet  Fcvep  , 
Measles     .... 
l{iil)ella  (Wotiicln)    . 
Kpiilemic  Parotilis  (Miiiii|)s) 

Wlloopillfr-COllgh 

Iridiienzii .... 
I)enj,Mic     .        .         ,        , 
("erel)ro-spiiial  Meningitis 
Pneumonia 
I)i|)Iitheria 
Krysipeias 

Septiea'inia  and  I'yaMnia 
Septiea'niia 
Septieo-I'ya'uiia. 
Terminal  Infect i'  us  . 
Rheumatic  l'\>ver     . 
Cholera  Asiatioa 
Yellow  Fever   . 
The  Bubonic  Plague 
Dysentery 
Malarial  Pevci' 

Intermittent  Fover 
Continued  and  Remittent  Malarial  Fever 
Pernicious  Mala  rial  Fever 
Malarial  Cachexia 
XXV.  Malta  Fever    . 
XXVI.  Reri-bcri  . 
XXVII.  Anthrax  .        .        .        '. 
XXVIII.  Hydrophobia  . 
XXIX.  Tetanus    .... 
XXX.  Glanders  .... 


V, 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 


XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 


PA  II  It 

1 

41) 
5!$ 
50 
50 
03 
OH 
08 
74 
75 
H5 
8» 
1)0 
08 
05 
0!» 
100 
lOH 

i;iH 

157 

HU) 

101 

16:j 

105 

100 

175 

183 

180 

103 

203 

200 

21.'! 

215 

210 

210 

220 

224 

227 

2.30 

233 


vu 


vm 


CONTKNTH. 


XXXI 
XXXII 


XXXI 11 
XX  XIV, 


ActiiioinycoHis 

S_V|plliliH 

A(i|iiiri'(l 

('(iiigcnitiil 

Visceral 

(loiiorrlid'ul  liirnlioii 

'riilicri'iildsis 

1.  (icticni!  Miidjo^jy  and  Morliid  Anatomy 

2.  Aculc  'riilH'ri'uid.sis         .... 

3.  TulR'i'(!iil().si.s  of  tilt!  Iiyiii|ilialie  System  , 


4. 

S. 

e. 

7. 
8. 
9. 

10. 


It 
t< 
«i 
(( 
)• 
tt 


XXXV, 
XXXVI. 


of  Hie  Lungs  (Plitliisis,  ('(insiiniptioii) 

of  the  Alimentary  Canal  . 

of  the  liiver 

of  the  Urain  and  Spinal  Cord 

of  the  (lenito-iirinury  System 

of  the  Mammiii'v  (iland 

of  Hie  Circulatory  System 

11.  Diagnosis  of 'riil)ciriil<isis 

12.  I'l'ogiiosis  ill  Tulierciilosis 
i;5.  Prophylaxis  in  'rulierciilosis  . 
14.  Treatment  of 'I'uliercnlosi.H      .         .   • 

Leprosy    

Infectious  Diseases  of  Dnuldful  Nature. 

1.  l-'ebricula  (I'lpheinenil  Fever) 

2.  Weil's  Disease  .... 

'S.  Milk-sickness 

4.  (ihiiidular  l-Vver  .... 
T).  Mouii'uin  l'\'ver  .... 
0.  Miliary  Fever  (Sweating  Sickness) 
7.  Foot  and  Monlii  Disease 


I  AUM 

2:i.'> 

2!»8 
240 
242 
244 

2.V) 

25H 

as8 

878 
280 
281) 
317 
820 
821 
822 
827 
827 
828 
828 
880 
881 
888 
842 
842 
844 
344 
345 
840 
846 
847 


SECTION   II. 
DISEASES  DUE  TO  ANIMAi.  I'AUASITES, 


I.  Psorospermiasis 

1.  Internal  I'sorosperininsis 

2.  Cutaneous  Psorospermiasis . 

II.  Parasitic  Infusoria         .... 

III.  Distomi.'isis 

IV.  Diseases  caused  hy  Nematodes     . 

1.  Ascariasis 

3.  Trichiniasis 

3.  Anehylostomiasis 

4.  Filariasis 

.').  Dnicoiitiasis  .... 

0.  Other  Nematodes 

Acanth"C(>|iliala 
V.  Diseases  caused  by  Ccslodes 

1.  Intestinal  Cestodes ;  Tape-worms 
8.  Visceral  Cestodes 

Cysticorcus  Cellulosa^ 
Echinoeoccus  Disease 
Multilocidar  Echinoeoccus      . 


349 
840 
850 
351 
351 
3112 
352 
854 
359 
360 
802 
864 
805 
805 
865 
308 
308 
370 
374 


CONTKNTS. 


IX 


FAua 

.   a;<5 

.  I'il8 

.  ii'lO 

.  242 

.  2I» 

.  8M 

,  2SN 

,  258 

27a 

280 
281) 
317 
i}2() 

im 

.'i23 
«27 
«27 
;J28 

;i2H 

:)!M 

;i:iH 

;i4i 

Ui 
34o 

:{4(i 

;J40 

047 


VI.  I'iiriisiti<!  ArHchiiiila 
VM.  I'liiiiftilic  liiHcuts  . 
VIII.  Myiusis 


I'AriR 

:I7.1 
:J7« 


SK(T 
TIIH  IXTOXICATION 

I.  Alcolioli.sin 

1.  Acute  Alcoholism 

2.  ('liroiii(!  Alcoholism 
!i.  Delirium  Tiviucim    . 

II.  .Morphiii  lliihit  .... 
III.  liCiiil  I'oisoninj^  .... 
I\'.  Ai'sciiiciil  I'oi.soniuff 

V.  K(i()(l  Poisoning       .... 

1.  Meat  I'oisoiiitif^ 

2.  Poisoning  by  Milk  Products    . 
\i.  Poisoning  by  .ShclI-flsh  and  Finh 
4.  (irain  Poisoning 

VI.  .Sun-stroko 


SECTION   IV. 
CON.STITUTIOXAL    DI.S 
I.  Arthritis  Deformans    . 
II.  t'hronic  UheunuUisin   . 

III.  Muscular  Hheumatism 

IV.  Gout 

V.  Diabetes  Mellitus 

VI.  Diabetes  Insipidus 

VII.  Rickets 

VI II.  Ubesity.        ....".* 


ON    HI. 

S   AND   Sry-STUOKI-]. 


KA.SKS. 


;{78 


.180 

;iH(» 
:iH() 
;iH2 
;)H4 
;iH(i 
:iiK) 
;it)i 
:!t)i 

;«»;{ 
;ti»4 


'•m 

40") 
406 
407 
418 

4;{2 

4.T, 
430 


349 

349 

350 

351 

351 

3)2 

352 

354 

359 

360 

303 

304 

365 

305 

;}05 

308 

308 

370 

374 


SECTION  V 


DISEASE.S  OF 

I.  Diseases  of  the  Mouth  . 
Stomatitis 

Aphthous  Stomatitis 
Ulcerative  Stomatitis 
Parasitic  Stomatitis  (Thrush) 
Gangrenous  Stomatitis     . 
Mercurial  Stomatitis 
Eczema  of  the  Tongue 
Leukoplakia  buccalis 
II.  Diseases  of  the  Salivary  Glands 
Supersccretion  . 
Xerostomia 

Inflammation  of  the  Salivary 
III.  Diseases  of  the  Pharynx 

Circulatory  Disturbances 
Acute  Pharyngitis    . 
Chronic  Pharyngitis 


HE    DIGESTIVE  SYf 


land 


TEM. 


441 
441 
441 
442 
443 
444 
444 
445 
440 
440 
440 
447 
417 
448 
448 
448 
449 


CONTENTS. 


nx 


IV 


Ulccrntinn  of  tlio  Pliiirynx 
Aciilo  IiilVcliniis  I'lilt'ginon  of  the  Pliiir 
Ketr<)-i)lmryiig('iil  Abscess 
Aiiyina  Ludovici      .... 
I)is(>asos  of  tlic  'I'oiisils 
Follicular  or  Lucuiiiir  Tonsillitis     . 
Suiipurativo  Tonsillitis     . 
Chronic  Tonsillitis    .... 
V.  Diseases  of  the  (I'isofihagus  . 

Acute  (Ksophiij;itis  .... 
Si)asni  of  the  (Ksojihagus 
Stricture  of  the  (Ksoiihagns     . 
Cancer  of  the  (Ksophagus 
Rupture  of  the  (Ksophagus 
Dilatatio:::  and  Divertieulu     . 
VI.  Diseases  of  the  Stomach 

Acute  Gastritis 

Phlegmonous  (lastritis  . 

Toxic  Gastritis      .... 

Diphtheritic  Gastritis   . 

Mycotic  Gastritis  .... 
Chronic  Gastritis  (Chronic  Dyspepsia) 
Dilatation  of  Stomach 
Peptic  Ulcer  (Gastric  and  Duodenal) 
Cancer  of  Stomach    .... 
Hypertrophic  Stenosis  of  the  Pylorus 
Ihemorrhage  from  the  Stomach 
Neuroses  of  the  Stomach  . 
VII.  Diseases  of  the  Intestines    . 

1.  Diseases  of  the  Intestines  associated  \v 

Catarrhal  Knlerilis    . 

Diarrlicea 

P^nteritis  in  Children 
Diphtheritic  or  Crou|)ous  Enteritis 
Phlegmonous  Enteritis 
Ulcerative  Enteritis  . 

2.  Appendicitis  (Typhlitis  and  Peritj-phlitis) 

3.  Intestinal  Obstruction . 

4.  Constipation  (Cost iven ess)   . 

5.  Enteroptosis  (Glenard's  Disease) 

6.  Miscellaneous  Afifections 

Mucous  Colitis  .... 
Dilatation  of  the  Colon     . 
Intestinal  Sand 
Affections  of  the  Mesentery 
V^III.  Diseases  of  the  Liver    .... 

1.  Jaundice  (Icterus) 

2.  Icterus  Neonatorum 

3.  Acute  Yellow  Atrophy 

4.  Affections  of  the  Blood-vessels  of  the  Liver 

5.  Diseases  of  the  IMle-passages  and  Gall-bladder 

6.  Cholelithiasis 

7.  Cirrhoses  of  the  Liver 

8.  Abscess  of  the  Liver 


ith  Diarrhoea 


PA(iE 

44)) 

4r)() 

450 

4.'3() 

401 

451 

452 

454 

458 

458 

459 

460 

461 

462 

462 

403 

463 

464 

465 

465 

40() 

40() 

474 

478 

486 

494 

495 

497 

505 

505 

505 

505 

508 

512 

512 

513 

519 

531 

538 

541 

544 

544 

545 

546 

546 

548 

548 

551 

551 

553 

555 

561 

569 

577 


COXTP]NTS. 


XI 


PA(ir 

.  44)) 

.  4.'j() 

,  450 

,  450 

,  451 

451 

452 

454 

458 

45H 

450 

460 

461 

462 

402 

4o;] 

463 

464 

465 

465 

406 

400 

474 

478 

480 

494 

4&5 

497 

505 

505 

505 

505 

508 

513 

512 

512 

519 

531 

538 

541 

544 

544 

545 

540 

546 

548 

548 

551 

551 

553 

555 

561 

569 

577 


9.  New  Growths  in  the  Liver  . 

10.  Fatty  Livvr 

11.  Amyloid  Liver      .... 

12.  Anomalies  in  Form  and  Position  of 
TX.  Diseases  of  tiio  Pancreas 

1.  lliumorrhage         .... 

2.  Acute  Pancreatitis 

8.  Chronic  Pancreatitis    . 

4.  Pancreatic  Cysts  .... 

5.  Tumors  of  the  Pancreas 

6.  Pancreatic  Calculi 

X.  Diseases  if  the  Peritonaeum 

1.  Acute  General  Peritonitis     . 

2.  Peritonitis  in  Lifants  . 

3.  Localized  Peritonitis    . 

4.  Chronic  Peritonitis 

5.  New  Growths  in  the  Peritona' 

6.  Ascites  (Ilydro-peritoniuum) 


II 


III 


IV, 


um 


Li 


\or 


SECTION  VI. 
DISEASES  OF   THE   RESPIRATORY    SYSTEIM. 

Diseases  of  the  Nose        .... 

Acute  Coryza 

Chronic  Nasal  Catarrh 

Autumnal  Catarrh  (Ilay  Fever) . 

Epistaxis 

Diseases  of  the  Larynx   .... 

1.  Acute  Catarrhal  Laryngitis    . 

2.  Chronic  Laryngitis. 

3.  Edematous  Laryngitis  . 

4.  Spasmodic  Laryngitis  (Laryngismus  stridulus) 

5.  Tuberculous  Laryngitis  . 

6.  Syphilitic  Laryngitis 
Diseases  of  tlie  Bronchi  .... 

1.  Acute  Bronciiitis     .... 

2.  Chronic  Bronciiitis .... 

3.  Bronchiectasis         .... 

4.  Bronchial  Asthma  .... 

5.  Fibrinous  Bronchitis 
Diseases  of  the  Lungs     .... 

1.  Circulatory  Disturbances  in  tlie  Lungs 

2.  Broncho-pneumonia  (Capillary  Bronciiitis) 

3.  Chronic  Interstitial  Pneumonia  (Cirrhosis  of  Lung) 

4.  Pneumonokoniosis  .... 

5.  Emphysema 

Compensatory  Empliysema 
Hypertrophic  Empliysema  . 
Atrophic  Emphysema 
Acute  Vesicular  Emphysema 
Interstitial  Empliysema 

6.  Gangrene  of  the  Lung    . 

7.  Abscess  of  the  Lung 

8.  New  Growths  in  the  Lungs    . 


TAOE 

.')H2 
585 
586 
587 
588 
588 
58!) 
593 
592 
594 
595 
590 
596 
000 
600 
003 
004 
005 


610 
610 
611 
013 
014 
615 
015 
610 
017 
017 
019 
030 
021 
031 
033 
036 
038 
032 
034 
634 
641 
049 
652 
654 
055 
655 
659 
660 
600 
600 
662 
603 


Xll 


{'()\T|.;\TS. 


y.  I)is(>iis('s  (if  llic  I'lt'iini     .... 

1.  Aciilt'  I'liMirisy        .... 

l-'iliriiiiius  or  I'laslic  IMciirisy 
.Scru-liliriiiuus  IMciii'isy 
I'linili'iil  I'li'iirisy  (l'liii|iyi'iiin)    . 
'I'lilu'rciiloiis  I'lt'iirisy  . 
OlluT  N'arit'lics  of  Pleurisy 

2.  Cliroiiic  I'liMii'isy      .... 

;t.   Ilyili'otlioriix 

■I.   l*iu'Uiii()tli(inix  (lly(li<i-|iii('iim()tliorax  and  I'yti-piiciiiiKillionix) 

AUVctiuns  of  till' MiMliaslimiiii 


■  •AIIK 

(Kir» 
(105 
(105 

(too 

(i71 

07:{ 
(17H 
(JHO 
OHl 
084 


.•SECTION  vir. 


DISKASK.S   ()!•'   Till-:   CIRCl 


1.  Diseases  of  tho  IVi'i<'anliuiii    . 

1.  i'ericanlitis 

2.  Oilier  AlTeclioiis  of  tlie  Perieanliiiin 
II.  Diseases  of  the  '  eart        .... 

1.  Kiidoeaniitis 

.\eiilc  MiKloearditis 
Clironic  I'iiidoeardilis  . 

2.  Chroiiii'  Valvular  Disease 

General  Introduelioii   . 
Aortie  Ineonipetency    . 
Aortic  Stenosis 
Mitral  Ineonipetency    . 
Mitral  Stenosis 
Tricuspid  N'alvo  Disease 
Pulmonary  Valve  Disease    . 
('oml)ined  Valvular  Lesions 

3.  Ilypertropliy  and  Dilatation    . 

Hypertrophy  of  the  Heart  . 
Dilatation  of  the  Heart 

4.  AlTectioiis  of  the  Myocardium 

Aneurism  of  the  Heart 
linpture  of  the  Heart   . 
New  (irowt lis  and  Parasites 
Wounds  and  Foreign  Bodies 

5.  Neuroses  of  the  Heart 

Palpitation 

Arrhythmia 

Hapid  Heart  (Tachycardia.)  . 
Slow  Heart  (Bradycardia)  . 
Angina  Pectoris    .... 

6.  Congenital  AfTections  of  the  Heart 
111.  Diseases  of  tiie  Arteries  . 

1.  Degenerations 

2.  Arterio-selerosis  (Arterio-capillary  Fibrosis) 

3.  Aneurism 

Aneurism  of  the  Thoracic  Aorta 

Aneurism  of  the  Alidomiual  Aorta 

Aneurism  of  tlie  Branches  of  the  Abdominal  Aorta 


LATORV   SYSTFM. 


688 

688 
0!)7 
6!»8 
6!»H 
6!)8 
705 
707 
70. 
700 
715 
717 
721 
725 
727 
728 
7^5 
735 
741 
746 
753 
753 
754 
754 
755 
755 
756 
758 
759 
761 
765 
770 
770 
770 
776 
777 
786 
787 


noNTKNTS. 


Xlil 


PAOI 

(105 

(ior> 

(105 
000 
071 

o:;) 
07;{ 

07H 
080 
081 
084 


.    088 
.    088 
.     097 
.     0!)H 
.     C!>8 
.     (i!)8 
.     705 
.     707 
.     70'. 
709 
715 
717 
721 
725 
727 
728 

7^5 

7.'}5 

741 

746 

753 

753 

754 

754 

755 

755 

756 

758 

759 

761 

765 

770 

770 

770 

776 
777 
786 
787 


Artcrio-vciioiH  AinMiriMin     .... 

('()ii;,'('iiitiil  AiiiMirism 

SKCTION    VI IF. 
DFSKASKS   OK  TIIK    MliOOj)    AND   DUfTr.ESS  GLANDS. 

I.   .Aninniii 

Secondary  Aiiiciniii  . 
Priiiiiiry  or  Mshc  ntiiil  Aiin'iiiin 
II.  liriikicinjii      .... 
1 1 1.   Ilod^'kin'.s  DisL'iisf 
l\'.   I'lirpiini         .... 
\'.  llnMii()|iliiliH  .... 

VI.  Scurvy 

\'ll.  Slutiis  liyinpliiiticus      . 
\lll.   Diseases  of  tjic  Supraroim!  Modies 
l.\.   Diseases  of  the  Spleen  . 
X.  Diseases  oi  tlie  Thyroid  Olaiid 
(ioilns         .... 
Tumors  of  (lie  Thyroid     . 
Exophlhalniic  (ioifrc 
I\ly.\(edcnia. 
.\I.  Diseases  of  the  Thymus  (iland 


7H8 
7H« 


I 

II, 

III, 

IV 


V. 

VI. 

VII. 


VIII. 

IX. 

X. 


SKCTiON 

DISEASKS  OF   Till' 

Malformations      .... 
IMovahle  Kidney    .... 
(Circulatory  I)ist,uri)ances 
,  Anomalies  of  the  Urinary  Secretion 

1.  Anuria         .... 

2.  Ila'maturia  .... 

3.  ILrmoglohinuria 

4.  Alhumimiria 

5.  Pyuria  (Pus  in  the  Urine)  . 

6.  Chyluria  (Non-parasitic)     . 
7   Lithuria      .... 

8.  Oxaluria      .... 

9.  Cystinuria   .... 
10    Phosphaturia 

11.  Indicanuria 

12.  Melanuria   .... 

13.  Pneumaturia 

14.  Other  Substances 

UraMnia 

Acute  Bright's  Disease 
Chronic  Bri-jht's  Disease 

Chronic  Parenchymatous  Neplirili.- 
C;hronic  Interstitial  Nephritis  . 

Amyloid  Disease  .... 

Pyelitis         '••... 

Hydronephrosis  .... 


IX. 

:  KIDNEYS. 


780 

iH'.i 

V.f-l 
H(r^ 
809 
814 
HI!) 
821 
820 

mn 

832 
835 
835 
836 
836 
840 
843 


846 
846 

849 

850 

850 

851 

852 

854 

858 

859 

859 

861 

861 

862 

863 

863 

864 

864 

865 

869 

874 

875 

877 

884 

886 

889 


XIV 


CONTKNTS. 


XI.  Nephrolitliiasis  (Ivciml  ralcnliis). 
Xl[.  Tumors  of  llio  Kidney 

XIII.  (Jyslic  Disoiisc  of  the  Kidney 

XIV.  Perinephric  Abscess 


PAOR 

801 
890 

898 
900 


S 


igitis) 


YSTKM. 


KECTTON   X. 

DISEASES   OF  THE   NERVOUS 

I.  General  Introduction 

II.  System  Diseases 

1.  Introduction 

2.  Diseases  of  the  AlTerent  or  Sensory  System 

Lof.'on'iotor  Ataxia 

3.  Diseases  of  tiie  EfTerent  or  Motor  Tract 

Of  the  Whole  Tract 

Progressive  ((Jentral)  Muscular  Atrophy 
Hulbar  Paralysis        .... 

Progressive  Neural  Muscular  Atrophy 

The  Muscular  I)ystro|)hies    . 
System  Diseases  of  the  U|iper  Motor  Segment 

Spastic  Paralysis  of  Adults  . 

Spastic  Paralysis  of  Infants. 

Hereditary  Spastic  Paraplegia 

Erb's  Syphilitic  Spinal  Paralysis  . 

Secondary  Spastic  Paralysis, 

Hysterical  Spastic  Parajjlcgia 
System  Diseases  of  tiic  Lower  Motor  Segment 

Chronic  Anterior  Polio-myelitis   . 

Ophthalmoplegia  .... 

Acute  Anterior  Polio-myelitis 

Acute  and  Sul)acute  P  tio-aiyelitis  in  Adults 

Acute  Ascending  (La  dry's)  Paralysis 

Asthenic  (Bulbar)  Pan   vsis. 

4.  Combined  System  Diseases  .... 

Ataxic  Paraplegia 

Primary  Combined  Sclerosis  (Putnam)    . 

Hereditary  Ataxia  (Friedreich's  Ataxia) 

Progressive  Interstitial  Hypertrophic  Neuritis  of  Infants 

T(<xic  Combined  Sclerosis 

III.  DilTuse  Diseases  of  the  Nervous  System 

1.  AfTections  of  the  Jleninges  . 

Diseases  of  the  Dura  Mater  (Pachymenin 
Ha'morrhagic  Pachymeningii   ■ 
Diseases  of  the  Pia  Mater 
Posterior  Meningitis  of  Infants 

2.  Scleroses  of  the  Brain  .... 

Insular  Sclerosis        .... 
.3.  Chronic  Diffuse  Meningo-encojihalitis 

IV.  Diffuse  and  Focal  Diseases  of  the  Spinal  Cord 

1.  Topical  Diagnosis         .... 

3.  Affections  of  the  Blood-vessels    . 

Congestion 

Anirmia 

Embolism  and  Thrombosis 


901 

919 

919 

920 

920 

928 

928 

928 

932 

933 

933 

936 

937 

938 

940 

940 

941 

941 

941 

941 

942 

942 

946 

946 

947 

947 

948 

949 

949 

951 

951 

951 

951 

951 

952 

954 

957 

957 

959 

960 

964 

964 

960 

966 

966 

966 


CONTENTS. 

XV 

PAna 

Endarteritis «07 

Ilu'inorrhage  into  the  Spinal  Mombranes 

flrt7 

Ilojmorrliage  into  the  Spinal  Cord 

■ 

ms 

Caisson  Disease 

!»fi» 

8.  Compression  of  the  Spinal  Cord        .... 

D70 

Lesions  of  the  Cauda  Kquina  and  Conns  Meduliaris 

i)72 

4.  Tumors  of  the  Spinal  Cord  and  its  Membranes . 

973 

5.  Syringomyelia 

975 

6.  Acute  Myelitis 

976 

v.  Diffuse  and  Focal  Diseases  of  the  Brain  .... 

979 

1.  Topical  Diagnosis 

979 

2.  Aphasia 

988 

8.  Affections  of  the  Blood-vessels 

994 

llypenumia 

994 

Anii'mia 

995 

(Edema  of  the  Brain 

997 

Cerebral  Ilii'inorrhage 

997 

Embolism  and  Thrombosis 

1008 

Aneurism  of  the  Cerebral  Arteries 

loia 

Endarteritis 

1014 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins 

1015 

Hemiplegia  in  Children 

1017 

4.  Tumors,  Infectious  Granulomata.  and  Cysts  of  the  Brair 

1020 

5.  Inflammation  of  the  Brain 

1024 

Acute  Encephalitis 

1024 

Abscess  of  the  Brain 

1025 

6.  Hydrocephalus 

1028 

VI.  Diseases  of  the  Peripheral  Nerves 

1031 

1.  Neuritis  (Inflammation  of  the  Bundles  of  Nerve  Fibres) 

1031 

2.  Neuromata 

1037 

3.  Diseases  of  the  Cerebral  Nerves         .... 

1038 

Olfactory  Nerves  and  Tracts 

1038 

Optic  Nerve  and  Tract 

1039 

Lesions  of  the  Retina 

1039 

Lesions  of  the  Optic  Nerve         .... 

1040 

Affections  of  the  Chiasma  and  Tract . 

1041 

Affections  of  the  Tract  and  Centres  . 

1042 

Motor  Nerves  of  the  Eyeball 

1045 

Fifth  Nerve     . 

1050 

Facial  Nerve  .... 

1051 

Auditory  Nerve 

10.56 

The  Cochlear  Nerve 

1056 

The  Vestibular  Nerve . 

1058 

Glosso-pharyngeal  Nerve 

1059 

Pneumogastric  Nerve 

1060 

Spinal  Accessory     . 

1063 

Hypoglossal  Nerve  . 

1066 

■                   4.  Diseases  of  the  Spinal  Nerves 

1007 

m                           Cervical  Plexus 

1067 

9                            Brachial  Plexus 

1069 

M                           Lumbar  and  Sacral  Plexuses 

1072 

1                            Sciatica    .... 

.     1073 

m       VII.  General  and  Functional  Diseases 

.     1075 

■                     1.  Acute  Deliri  -m  (Bell's  Mania) 

1075 

xvi 


CONTKNTS. 


rAuic 

2.  Paralysis  Apitftns 107« 

Other  Pdriiis  of  Tremor 107') 

3.  Acute  Chorea  (Sydoiiluiiii's  Chorea;  St.  Vitus's  Dance).         .         .         .  107!( 

4.  Other  A  fTecl  it  IIS  described  as  Chorea lOHM 

5.  Infantile  Con *'iilsions  (KcJHinpsia) 1(M)1 

0.  Epilepsy l()«;t 

7.  Migraine 1103 

8.  Neuralgia 1104 

9.  Professional  Spasms;  Occupation  Neuroses 1107 

10.  Tetany 11(10 

11.  Hysteria 1111 

12.  Neurasthenia 1123 

13.  The  Traumatic  Neuroses 1 1;!2 

14.  Other  Forms  of  Functional  Paralysis 1130 

Periodical  Paralysis 1136 

Astasia;  Abasia 1136 

VIII.  Vaso-motor  and  Trophic  Disorders 1137 

1.  Raynaud's  Disease .1137 

2.  Erythroraelalgia 1139 

3.  Angio-neurotic  (Edema 1140 

4.  Facial  Hemiatrophy 1141 

5.  Acromegaly 1142 

Ost'^itis  Deformans 1144 

Hypertrophic  Pulmonary  Arthropathy 1144 

Leontiasis  Ossea 1145 

Micromegaly 1145 

6.  Scleroderma 1145 

Ainhum 1147 


SECTION  XI. 

DISEASES  OP  THE  MUSCLES. 

I.  Myositis 1148 

II.  Myotonia  (Thorasen's  Disease) 1149 

III.  Paramyoclonus  Multiplex 1150 


TAUB 

.  107« 

.  1071) 

.  107!) 

.  lOHM 

.  1(M)1   1 

.  i()i);t   ' 

.  1103 

.  1104 

.  1107 

.  110!) 

.  1111 

CUART 

I. 

II. 

.  1133 

.  Ilii3 

.1180   i 

III. 

.     1136   1 

IV. 

1 

V. 

.  iiae  1 

.  1137 

VI. 

.  1137 

VII. 

.  1139 

VIII. 

.  1140 

IX. 

.  1141 

X. 

.  1143 

1 

.  1144 

I     XI. 

.  1144 

j    XII. 

.  1145 

XIII. 

.  1145 

.  1145 

XIV. 

.  1147 

XV. 

XVI. 

xvn. 

XVIII. 

•XIX. 

.  1148 

XX. 

.  1149 

XXI. 

.  1150 

FKll-RE 

CHARTS  AND   ILLUSTRATIONS. 


PA  01 

Typhoid  Fever  witl.  Relapse 15 

Illustrntint?  the  Blood  Changes  in  Typhoid  Fever 20 

Typhoid  Fever — I Ifeinorrhage  from  the  Bowels*  .         .        .         .        .         .  34 

Illusti-ating  Influenee  of  Baths  in  Typhoid  Fever 45 

Helapsiiig  Fever  (after  Murehison) 55 

Small-pox  (after  Strllmpell) 60 

Scarlet  Fever  (after  Strllmpell) 78 

Measles  (after  Strllmpell) 86 

Temperature,  Pulse,  and  lle.spiration  Chart  in  Pneumonia   ....  116 
Showing  Coincident  Drop  in  the  Fever  and  in  the  Leucocytes  in  Pneu- 
monia                    121 

JIalaria— Tertian  Ague 210,  211 

Chronic  Tuberculosis.  Two-hourly  Chart  for  Three  Days      ....  305 
Case  of  Sun-stroke  treated  with  Ice-bath.     Recovery.    (Rectal  Tempera- 
tures)      397 

Showing  Uric  Acid  and  Phosphoric  Acid  Out|)nt  in  a  Case  of  Acute  Gout.  413 

Illustrating  Influence  of  Diet  on  Sugar  and  Amount  of  Urine  in  Diabetes.  430 
Diagrams  after  Martins,  showing  schematically  the  Power  of  the  Heart 

Muscle 708 

Blood  Chart,  illustrating  Anremia  in  Purpura  Ha'morrhagica      .        .        .  790 

Blood  Chart,  illustrating  Chlorosis 793 

Blood  Chart,  illustrating  Pernicious  Anivmia 798 

Blood  Chart,  illustrating  Leukaemia 807 

Blood  Chart,  illustrr.cing  Rapid  Production  of  Ana;mia  in  Purpura  Iliem- 

orrhagica 817 


1.  Diagram  of  Motor  Path  (Van  Gehuchten) 903 

3.  Diagram  of  Motor  Path  from  Right  Brain  (Van  Gehuchten)        .        .        .  904 

3.  Diagram  of  Cerebral  Localization 907 

4.  Diagram  of  Motor  and  Sensory  Representation  in  the  Internal  Capsule       .  908 

5.  Diagram  of  Motor  and  Sensory  Paths  in  Crura f)09 

6.  Diagram  of  Cross-section  of  Spinal  Cord 909 

7,  8.  Head's  Diagrams  of  Skin  Areas  corresponding  to  the  Different  Sjiinal 

Segments 910,  911 

9.  Lichtheim's  Schema 989 

10.  Diagram  of  Motor  Path  from  Right  Brain 1003 

11.  Diagram  of  Visual  Paths  (Vialet) 1043 


*  The  red  shows  the  two-hourly,  the  black  the  morning  and  evening  temperature. 

xvii 


"  Experience  is  fiilhieious  and  judgment  difficult." 
Hippocrates:  Aphoriums,  I. 

"And  I  said  of  medicine,  tluit  this  is  an  art  which 
considers  tlie  constitution  of  tlio  patient,  and  has 
principles  of  action  and  reasons  in  eacii  case." 

Plato:  Oorgias. 


A   TEXn^-llOOK    OX 

THE  rPvACTiciii  OF  mj^:dictne. 


SKCTIOX   T. 


SPECIFKJ    INFECTIOUS    DISEASES. 


I.    TYPHOID    FEVER. 

Definition. — A  ^a'ticnil  infection  cansi'd  by  tlio  baoillus  tyithosus, 
cliiiriKtt'rizcd  aiiiitomu'iiliy  by  liyiJt'rjjliisiu  and  ulceration  of  the  lyni])!.- 
folliclcH  of  tlie  intestines,  swelling;  of  the  mesenteric  <:lands  and  spleen, 
and  |iarencliyniatons  cbanires  in  the  other  or<jans.  While  these  lesions  are 
ahnc-it  constant,  there  are  cases  in  which  the  local  chanj;es  ai'e  sli;;:ht  or 
absent,  and  there  are  others  with  intense  localization  of  the  poison  in  the 
lunps,  spleen,  kidneys,  or  cerebro-spinal  system.  Clinically  tlu'  disease  is 
marked  by  fever,  a  rose-colored  eruption,  diarrlio^a,  abdoininal  tenderness, 
tympanites,  and  eidar(,'ernent  of  the  s]deen ;  but  these  syni])toms  are  ex- 
tremely inconstant,  and  even  the  fever  varies  in  its  character. 

Historical  Note. — The  dates  IHi:}  and  1850  include  the  modi-rn  dis- 
cussion of  the  subject.  I'rior  to  the  former  year  many  observe  Iiad  noted 
clinical  differences  in  the  continued  fevers.  Iluxham  in  particular,  in 
his  remarkable  Essay  on  Fevers,  had  "taken  notice  of  the  very  threat  dif- 
ference there  is  between  tbe  pufrid  nialiniiant  and  the  slow  ticn'oKsferc/:''^ 
In  ISIIJ  Pierre  Bretonneau,  of  Tours,  distinguished  "dothienenterite  "  as 
a  separate  disease  ;  and  Petit  and  Serres  described  entero-mesenteric  fever. 
Trousseau  and  Vel])eau,  students  of  Bretonneau,  were,  in  IS'^O,  instru- 
mental in  niakin<j:  his  views  known  to  Andral  and  others  in  Paris.  In  1S;3!) 
I.ouis' great  woi'k  appeared,  in  Avhich  the  name  "typhoid"  was  given  to 
the  fever.  At  this  period  typhoid  fever  alone  prevailed  in  Paris,  and  it 
was  uiuversally  believed  to  be  identical  with  the  continued  fever  of  (Jreat 
Britain,  where  in  reality  typhoid  and  typhus  coexisted ;  and  the  intestinal 
lesion  was  regarded  as  an  accidental  occurrence  in  the  course  of  oi'dinary 
lyplms.  Louis'  students  returning  to  their  homes  in  dilferent  countries 
had  opportunities  for  studying  the  prevalent  fevers  in  the  thorough  and 
systematic  manner  of  their  master.  Among  these  Avero  certain  young 
American  physicians,  to  one  of  wiiom,  (Jei'hard,  of  Philadel))hia,  is  due  the 
irrcat  honor  of  having  first  clearly  laid  down  the  dilferenccs  between  the 
two  diseases.  His  papers  in  the  American  Journal  of  the  ^ledical  Sci- 
1  1 


SPKC'IPir  IXFKfTIDrs   IHSKASKS. 


ciu'cs,  lcS:57,  iirc  imdoiihtcdly  (lie  first  in  any  Iiiii^'uiifjc  wliiili  ^fivc  a  full 
and  Hatist'uctory  account  of  the  clinical  and  anatomical  distinctions  \vc  now 
rcco^rnizc.  No  student  slionld  fail  to  read  these  articles,  amoiif,'  the  most 
classical  in  American  medical  literature. 

Louis'  inlluence  was  early  felt  in  U(»sloii,  wliitlicr,  in  ls;{;{,  .lanu's  .lack- 
Hon,  .Ir.,  had  returned  from  I'arirt.  In  this  year  he  demctnslrated,  in  his 
father's  wards  at  the  Massachusetts  (Jeneral  Hospital,  the  identity  of  the 
typhus  of  this  country  with  the  typhoid  of  Louis,  lie  had  already,  in 
ls:t(>,  noticed  the  intestinal  lesions  in  tlieconnnon  fever  of  .New  Ln;,dand. 
'rh(Mi<,di  cut  oil"  at  the  very  outset  of  his  career,  we  may  reasonahly  attribute 
to  his  inspiration  the  two  elahorati*  iuenu)irs  on  typhoid  fever  which,  in 
1S;5H  and  IH;J!I,  were  issued  from  the  Massachusetts  (ieneral  Hospital,  hy 
.lames  .lackson,  Sr.,  and  Lnoch  Hale.  These,  with  (ierhard's  articles,  con- 
trihuted  to  make  typhoid  fever,  as  (list  inj.':uished  fiom  typhus,  widely  known 
in  the  profession  here  l(»n^  before  the  distinctions  were  rcco;,Mii/ed  j,fener- 
ally  in  Kurope.  Thus,  they  were  described  with  admirable  clearness  under 
diU'erent  headin;;s  in  the  lirst  editi<jn  of  IJurtlett's  work  on  l-'cvcrs,  ]iub- 
lished  in  \S4'2. 

The  rcco<fnition  in  Paris  of  a  fever  distinct  from  typhoid,  witlnuit  intes- 
tinal lesions,  was  due  lar^rely  to  the  inlluence  of  the  able  papt'rs  of  (ieor^'o 
('.  Shattuck,of  Boston,  and  Alfred  Stille,  of  JMiiladelphia,  wiiich  were  read 
beforo  the  Sooiete  niedicalc  d'Ohservation  in  l.s:5,s.  At  Louis'  i-ccpu-st, 
Shattuck  went  to  the  Loiulon  Fever  Hospital  to  study  the  disease  in  I'ln;;-- 
land,  where  he  saw  the  two  distinct  allVctions,  and  brou^^dit  back  a  re])oi't 
Avhicii  was  very  convincin<^  to  tlie  mendjcrs  of  the  society  (Medical  lv\- 
aniiner,  Philadelphia,  ISK)), 

Stille  had  the  iidvautaj^o  of  jjoinjj  to  Paris  knowing;  thorou^ddy  the 
clinical  features  of  typhus  fever,  for  he  had  been  (ierhard's  house-physician 
at  the  Phihulelphia  Hospital  durinfjj  the  epidemic  of  LS;}(),  At  La  Pitie, 
with  Louis,  lie  saw  quite  ii  different  aU'ection,  whilo  in  London,  Dublin, 
and  Naples  be  recognized  tyi)hus  as  be  had  seen  it  in  Philadelphia.  ^J'be 
results  of  bis  observations  were  given  in  an  exhaustive  ]ia})er  wliicli  pre- 
sented in  tabubiv  form  the  contrasts  and  distinctions,  clinical  and  anatom- 
ical, which  we  now  recognize. 

In  Great  Ib'itaiu  the  non-identity  of  typhus  and  tyi)lioid  was  clearly 
cstablisbed  at  Glasgow,  where  from  1830  to  1838  A.  P.  Stewart  studied  the 
continued  fevers,  and  in  1840  publisbed  the  results  of  bis  observations.  In 
the  decade  which  followed,  many  important  works  were  issued  and  more 
correct  views  gradually  pri'vailed  ;  but  it  was  not  until  the  publication  of 
Jenner's  observations  between  184:1»  and  1851  that  tbo  question  was  finally 
settled  in  Englaiul. 

Etiology. — Typlioid  fever  prevails  especially  in  temperate  climates, 
in  wbicb  it  constitutes  the  most  common  continued  fever.  Widely  dis- 
tributed throughout  all  jiarts  of  the  world,  it  probably  i)resents  everywhere 
the  same  essential  cbaracteristics,  and  is  everywhere  an  index  of  the  sani- 
tary intelligence  of  a  community.  Defective  drainage  and  contaminated 
water  supply  are  the  two  special  conditions  favoring  the  distribution  and 


TYlMlolIt   FKVKI{.  3 

"•rowtli  of  tlif  Imcilli ;  (lltli,  nvcrcrowtliii'',  and  l)ii<l  vcntilutioii  arc  urccs- 
.'.(ii'icH  ill  lowcriii;;  the  rcsistaiicc  ol'  the  iiidividuHls  ('XpostMl. 

Uliik'  iniproviMl  Hai.it.ati(»ii  has  done  iniich  to  rcdiici'  tlu' mortality  IVoin 
tvplioid  fi'ViT,  partii'ularly  in  tin'  lar;,'('  citifs,  u  reduction  ainout'tin;,'  to 
•l.'t.l  JUT  <'i!lit  ill  ^I  ont  of  'M  I'ln^disii  towns  (Dn-sclifcld)  (li;,Min'S  illnstnit- 
inLf  which  will  lie  referred  to  under  I'lupliylaxis),  tiie  disease  is  still  far  too 
jirevuli'iit,  iiiid  ill  siihiirhaii  and  rural  districts  in  this  c(tiinlry  thei'c  is 
evidence  to  show  that  it  in  on  the  increaH(^  In  1S!)()  the  ileath-rate  from 
tvplioid  fever  per  l()0,()n()  (d"  pdpiilatioii  wuh,  in  tlio  I'liited  States,  4'1.:;*7 ; 
in  Knjfland  and  Wales,  1T.!»;  in  Italy,  (i5.H;  in  Austria,  17.0;  ami  in  Prus- 
sia, '.'»). 1. 

Sitisini. — It  prevails  most  in  the  autumn  months.  Of  l,S,s!)  eases  ad- 
mitted to  the  Montreal  (ieiieral  Hospital  in  twenty  years,  more  than  lifiy 
per  cent  wer((  in  the  months  of  An;,'iist,  Septemher,  and  Octoher.  Of  1,:ImI 
cases  treated  durinj^'  twelve  years  at  the  Toronto  (leneral  Hospital,  If.  1 
occurred  in  these  months  ((Iraham).  it  has  heen  well  called  the  autumnal 
fever.  Jt  has  heen  ohserved  to  he  especially  prevalent  ill  hot  and  dry 
seasons.  Aecordiiif,'  to  I'ettenkofer,  epidemics  are  most  common  when  the 
j:r(»und-water  is  low,  under  whi(di  circumstanceH  the  s])riii;,'s  and  water- 
sources  drain  more  tlioroiif^ddy  contaminated  foci  and  arc  more  likely  to  he 
hi;4hly  (diar<,a'd  with  poison.  It  may  he  also,  as  Hannifrarten  sii;:'^'ests,  that 
in  dry  seasons  the  jtoison  is  more  disseminated  in  the  dust. 

AVv. —  Males  and  females  are  ahout  erpially  liahle  to  the  disease,  hut 
males  with  typhoid  are  much  more  fre(|ucntly  a<l'nitted  into  hospitals. 

Af/r. — 'ry])lioid  fev<'r  is  a  disease  of  youth  and  eaily  adult  life.  The 
jireatest  susce]»til)ility  is  hetween  the  af^a-s  of  lifteen  and  twenty-live.  Of 
('.s,>  cases  treated  to  January  1,  1S!»H,  in  my  wards  at  th>'  Johns  Hopkins 
llos])ital  there  were  under  lifteen  years  (»f  af,'e,  75;  hetween  lifteen  and 
twenty,  i;]8;  hetween  twenty  and  thirty,  'M7 ;  hetween  thirty  and  forty, 
'.IS;  hetween  foi'ty  and  fifty,  ;{:2 ;  hetween  lifty  and  sixty,  («;  ahove  sixty, 
(i ;  age  douhtful  in  1:5*.  Cases  are  rare  over  sixty,  althougli  Manges  he- 
lieves  that  they  are  more  common  than  the  records  show.  As  the  course 
is  often  atypical  the  diagnosis  may  he  uncertain.  In  two  of  my  cases  the 
disease  was  not  recognized  until  the  autopsy.  It  is  not  very  infrequent  in 
cliildhooil,  hut  infants  are  rarely  attacked.  Murchison  saw  a  case  at  the 
sixth  montii.  The  disease  may  he  congenital  in  casos  in  which  the  motlu'r 
has  contracted  it  late  in  pregnancy, 

Jinniiniifi/. — As  in  other  fevers,  not  all  exposed  to  the  infecti(jn  take 
the  disease,  aiul  there  are  grades  of  susce})tihility.  Some  families  seem 
more  disi)osed  to  infection  than  others.  One  attack  usually  ]»roteots.  "  Of 
X',0()()  cases  of  enteric  fever  at  the  Ilamhurg  (ieneral  Ilosi»ital,  only  14  per- 
sons were  atfectcd  twice  and  only  1  person  three  times"  (Dreschfeld). 

The  Bacillus  typhosus. — The  reseandies  of  Eberth,  Koch,  (ialfky,  and 
others  have  shoAvn  that  there  is  a  special  micro-organism  contitanfli/  asso- 


f 


*  Vols.  Iv,  V,  and  vii  of  the  Jolins  Iloiikiiis   Flospitiil  Reports  contain  the  Studies 
on  Typhoul  Fever  referred  to  in  this  article  as  Studies  I,  II,  and  III. 


SI'MCII'IC   I\FK("ri(>['S   msKASKS. 


c'iiitcd  witli  typlmi"!  rcvcr.  (n)  (IniirnlCliiii'iirfirK. —  It  is  ii  rutlicr  Kli(tit, 
thick,  Ilii;^'i'iliii('<l,  iiiotilf  )iiirillii<4,  with  riiiMidt'tl  cuds,  in  one  of  which, 
Koiiictiincs  ill  both  (particiihirly  in  ciillurcM),  there  can  In-  seen  ii  ^diHtciiiii;; 
round  hody,  at  one  time  helicvcil  to  he  a  spore;  hut  thenc  polar  Htiiicturcrt 
arc  prdliiihly  only  ureas  of  (h';:eiirriitcd  protdphisni.  It  ^rows  readily  on 
various  iiiiti'iti\e  media,  and  can  now  he  dilfeicnliatccl  from  the  hitrhriiini 
villi  riminniui;  wiili  wliieli,  and  with  certain  »»tlier  hacilli,  it  is  apt  to  ho 
coiifoiiiided.  This  orj,'anism  fiillils  two  of  the  re<|iiireiiients  of  Koch's  hiw 
— it  l«  constantly  present,  and  it  ;,'rows  outside  the  h((dy  in  a  specilic  nuiii- 
lier.  The  third  re(|iiirenient,  the  |)roduction  of  the  disease  experimentally 
hy  the  cultures,  has  not  yet  hecii  met.  i'rohahly  the  animals  used  for  cx- 
jierimeiitatioii  are  n(»t  susceptilde  to  typhoid  fever.  'I'lie  l)acilli  or  their 
toxins  iiioculateil  in  large  (|Uimtities  into  the  hlood  »d"  rahhit.s  are  patho- 
lienic,  and  in  some  instances  ulcerative  and  necrotic  lesions  in  the  intes- 
tine may  l»c  produced.  i?iit  similar  intestinal  lesions  may  he  caused  liy 
other  l>acteria,  includinj;  the  liiiiirriidit  rali  miiiiiiKiiv. 

Cultures  are  killed  withii.  ten  minutes  when  exposed  to  a  tempi'raturo 
of  (iO  ('.,  while  they  resist  for  days  temperatures  as  low  as  —  lo"  C,  even 
when  frozen  and  thawed  successively.  Although  the  t_\  plioid  hacillusdoes 
not  jtroduce  spores,  it  resists  ordinary  drying  for  months,  'i'lu!  dire(!t  rays 
of  the  sun  (piickly  injure  tin*  Itacilli  in  cult  iires,  and  c(»mi)ietely  destroy 
them  in  from  four  to  ten  hours' exposure.  Bouillon  cultures  iiro  destroyed 
l)y  earl)oli(!  acid,  I  to  "iOO,  and  hy  corrosive  suhlimate,  1  to  •,',.')()(). 

{//)  Pisfrihidion  ill  llir  IUkIij. — In  recent  typhoid  infections  the  hacilli 
ji.  found  in  the  lymphoid  tissues  f)f  the  intestines,  in  the  mesenteric 
glands,  in  the  spleen,  in  the  l)oiie  marntw,  in  the  liver,  and  in  the  hile. 
They  occur  also  in  irregular  clnmjis  in  the  contents  of  the  intestines  and 
in  the  sto  )ls ;  and  since  the  introdiicti(.  of  iiin»roved  methods  of  cultiva- 
tion (KIsner,  C'apaldi)  tliey  have  ])een  deiiionstrated  in  the  latter  in  ahout 
t)()  per  cent  of  the  cases  examined.  Tlu'y  may,  howe-ver,  he  inca])ahle  of 
demonstration  even  in  fatal  cases,  'i'he  hacilli  luivc  been  found  in  the 
1)l()od  and  in  the  rose-colored  spots.  In  the  urine  they  may  be  jiresent  in 
numl)ers,  where  tliey  may  persist  for  months  after  recovery  (Mark  liichard- 
son),  and  they  liave  l)een  found  in  the  sweat  and  sputa.  From  the  endo- 
cardial vegetations,  from  meningeal  and  jjlcural  exudates,  and  from  foci  of 
suppuration  in  various  ]»arts,  the  hacilli  have  also  1)"(mi  isolated. 

(r)  The  lldcllli  On  I  side  I  he  lUuhj. — Outside  the  body,  in  water,  the 
hacilli  retain,  their  vitality  for  weeks;  but  wliether  an  increase  can  occur 
is  1  X  yet  linally  settled.  Bolton  denies  it,  hut  the  general  opinion  seems 
to  he  thii  it  may  take  place  to  some  extent  at  first.  'J'liey  disajipear  from 
ordinary  water  in  competition  with  sajirojihytes  in  a  few  days.  In  milk 
they  undergo  rapid  development  without  clianging  its  appearance.  They 
may  increase  in  the  soil  and  retain  thoir  vitality  for  months.  Tliey  are  not 
killed  by  freezing,  l)ut,  as  I'rudden  has  shown,  may  live  in  ice  for  months. 
\\\  many  c[>idemics  the  bacilli  have  been  isolated  from  the  infected  water. 
The  detection,  however,  of  the  typhoid  bacillus  in  drinking-water  is  by  no 
means  easy,  and  the  question  in  individual  cases  must  be  settled  by  experts 


TYIMIOIF)   I'KVKIJ. 


ulio  Imvo  lin«1  i^ppcial  rx])pri<>iir('  witli  tliMpTni.  Hntli  TVinMfn  and  TlriiMt-. 
Iiiivi'  foiinil  it  in  wntrr-llitir-i.  'rhnmjL'li  the  use  nf  Misnci-V  riilhirc-tiicdiiiiM 
I,'i'iiilin;.r<  r  ami  Scliiit'ltliT  claiin  In  liavf  dlilaiiu'd  \hv  Inu-illus  in  "Miall 
iiiimiImts  from  tlu'  ntnuls  of  licaltliy  itcrsoii^. 

Tlic  (lirct't  infect  ion  Ity  <ln«<t  nf  cxiwiscd  fnod-MtiilTs,  surli  as  iiiillx.  is 
\crv  prohaltlc.  'I'Ih-  l»a<ilii  retain  their  vitality  for  many  weeks;  in  ;.'ar- 
(li'n  earth  t wi'nty-une  <hiys,  in  liltcr-sand  ei;.dity-t\vi)  days,  in  dust  >\  the 
street  tliirty  thiys,  mi  linen  nixiy  to  seventy  days,  on  wo''  I  ihirty-two  (hiys 

( I'lTelmann)- 

Modes  of  C()nv»^yanre. — (")  Cntifoi/iitu. — The  pnssihility  <»!  ihe  dincl 
tiaiismlssioii  tiiruiiiih  tlie  air  fr(»m  (tiie  person  to  anotlier  must  he  aekmiwl- 
cilLred,  althoii.irli,  as  shown  l>y  (iermano,  when  idih/i/i/i/i/  dried  in  air-eiir- 
reiils,  Ihespeeilie  haeiliiis  (| nick ly  dies.  There  are  house  cpideliues  in  whieii 
((iiitamination  of  water  or  food  eoidd  lie  almost  jiositively  exeluded.  The 
nurses  and  ai'eiidants  who  have  to  do  with  the  stools  and  hody-lineii  of 
the  patients  ■  I'c  alone  liahle  to  direct  infe<tion.  Diirin;,'  six  years  one 
nurse,  oiH'  onleily,  ami  one  patient  contra<'tcd  the  disease  in  my  wards. 
The  contairioii  may  he  sjiread  hy  means  of  (dolhin<r  and  washdinen — a 
tiiodc  of  infection  which  is  especially  to  he  feai-ed  in  military  jrarrisons, 
where  the  same  ('lothin<,'  is  sometimes  used  hy  ditferent  persons. 

(/y)  Jiif'trfio/i  (if  ii'iifvr  is  um|Ueslionahly  the  most  common  mode  of 
conveyance.  Many  epidciiucs  have  heen  shown  to  ori^dnatc  in  the  coii- 
tiimiiuition  of  a  well  or  a  spriii<r.  A  very  strikin.ir  one  occnrrcd  at  I'lym- 
outh,  I'a.,  in  IHSA,  which  was  invcsti^^'ated  hy  Shakespeare.  The  town, 
with  a  ])opulation  of  S,()(»(),  was  in  part  HU))plied  with  driiikinir-water  from 
a  reservoir  fe<l  hy  a  mountain  stream.  I)urintr  .lanuaiy,  l''chruary,  and 
Marc  h,  in  a  cotta^^e  hy  the  side  of  and  at  a  distance  of  from  tiO  to  SO 
feet  from  tliis  stream,  a  man  was  ill  with  typhoid  fever.  'IMk^  attendants 
were  in  t!io  hahit  at  ni<;ht  of  throwing'  out  the  evacuations  on  the  ;,ri-ound 
toward  the  stream.  Durin;^'  these  months  the  ^'round  was  frozen  and  cov- 
(•rc(l  with  snow.  In  the  latter  ])art  of  Mandi  and  early  in  April  there  wa« 
ciiusiderahle  rainfall  and  a  thaw,  in  which  a  larjre  ])art  of  tlu-  three  nuinths' 
iii'cumiilation  of  dis(diar<.'es  was  washed  into  the  Ijrook,  not  00  feet  dis- 
timt.  At  the  very  time  of  this  thaw  the  patient  luid  numerous  and  coi)iou.s 
discharges.  About  the  10th  of  .\i)ril  cases  of  ty])hoid  fcvr  l)roke  out  in 
the  town,  appearing  for  a  time  at  the  rate  of  tifty  a  dry.  In  all  about 
b'.'OO  people  were  attacked.  An  imnu'iise  majority  of  all  the  cases  were  in 
the  part  of  the  town  whiidi  received  water  from  tlu'  infected  reservoir. 

The  recent  experiem^e  at  Maidstone  illustrates  the  widespread  and  st-ri- 
ous  character  of  an  epidemic  wlien  the  water-su])ply  bt'cojncs  badly  con- 
tMuiimited.  The  outbreak  began  about  the  middle  of  Septend>er,  ami 
wiihin  the  first  two  weeks  50!)  cases  were  reported.  By  O(;toi)er  'Z'^tth  therc^ 
wti'c  1,748  cases,  and  by  Xovember  ITth  1,848  cases.  In  all,  in  a  p()[)ula- 
tioii  of  35,000,  about  1,900  persons  were  attacked.  N'o  ei)idemic  of  tlu; 
.^aiue  magnitude  has  ever  occurred  in  England,  and  it  shows  the  terrible 
danger  of  a  badly  constructed  water-supply  easily  contaminated  by  surface 
drainage. 


f 


SPECIFIC  INFECTIOUS  DISEASES. 


(r)  Infcrtion  of  Fond. — ^fil]c  may  be  the  source  of  infection.  One  of 
the  most  tliomu;?lily  studied  epidemics  duo  to  this  cjiuse  was  that  investi- 
gated by  ]{allard  in  Islin^'ton.  The  milk  may  be  contaminated  by  infected 
water  used  in  ck-ansiiif,'  tlie  cans.  In  fresli  milk  it  has  been  shown  that 
the  fjerms  ^'roAV  rapidly.  I'fuhl  has  re])orte(l  an  epidemic  in  a  military 
garrison  caused  by  milk.  The  daii'ynian  was  nursing  a  son  sick  of  tyi)hoid 
and  afterward  became  himself  ill.  Oidy  those  who  drank  the  milk  un- 
boiled suffered.  The  milk  epidemics  have  been  collected  by  Ernest  Hart 
and  by  Kober,  of  Washington. 

In  addition,  the  germs  may  be  conveyed  in  ice,  salads  of  various  sorts, 
celery,  etc.  ;  and  the  food  may  bo  readily  contaminated  by  the  soiled  fin- 
gers of  the  attendants  or  of  the  patient  himself.  A  fly  which  has  alighted 
on  the  soiled  linen  of  a  tyjihoid  patient  in  a  ward  may  subsequently  con- 
taminate the  milk  or  other  food. 

Oijsters  may  become  infected  during  the  process  of  fattening  or  fresh- 
ening. In  the  Middletowu  epidemic,  reported  by  II.  W.  Conn,  the  chain 
of  circumstantial  evidence  seems  complete ;  Lavis  reports  an  epidemic  oc- 
curring in  Naples  caused  by  infected  oysters  ;  and  most  suggestive  sporadic 
eases  have  been  recorded  by  Sir  William  Broadbent  and  others. 

C.  J.  Foote  has  made  an  interesting  bacteriological  study  of  the  subject. 
Oysters  taken  from  the  feeding-grounds  in  rivers  contain  a  very  much 
larger  number  of  micro-organisms  of  all  sorts  than  those  from  the  sea.  He 
has  shown,  too,  that  Eberth's  bacillus  will  live  in  the  brackish  water  in 
which  oysters  arc  fattened  even  when  frozen  ;  and  that  it  will  also  live  in 
the  oyster  itself,  and  for  a  longer  time  than  in  the  water  in  which  the 
oyster  grows.  Whether  multiplication  takes  place  in  the  oyster  is  doubt- 
ful. ChantemessG  also  found  typhoid  germs  in  oysters  which  had  lain  in 
infected  sea-water  even  after  they  had  been  transferred  to  and  kept  in 
fresh  water  for  a  time. 

{il)  Contamination  of  tlie  Soil. — Pettenkofer  holds  that  the  poison  is 
not  eliminated  in  a  condition  capable  of  conmiunicating  the  disease  di- 
rectly, but  that  it  must  first  undergo  changes  in  the  soil,  which  changes 
are  favored  by  the  ground-water. 

Filth,  bad  sewers,  or  cesspools  can  not  in  themselves  cause  typhoid 
fever,  but  they  furnish  the  conditions  suitable  for  the  preservation  of  the 
bacillus,  and  possibly  for  its  propagation. 

The  history  o^  typuoid  fever  in  Munich,  as  told  anew  by  Childs  (Lan- 
cet, 1898,  ii),  indicates  that  the  soil  pollution  has  much  to  do  with  the  oc- 
currence of  si)oradic  cases  and  of  recurrent  outbreaks.  Kobertson's  stud- 
ies shoAV  that  the  typhoid  bacillus  is  capable  of  growing  rapidly  in  certain 
soils,  and  that  it  can  under  certain  conditions  survive  from  one  summer 
to  anotaer. 

Modes  of  Infection. — The  work  of  the  past  feAV  years  has  widened  con- 
siderably our  conception  of  the  intimate  processes  of  infection  in  tyjihoid 
fever.  Sidney  Phillips,  J.  W.  Moore,  and  otbers  had  reported  cases  of 
typhoid  fever  without  enteric  lesions.  The  wide  existence  of  the  typhoid 
bacilli  has  been  repeatedly  shown  in  cases  which  had  the  clinical  features 


TYPHOID   FKVER. 


of  the  disease,  but  without  h'sions  in  the  small  intestine.  The  question 
has  beeji  very  fully  considered  by  Cliiari  and  Kraiis,*  llodcnpybf  Xicdiolls 
and  Keenan,  ;j:  and  by  Flexner  (Studies  111).  'J'ypboid  fever  is  no  more 
primarily  intestinal  tlian  is  snuilli)ox  i)rinnirily  a  cutaneous  disease.  Wo 
may  recognize  tbe  following  groups:  1.  (h-diiuir//  hijilioid  fvvvi'  ^"ifh 
marked  enteric  h'siims.  An  immt'nse  majority  of  all  the  cases  are  of  tins 
character.  The  infection  has  taken  place  through  the  intestines,  and 
while  the  spleen  and  mesenteric  glands  are  involved  the  lymphatic  appa- 
ratus of  the  intestinal  walls  bears  the  brunt  of  the  attack.  2.  TiipJtoid 
scptiaemia.,  a  gener(d  infection  with  the  bacilli  withoat  sj)eci<d  local  inani- 
f'esfationK.  Anatomically,  as  Chiari  points  out,  thcoo  cases  may  not  be 
ri'cognizable,  and  the  diagnosis  may  rest  upon  the  existence  of  the  Widal 
reaction  and  the  demonstration  of  the  bacilli.  They  present  the  symptoms 
of  a  severe  intoxication  with  high  fever  and  delirium.  ;}.  7)/])hoid  fever 
with  localizations  other  than  enteric.  In  the  ordinary  form  it  is  common 
I'uough  to  find  in  conjunction  with  the  enteric  lesions  special  localizations 
in  different  parts  of  the  body ;  but  we  have  of  late  learned  to  recognize 
that  these  particular  localizations  may  exist  either  with  very  slight  or  with- 
out any  intestinal  lesions.  The  organs  attacked  may  be  the  lungs,  the 
spleen,  the  kidneys,  or  the  cerebro-spinal  meninges.  Clinically  we  have 
long  recognized  this  variable  character  of  the  infection,  and  have  spoken 
of  cases  of  pneumo-typhoid,  nephro-typhoid,  cerebro-spinal  typhoid,  and 
spleno-typhoid.  The  case  recently  reported  by  Flexner  illustrates  very 
well  the  importance  of  recognizing  these  forms.  A  man  aged  sixty  was 
admitted  to  my  ward,  October  28,  with  shortness  of  breath  and  signs  of 
pneumonia  in  the  lower  lobe  of  the  right  lung.  lie  died  twentv-four 
hours  after  admission,  after  an  illness  of  about  two  months'  duration.  The 
case  was  naturally  regarded  as  one  of  senile  pneumonia.  The  autopsy 
sliowed  an  extensive  involvement  of  the  lower  lobe  in  fresh  pneumonia, 
passing  on  to  gangrene  without  any  lesion  of  the  intestine.  Pure  cultures 
of  the  typhoid  bacillus  were  isolated  from  the  lungs,  liver,  kidneys,  and 
spleen.  Xo  other  organisms  were  present.  4.  Mixed  infection^!.  It  is 
well  to  distinguish,  as  Dreschfeld  points  out,  between  double  infections,  as 
with  the  bacillus  tuberculosis,  the  diphtheria  bacillus,  and  the  plasmodia 
of  Laveran,  in  which  two  diiferent  diseases  are  present  and  can  be  readily 
distinguished,  and  the  true  mixed  or  secondary  infections,  in  which  the 
conditions  induced  by  one  organism  favor  the  growth  of  other  pathogenic 
forms ;  thus  in  the  ordinary  typhoid  fever  cases  secondary  infection  with 
the  colon  bacillus,  the  streptococcus,  staphylococcus,  or  the  pneumococcus, 
is  f(uitc  common.  The  part  played  by  the  paracolon  ])acillus  of  Widal  in 
tyithoid  infection  is  yet  to  be  defined.  Ciwyn  *  isolated  from  the  blood  of  a 
typical  case  of  typhoid  fever,  occurring  in  my  wards,  this  organism,  which 
agglutinated  with  the  patient's  serum,  while  no  action  was  exerted  upon 
the  typhoid  bacillus. 


f 


*  Zoitschrift  f.  Iluilktiiulo.  1897. 
}  lirit.  Mod.  Jour.,  1897,  ii. 


X  ^rontroiil  :\rc(l.  .Tour.,  18i»S. 

*  Johns  Hopkins  Hospital  Bulletin,  1898. 


8 


SPECIFIC  IXFECTIOUS  DISEASES. 


rrodiirfs  of  fhr  (Irawlh  of  the  litiriUi. —  Hrio^'cr  iiTul  Friionkel  huve 
sopiiviitcMl  from  Ixxiilloii  ciilturcH  ii  jjoisoii  hdonj^iiifi^  to  tlic  ^roup  of  tox- 
albiiniius,  to  wliiili  llic  iiuiiie  tvpliotoxiii  has  been  a])i»li('(l.  Tlie  cliicf 
poison,  iicr'or(lin<,'  to  IMVilfcr,  ]»r()(liic(Ml  )iy  the  typhoid  j^mtim,  is  ititiiiuitcly 
hoiuid  up  witli  the  ])roti'i(l  of  tlio  Ijac'tcrial  cell,  and  j^ot's  over  in  siiiali 
fjuautitii's  into  tlio  fluids  in  wliich  the  bacilli  are  cultivatt'd.  Sti-rilizcd 
cultures,  therefore,  are  still  toxic.  Cultures  sterilized  by  heat  or  by  filtra- 
tion ^'ive  rise,  when  injected  into  susceptible  animals,  to  an  intoxication 
similar  to  that  caused  ])y  the  livin^,'  ^'ci'ius.  C'liantres  in  the  lym])hatic 
ai)paratus  of  the  intestine  are  produced  by  this  i)oison  as  well  as  by  that 
yielded  l)y  the  bacillus  coli  communis. 

Morbid  Anatomy. — The  statistical  details  under  this  hcadin«r  are 
based  ui)on  eii^bty  autopsies,  a  majority  of  which  were  i)erforme(l  at  the 
^Montreal  (ieneral  Jlospilal,  and  u])<)n  the  records  of  two  thousand  post- 
mortems at  the  Munich  J'atholoj^ical  Institute.* 

Intestines.— A  catarrhal  condition  exists  throu,i>-hout  the  small  and 
large  bowel,  and  to  this  is  due,  in  all  i)ro])ability,  the  diarrhiea  with  the 
thin  pea-soup-like  stools.  Associated  with  this  catarrh  there  is  some  epi- 
thelial des(|uamation. 

tSpeeilic  chauLTes  occur  in  the  lymphoid  elements  of  the  bowel,  chielly 
at  the  lower  end  of  the  ileum.  The  alterations  which  occur  are  most  con- 
veniently described  in  four  stages  : 

.  1.  JIi//i(')-p?asii/,  which  involves  the  glands  of  Peyer  in  the  jejunum  and 
ileum,  and  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swollen,  grayisli-white  in  coloi',  and  the  patches  may  i)roject  to  a  dis- 
tance of  from  three  to  five  mm.  In  exceptional  cases  they  may  be  still 
more  prominent.  The  solitary  glands,  which  range  in  size  from  a  pin's 
head  to  a  hirge  pea,  are  usually  deei)ly  imbedded  in  the  submucosa,  but 
project  to  a  variable  extent.  Occasionally  they  are  very  prominent,  and 
may  be  almost  pedunculated.  Microscopical  examination  shows  at  the 
outset  a  condition  of  hypera^mia  of  the  follicles.  Later  there  is  a  great 
increase  and  accumulation  of  cells  of  the  lymph-tissue  which  may  even 
infiltrate  the  adjacent  mucosa  and  the  muscularis  ;  and  the  blood-vessels 
are  more  or  less  compressed,  which  gives  the  whitish,  antemic  appearance 
to  the  follicles.  The  cells  have  all  the  characters  of  ordinary  lymph-cor- 
puscles. Home  of  them,  however,  are  larger,  epithelioid,  and  contain  several 
nuclei.  Occasionally  cells  containing  red  blood-corpuseles  are  seen.  This 
so-called  medullary  infiltration,  which  is  ahvays  moi'e  intense  toward  the 
lower  end  of  the  ileum,  reaches  its  height  from  the  eighth  to  the  tenth 
day  and  then  undergoes  one  of  two  changes,  resolution  or  necrosis.  Death 
very  rarely  takes  place  at  this  stage.  Resolution  is  accomplished  by  a  fatty 
and  granular  change  in  the  cells,  which  are  destroyed  and  absorbed.  A 
curious  condition  of  the  patches  is  prodiiced  at  this  stage,  in  which  they 
have  a  reticulated  aj)pearance,  the  pliKjuex  a  futrfare  reticnUc.  The  swoll- 
en follicles  in  the  patch  undergo  resolution  and  shrink  more  rapidly  than 


*  Muneheiicr  medieinische  Woehcnschrift,  Nos.  3  and  4,  1891. 


TYPHOID  FEVER. 


9 


the  suiToiiiidiiifr  fi'amowork,  or  wliiit  is  more  jiroljiiMc  tlic  folliclos  nloiic, 
(iwiiij;  to  tlu!  iiitt'iiso  liyp('r))lasia,  bi-eomc  iicorotic  iiiid  (lisiiitci^Tatc,  leaving,' 
the  littlo  pits.  Ju  this  }>n)C(.'ss  suix'ilicial  ha'iiiori'haj^t's  may  ri'siill,  and 
small  ulcers  may  originate  by  the  fusion  of  these  .su})erlicial  losses  of  >uli- 
stanee. 

'riiere  is  uothiji.ir  distinctive  in  the  hyperjtlasia  of  the  lympli-follicles 
in  typlioid  fever;  but  a])art  from  this  disease  v,e  rarely  see  in  adults  ii 
marked  altection  of  these  glands  with  fever.  In  children,  however,  it  is 
not  uncommon  when  death  has  occurred  from  intestinal  affections,  and  it 
is  also  met  with  in  measles,  diphtheria,  and  scarlet  fever. 

2.  yrrrof<i,s  and  SldHjiliitKj. — When  the  hyjji'rplasia  of  the  lyrn])h-fol- 
licles  reaches  a  certain  grade,  resolution  is  no  longer  possible.  The  Idood- 
vessels  become  choked,  there  is  a  condition  of  aiwemic  necrosis,  and 
sloughs  form  which  must  be  separated  and  tiirown  (.tlf.  ^J'he  necrosis  is 
])rol)ably  due  in  great  part  to  the  direct  action  of  the  bacilli.  'V\w  ])rocess 
may  be  superficial,  affecting  only  the  u])])er  ])art  of  the  mucous  coat,  or  it 
may  extend  to  ami  involve  the  submuCosa.  The  '"  slough  "  may  sonu'times 
lie  u})on  the  IV"  . '^  patch,  scarcely  involving  the  epithelium  {Mar(diand). 
It  is  ahvays  m  intense  toward  the  ileo-ca'cal  valve,  ami  in  very  severe 
cases  the  greater  part  of  the  mucosa  of  the  last  foot  of  the  ileum  may  be 
converted  into  a  ])rownish-black  eschar.  'J'he  necrotic  area  in  the  solitary 
glands  forms  a  yellowish  cap  which  often  involves  only  the  most  promi- 
nent point  of  a  follicle.  The  extent  of  the  necrosis  is  very  variable.  It 
may  pass  deep  into  the  muscular  coat,  reaching  to  or  even  perforating  the 
})eritona,nim. 

o.  U/rcrti/ioii. — The  separation  of  the  necrotic  tissue — the  slougliing — 
is  gradually  effected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  the 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the 
mucosa  may  not  be  involved  and  the  loss  of  substance  may  be  small  and 
shallow.  More  commonly  the  slough  in  separating  exposes  the  submucosa 
and  muscularis,  particularly  the  latter,  wdiich  forms  the  floor  of  a  majority 
of  all  typhoid  ulcers.  It  is  not  common  for  an  entire  Peyer's  patch  to 
slough  away,  and  a  perfectly  ovoid  ulcer  opposite  to  the  mesentery  is 
rarely  seen.  Irregularly  oval  and  rounded  forms  are  most  common.  A 
large  patch  may  present  three  or  four  ulcers  divided  by  septa  of  mucous 
membrane.  The  terminal  6  or  8  inches  of  the  mucous  membrane  of  the 
ileum  may  form  a  large  ulcer,  in  which  are  here  and  there  islands  of 
mucosa.  The  edges  of  the  ulcer  are  usually  swollen,  soft,  sometimes  con- 
gested, and  often  undermined.  At  a  late  period  the  ulcers  near  the  valve 
may  have  very  irregular  sinuous  borders.  The  base  of  a  typhoid  ulcer 
is  smooth  and  clean,  being  usually  formed  of  the  submucosa  or  of  the 
muscularis. 

There  may  be  large  ulcers  near  the  valve  and  swollen  hyi)erannic 
})atclies  of  Peyer  in  the  upper  part  of  the  ileum. 

4r.  IleaUnfj. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base  and  gives  to  it  a  soft,  shining  appearance. 


f 


10 


SPECIFIC  INFECTIOUS  DISEASES. 


Tlio  iiinoosii  fri'iKlniilly  cxtciids  from  tlie  edge,  find  a  new  growth  of  ipi- 
thelinm  i.s  formed.  Tlie  gliindidiir  elements  arc  reformed;  the  healed 
nicer  is  somewliut  depressed  and  is  nsnally  jjigmented.  Occasionally  an 
appearance  is  seen  as  if  an  ulcer  had  healed  in  one  })lace  and  was  extend- 
ing in  another.  In  death  during  relapse  healing  ulcers  may  he  seen  in 
some  patches  with  fresh  ulcers  in  others. 

^\e  may  say,  indeed,  that  healing  begins  with  the  separation  of  the 
sloughs,  as,  when  resolution  is  impossible,  the  removal  of  the  necrosed 
part  is  the  first  step  in  the  process  of  repair.  Practically,  in  fatal  cases, 
we  seldom  meet  Avith  evidences  of  cicatrization,  as  the  majority  of  deaths 
occur  before  this  stage  is  reached. 

Large  Intestine. — The  caecum  and  colon  are  affected  in  about  one  third 
of  the  cases.  Sometimes  the  solitary  glands  are  greatly  enlarged.  The 
xilcers  are  usually  larger  in  the  caecum  than  in  the  colon. 

Perforation  of  the  Bowel. — Incidence  at  Antopsn. — In  114  cases  of  the 
2,000  Munich  autopsies  (5.7  per  cent)  and  in  22  instances  in  my  series,  the 
intestine  was  perforated  and  death-  caused  by  peritonitis.  According  to 
Chomel,  "  the  accident  is  sometimes  the  result  of  ulceration,  sometimes  of 
a  true  eschar,  and  sometimes  it  is  produced  by  the  distention  of  the  intes- 
tine causing  the  ru])ture  of  tissues  weakened  by  disease."  In  only  a  few 
cases  is  the  perf^i'ation  at  the  bottom  of  a  clean  thin-walled  ulcer.  In 
one  instance  it  had  occurred  two  Aveeks  after  the  temperature  had  becc^ie 
normal.  The  sloughs  are,  as  a  rule,  adherent  about  the  site  of  perforation, 
Avhich  in  a  majority  of  the  cases  occur  in  small  deep  ulcers.  There  may  be 
two  or  three  perforations ;  in  a  few  instances  they  have  been  very  numer- 
ous. The  orifice  is  usually  within  the  last  foot  of  the  ileum.  In  only  one 
of  my  cases  was  it  distant  18  inches.  In  4  cases  of  my  series  the  appendix 
was  perforated  and  in  2  the  large  bowel.  Peritonitis  was  present  in  every 
instance.  In  1()7  cases  collected  by  Fitz  the  ileum  was  perforated  in  130, 
the  large  intestine  in  20,  the  appendix  in  5,  Meckel's  diverticulum  in  4, 
and  the  jejunum  in  2.  In  the  large  intestine,  according  to  Hawkins,  the 
sigmoid  tlexure  is  the  most  frequent  seat  of  perforation. 

Death  from,  hannorrliafje  occurred  in  99  of  the  Munich  cases,  and  in  11 
of  5(i  deaths  in  my  085  cases.  The  bleeding  seems  to  result  directly 
from  the  separation  of  the  sloughs.  I  was  not  able  in  any  instance  to  find 
the  bleeding  vessel.  In  one  case  only  a  single  patch  had  sloughed,  and  a 
firm  clot  Avas  adherent  to  it.  The  bleeding  may  also  come  from  the  soft 
SAVollen  edges  of  the  patch. 

The  inesentcric  ffhtnds  at  first  shoAV  intense  hyperjemia  and  subsequently 
become  greatly  SAVollen.  Spots  of  necrosis  are  common.  In  several  of  my 
cases  suppuration  had  occurred,  and  in  one  a  large  abscess  of  the  mesentery 
Avas  present.  Fatal  haemorrhage  into  the  peritonaeum  may  come  from  rup- 
ture of  a  SAVollen  gland.  The  bunch  of  glands  in  the  mesentery,  at  the 
loAver  end  of  the  ileum,  is  especially  involved.     The  retroperitoneal  glands 


are  also  swollen. 


The  spleen  is  invariably  enlarged  in  the  early  stages  of  the  disease.     In 
only  one  of  my  cases  did  it  exceed  20  ounces  (GOO  grammes)  in  Aveight. 


TYPHOID   FEVER. 


11 


Tho  tissue  is  soft,  even  difflnont.  Infarction  is  not  infrcfiucnt.  Iiupture 
may  occur  spontaneously  or  as  a  result  of  injury,  Jn  thi'  Munich  autopsies 
tiiero  were  5  instances  of  rui)ture  of  the  spleen,  one  of  which  resulted 
from  a  gangrenous  abscess. 

The  liver  shows  signs  of  parcjichymatous  degeneration.  Early  in  the 
disease  it  is  hypera'inic,  and  in  a  nnijority  of  instances  it  ifi  swollen,  some- 
what pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granu- 
lar and  loaded  with  fat.  Xodular  areas  (microsco])ic)  occur  in  many  eases, 
as  described  by  Ilandford.  Reed,  in  Welch's  laboratory,  could  not  deter- 
mine any  relation  between  the  groups  of  bacilli  and  these  areas  (Studies 
II).  Some  of  the  nodules  arc  lymphoid,  others  are  necrotic  (Amyot).  h\ 
I'l  of  the  Munich  autopsies  liver  abscess  was  found,  and  in  ;J,  acute  yellow 
atrophy.  I'ylephleliitis  may  follow  abscess  of  the  mesentery  or  i)erforation 
of  the  appendix.  Affections  of  the  gall-bladder  are  not  uncommon,  ami 
are  fully  described  under  the  clinical  features. 

Kidneys. — Cloudy  swelling,  with  granular  degeneration  of  the  cells  of 
the  convoluted  tubules,  less  commonly  an  acute  nephritis,  may  be  present, 
Kayer,  Wagner,  and  others  described  the  occurrence  of  numerous  snniU  areas 
infiltrated  with  round  cells,  which  may  have  the  appearance  of  lymphomata, 
or  may  pass  on  to  softening  and  suppuration,  producing  the  so-called  miliar i/ 
absresms.  It  is  usually  a  late  change.  The  typhoid  bacilli  alone  have  l)een 
found  by  some  observers  in  these  areas.  They  may  also  be  fouiul  in  the 
urine.  In  10  cases  of  pyuria  in  typhoid  f'  ver  in  my  wards,  Blumer  found 
the  bacilli  in  2.  Diphtheritic  inflammation  of  the  pelvis  of  the  kidney 
nuiy  occur.  It  was  present  in  3  of  my  cases,  in  one  of  which  the  tips  of 
the  papillte  Avcre  also  affected.  Catarrh  of  the  bladder  is  not  uncommon. 
IMphtheritic  inflammation  of  this  viscus  may  also  occur.  Orchitis  is  occa- 
sionally met  with. 

Respiratory  Organs. — Ulceration  of  the  larynx  occurs  in  a  certain  num- 
ber of  cases ;  in  the  Munich  series  it  was  noted  107  times.  It  may  come 
on  at  the  same  time  as  the  ulceration  in  the  ileum,  but  the  bacilli  have 
not  yet,  I  believe,  been  found  in  the  ulcers.  They  occur  in  the  posterior 
Avail,  at  the  insertion  of  the  cords,  at  the  base  of  the  epiglottis,  and  on  the 
ary-cpiglottidean  folds.  The  cartilages  are  very  apt  to  become  involved. 
In  the  later  periods  catarrhal  and  diphtheritic  ulcers  may  be  present. 

CEdema  of  the  glottis  was  present  in  'ZQ  of  the  ^Munich  cases,  in  S  of 
which  tracheotomy  was  performed.  Diphtheritis  of  the  pharynx  and  larynx 
is  not  very  uncommon.  It  occurred  in  a  most  extensive  form  in  2  of  my 
cases.  Lobar  pneumonia  may  be  found  early  in  the  disease  (see  Pxeumo- 
TVPiius),  or  it  may  be  a  late  event.  Hypostatic  congestion  and  the  con- 
dition of  the  lung  spoken  of  as  splenization  are  very  common,  (iangrene 
of  the  lung  occurred  in  40  cases  in  the  Munich  series ;  abscess  of  the  lung 
in  14;  hnsmorrhagic  infarction  in  121).  Pleurisy  is  not  a  very  common 
event.  Fibrinous  pleurisy  occurred  in  about  0  per  cent  of  the  Muni(  h 
cases,  and  empyema  in  nearly  2  per  cent. 

Changes  in  the  Circulatory  System. — Heart  Lesions. — Endoeardifis  is 
rare.     I  have  met  with  2  cases.     The  typhoid  bacilli  have  been  found  in 


f 


12 


SI'K('II''I('   IXFKCTIOI'S    DISK  ASKS. 


the  V(';,'t'lati(Hi.-i,  /'i/iiun/i/is  \v:\-{  jircsciit  in  II  cases  of  tlic  Miiiiicli  iiii- 
topsics.  .Mjidiiirilifis  is  nut  very  iiilV('(|iu'iit.  Dcwivrc,  in  ii  sci-ics  of  4n 
cMst's,  roiiiKl  ill  ir.  liTiniiilar  ov  Tatty  (icirciu'ratioii,  and  in  .'{  a  proli feral iii;^' 
eiKJartei'il  is  In  the  small  vessels.  It  is  reinai'kal»le  that  even  in  eases  of 
death  fi'oin  heai't-failnre,  with  intense  fever,  the  eell-lil)res  may  present 
little  or  lu)  oI»serval)le  elian;;;e. 

Lfsidiis  of  IIk'  lilitoil-i'vssi'ls — Tjiphoid  (laiKjrciic. —  Inllammation  of  the 
arterii's  with  thn)iid)us  formation  has  heen  fre(|iu'iitly  deserihed  in  tyjthoid 
fever.  '  'illi  have  heen  found  in  tlu'  thrombi.  The  artery  may  he 
l)loeked  hromhiis  of  eanliae  origin — an  endxthis— hut  in  the  fi'reat 

majorit\  .  stances  they  are  autoi-Jithonous  and  due  to  arterit  is,  ohlit- 
(Tatini;  or  partial.  'rhrond)osis  in  the  veins  is  very  luueii  mort'  fre(|uent 
tlian  in  the  arteries,  l)ut  is  not  su(di  a  serious  event.  It  is  most  fretjueut 
in  the  fi'inoral,  and  in  the  left  more  often  than  the  iMi,'ht.  'J'lie  eonso- 
(juenees  ai'e  fully  considered  under  the  si/ii/p/onis. 

Nervous  System. — There  are  very  few  coarse  (dian,i;i's  met  with.  .Men- 
in<;itis  is  extremely  rai'e.  I  liavt'  nevi-rseeii  a  case  at  auto])sy.  It  occurred 
in  only  II  of  the  ::i,00()  Munich  eases,  'i'he  exudation  may  hi'  either  serous, 
sero-tihrinous,  or  ])urulent,  and  typhoid  l)acilli  have  been  fre(|Uently  iso- 
lati'd.  Two  iid(>restinir  cases  have  recently  been  reported  by  Ohlmaelier 
from  the  Cleveland  t'ity  Ilos[)ital.  In  both  bacilli  were  i'ound  in  the 
menin,<,'es.  In  some  of  the  oases,  as  Kumeu's,  the  enteric  lesions  have 
been  slij^ht.  Optic  neuritis,  which  occurs  sometimes  in  typhoid  fevi'r,  has 
not,  so  far  as  I  kr.ow,  been  described  in  I'onneetion  with  the  meningitis. 
The  anatomical  lesion  of  (he  ai)hasia — seen  not  infre(piently  in  children — 
is  not  known,  possibly  it  is  an  encephalitis.  Parenchymatous  (dian<,n's 
liave  been  met  with  in  the  peripheral  nerves,  and  ai)i)ear  to  be  not  very 
uncommon,  even  when  there  have  been  no  symj)toms  of  nenritis. 

The  vtiluntat'n  muscles  show,  in  certain  instances,  the  chan<fes  described 
by  Zi'uker,  whicli  occur,  however,  in  all  long  standing  febrile  affections, 
and  are  not  peculiar  to  tyi)hoid  fever.  The  muscle  substance  within  the 
sarcolemina  undergoes  either  a  granular  degeneration  or  a  hyaline  trans- 
formation. The  abdominal  muscles,  the  adductors  of  the  thighs,  and  the 
pectorals  are  most  commonly  involved.  Kupture  of  a  rectus  abdominis 
has  been  found  post  mortem.  Ila'morrhage  may  occur.  Abscesses  may 
develop  in  the  muscles  iluring  convalescence. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well 
first  to  give  a  general  description,  and  then  to  study  more  fully  the  symji- 
toms,  complications,  and  se»iuel!\3  according  to  the  individual  organs. 

General  Description. — The  period  of  incubation  lasts  from  "  eight  to 
fourteen  days,  sometimes  twenty-three  "  (Clinical  Society),  during  which 
there  are  feelings  of  lassitude  and  inaptitude  for  work.  The  onset  is  rarely 
abrupt.  There  may  be  prodromal  symptoms,  either  a  rigor,  which  is  rare, 
or  chilly  feelings,  headache,  nausea,  loss  of  appetite,  pains  in  the  back  and 
legs,  and  nose-bleeding.  These  symptoms  increase  in  severity,  and  the 
patient  at  last  takes  to  his  bed.  From  this  event,  in  a  majority  of  cases, 
the  definite  onset  of  the  disease  may  be  dated.     During  iXiQjirst  week  there 


TVI'lioll)    FKVKll. 


gilt  to 
which 
5  rarely 
is  rare, 
ck  and 
id  the 
cases, 
there 


is,  in  some  cusi'H  (hut  hy  no  iiieaiirf  in  all,  as  has  long  In'vw  taught),  a 
steady  rise  in  the  I'evi'r,  tiu'  evi-niug  record  rising  a  (h'gree  or  a  degree  and 
a  iudf  iiiglu'r  eai'h  day,  reachiug  lo;)'^  or  loi ".  'JMie  pulse  is  rapid,  from 
lot)  to  IK),  full  in  voluiiu',  hut  cd"  low  tension  and  often  dicrotic;  the 
tongue^  is  coaled  and  white;  the  ahdonieii  is  slightly  distended  and  tender. 
Unless  the  fever  is  high  there  is  no  delirium,  hut  the  patient  complains  of 
headacdu',  and  then;  imiy  hi'  mental  confusion  and  wandering  at  night. 
The  howels  nuiy  he  constipated,  or  there  nuiy  l>e  two  or  three  loose  move- 
nu-nts  daily.  'I'oward  the  end  of  the  week  the  spleen  heconu's  enlarged 
and  the  rash  ai)i>ear.s  in  the  form  of  rose-colored  spots,  Hcen  lirst  on  tho 
skin  of  the  ahdomen.  Cough  and  hronchitlc  symptoms  are  not  uiu'ommou 
at  the  outset. 

In  the  srriiiiil  iccrk,  in  cases  of  moderate  severity,  the  symptoms  he- 
conui  aggravati'd  ;  the  fever  remains  high  and  *ht^  morning  renussion  is 
slight.  'J'he  pulse  is  rai)id  and  loses  its  dicro'  .•.  character.  'J'here  is  no 
longer  headacdu',  hut  there  are  mental  tor})or  auvl  dullness.  'J'he  face  looks 
heavy;  tlu^  lips  are  dry;  the  tongue,  in  severe  cases,  heciomes  dry  also. 
The  ahdominal  symptoms,  if  present — diarrho'a,  tyjupaintes,  and  tender- 
ness— hecome  aggravated.  Death  imiy  occur  during  tins  week,  with  ])ro- 
nounced  nervous  symptoms,  or,  toward  the  end  of  it,  from  lufmorrhagc!  or 
perforation.  In  uuld  cases  the  tem])erature  declines,  and  hy  the  four- 
teenth day  may  he  normal. 

Ill  the  third  irrr/t\  in  cases  of  moderate  severity,  the  puls(!  ranges  from 
110  to  i;}0;  the  temperature  now  shows  marked  morning  renussions,  and 
there  is  a  gradual  decline  in  the  fever.  The  loss  of  tlesh  is  now  more 
notieeahle,  and  the  weakness  is  pronounced.  ])iarrh(i'a  and  meteorism 
may  now  occur  for  the  first  time,  rnfavorahle  sym])toins  at  this  stage  are 
tlu'  pulmonary  complications,  increasing  feehleiiess  of  the  heart,  and  ])ro- 
nouiu'cd  delirium  with  mus(;ular  tremor.  Special  dangers  are  perforati(Ui 
and  luomorrhage. 

AVitli  the  fourth  irrcl',  in  a  majority  of  instances,  convalescence  hegins. 
The  temperature  gradually- reaches  the  normal  ])oint,  the  diarrluea  sto[)s, 
the  tongue  cleans,  and  the  desive  for  food  returns.  In  severe  cases  the 
fourth  and  even  the  fifth  week  may  present  an  aggravated  picture  of  the 
third;  the  patient  grows  weaker,  the  pulse  is  more  rapiil  and  feehle,  the 
tongue  dry,  and  the  ahdomen  distended.  He  lies  in  a  condition  of  i)ro- 
found  stupor,  with  low  muttering  delirium  and  suhsuKus  tendinum,  ami 
passes  the  faeces  and  urine  involuntarily,  ileart-failure  and  secondary 
complications  are  the  chief  dangers  of  this  period. 

In  the  fifth  (iiid  sixth  wcc/i-s  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In  this 
period  we  meet  with  relapses  in  the  milder  forms  or  slight  recrudescence 
of  the  fever.    At  this  time,  too,  occur  many  of  the  complications  and  sequelce. 

Special  Features  and  Symptoms — Mode  of  Onset. — As  a  ride,  the 
symptoms  develop  insidiously,  and  the  patient  is  unahle  to  fix  definitely 
the  time  at  which  he  began  to  feel  ill.  The  following  are  the  most  impor- 
tant deviations  from  this  common  course  : 


1  !'; 
I" 


14 


SI'KCIKIC   IN'KKCTlors   DISKASKS. 


H 


(ii)  (hisi'f  irllJi  Pi'dnoHHCod^Hnmrtimrx  Siahlfit^  Xrrvoxs  M(t)ilfvsltili<nix. 
— HcikIikOio,  of  a  Hovcro  and  intnictiibli)  luituro,  is  by  no  inciins  an  infr(»- 
(|Uont  initial  8yni|»t()ni.  A<;ain,  a  Hi'voro  facial  ncnrul^na  nniy  for  a  few 
(lays  i)ut  the  practitioner  oil"  his  jjuanl.  in  cases  in  which  the  jiatients 
have  ke[)t  aI)oiit  antl,  as  they  say,  fonj,'lit  the  disease,  tlu*  very  lirst  mani- 
festation may  l>e  ])ronounced  delirinni.  Snch  patients  may  oven  leavi' 
home  and  wander  about  for  days.  In  rare  cases  the  disease  sets  in  with 
the  most  intense  cere!)ro-spinal  Hym])toms,  simulatinj;  menin<j:i(is — sovero 
headache,  photo|)hobia,  retraction  of  the  head,  twitchinji;  of  tlie  muscles, 
and  even  convidsions.  Occasionally  drowsiness,  stupor,  and  si^^ns  of  basi- 
lar menin<,Mtis  may  exist  for  ten  days  or  nu)re  before  the  characteristic 
symptoms  develop;  occasioiudly  the  onset  is  with  mania. 

(//)  11'////  Proiioinirci/  /'iihnoiKiri/  Siimpfonis. — Tlie  initial  bronchial 
catarrh  may  be  of  <rreat  severity  anil  o])scure  the  other  features  of  tlu; 
disease.  More  strikin;^  still  are  those  cases  in  which  the  disease  sets  in 
with  a  sin,!j;le  chill,  with  pain  in  the  side  aiul  all  the  characteristic  features 
of  lobar  pneumonia,  or  of  acute  j)leurisy. 

(r)  117///  Iiifcnse  (histr(hi}itrsli)i(tJ  Si/ni/)fn/ns. — The  vomitinf?  may  bo 
incessant  and  uncontrollable.  Occasionally  there  are  cases  with  such  in- 
tense vomitinj^  and  diarrluea  that  a  susi)icion  of  iK.isonint,''  may  l)o  aroused. 

{i/)  U't'f/i  Ki/iii/i/oiiis  (if  (in  ariife  iicji/in'/is,  smoky  or  bloody  urine,  with 
much  albumin  and  tube-casts. 

(/')  Ainhiildtunj  Fiinti. — Deserving  of  especial  mention  are  those  rases 
of  typhoid  fever  in  which  tlie  ])atiei\t  keeps  about  and  attem])ts  to  do 
work,  or  perhaps  takes  a  lon^  journey  to  his  home,  lie  may  come  under 
observation  for  the  first  time  with  a  temperatnro  of  104°  or  105",  and  with 
the  rash  well  out.  ^lany  of  these  eases  run  a  sovero  course,  and  in  general 
hospitals  they  contribute  largely  to  the  total  mortality.  Finally,  there 
are  rare  instances  in  wdiich  typhoid  is  unsuspected  until  perforation,  or  a 
profuse  luemorrliage  from  the  bowels  occurs. 

Facial  Aspect. — Early  in  the  disease  the  cheeks  are  Hushed  and  th" 
eyes  bright.  Toward  the  end  of  the  first  week  the  expression  becomes 
more  listless,  and  when  the  disease  is  well  established  the  patient  has  a 
dull  and  heavy  look.  There  is  never  the  rapid  anaMuia  of  malarial  fever,  aiul 
the  color  of  the  lips  and  cheeks  may  be  retained  even  to  the  third  Aveek. 

Fever. — {a)  Jxcgular  Course.  (Chart  I.) — In  the  stage  of  invasion  the 
fever  rises  steadily  during  the  first  five  or  six  days.  The  evening 
temperature  is  about  a  degree  or  a  degree  and  a  half  higher  than  the 
morning  remission,  so  that  a  temperature  of  104:°  or  lOo""  is  not  uncom- 
mon by  the  end  of  the  first  week.  Having  reached  the  fastigium  ov 
height,  the  fever  then  persists  with  very  slight  daily  remissions.  The 
fever  may  be  singularly  persistent  and  but  littl*)  infiuenced  by  bathing 
or  other  measures.  At  the  end  of  ,the  second  and  throughout  the  third 
week  the  temperature  becomes  more  distinctly  remittent.  The  dilference 
between  the  morning  and  evening  record  may  be  .'5"  or  4°,  and  the  morning 
temperature  may  even  be  normal.  It  falls  by  lysis,  and  the  temperature 
is  not  considered  normal  until  the  evening  record  is  at  08.2°. 


TYl'llOll)  FEVKU. 


15 


^33322 


111(1  ti^'^ 

|)CC011103 
lit  llilS  il 

(M-,  ami 

•tvk. 

lion  the 

'voning 

liaii  the 

UUCOlll- 

liuiu  or 
The 

»athin;i: 

je  third 

Korence 

prning 

H-ature 


a. 


C       Is 


o 


Eh 


H 

ft 

a 
O 


16 


SPKCIKIC   INKKCTIors  DISHASES. 


(/')  A'liriiitionH  from  tlu'  typical  tciiipcraturc  curve  arc  coiimioii.  Wo 
do  not  iihviiys  soo  thi>  gradual  stcpliko  ascent  in  the  (Mirly  Hta^'o ;  the  cases 
(h)  not  often  conic  under  ohscrvation  at  this  time.  When  the  disease  sets 
in  with  a  chill,  or  in  children  with  u  convulsion,  the  temperature  may  rise 
at  oiu'c  to  \i)'-\'  or  lot".  In  nniny  cases  del'ervcscence  occurs  at  the  end  of 
the  second  week  and  the  Icmperature  may  fall  rapidly,  reaching'  the  nor- 
mal within  twelve  or  twenty  hours.  An  inverse  ty[)e  of  temperature,  hi<:h 
in  the  mornin;,'  and  low  in  the  evening',  is  occasioiuilly  seen  hut  has  no 
especial  si;,'niiicance. 

Sudden  falls  in  the  temperature  may  occur;  thus,  as  shown  in  Chart 
III,  a  ilrop  of  10"  may  follow  an  intestinal  ha-morrhaj^e,  and  the  fall  may 
1)0  very  api»arent  even  heforo  the  hlood  luis  appeared  in  the  stools.  Some- 
times durinj,'  the  ana'mia  which  follows  a  severe  iufmorrhaj^'e  from  the 
bowels  there  are  remarkable  oscillations  in  the  temperature.  Hyperpy- 
rexia, temperature  above  KXi^,  is  not  very  common  in  ty})h(»id  fever  except 
just  before  death,  when  I  have  known  the  thermometer  to  register  lOlKo'. 

(r)  rost-Tjiphoid  Lli'VdfioN.s — Fi-rrr  tif  ('lun'dh'un'ure. — During  con- 
valesce' .  o,  after  the  temperature  lias  been  nornud,  jierhaps  for  live  or  six 
days,  the  fever  may  rise  suddenly  to  10"^°  or  lO.'J",  and,  after  pei'sistiiifj  for 
from  one  to  three  days  or  even  longer,  fall  to  normal.  \\  ith  this  there  is 
no  constitutional  dist  '."bance,  no  furring  of  the  tongue,  no  distention  of 
the  abdomen.  These  so-called  recrudescences  are  by  no  means  uncom- 
mon, and  are  of  especial  importance,  as  they  cause  great  anxiety  to  the 
])ractitioner.  They  are  attributed  most  fre(|uent]y  to  errors  in  diet,  con- 
stipation, emoti(ms,  and  excitement  of  any  sort,  such  as  seeing  friends. 
A  lou"-  series  of  these  cases  is  recorded  in  our  re^iorts  (Studies  11  aiul  III). 

There  are  cases  in  which  the  temperature  declines  almost  to  the  nor- 
mal at  the  end  of  the  third  week,  the  tongue  cleans,  and  the  patient  enters 
apparently  upon  a  satisfactory  convalescence.  The  evening  temperature', 
hoAvever,  does  not  reacdi  0S.,5°,  but  constantly  keeps  about  !)!).5°  or  100', 
and  occasionally  rises  to  100.5°.  This,  in  the  late  stages  of  convalescence, 
I  have  seen  due  to  the  post-typhoid  anaemia.  Complications  shoukl  be 
carefully  looked  for,  particularly  insidious  pleurisy  or  bone  lesions. 

In  certain  of  these  cases  the  persistence  of  the  fever  seems  to  be  really 
a  nervous  phenomenon,  aiul  there  is  nothing  in  the  condition  of  the  pa- 
tient to  cause  uneasiness  except  the  evening  elevation  of  temperature.  If 
the  tongue  is  clean,  the  appetite  good,  and  there  are  no  intestinal  symp- 
toms, it  may  be  disregarded.  I  have  frequently  found  this  condition  best 
met  by  allowing  the  patient  to  get  up  and  by  stopping  the  use  of  the  ther- 
mometer. This  prolonged  slight  elevation  of  the  temperature  after  the 
disappearance  of  all  the  symptoms  is  most  common  in  children  and  in  pa- 
tients of  marked  nervous  temperament. 

(t/)  T/te  Fercr  of  tJte  Jielapi<e. — This  is  a  repetition  in  many  instances 
of  the  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at 
a  ci'ftain  height  and  then  a  gradual  decline.  It  is  shorter  than  the 
original  pyrexia,  and  rarely  continues  more  than  tAvo  or  three  weeks. 
(Chart  I.)' 


f.'iit 

The 

com 

( 
idly 
swt'a 
picll 
pyre 
|i.'l'i< 
prol 
may 
latlt 
'I'yp 


TYI'IIOII)   I'KVKR. 


17 


(i')  Afi'lirih'  7't//)/iiiii/. — Tlicro  arc  oumcm  (Ifscril»<'il  in  wliirli  tlu>  cliicf 
t'ciitun's  of  tlic  (list'iisc  liuvi' Ix'i'ii  [(I't'scnt  without  the  cxisti'iict'  of  fever. 
'I'liey  are  extremely  rare  in  this  country.  No  instiuice  of  the  kind  had 
come  under  my  observation.     Fisk,  of  Denver,  has  met  with  it. 

( /■)  Chills  occur  (^<)  sometimes  witli  tlie  fever  of  onset;  (/>)  occasion- 
idly  lit  intervals  (hi'oM;,diout  the  course  of  tiie  disease,  and  followcil  hy 
sAveats  (so-called  sudoral  form);  (')  with  the  advent  of  complications, 
pleurisy,  pneumonia,  otitis  media,  jx-riostitia,  etc.;  {<l)  witlj  active  anti- 
pyretic treatment  hy  the  coal-tar  renu'dii's;  {(•)  occasionally  during  tho 
p.'riod  of  defervescence  without  relation  to  any  complication  or  seciucl, 
pi'ohahly  due  to  a  septic  infection;  (_/")  according  to  llerringham,  chills 
mav  result  from  constipation.  There  are  cases  in  >vhich  thi'oughout  the 
hitter  half  of  the  disease  chills  recur  with  great  severity.  (See  Chills  in 
Typhoid  Fever,  Studies  II.) 

Skin. — Tho  rash  of  tyiihoid  fever  is  very  characteristic.  It  consists  of 
a  variahle  nund)er  of  rose-colored  spots,  whi(di  appear  from  the  seventh  to 
the  tenth  day,  usiuilly  lirst  u(»on  the  al)donien.  The  spots  are  llatleni'd 
papuh's,  slightly  raised,  of  a  rose-red  color,  disai)pearing  on  pressure,  and 
ranging  in  diameter  from  'Z  to  \  millimetres.  They  can  he  felt  as  dis- 
tinct elevations  on  the  skin.  Sometimes  each  spot  is  ca[)pe(l  hy  a  small 
vesi(de.  The  spots  may  be  dark  in  color  and  occasionally  become  pete- 
chial. After  i)ersisting  for  two  or  three  days  they  gi'adually  disa[tpcar, 
leaving  a  brownish  stain.  They  como  out  in  successivo  crops,  but  rarely 
appear  after  the  middle  of  the  tinrd  week.  They  are  present  in  tho  ty^)- 
ical  relapse.  The  rash  is  most  abun<lant  upon  the  abdomen  and  lower 
thoracic  zone,  often  abounds  upon  the  back,  and  may  spread  to  the 
extremities  or  even  to  the  face.  I  can  not  say  that  in  my  experienc(!  these 
cases  witli  the  more  abundant  eruption  have  been  of  especially  severe  type. 
The  rash  is  not  always  present.  Murchison  states  that  it  is  fre(|uently 
absent  in  children.  In  several  instances  within  the  past  fi'W  years  the 
rash  has  [)ersisted  after  the  tenii»erature  has  subsided. 

A  branny  des(puimatiou  is  not  rare  in  children;  it  is  associated  usually 
with  abumlant  sudamina.     Occasionally  the  skin  may  peel  in  large  Hakes. 

The  following  accidental  rashes  are  met  with  in  typhoid  fever : 

1.  Enjiliciiiu. — It  is  not  x^'vy  uncommon  in  the  lirst  week  of  typhoid 
fever  to  liiid  the  skin  of  the  abdonu'n  and  (diest  of  a  vivid  red  color;  tho 
rash  may  also  spread  to  the  extrenuties.  It  may  possibly  in  some  instances, 
l)ut  certainly  not  always,  be  due  to  (juinine.  I  have  seen  it  much  more  fre- 
i|uently  in  the  past  live  years  (during  which  time  I  have  rarely  ordered  a 
(lose  of  quinine  in  this  disease)  than  I  did  in  ^lontreal,  where  we  used  this 
drug  largely  as  an  antipyretic. 

2.  The  f(ff/te,s  blvudtrvs — Peliomata. — These  are  pale-blue  or  steel-gray 
spots,  subcuticular,  from  -t  to  10  mm.  in  diameter,  of  irregular  outline  and 
most  abundant  about  the  chest,  abdomen,  and  thighs.  They  sometimes 
give  a  very  striking  appearance  to  the  skin.  It  can  l)e  readily  seen  that 
the  injection  is  in  the  deeper  tissues  and  not  superfh.'ial.  This  rash  is 
quite  without  significance.     Since  my  attention  was  called  to  its  associa- 


la 


SPI'Xii'MC   IN'l''H<TIorS   lUsKASKS. 


tion  with  body  lice,  I  liiivo  met  with  no  iiistaiHf  in  wliidi  llicsi-  \vt  re  iioi 
pi'crtciit.  St'vcnil  French  ohHcrvcrH  rniiintuin  that  they  arc  (hit'  t(»  tht>  h'ri- 
tiilin;,'  clTcctrt  of  ihf  (hiid  Hccrcti'd  Ity  prdiruli  {riih'  Ilcwctson,  .1.  II.  II. 
lUillt'tin,  vol.  v).     Tlwy  arc  not  pccnliar  to  ty|ih(»itl  fever  ( I)ii(k\v<»rtli). 

H.  Suilaniinal  and  miliary  erupliuua  arc  common  in  uU  cusi'.s  in  wiii(  li 
there  i.s  profuse  HWeutln^. 

4.  Urticaria  ia  oceu.sionally  met  with  ;  and  lastly  herpes,  very  uncom- 
mon in  typiioid  fever,  in  comparison  with  its  frcfpiency  in  nuilaria  and 
pneumonia. 

The  hn-hc  rvi'c/rnili;  a  red  line  with  white  l)or<lerH,  cnn  l»e  produced  l»y 
drawinj^  tho  nail  over  the  skin.  It  is  a  va8o-motor  i)henomenon  whi(di,  as 
in  otlu-r  fevers,  can  l)e  readily  elicited,  })artieularly  in  iiervou.s  8ul)je(!ts. 
IvNposure  of  the  ahdoineii  may  he  Hullicient  to  cause  a  pinkish  injection, 
which  nuiy  in  places  (  han^n*  to  an  ivoiy  white,  K'vin;,'  a  curious  mottled 
ap[)earance  to  the  skin.  A  similar  appearance  nuiy  he  seen  on  tlu^  arms. 
The  jjfeneral  tint  may  he  white,  with  irre^nilar  patches  or  streaks  of  i)ink 
or  dark  rod.  The  skin  of  tho  })alms  of  the  hands  may  heeomo  vory  dry 
and  yellow. 

iSirriifs. — .\t  the  hei^'ht  of  the  fever  the  skin  is  usually  dry.  I'rofusc 
HWeatinj;  is  rare,  hut  it  is  not  very  une(,mn:on  to  see  the  abdomen  or  chest 
moist  with  perspiration,  ])articularly  in  the  reaction  which  follow.s  the 
hath.  Sweats  in  sonu'  instances  constitute  a  strikiiifjf  feature  of  tho  dis- 
ease. They  may  occasiomilly  he  associated  with  chilly  sensations  or  actual 
chills.  Jaccoud  and  others  in  Franco  havt^  especially  descrihed  this  smlinud 
form  of  typhoid  fevor.  There  may  ho  recurring  ])aro.\ysm8  of  chill,  fever, 
and  sweats  (ovon  several  in  twenty-four  hours),  and  the  case  may  bo  mis- 
taken for  one  of  intermittent  fever.  Tho  fever  toward  tho  eno  of  the 
second  week  and  during  tho  third  week  may  he  intermittent.  The  char- 
acteristic rash  is  usually  present,  and,  if  absont,  tho  negative  condition  of 
the  blood  is  sulHcient  to  exclude  malaria.  I  have  seen  cases  of  this  form  in 
Montreal,  where  there  could  have  been  no  suspicion  of  malarial  infection. 

CEdcmn  of  tho  skin  occurs  : 

1.  As  the  result  of  vascular  obstruction,  most  commonly  of  a  vein,  as  in 
thrombosis  of  the  femoral  vein. 

2.  In  connection  with  nephritis. 

3.  In  association  with  tho  anaemia  and  cachexia. 

The  hair  is  very  apt  to  fall  out  after  an  attack  of  typhoid  fever.  In- 
stances of  permanent  ])aldness  are  of  extreme  rarity.  As  in  other  diseases 
associated  with  fever  tho  nutrition  of  tho  nails  suffers,  and  during  and 
after  convalescence  transverse  ridges  are  seen. 

It  is  stated  that  a  peculiar  odor  is  exhaled  from  the  skin  in  tyjdioid 
fevor.  AVhether  duo  to  a  cutaneous  exhalation  or  not,  there  certainly  is  a 
very  distinctive  smell  connected  with  many  patients.  I  have  repeatedly 
had  my  attention  directed  to  it  by  nurses.  Nathan  Smith  describes  it  as 
of  a  "  semi-cadaverous,  musty  character." 

As  a  sequel,  lines  of  atrophy  of  the  skin  may  develop  on  the  abdomen 
and  lateral  aspects  of  the  thighs,  similar  in  all  respects  to  those  seen  after 


were  not 
tln'  irrl- 
.1.  II.  II. 
>rtli). 
in  which 

■  ntu'oin- 
ariii  iiikI 

luct'd  hy 
ivhich,  iiH 
sul>j('('ts. 
njct'tion, 

niotlU'tl 
hu  iwmn. 

of  ])ink 
very  diy 

Trofusc 
I  or  clu'.st 
lh)WS  the 
f  the  elis- 
or HctUill 
H  SUlloiUtI 

ill,  fovor, 
!)('  niis- 
i  of  tlu' 
Mio  clmr- 
(lition  of 
s  form  in 
fc'ction. 

c'in,  as  in 


Ivor.     In- 
(liseusos 
ring  and 

typhoid 
Unly  is  a 
(peatedly 

)es  it  as 

Ibdomen 
m  after 


TVIMI(»II»    I'llVKIt. 


19 


pnjjnuncy.  THpho  liura*  tifrop/iinn  arc  poHKihly  due  to  neurit  in,  and  Duck- 
worth luiH  rcport('(l  a  case  in  which  the  nkin  adjacent  to  thcin  was  hy|>cr- 
n'sthctic. 

/{i'i/-.s<ins  arc  not  unc(»nunon  in  protracted  cases,  with  ;,'reat  emacia- 
tion. As  H  ruU',  they  result  from  pressure  and  are  seen  ujion  the  sacriun, 
more  rarely  tlu!  ilia,  the  shoultlcrs,  and  the  heels.  Theso  art»  less  com- 
mon, I  think,  sinci*  tlio  introduction  of  hydrotherapy.  Scrupulous  caro 
and  watchfulness  do  much  for  their  prevention,  lint  it  is  to  he  remem- 
bered that  in  cases  with  profound  involvement  of  the  nerve  centres 
acutu  bed-sores  of  tho  back  and  hi-els  may  occur  witli  very  slight  })re8- 
sure. 

/{oils  rn!istitnto  a  common  and  troublesome"  sequel  of  the  disease. 
They  appear  to  be  more  frccpicnt  after  hydrotherapy. 

Circulatory  System. — The  ///aod  presents  important  changes.  The  fol- 
lowing statements  are  based  on  studies  which  W.  S.  Thayer  has  made  in 
my  wards  (Studies  I  ami  III):  During  tlio  first  two  weeks  there  may  bo 
little  or  no  (dumge  in  the  blood.  I'rofuso  sweats  or  co})ious  diarrlui'a  niay, 
as  Ilayem  has  shown,  cause  the  eor])us('les — as  in  the  collapse  stage  of 
cholera — to  rise  above  nornud.  In  the  third  week  a  fall  usually  takes 
pla(;e  in  corpuscles  and  luemoglobin,  and  the  number  may  sii'.k  rapidly 
even  to  1,3()(),()()0  per  c.  mm.,  gradually  rising  to  normal  during  eonvu- 
lesconce.  When  the  patient  tlrst  gets  up,  there;  nniy  be  a  slight  fall  in  the 
nund)er  of  corpuscles.  They  diminish  slightly  throughout  the  course,  and 
reach  the  lowest  point  toward  the  end  of  defervescence. 

The  amount  of  luemoglobin  is  always  reduced,  and  usually  in  a  greater 
relative  proportion  than  the  number  of  red  corpuscles,  and  during  recov- 
ery the  normal  color  standard  is  reached  at  a  later  period.  The  number 
of  colorless  corpuscles  varies  little  from  th-  lormal  standard  (f;,()()(l  ±  per 
c.  mm.).  They  diminish  slightly  throughout  the  course  and  reach  the 
lowest  point  when  convalescence  is  well  begun.  The  absence  of  leucocyto- 
sis  may  be  at  times  of  real  diagnostic  value  in  distinguishing  typhoid  fever 
from  various  8ei)tic  fevers  and  acute  inflammatory  processes.  The  relative 
proportion  of  the  leucocytes  shows  fairly  constant  variations,  the  large 
mononuclear  and  transitional  forms  are  increased,  while  the  polynuciear 
nentrophiles  are  dinunished  often  below  00  or  even  50  per  cent.  This  is 
in  marked  contrast  to  the  condition  in  other  acute  diseases  in  which  the 
polynuciear  nentrophiles  are  increased.  When  an  acute  inflammatory  pro- 
cess occurs  in  typhoid  fever  the  leucocytes  show  an  increase  in  the  poly- 
nuciear forms,  and  this  may  be  of  great  diagnostic  moment,  as  in 
perforation. 

The  accompanying  blood-chart  shows  these  changes  woll.     (Chart  11.) 

The  post-typhoid  ansemia  may  reach  an  extreme  grade.  In  one  of  my 
cases  the  blood-corpuscles  sank  to  1,300,000  per  c.  mm.  and  the  luemo- 
globin to  about  20  per  cent.  These  severe  grades  of  amemia  are  not  com- 
mon in  my  experience.  In  the  Munich  statistics  there  were  54  cases  with 
general  and  extreme  ansemia. 

Of  changes  in  the  blood  plasma  very  little  is  known. 


20 


SPECIFIC   INFECTIOUS   DISEASES. 


The  piihe  in  typhoid  fever  presents  no  special  characters.  It  is  in- 
creased in  rapidity,  but  not  always  in  proportion  to  the  height  of  the 
fever.  As  a  rule,  in  the  first  week  it  is  above  100,  full  in  volume  and  often 
dicrotic.  There  is  no  acute  disease  with  which,  in  the  early  stage,  a 
dicrotic  jnUse  is  so  frequently  associated.  Even  with  high  fever  the  pulse 
may  not  be  greatly  accelerated.  As  the  disease  progresses  the  pulse  be- 
■comes  more  rapid,  feebler,  and  small.     In  the  extreme  prostration  of  severe 


lOO,-; 

5,000,000 

DEC  ,  1890 

JANUARY,  imt 

FEDBUARY. 

MARCH 

19 

22 

3S 

I'. 

3) 

a 

6 

9_ 

H 

.'.? 

_1B 

21124 

2.7 

30 

2 

.?_ 

% 

11 

14 

.'.?. 

20 

i?. 

26 

-?.. 

4lr 

10 

IS 

16 

in 

w% 

B0% 

4,C  yO.OOO 

1 

/ 

to% 

\ 

1 
1 

/ 

\ 

J 

r  1 

m% 

3,000,000 

/ 

/ 

\ 

/ 

/ 

&o% 

/ 

/ 

^A 

/ 

\ 

1 

1 

f 

-- 

,^ 

^0% 

2,000,000 

\ 

/ 

r 

■-> 

< 

f 

\ 

V 

y 

/ 

so% 

\ 

V 

y 

/ 

\ 

- 

-1 

<^ 

/" 

20% 

1,000,000 

: 

10^ 

500,000 

*- 

•If        -j.       -j. 

•\ 

j- 

* 

■\ 

i, 

•fr 

•ft 

Y 

* 

-- 

->' 

\ 

10,000 

- 

8,000 

A 

^. 

6,000 

^ 

r- 

- 

— « 

s 

\ 

tf 

--< 

^ 

^ 

.... 

.... 

/ 

/ 

> 

4,000 

( 

y 

2,000 

\ 

/ 

/ 

1- 

BLACK,   RED  CORPUSCLES. 


RED,  HAEMAQLOBIN, 


MEAN  NORM, 

NUMBER  OF 

WHITE 

CORPUSCLES 


BLUE,   COLORLESS  CORPUSCLES. 


Chart  II. 


cases  it  may  reach  150  or  more,  and  is  a  mere  undulation — the  so-called 
running  pulse.  The  lowered  arterial  pressure  is  manifest  in  the  dusky 
lividity  of  the  skin  and  coldness  of  the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  occa- 
sionally becomes  very  sloiv.     After  no  other  acute  fever  do  we  so  fre- 


TYPHOID  FEVER. 


21 


quontly  moot  witli  hradyciirdiu.  I  luivo  omintod  tlio  pulse  as  low  as  HO, 
and  iustaneos  are  on  recDnl  of  still  fewer  beats  to  tlio  inimite. 

The  h'drl-sitHntls  are  at  first  elear  and  loud,  and  free  from  niurniur, 
but  in  severe  cases,  as  the  prostration  develops,  the  first  sound  becomes 
feeble  and  there  is  often  to  bo  heard,  at  the  apex  and  along  the  left  sternal 
nuirgin,  a  soft  systolic  murmur.  The  first  sound  may  be  <rnidiially  anni- 
■hilated,  as  pointed  out  by  Stokes.  In  the  extreme  feebleiu'ss  of  tlu'  gravi  r 
forms,  the  first  and  second  sound  become  very  similar,  and  tbe  long  pause 
is  much  shortened  (embryocardia).  I  am  much  impressed  with  the  rarity 
of  grave  heart  symptoms  in  typhoid  fever. 

Of  cardiac  complications,  jicn'rardi/is  is  rare  and  has  been  met  with 
ehiefiy  in  children  aiul  in  association  with  pneumonia.  It  was  not  pres- 
ent in  any  of  my  cases  and  occurred  in  only  14  of  the  53,000  Munich  i)ost- 
mortems.  EiiilocariUlis  is  also  uncommon.  I  have  seen  only  2  cases ;  and 
there  were  only  II  cases  noted  in  the  Munich  records.  Myocarditis  is  more 
common.  Tlie  following  statement  nuiy  be  made  with  reference  to  the 
condition  of  the  heart-muscle  in  this  disease :  In  protracted  cases  the  mus- 
cle-fibre is  usually  soft,  flabby,  and  of  a  pale  yellowish-brown  color.  The 
softening  may  be  extreme,  though  rarely  of  the  grade  described  by  Stokes, 
in  which,  when  held  apex  up  by  tlie  vessels,  the  organ  collapsed  over  the 
hand,  forming  a  mushroom-like  cap.  Microscopically,  the  fibres  may  show 
little  or  no  change,  even  when  the  impulse  of  the  heart  has  been  extremely 
feeble.  A  granular  parenchymatous  degeneration  is  common.  Fatty  de- 
generation may  be  present,  particularly  in  long-standing  cases  with  ansemia. 
The  hyaline  change  is  not  common.  The  segmenting  myocarditis,  in  which 
the  cement  substance  is  softened  so  that  the  muscle-cells  separate,  has 
also  been  found,  but  probably  as  a  post-mortem  change. 

Complications  in  the  Arteries. — Obliteration  of  large  or  small  arterial 
trunks  is  one  of  the  rare  con>plications  of  typhoid  fever.  A  considerable 
number  of  cases  are  scattered  through  the  literature.  The  obliteration 
may  be  due  either  to  embolism  or  to  thrombosis.  In  a  majority  of  cases 
the  femoral  artery  is  involved  and  gangrene  of  tlie  foot  and  leg  occurs. 
In  several  cases  there  has  been  obliteration  of  both  femorals  with  extension 
of  the  clot  into  the  aorta  with  gangrene  of  both  legs.  In  a  case  which 
I  saw  with  Eoddick,  of  ^lontreal,  the  obliteration  of  the  left  femoral 
occurred  on  the  sixteenth  day.  On  the  twentieth  day  the  patient  had 
pain  in  the  right  leg  and  there  was  no  pulsation  in  the  femoral  artery. 
Gangrene  gradually  developed  in  both  feet,  and  death  took  place  in  the 
sixth  week.  In  these  cases  the  condition  is  probably  due  to  thrombosis, 
not  embolism,  and  is  associated  with  a  blood  state  which  favors  clotting, 
or  possibly  with  a  local  arteritis.  In  his  recent  monograph  Keen  refers  to 
46  cases  of  arterial  gangrene,  of  which  8  were  bilateral,  19  on  the  right 
side,  and  19  on  the  left. 

Thrombi  in  the  Veins. — This  is  a  much  more  frequent  complication, 
and,  according  to  Murchison,  is  met  with  in  about  1  per  cent  of  the 
cases.  It  occurs  most  frequently  in  a  crural  vein,  and  more  commonly  in 
the  left  than  in  the  right ;  due  possibly,  as  suggested  by  Liebermeister, 


22 


SPECIFIC   INFECTIDUS  DISEASES. 


to  the  fact  tliiit  in  tlio  left  coinnion  iliiu;  vein,  boiiiij  r-rossod  l)y  the  ri^rlit 
iliac  artery,  tlie  How  of  l)]oo(I  is  not  so  free  as  in  the  I'i^i'lit  vein.  Tliroiii- 
bosis  is  indicated  l)y  eniar^^'enient  and  oedema  of  the  linil).  It  is  not  a  very 
nnfavorable  complication,  in  one  case  of  my  series  the  thromlnis  snppii- 
rated  and  there  was  ])yiemia.  Occasionally  the  thi'omhosis  may  extend  into 
the  pelvic  veins  anil  into  the  vena  cava.  In  one  instance  the  thrombus 
was  in  the  rij^ht  circumflex  iliac  vein  alone,  and  the  sujjerficial  veins  on 
the  ri<:;ht  side  of  the  aljdomen  were  in  ctmscquenco  greatly  enlarged. 
Sudd(;n  death  has  been  caused  by  dislodgment  of  a  thrombus  and  plugging 
of  the  ])ulin()iuiry  artery.  Tyfjlioid  bacilli  have  been  found  in  the  wall  of 
the  vein  aiul  in  the  clot.  Keen  has  collec^ted  1:*.S  cases  of  venous  coagula 
following  typhus  and  typhoid.  "Only  4  involved  the  ujiper  extremity 
alone,  2  of  which  were  followed  by  gangrene;  2  involved  both  arm  and  leg, 
but  all  the  other  I'-ii  cases  were  limited  to  the  lower  extreinities."  I  do 
not  think  that  gangrene  ever  results  fron>  obstruction  of  the  vein  alom\ 

Jnfar(!ts  in  the  kidneys,  spleen,  and  lungs  are  by  no  nu'ans  uncommon 
in  typhoid  fever.  They  are  associated  usually  with  thrombosis  in  the  arte- 
ries, rarely  with  embolism. 

Tjiphoid  Gamirene. — Following  blocking  of  the  femoral  or  pojiliteal 
arteries  the  leg  becomes  numb  and  cold.  There  may  be  complete  anes- 
thesia with  motor  paralysis,  and  occasiomdly  a  good  deal  of  pain.  There 
is  rarely  much  swelling ;  gradually  the  skin  becomes  discolored  and  the 
process  of  dry  gangrene  begins.  AVhen  both  artery  and  vein  are  involved 
the  gangrene  is  usually  moist,  and  sjireads  more  rapidly.  In  a  number  of 
oases  the  gaiigrene  is  not  specially  localized  to  vascular  areas  ;  thus  the  dis- 
tribution in  the  cases  collected  by  Keen  is  as  follows :  Ears,  6  cases ;  nose, 
10  eases  ;  face,  neck,  and  trunk,  47  cases  ;  anus,  5  cases  ;  genitals,  20  cases ; 
legs,  126  cases. 

Digestive  System. — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food  is  not  regained  until  convalescence.  Thirst  is  constant,  and 
should  be  fully  and  freely  gratiiied.  Even  when  the  mind  becomes  bo- 
numbed  and  the  patient  no  longer  asks  for  water,  it  should  be  freely  given. 
The  toiifine  presents  the  changes  inevitable  in  a  prolonged  fever,  but  there 
are  no  distinctive  characters.  Early  in  the  disease  it  is  moist,  swollen,  and 
coated  Avith  a  thin  white  fur,  which,  as  the  fever  progresses,  becomes 
denser.  It  may  remain  moist  throughout.  In  severe  cases,  particularly 
those  with  delirium,  the  tongue  becomes  very  dry,  partly  owing  to  the  fact 
that  such  patients  breathe  Avith  the  mouth  open.  It  may  be  covered  with 
a  brown  or  brownish-black  fur,  or  with  crusts  between  which  are  cracks 
and  fissures.  Acute  glossitis  occurred  in  one  case  at  the  onset  of  the 
relapse.  In  these  cases  the  teeth  and  lips  may  be  covered  with  a  dark 
brownish  matter  called  sordes — a  mixture  of  food,  epithelial  debris,  and 
micro-organisms.  By  keeping  the  mouth  and  tongue  clean  from  the  out- 
set the  fissures,  which  are  extremely  painful,  may  be  prevented.  During 
convalescence  the  tongue  gradually  becomes  clean,  and  the  fur  is  thrown 
oif,  almost  imperceptibly  or  occasionally  in  flakes. 

The  secretion  of  saliva  is  often  diminished;  salivation  is  rare. 


TYPHOID  FEVER. 


23 


given. 

lilt  there 

ion,  and 

hc'comes 

liculariy 

;hc  fact 

led  with 

cracks 

of  the 

a  dark 

■is,  and 

|;hc  ont- 

jDuring 

thrown 


Parofifia,  not  so  frequent  as  in  typlius  fever,  was  present  in  45  of 
the  2,000  Munich  cases.  It  occurred  in  only  2  of  my  series  of  fatal  cases. 
Of  428  instances  collected  by  Keen  occurring  after  typhus  and  typhoid, 
only  75  followed  the  latter.  Usually  unilateral,  and  in  a  majority  of  cases 
going  on  to  suppuration,  it  is  regarded  as  a  very  fatal  complication,  but 
recovery  has  followed  in  4  or  5  of  my  cases.  It  undoubtedly  may  arise 
from  extension  of  inflammation  along  Steno's  duct.  This  is  probably  not 
so  serious  a  form  as  when  it  arises  from  metastatic  inflammation.  The 
submaxillary  gland  may  be  involved  alone.  Parotitis  may  oc(;ur  after  the 
fever  has  subsided.  A  remarkable  localized  sweating  in  the  parotid  region 
is  an  occasional  sequel  of  the  abscess  (see  Studies  III). 

The  jiharynx  may  be  the  seat  of  slight  catarrh.  Sometimes  the  fauces 
are  deeply  congested.  Membranous  pharyngitis,  a  serious  and  fatal  com- 
plication, may  come  on  in  the  third  week.  Difficulty  in  swallowing  may 
result  from  ulcers  of  the  oesophagus,  and  in  one  of  our  cases  stricture  fol- 
lowed.*    F.  A.  Packard  has  also  reported  a  case. 

The  gastric  symptoms  are  extremely  variable.  Nausea  and  vomiting 
are  not  common.  There  are  instances,  however,  in  which  vomiting,  re- 
sisting all  measures,  is  a  marked  feature  from  the  outset,  and  may 
directly  cause  death  from  exhaustion.  Vomiting  does  not  often  occur 
in  the  second  and  third  week,  unless  associated  with  some  serious  com- 
plication. In  a  few  of  these  cases  ulcers  have  been  found  in  the  stom- 
ach. 

Intestinal  Symptoms. — Diarrh(jea  is  a  very  variable  symptom,  occurring 
in  only  25  or  30  per  cent  of  the  cases,  and  in  only  about  10  per  cent  of  my 
cases  have  the  movements  been  frequent.  Of  99  cases  under  my  care 
during  1897  diarrhoea  occurred  in  only  12.  Its  absence  must  not  be  taken 
as  an  indication  that  the  intestinal  lesions  are  of  slight  extent.  I  have 
seen,  on  several  occasions,  the  most  extensive  infiltration  and  ulceration  of 
the  Peyer's  glands  of  the  small  intestine,  with  the  colon  filled  with  solid 
faeces.  The  diarrhoea  is  caused  less  by  the  ulcers  than  by  the  associated 
catarrh,  and,  as  in  tuberculosis,  it  is  probable  that  when  this  is  in  the  large 
intestine  the  discharges  are  more  frequent.  It  is  most  common  toward  the 
end  of  the  first  and  throughout  the  second  week,  but  it  may  not  occur 
until  the  third  or  even  the  fourth  week.  The  number  of  discharges  ranges 
from  3  to  8  or  10  in  the  twenty-four  hours.  They  are  usually  abundant, 
thin,  grayish-yellow,  granular,  of  the  consistency  and  appearance  of  pea- 
soup,  and  resemble  very  much,  as  Addison  remarked,  the  normal  contents 
of  the  small  bowel.  The  reaction  is  alkaline  and  the  odor  offensive.  On 
standing,  the  discharges  separate  into  a  thin  serous  layer,  containing  albu- 
min and  salts,  and  a  lower  stratum,  consisting  of  epithelial  debris,  remnants 
of  food,  and  numerous  crystals  of  triple  phosphates.  Blood  may  be  in  small 
amount,  and  only  recognized  by  the  microscope.  Sloughs  of  the  Peyer's 
glands  occur  either  as  grayish-yellow  fragments  or  occasionally  as  ovoid 
masses,  an  inch  or  more  in  length,  in  which  portions  of  the  bowel  tissue 

*  ]\Iitchell,  CEsophageal  Complications  in  Typhoid  Fever  (Studies  III). 


24 


SPECIFIC  INFECTIOUS  DISEASES. 


may  be  found.     The  bacilli  are  not  found  in  the  stools  until  the  end  of 
the  first  or  the  middle  of  the  second  week. 

Hmmorrhtge  from  the  bowels  is  a  serious  complication,  occurring  in 
from  3  to  5  per  cent  of  all  cases.  It  had  occurred  in  99  of  the  2,000 
fatal  Munich  cases.  In  685  cases  treated  in  my  wards,  haemorrhage  oc- 
curred in  33,  and  proved  fatal  in  1.0  per  cent  of  the  total  series.     Of  60 


s 

u 

s 


o 
Is 


o 

.a 


cases  reported  by  R.  G.  Curtin,  28  died.  It  was  present  in  3.77  per  cent  of 
Murchison's  1,564  cases.  There  may  be  only  a  slight  trace  of  blood  in  the 
stools,  but  too  often  it  is  a  profuse,  free  haemorrhage,  which  rapidly  proves 
fatal.     It  occurs  most  commonly  between  the  end  of  the  second  and  the 


1)cginninf]f  of  tlio  fourth  wook,  the  tiino  of  tlio  s('i)aratioii  of  tlio  sloufrlH. 
Occasioiiiilly  it  results  simply  from  tlic  intouso  liyiicra'mia.  It  usually 
couios  on  without  Avarniu;^^  A  sciisatiou  of  siukiii;^  or  coUapso  is  ox])cri- 
I'ueod  l)y  the  ])atic'nt,  the  temperature  falls,  ami  may,  as  in  tlie  annexecl 
(•hurt,  drop  H°  or  10°  in  ti  few  liours.  Fatal  eollai)se  may  supervene  hefore 
tlie  hloocl  appears  in  the  stool.  lIaMiU)rr]iago  usually  occurs  in  cases  of 
considorahle  severity.  (Jraves  and  Trousseau  held  that  it  was  not  a  very 
(lani^erous  sym])tom,  hut  statistics  show  that  death  follows  in  from  ;)()  to 
,">()  ])cr  cent  of  the  cases. 

It  must  not  he  forgotten  that  mehena  may  also  he  part  of  a  general 
ha'morrhagic  tendency  (to  be  referred  to  later),  in  which  case  it  is  associ- 
ated with  i»etechiie  and  ha?maturia.  There  may  be  a  s})ecial  family  pre- 
disposition to  intestinal  hannorrhages  in  typhoid  fever.  Thus  I'ate*  re- 
ports 34  cases  in  four  generations  in  one  family  occurring  between  the 
years  1884  and  18!)1. 

Meteorism,  a  frequent  symptom,  is  not  serious  if  of  moderate  grade, 
but  when  excessive  is  usually  of  ill  omen.  Owing  to  defective  tone  in  the 
walls,  in  severe  cases  to  their  infiltration  with  serum,  gas  aeeumulates  in 
the  small  and  large  bowels,  particularly  in  the  latter.  It  is  rightly  held  to 
be  to  some  extent  a  measure  of  the  intensity  of  the  local  lesions.  When 
extreme,  it  pushes  u]i  the  diaphragm  and  intei'feres  very  much  with  the 
action  of  the  heart  and  lungs.     It  undoubtedly  also  favors  ])erf()ration. 

Ali<l(nn!)i(i1  /on/cnirss  on  ])ressure  und  fj/o'f/h'iH/  in  the  right  iliac  fossa 
exist  in  a  large  proportion  of  all  the  eases.  The  tenderness  may  be  more 
or  less  diffuse  over  the  abdomen,  but  it  is  commonly  limited  to  the  right 
side.  It  is  rarely  excessive,  and  may  be  elicited  only  on  (lee]i  ])r('ssure. 
(iurgling  indicates  simply  the  presence  of  gas  and  lluid  fa'ces  in  the  colon 
and  caM'um.  In  a  few  instances  the  pain  is  very  severe  at  tlie  onset,  local- 
ized in  the  right  iliac  fossa,  and  may  suggest  appendicitis. 

Occasionally  severe  pain  may  be  associated  with  the  degeneration  of 
the  abdominal  muscles,  or  with  rupture  of  the  recti  abdomiiuiles.  It  is 
stated  that  the  thickened  ileum  may  be  felt  in  typhoid  fever,  and  also  that 
the  mesenteric  glands  may  be  palpable.  This  is  a  point  of  some  moment. 
The  resistance  and  apparent  tumor  have  led  to  the  diagnosis  of  appendicitis 
and  operation. 

Perforation. — Of  my  G85  cases  there  were  34  (4.9G  per  cent)  with  per- 
foration. In  4,G80  cases  tabulated  by  Fitz  the  mortality  from  this  accident 
was  (5.58  per  cent.  It  is  more  frequent  in  men  than  in  women.  It  is  usually 
indicated  by  the  onset  of  sudden  acute  pain  in  the  abdomen,  and  sym])- 
toms  of  collapse.  It  is  most  common  at  the  end  of  the  second  or  in  the 
third  week,  but  in  one  of  my  cases  it  occurred  as  early  as  the  eighth  day 
and  in  another  in  the  sixth  week,  two  weeks  after  the  evening  temperature 
had  become  normal.  In  Fitz's  series  40. 5  per  cent  occurred  in  the  third 
or  fourth  week,  4  cases  occurred  in  the  first  week,  and  1  case  as  late  as  the 
sixteenth  week.     It  is  not  infrequently  associated  with  ha'morrhage. 


*  North  Carolina  Medical  Journal,  September,  1894. 


20 


SPKCIFIC  INFECTIOUS  DISEASES. 


AVo  do  not  know  iill  tlio  fircumstiinooH  wliicli  loiul  to  pci-foration, 
Tlioro  is  (•crtiiinly  no  rcliitionshii)  bctwooti  this  jicfidcnt  and  tlio  severity 
of  the  disojiHC.  It  occurs  not  infrequently  in  very  mild  ciises.  Among 
ciiuses  iiH.si<(ned  are  the  taking  too  early  of  indigestible  food,  severe  vomit- 
ing, excessive  meteorism,  and  ascarides.  The  tubbing  has  ])een  accused  of 
increasing  the  jiercentage,  Imt  Hare's  Brisbane  statistics  do  not  show  it, 
nor  do  ours.  I'erforatiou  of  the  appendix  is  not  very  unconunon,  and  may 
cause  pain  in  the  right  iliac  fossa,  (ieueral  peritonitis  or  a  localized  al> 
scess  may  result,  llecovery  from  perforation  is  undoubtedly  jjossible, 
though  rare.  I'critonitis  without  perforation  may  also  occur  by  extension 
from  the  ulcer  or  occasionally  by  rupture  of  a  softened  mesenteric  gland. 
It  was  present  in  2.2  per  cent  of  the  ^lunicli  autopsies. 

Sjiniptoms  of  Perforation. — The  cases  may  be  grouped  into  {a)  those 
with  abrupt  and  well-defined  onset.  In  about  three  fourths  of  the  cases 
there  is  a  sudden  a<'ute  pain  in  the  abdomen,  followed  by  marked  teiuler- 
ness,  rigidity  of  the  abdominal  walls,  vomiting,  a  collai)sed,  i)inched  ex- 
pression, and  a  small  rapid  pulse.  l\\  cases  in  "whicji  there  has  been 
marked  tympanites  and  tenderness  the  symptoms  may  be  nu)re  obscure, 
and  I  have  once,  at  least,  been  deceived  by  the  good  quality  of  the  pulso 
and  general  condition  in  the  ])reseiu'C  of  pretty  well  marked  local  signs, 
(/y)  Cases  in  Avhich  the  onset  is  gradual  and  the  symptoms  ill-defined. 
When  the  patient  has  been  very  ill  and  delirious  or  comatose,  the  increas- 
ing distention  of  the  abdomen  and  signs  of  tenderness  on  deep  pressure 
may  be  the  only  suggestive  features.  It  is  to  be  borne  in  mind  that  tym- 
panitic distention  is  by  no  means  a  necessary  accompaniment  of  i)crfora- 
tion.  The  al)domen  nuiy  be  flat,  with  boardlike  hardness,  {r)  In  a  small 
group  of  cases  there  are  7io  symptoms  whatever  suggestive  of  perforation, 
and  it  is  found  accidentally  post  mortem.  These  are  usually  cases  which 
have  been  desperately  ill,  and  the  local  features  are  completely  masked  by 
the  severity  of  the  toxannia.  Of  additional  features  the  fall  in  tempera- 
ture is  sometimes  well  marked  and  suggestive.  01)literation  of  the  liver 
dullness  in  front  may  be  almost  complete,  and  woitld  be  a  very  valuable 
siizn  were  it  not  for  the  fact  that  one  sometimes  in  extreme  meteorism 
finds  the  same  condition.  In  the  absence  of  local  abscess  or  otitis  media 
the  presence  of  a  leucocytosis  is  a  much  more  important  symptom,  the 
value  of  which  in  the  diagnosis  of  perforation  has  been  demonstrated  by 
Thayer  in  several  cases  in  my  wards. 

The  spleen  is  invariably  enlarged  in  typhoid  fever,  and  in  a  majoi'ity  of 
case  the  edge  can  be  felt  below  the  costal  margin.  ]>y  the  end  of  the  first 
week  the  enlargement  is  evident,  unless  there  is  great  distention  of  the 
colon,  Avlien  the  spleen  nuiy  be  pushed  far  back  and  difhcult  to  feel.  Even 
the  normal  area  of  dullness  may  not  be  obtainable.  I  have  seen  a  very 
large  spleen  post  mortem,  when  during  life  the  increase  in  size  was  not 
observable.  Toward  the  fourth  week  it  diminishes  in  size.  In  four  of 
my  autopsies  it  weighed  less  than  normal.  Infarcts  and  abscesses  are 
occasionally  found.  Eupture  of  the  sploen  in  typhoid  fever,  due  to  a  slight 
blow,  has  been  seen  by  Bartholow.     Spontaneous  rupture  may  also  occur. 


TVPIIOII)   FEVEU. 


27 


Liver. — Symptoms  on  the  part  of  tliis  or;,'!in  iiro  rare. 

{»)  Jiiinii/icc  is  occasioiiiilly  seen,  and  may  l>e  due  to  catarrh  of  tlio 
ducts,  to  toxa'inia,  to  abscess,  .ind  occasionally  to  pill-stoncs. 

(/»)  .ILsre.ss. — Solitary  al  sccss  is  exceed in<,dy  rare.  1  liav(*  never  seen 
an  instance.  It  may  follow  the  intestinal  lesion  or  more  commonly  on(!  of 
the  com])li('ations,  as  ])arotitis  or  necrosis  of  bone.  Suppurative  pyleplde- 
bitis,  which  is  more  fre(|Uent  than  abscess,  may  follow  perforation  of  the 
appendix.     Suppurative  cholangitis  has  been  descri!)ed. 

(r)  ('holrrjistitin  and  ChuhuKjilis. — Kecent  observations  have  shown 
that  tlie  gall-bladder  in  fatal  cases  often  contains  tyjjhoid  bai  iUi  :  1!»  of  'i'l 
cases  in  Chiari's  series,  7  in  14  of  Flexner's.  They  maybe  itresent  without 
(  ausing  any  mischief,  or  they  may  excite  an  acute  inllammatiou  with  sup- 
l»uration,  perforation,  and  peritoiutis.  The  symptoms  may  occur  during 
the  course  of  the  disease  or  months  after  convalescence  luis  been  estab- 
lished. Three  cases  have  been  operated  upon  at  the  Johns  noj)kins  llos- 
l)ital.  Keen  has  collected  ;50  cases  of  perforation,  !^^ason's  paper  in  the 
Transactions  of  the  Association  of  American  Physicians,  vol.  xii,  and  those 
by  Camac  and  myself*  show  how  important  is  this  complication. 

{(l)  (Idll-Stoncs. — Bendieim  called  attention  to  tlie  frequency  of  chole- 
lithiasis after  typhoid  fever.  It  is  probably  associated  with  the  presence 
of  typhoid  1)acilli  in  the  gall-ldadder  (see  under  CJall-Stones). 

Respiratory  System. — Ejtisldxix,  an  early  symptom,  precedes  typhoid 
fever  more  commonly  than  any  other  febrile  alfection.  It  is  occasionally 
profuse  and  serious. 

Larj/iH/ifis  is  not  very  common.  The  ulcers  and  the  perichondritis 
have  already  been  described.  (Edema,  apart  from  ulceration,  is  rare.  Jii 
this  country  the  laryngeal  complications  of  tyi)hoid  fever  seem  much  less 
frequent  than  on  the  Continent.  1  have  twice  only  seen  jiericliondritis; 
both  of  the  cases  recovered,  one  after  the  expectoration  of  large  portions 
of  the  thyroid  cartilage. 

Keen  aiul  Liining  have  collected  221  cases  of  serious  surgical  complica- 
tions of  the  larynx.  General  emphysema  may  follow  the  perforation  of  an 
ulcer.     Stenosis  is  a  very  serious  sequence. 

From  some  recent  studies  it  would  appear  that  paralysis  of  the  laryn- 
geal muscles  is  mxudi  more  common  than  we  have  supposed.  l*rzedborski 
(Volkmann's  Sammlung,  Xo  lS-2)  has  systenuitically  examined  the  larynx 
in  100  consecutive  cases  and  found  35  Avith  paralysis.'  The  condition  is 
nearly  always  due  to  neuritis,  sometimes  in  connection  with  aifections  of 
other  nerves. 

Brunch  His  is  one  of  the  most  freqnent  initial  symptoms.  It  is  indi- 
cated by  the  presence  of  sibilant  rales.  The  smaller  tubes  may  be  involved, 
producing  urgent  cough  and  even  slight  cyanosis.  Collapse  and  lobular 
pneumonia  may  also  occur. 

Lobar  pneumonid  is  met  M'ith  under  two  conditions  : 

1.  It  may  be  the  initial  symptom  of  the  disease.     After  an  indisposition 


*  Studies  in  Typhoid  Fever,  Scries  III,  Johns  Hopkins  Hospital  Reports,  vol.  vii. 


28 


SPKCIFIC   IXFKf'TIors   DISKASLS. 


of  ii  (lay  or  so,  tlio  ]))i1ioiit  is  RciziMl  witli  ii  cliill,  has  liij,'li  fever,  ])!iiii  in  the 
Hide,  mill  within  fort y-i'i;,'ht  hours  there  are  Hi;^Mis  of  coiisolidatioii  anil  the 
cvidcMieos  of  an  onlinary  h)har  })ncunionia.  Tlio  intestinal  Kymptonis  may 
not  develop  until  toward  the  end  of  the  first  week  or  later  ;  the  i)ulinonary 
syjuptouis  persist,  crisis  does  not  oeeur  ;  the  aspect  of  the  ])atient  chancres, 
and  hy  the  end  of  tlie  second  weidv  tlie  clinical  picture  is  that  of  tyiihoid 
fever.  Spots  may  then  he  present  and  dt)uhts  as  to  tlu(  nature  of  the  case 
are  solved.  In  other  instances,  in  the  ubseueo  of  a  characteristic  erui)tion, 
the  ease  remains  doubtful,  and  it  is  impossible  to  Bay  whether  the  disease 
lias  been  pneumonia,  in  Avhiidi  the  so-called  typhoid  symptoms  have  devel- 
oped, or  whether  it  was  ty[)hoi(l  fever  Avith  early  implication  of  the  lun<?s. 
'JMiis  condition  may  depend  upon  an  early  localization  of  the  typhoid  bacil- 
lus in  the  luiifjf.  I  have  twice  performed  autopsies  in  cases  of  thin  pneunio- 
ijIphuH,  as  it  is  called  by  the  French  and  (Jermans,  and  can  speak  positively 
of  its  onset  with  all  the  symptoms  of  a  frank  pneumonia. 

)l.  Lobar  imeumonia  forms  a  serious  and  by  no  means  infre(|uent  com- 
plication of  the  second  or  third  week.  It  was  present  in  over  H  per 
cent  of  the  Munich  cases.  The  symptoms  are  usually  not  marked.  There 
may  be  no  rusty  sputa,  and,  unless  sought  for,  the  condition  is  frequently 
overlooked.  Infarction,  abscess,  and  gangrene  are  occasional  pulmonary 
com])lications. 

Jfilj)i)st(ilir.  conijextion  of  the  lungs  and  wdema,  due  to  enfeebled  circu- 
latioTi  in  the  later  jieriods  of  the  disease,  are  very  common.  The  physical 
signs  are  defective  resonance  at  the  bases,  feeble  breath-sounds,  and,  on 
deep  inspiration,  moist  rales.  I'leiirisy  is  by  no  means  an  uncomniou  com- 
plication. It  Avas  jtrescnt  in  about  S  per  cent  of  the  Munich  aiito|)sies. 
It  may  develop  at  the  outset — pleuro-typhoid — or  slowly  during  convales- 
cence, in  which  case  it  is  almost  always  purulent.  Pneumothorax  occa- 
sionally develops.  Hale  White  has  reported  two  cases,  in  both  of  which 
])leurisy  existed.  The  condition  may  be  due  to  straining,  or  to  the  rup- 
ture of  a  small  pyivmic  abscess.  Another  occasional  pulmonary  comjilica- 
tion  is  luondpfiisis,  Avliich  I  once  saw  at  the  height  of  the  disease.  It  nuiy 
occur  also  during  convalescence.  After  death,  no  lesions  of  the  lungs  or 
bronchi  were  discovered.  Creagh  reports  a  case  in  which  the  ha.'moptysis 
caused  death. 

Nervous  System. — Cereiro-spifial  Form. — As  already  noted,  the  disease 
may  set  in  with  intense  and  persisting  headache,  or  an  aggravated  form 
of  neuralgia.  There  are  cases  in  which  the  effect  of  the  poison  is 
manifested  on  tV  nervous  system  early  and  with  the  greatest  intensity. 
There  are  headiiclie,  photophobia,  retraction  of  the  neck,  marked  twitcli- 
ings  of  the  muscles,  rigidity,  and  even  convulsions.  In  such  cases  the  diag- 
nosis of  meningitis  is  invariably  made.  I  have  examined  post  mortem  three 
such  cases,  in  two  of  which  the  diagnosis  of  cerebro-spinal  fever  had  been 
made.  In  not  one  of  them  was  there  any  trace  of  meningeal  inflannnation, 
only  the  most  intense  congestion  of  the  cerebral  and  spinal  pia.  Menin- 
gitis, however,  nuiy  occur,  but  is  extremely  rare,  as  shown  by  the  Munich 
record,  in  which  there  were  only  11  among  the  2,000  cases.     Convulsions, 


TVIMlolI)    KKVMR. 


20 


on 


diag- 
thrce 
been 
iitioii, 
eiiin- 
Linic'li 
sioiis, 


iimi'ki'd  oj)istlu)tonos,  strtibisinus,  1111(1  signs  of  iiivolvcmont  of  tlif  criiiii;!! 
iicrvi's  iin-  iic'ccssury  in  tyi)lioi<l  Fever,  as  in  ])iieuiiioiiia,  for  the  positive 
diagnosis  of  meiiiiigilis.  A  iiuinber  of  genuine  eases  Iiave  been  reported 
of  late  years,  and  tiie  literature  is  (jtiile  fully  given  by  Olilniaelu'r  *  to 
.May,  1S!)T.  WOlIf  lias  ('((Ueeted  174  eases  in  \vlii<'ii  a  ba('teri()b)gieal  exam- 
ination was  made;  in  only  3.87  per  cent  woro  the  typhoid  ba<'illi  found. 
Marked  eonviilsivo  niovcnieiits,  local  or  general,  whh  eonia  and  delirium, 
ure  seen  also  in  thromliosis  of  the  cerebral  veins  and  sinuses. 

Jh'lin'/iDi,  usually  [iresent  in  very  severe  eases,  is  certainly  less  fre<|Uent 
under  ii  rigid  plan  of  hydrotherajiy.  It  may  exist  from  the  outset,  but 
usually  does  not  develop  until  the  second  and  sometimes  not  until  the 
third  week.  It  may  bo  alight  and  only  nocturnal.  It  is,  us  a  rule,  a  (piiet 
delirium,  though  there  uro  cases  in  whiidi  the  patit'iit  is  very  noisy  and 
constantly  tries  to  get  out  of  bed,  and,  unless  carefully  watched,  may  es- 
cape. The  patient  does  not  often  become  nuiniaeal.  In  heavy  drinkers 
the  delirium  may  have  the  character  of  delirium  tremens.  Even  in  cases 
which  have  no  positive  delirium,  the  mental  processes  are  usually  dulled 
and  the  aspect  is  listless  and  apathetic,  in  severe  cases  the  jiatient  passes 
into  a  condition  of  unconsciousness.  The  eyes  may  be  open,  but  he  is  ol)- 
livious  to  all  surrounding  circumstances  and  neither  knows  nor  cun  indi- 
cate his  wants.  The  urine  and  fieces  are  passed  involuntarily.  In  this 
pseudo-wakeful  state,  or  coma  vigil,  as  it  is  called,  the  eyes  are  open  and 
the  patient  is  constantly  muttering.  The  lips  and  tongue  are  tremulous  ; 
there  are  twitchings  of  the  fingers  and  wrists — suhsultus  ten<liniim  and 
carphologia.  lie  picks  at  the  liedelothes  or  grasps  at  invisible  olijects. 
These  are  among  the  most  serious  symptoms  of  the  disi'ase  and  always 
indicate  danger. 

Coiirnlsiaiix  in  typlioid  tVvi'r  ari'  rare.  In  children  they  may  occur  at 
the  onset.  In  Septenii)cr,  ISilCi,  u  child  of  ten  years  was  admitted  in  coma 
following  a  sudden  convulsion  after  a  full  meal.  This  was  the  starting- 
point  of  a  severe  attack  of  tyjihoid.  Their  rarity  nuiy  be  gathered  from  the 
fact  that  in  5?, 000  cases  Murchison  only  met  with  convulsions  in  (!.  Tlu'y 
may  be  associated  with  an  acute  ence])lialitis  or  with  thrombi  in  the  arte- 
ries or  in  the  veins.  In  the  case  of  my  late  assistant,  Dr.  Opjienheimer,  the 
convulsions  developed  on  the  eighth  day  of  the  fever,  and  proved  fatal  in 
twelve  hours.  Thrombosis  of  the  branches  of  the  left  middle  cerebral 
artery  was  found.  In  other  instances,  as  in  one  reported  by  J.  \\.  Moore, 
no  brain  lesions  are  found.  In  very  nervous  women  I  have  seen  hysterical 
convulsions. 

Neuritis^  Avhicli  is  not  uncommon,  may  be  local,  or  a  widesjiread  affec- 
tion of  the  nerves  of  the  legs  or  of  both  arms  and  legs. 

Local  Xcuritis. — This  may  occur  during  the  height  of  the  fever  or  after 
convalescence  is  established.  It  may  set  in  with  agonizing  pain,  and  with 
sensitiveness  of  the  affected  nerve  trunks.  In  two  instances  I  have  seen 
gi-eat  tenderness  of  the  muscles,  and  some  of  tliese  may  be  cases  of  nwo- 

*  Journal  of  Aiiicviean  ^Icdiciil  Association,  1897,  ii. 


80 


SI'KCIKIC  INFKCTIOI'S  DISIOASKS. 


nitis.  Tlicro  niny  Ik'  cxtrcnic  HciisitivcncHrf  of  tlic  niusdivs  without  iiiiy 
siifiiaof  neuritis.  The  coiuiitioii  niiiy  siihsidi'  without  h-iiviii;,'  any  iiti'(»|ihy. 
Thi'  loc'ul  neuritis  followin;;  tyi)Ii(»i(l  fever  may  alTeet  the  nerves  of  an  arm 
or  of  H  1(%  ami  involve  chielly  the  extensors,  so  that  there  is  wrist-drop  or 
foot-drop  of  the  iilTeete<l  lind».  Some  of  the  cases  are  very  dillieult  to 
se})arate  from  those  with  poliomyelitis. 

A  curious  condition,  prol)al)ly  a  local  m-uritis,  is  that  which  was  llrst 
(lescril)ed  hy  llandi'(»nl  as  {cnibr  tars^  and  which  ap|)ears  to  he  much  moro 
common  after  the  cold-hath  treatment.  'J'he  tips  and  pads  of  the  toes, 
rarely  the  pads  at  their  hases,  become  ex(|uisitely  sensitive,  so  that  the 
]»atietit  can  not  hear  the  wcijjht  of  tlm  he(h'lothes.  There  is  no  discoloi'a- 
tion  and  no  swelling',  and  it  disai»pears  usually  within  a  week  or  fi-n  days. 

Miillipio,  neiin'/is  in  typhoid  ^'"ver  develojjs  usually  during'  convales- 
cenco.  The  le^s  may  h(!  att'ected,  or  the  four  extremities.  The  cases  are 
often  dillieult  to  dilTerentiate  from  those  with  subacute  poliomyc-litis.  l{e- 
covery  is  the  rule.  Of  4  cases  with  involvement  of  arms  and  le^'s,  ;)  recov- 
ered completely  and  1  improved  (Studies  Jl). 

Poliomyelitis  may  (levelo[)  with  the  symptoms  of  acute  asceiuliuj;  paral- 
ysis ami  prove  fatal  in  a  few  days.  More  fre(|uently  it  is  less  acute,  and 
causes  either  a  paraple<;ia  or  a  limited  atroi)hic  paralysis  of  one  arm  or  le^. 

llciiiiplrfiin  is  a  ran;  com])lication.  I-'raucis  Hawkins  has  collected  17 
cases  from  the  literature  ;  a[)liasia  was  ])resent  in  \'Z.  'Y\w  lesion  is  usually 
thrombosis  of  the  arteries,  less  often  a  meniugo-encephalitis.  The  aphasia 
in  children  often  disappears  (Studies  III). 

True  tcfioiji  occurs  sometimes,  and  a  number  of  cases  have  devclojied 
in  certain  epidemics.  It  may  set  in  durinjo^  the  full  hei,i,'ht  of  the  disease. 
This  comp''  ation  is  extri-mely  rare  in  this  country,  antl  Janeway,  so  far  as 
I  know,  has  alone  reported  instances. 

Post-febrile  insanifi/  is  perhaps  moro  frecpiont  after  typhoid  than  after 
any  other  disease.  Wood  regards  it  as  confusional  insanity,  the  result  of 
impaired  nutrition  and  exhaustion  of  the  nervous  centres.  Five  cases 
have  come  under  my  observation,  in  four  of  which  recovery  took  place 
(Studies  I). 

Special  Senses. — Ei/c. — Conjunctivitis,  simple  or  phlyctenular,  sometimes 
with  keratitis  and  iritis,  nuiy  develop.  Panophthalmitis  has  been  reported 
in  one  case  in  association  with  ha?niorrha!?e  (Finlay).  Loss  of  acconnnoda- 
tion  may  occur,  usually  in  the  asthenia  of  convalescence.  Oculo-motor 
paralysis  has  been  seen,  due  probal)ly  to  neuritis.  Retinal  luvmorrhages 
nuiy  occur  alone  or  in  association  with  other  ha^morrhagic  features.  Double 
optic  neuritis  has  been  described  in  the  course  of  the  fever.  It  may  bo 
independent  of  meningitis.  Atrophy  may  follow,  but  these  complications 
are  excessively  rare.  Cataract  may  follow  inflamnuition  of  the  uveal  tract. 
Other  rare  complications  are  thrombosis  of  the  orbital  veins  and  orbital 
luemorrhage.  (See  De  Schweinitz  in  Keen's  monograph  for  full  considera- 
tion of  the  subject.) 

£(ir. — Otitis  media  is  not  infr'-quent,  ^.5  per  cent  in  Ilongst's  collected 
cases.     AVo  have  never  found  the  typhoid  bacillus  in  the  discharge.     Seri- 


TYIMIOin   FKVRR. 


81 


■icase. 
far  as 

after 

lUlt  of 

cases 

place 

times 
)()rted 
iiioila- 
inotor 

liages 
double 
nay  be 

itions 

tract, 
jrbital 

idei'a- 

k'cted 
Seri- 


ous results  arc  rare ;  ojily  one  case  of  mastoid  disoivso  occurri'd.  Tlio  otitia 
may  set  in  with  a  chill  and  an  afjjjravation  of  the  fever. 

Renal  System. — Kctcntlon  of  urine  is  an  early  symi)tom  in  numy  eases, 
ami  is  more  fr('(|ueut  in  some  cpidemirs  than  in  others.  The  condition 
may  recur  for  several  \vcel\s.  'I'he  urini'  is  usually  diminished  at  lirst,  has 
the  ordimiry  febril.characters,  and  the  [)i;,MUents  are  iiu'reaseil.  Later  in 
tlu^  disease  it  is  more  abundant  and  li;4hter  in  color. 

Khrlicli  has  descrilx'd  a  reaction,  which  he  believes  is  rarely  nu>t  with 
exeept  in  typhoid  fever.  This  so-called  (liii):()-r(iirtltiii,  is  ])roduce(l  as  fol- 
lows :  Two  solutions  are  employi'il,  ki'pt  in  separate  bottles  :  one  c(»ntainin<^ 
a  .saturated  solution  of  suli>hanilic  acid  in  a  solution  of  hydroiddoric  acid 
(50  cc.  to  1,()()()  cc.);  the  other  a  half  i)er  cent  solution  ^^i  sodium  nitrite. 
To  make  the  test,  a  few  cnl)ic  centimetres  of  urine  are  jjlaccd  in  a  snniU 
test-tube  with  a)i  e((ual  (|uantity  of  a  mixture  of  the  solution  of  the  sul- 
l>hanilic  acid  (K)  cc.)  and  the  sodium  nitrite  (1  cc),  the  whole  bein<; 
thoroujjhly  shaken.  One  cubic  centimetre  of  ammonia  is  then  allowed 
to  How  carefully  down  the  side  of  the  tube,  t'ormin<(  a  colorless  zcme  above 
the  yellow  uriiu',  and  at  the  junction  of  the  two  a  deep  brownish-red 
ring  will  be  seen  if  the  reaction  is  ])resent.  With  normal  urine  a 
lighter  brownish  ring  is  pntdueed,  without  a  shade  of  red.  The  color  of 
the  foam  of  the  mixed  urine  and  reagent,  and  the  tint  they  produce 
when  largely  diluted  with  water,  are  characteristic,  being  in  i)oth  cases 
of  a  delicate  rose-red  if  the  diazo-reaction  be  present ;  l)ut  if  not,  l)rown- 
ish-yellow. 

It  was  present  in  lot!  of  190  cases  examined  at  my  cliiU(^  (llewetson, 
Studies  I).  It  may  be  present  previous  to  the  occurrence  of  the  rash,  and 
as  late  as  the  twenty-second  day.  The  value  of  the  test  is  lessened  by  its 
occurrence  in  cases  of  miliary  tuberculosis,  and  occasionally  in  the  acute 
diseases  associated  with  high  fever.  The  toxicity  of  the  urine  is  much 
increased  in  typhoid  fever,  and  the  toxic  products  are  eliminated  in  greater 
(quantities  in  cases  treated  with  the  cold  bath. 

The  renal  complications  in  typhoid  fever  may  bo  thus  grouped  : 

{(i)  Febrile  albuminuria,  which  is  very  common  and  of  no  special  sig- 
nificance;  thus,  in  the  iirst  tV,)  cases  admitted  to  the  Johns  Hopkins  Hos- 
pital albuminuria  was  noted  in  1(54,  Avith  tube-casts  in  lO.'J. 

{!))  Acute  nephritis  occurring  at  the  onset  or  during  the  heiglit  of  the 
disease — the  ncpliro-fi/phns  of  the  fiermans,  the  p^errc  fi/jt/io'ide  a  fonne 
renale  of  the  French — may  set  in,  witli  all  the  sym])toms  of  the  most  in- 
tense Bright's  disease,  masking  in  many  instances  tlie  true  nature  of  the 
malady.  After  an  indisposition  of  a  few  days  there  may  be  fever,  pain  in 
the  back,  and  the  passage  of  a  small  amount  of  bloody  urine.  In  2i  of  the 
220  cases  evidence  was  present  of  a  delinite  nephritis — much  albumin  and 
many  tube-casts.  In  10  there  were  also  red  blood-corpuscles.  In  2  there 
was  a  genuine  hfemorrhagic  nejdiritis.  Seven  of  these  21  cases  died — 5 
from  perforation,  not  one  from  the  renal  complication. 

{<■)  The  nephritis  of  convalescence.  This  is  more  common  but  less 
serious.    It  develops  after  the  fall  of  the  fever,  and  is  usually  associated 


82 


Sl'KCiriC   IN'KKCTlol'S   IHSKASKS. 


with  awlonirt.     Tt  (locH  lint  inT'Mcnt  rhariicfcrs  dilVc  rrtit   frntn  tin- ordiiuiry 
lio.-it-l'i'ltrilc  n('])liritiH. 

(i/)  The  n'iiiiirl<ahh'  lyniphoniatdiis  nephritis,  (h-scrihcd  hy  li.  \\'a;;nt'r 
niul  othtTH,  ami  ah'i'udy  referred  [a  in  tlic  section  on  niorhid  anatomy,  pro- 
(liieert,  as  u  rule,  no  Hyniptonis. 

(r)  f'l/nriff  is  a  not  uneornTnoii  eoinplieation.  lllumer  (Studies  II)  Imm 
reporteil  10  eases  in  my  wards,  in  7  the  eohtii  haeillus  was  present,  in  i 
tiu!  typhoid  bueilluH,  and  in  I  the  Htaphyloeoeeus  ulhnM. 

(/)  /'os/-fi//)/itiiil  J'l/i'lifis. — In  this  tlie  pelveH  of  tho  kidney  and  the 
calicH'H  are  at  lirst  eovered  with  a  meml)ranons  exinhition,  hut  erosicm  and 
ideeration  may  std»se(|nently  occur.  Tliere  may  Ite  blood  and  pus  in  the 
uriiu*.  This  condition  occurn-d  in  ;{  of  my  eases,  in  one  of  which  it  was 
us8()(!iate(l  with  extoiiHivo  nu'inhranous  inllammation  of  tho  bladder. 

Sim|ile  catarrh  of  the  bladder  is  rare. 

Orr/ii/is  is  oeeasionally  met  with  durinj;  convaU'scenee.  Sadrain  col- 
lected K)  cases  in  the  literature.  It  is  usually  associated  with  a  catarrhal 
urethritis.  Induration  or  atrophy  may  occur,  ami  more  rarely  sup|)ura- 
tion.  In  ono  cuso  double  hydrocele  developed  suddeidy  on  the  luneteenth 
day  (I)unla])). 

Osseous  System. — .\mon^'  tlu^  nu)st  eommou  aiul  troublesonu'  of  tho 
He(|uelie  of  the  diseas(!  an;  the  ftoiw  Irsimis.  Of  '^;{7  cases  collected  l)y 
Keen  there  were  ]icriostitis  in  110,  lu'crosis  in  Sfi,  uiid  caries  in  1;J.  They 
are,  I  am  sure,  much  more  frecjuent  than  the  litrurcs  indicate.  Six  cases 
came  under  my  notice  in  tho  course  of  a  year,  and  I'di'med  the  basis  of 
I'arsons'  paper  (Studies  II).  The  le<:s  are  chielly  involvi'd.  In  Keen's 
series  the  til)ia  was  alVi-cted  in  1)1  cases,  the  ril»s  in  -10.  A  majority  of 
the  cases  occur  after  convalesceiu'e  is  established.  Of  51  oases  in  whi(di 
l)aoteriol(),ixioal  examinations  were  made,  in  \'.\  pyo^'enic  bacteria  were  i'ountl ; 
in  ;}8  there  were  typhoid  bacilli  (Keen).  The  typho  '  bone  lesion  is  apt 
to  form  what  the  old  writers  called  a  cold  abscess  udy  a  few  of  the 
cases  are  a(nite.  Chroiucity,  iiulolence,  and  a  remarkable  tendency  to 
recnirrence  are  perhaps  the  three  most  striking  features  of  tho  ty}du)id 
bone  lesions.  If  not  thoron<i;hly  treated  sinuses  nuiy  renuiin,  and  typhoid 
bacilli  have  boon  found  in  these  old  lesions  for  as  long  as  seven  or  nH)re 
years. 

AiiJin'fis  is  fu'  ^f^nsidered  in  Keen's  nioiU)graph.  Rheumatic  and 
septic  forms  are  )ed,  as  well  as  a  typhoid  arthritis  proper.     1'ho 

complication  li^'t'ly  T^'<^ro,  and  yet  Keen  has  collected  from  the 

literature  8  .     One  of  the  most  important  points  relating  to  it  is 

the  frcqucncj    yith  which  spontaneous  dislocations  occur,  particularly  of 
the  hip. 

Ti//)Iioi(l  Spine. — There  is  a  remarkable  disorder  of  convalescence  to 
which  CJibney  has  given  this  name.  Tho  j)ationt  has  usually  been  \\\^  and 
about,  and  nuiy  have  had  a  slight  jar  or  sliock,  after  which  he  complains 
of  great  pain  in  the  back,  and  of  pain  on  moving  tho  legs.  'J'he  condition 
may  persist  for  weeks  without  fever  or  any  signs  of  Pott's  disease,  spondy- 
litis,  or  neuritis;  but  there   are   usually  marked  nervous   or   hysterical 


TNIMUMK    I'KVKU. 


and 

The 

In  tho 

it  is 
Irly  of 

Ice  to 


i)  and 
Main? 


Iition 


Hyniptoins.  Tlu'  outlook  is  •.'ooil.  It  i-i  not  known  n]i<ni  wluit  tills  coii- 
(liti(»ii  (li'|tt'n»l-i.  It,  scfiin  to  1m'  11  neurosis  ral  lirr  I  liaii  a  |ii'ris|iiinilylilis 
(  >l  inlics  I). 

'I'lic /////Av/r.-*  may  I'f  the  seal  of  tlic  (lr;,'('n('ration  aln-atly  rrrnTi'il  to, 
but  it  riu'v'ly  caiisi's  any  syinptoiu-.  Ila'riiorrlia;,'e  occusionally  occurs  into 
I  he  uiuscU's,  ami  late  in  |irotnictcil  cases  al»scesses  imiy  develop,  sometimes 
in  or  lietwccu  till'  alidominal  muscles. 

Post-typhoid  SepticeBmia  and  PyeBmia.  Following,'  severe  and 
prolracti'd  cases  there  may  l>c  si;,'ns  of  se|»l  ic  iMl'i-eiiou.  After  the  del'cr- 
veseeiiee  the  patient  may  in  a  week  or  so  present  ii  slijrht  fever,  risin;,'  to 
1 1)1)  or  IDI  ,  with  sweats  and  weakness,  hul  with  no  slj,'ns  other  than  revei- 
to  indicate  ii  relai»se.  'riiere  may  he  with  this  I'ccurrin^'  cliill.-!,  ol'len  of 
;ireat  severity.* 

Tyijlioid  [tya'tnia  has  its  chief  manifestation  in  multipli^  ahscesses, 
which  are  hy  no  means  uncommon  in  |)i'otracted  cas(>s.  In  a  majority  of 
instances  tlu'se  are  sul)culam'ous,  or  they  nniy  take  the  form  of  ixtils,  situ- 
ateil  ahout  the  huttocks,  the  calves,  the  thi^dis,  the  axilhe,  (M-  sh<tulders. 
iiiteriial  ahscesses  arc  less  common.  \\\'  have  had  in  the  hospital  scvi'rai 
iiistances  of  extensive!  ]ierirectal  aiisccss,  and  I  saw  with  l)r.  Salzer  an  ex- 
tensive perinephric  altscess.  In  no  case  from  the  hoils  or  fi'oin  the  suhcu- 
tatu'ous  ahscesses  has  the  typhoiil  l)a(nllus  heen  isolated  in  my  wards. 

Association  of  other  Diseases.  —  Mrysipelas  is  a  rare  complica- 
titm,  most  commonly  met  with  diirin<^  convalescence.  In  1,4'^()  cases  at 
Masel  it  occurred  10  times,  (iriesiiiger  states  that  it  is  met  with  in  2 
]>er  cent. 

Measles  nniy  develo])  during;  the  fever  or  in  convalescence.  Chi(d<en- 
])ox  and  niuna  liavi*  heen  rcporteil  in  children.  I'seudo-mcmhraiioMs  in- 
tlammatioiis  may  oc(mr  in  the  pliaryn.x,  larynx,  or  ^'cnitals.  Malarial  and 
typhoid  fevers  nniy  he  associatecl,  hut  a  majority  of  the  cases  of  so-called 
typho-malarial  fever  arc  either  remittent  malarial  fever  or  true  typhoid. 
It  is  interestinj^  to  note  that  amon^'  the  (IS")  cases  of  typhoid  ft^ver  in  not  a 
sinju'le  instance  were  the  plasmodia  found  in  the  blood  dui'ini,'  (he  courses 
of  the  disease.  Manv  of  our  tvphoid  fever  eases  came  from  malaiMous 
regions. 

Typhoid  fever  may  attack  an  individual  the  subject  of  tuliercidosis. 
Ill  I  of  my  so  autopsies  tuberculous  lesions  coexisted  M'ith  those  of  typhoid 
fever.  Miliary  tuberculosis  occasionally  developed  ufter  it,  but  my  ])er- 
soual  experience  does  not  warrant  the  belief  held  by  some  writers,  that 
there  is  a  greater  susceptibility  to  tuberculosis  after  typhoid  than  after 
othi'r  fevers.  Acute  miliary  tuberculosis  and  typhoid  fever  have  been  met 
with  in  the  same  subject. 

\n  epilepsy  and  In  chronic  chorea  the  fits  and  movements  usually  c(>aso 
during  an  attack,  and  in  typhoid  fever  in  a  diabetic  subject  the  sugar  may 
be  absent  during  the  height  of  the  disease. 

Varieties  of  Typhoid. — Typhoid  fever  presents  an  extremely  com- 


lon 


leric! 


dv- 


*  See  paper  on  Cliilis  in  Typlioid  Fever  (Studies  II). 


34 


SPECIFIC  INFECTIOUS  DISEASES. 


plox  symptomatolof]^}'.  ^laiiy  forms  liavo  been  described,  some  of  wliich 
present  exuggenitioii  of  coniinou  syinptoms,  otlier.s  niodilieiitioii  in  the 
course,  others  u^^uin  greater  intensity  of  action  of  the  i)()is<)n  on  certain 
orijans.  As  avc  liave  seen,  wlien  the  nervous  system  is  si)ecially  involved, 
it  has  l)een  called  the  cerebro-spinal  form  ;  when  the  kidneys  are  early  and 
severely  alTected,  nejjhro-typhoid  ;  when  the  disease  ])(\i;-ins  with  })ulm(i- 
nary  symptoms,  pneumo-typhoid  ;  wJtli  pleurisy,  pleuro-typhoid  ;  when  the 
disease  is  characterized  throughout  by  profuse  sweats,  the  sudoral  form 
of  the  disease.  It  is  a  mistake,  I  think,  to  recognize  or  speak  of  these  as 
varieties.  It  is  enough  to  remend)er  that  typhoid  has  no  fixed  and  con- 
stant course,  that  it  nuiy  set  in  occasionally  with  symptoms  localized  in 
certain  organs,  and  that  many  of  its  symptoms  are  extremely  varia])le — in 
one  epidemic  uniform  and  text-book-like,  in  another  slight  or  not  met  with. 
This  diversified  symptonnitcdogy  has  led  to  numy  clinical  errors,  and  in  tlie 
absence  of  the  salutary  lessons  of  morbid  anatomy  it  is  not  surprising  that 
practitioners  have  so  often  been  led  astray.  We  may  recognize  Avitii  Mur- 
chison  the  follov  'ng  varieties  : 

1.  The  milu  «iud  abortive  forms.  It  is  very  important  for  the  practi- 
tioner to  recognize  the  mild  ty])e  of  typhoid  fever,  often  spoken  of  as 
gastric  fever  or  oven  regarded  as  simple  febricula.  In  this  form,  the 
typhus  lerif^sinnis  of  (Jriesinger,  the  symptoms  are  similar  in  kind  but 
altogether  less  intense  than  in  the  graver  attacks,  although  the  onset  may 
1)0  sudden  and  severe.  The  temperature  rarely  reaches  103°,  and  the 
fever  of  onset  may  not  show  the  gradual  ascending  evening  record.  The 
spleen  is  eidarged,  the  rose-spots  may  be  marked ;  often  they  are  very 
few  in  number.  The  diarrhoea  is  variable,  often  it  is  not  present.  lu  such 
eases  the  symptoms  n^-iy  persist  for  from  ten  to  fourteen  days. 

In  the  abortive  form  the  symptoms  of  onset  may  be  marked  with  shiv- 
ering and  fever  of  103°  or  e\en  higher.  The  date  of  onset  is  often  defi- 
nite, a  point  npon  which  Jiirgensen  lays  great  stress.  Rose-spots  may 
occur  from  the  second  to  the  fifth  day.  Early  in  the  second  week  or  at 
the  end  of  the  first  week  the  fever  falls,  often  with  profuse  sweating,  and 
convalescence  is  established.  In  this  abortive  form  relapse  may  occur  and 
may  occasionally  prove  severe.  AVhen  typhoid  fever  prevails  extensively 
these  cases  are  not  nncommon,  I  agree  with  J.  C.  AMlson,  who  states  that 
they  are  not  nearly  so  common  in  this  country  as  in  Europe. 

2.  The  (/7'ave  form  is  usually  characterized  by  high  fever  and  pro- 
nonnced  nervous  symptoms.  In  this  category,  too,  come  the  very  severe 
cases,  setting  in  with  pneumonia  and  Bright's  disease,  and  with  the  very 
intense  gastro-intestinal  or  cerebro-spinal  symptoms. 

3.  The  latent  or  ambulatory  form  of  typhoid  fever,  which  is  particu- 
larly common  in  hospital  practice.  The  symptoms  are  often  very  slight, 
and  the  patient  scarcely  feels  ill  enough  to  go  to  bed.  He  has  languor, 
perhaps  slight  diarrhaui,  but  keeps  about  and  may  even  attend  to  his  work 
throughout  the  entire  attack.  In  other  instances  delirium  sets  in.  The 
worst  cases  of  this  form  are  seen  in  sailoi's,  who  keep  up  and  about,  though 
feeling  ill  and  feverish.     When  brought  to  the  hospital  they  often  develop 


t< 
tl 

'k<^ 

dii 

jnil 

th( 

cai- 

A'i( 


[h  shiv- 
•11  deti- 
3  miiy 
or  at 

g,  and 
and 

■cly 
!S  that 


11S1V( 


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le  very 

lirticu- 
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[iguor, 

work 

The 

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jvelop 


TYIMIOTD   FKVKIl. 


85 


symptoms  of  a  most  severe  type  of  the  disease.  ira>morrliage  or  perfora- 
tion may  he  the  first  marked  symptom  of  this  amhuhitory  type.  Sir  W. 
Jeniier  lias  calU'd  attention  to  the  dangers  ol"  tliis  foi-m,  and  partietdarly 
to  tlie  grave  prognosis  in  the  case  of  persons  who  liave  travcU'd  i'ar  witii 
tiie  disease  in  progress. 

Jf(('nion'Ji((//ic  Ti/j)i(oid  Fever. — This  is  excessively  rare.  Among  Ons- 
kow's  n,5i;J  cases  there  were  only  4  deaths  with  general  luvniorrhagic 
diathesis.  Oidy  one  instance  was  ])resent  in  our  (isr)  cases.*  Ha-niorrhages 
may  ho  marked  from  the  cnitset,  hut  more  commonly  they  develoj)  during 
the  course  of  the  disease.  The  condition  is  not  necessarily  fatal.  Our 
case  recovered,  as  did  several  of  those  ri'ported  1)y  Xicholls  from  the  Royal 
^'ictoria  Hospital,  Montreal. 

An  afebrile  typhoid  fever  is  recognized  hy  authors.  Liehermeister  says 
that  the  cases  were  not  uncommon  at  Hascl.  The  patients  pi'csonted  las- 
situde, depression,  headache,  furred  tongue,  loss  of  appetite,  slow  pulse, 
and  even  the  spots  and  enlarged  spleen.  I  have  no  personal  knowledge  of 
such  cases. 

Typhoid  Fever  in  Children. — Cases  are  not  uncommon  under  the  age 
of  ten,  hut  the  disease  is  rare  in  infants  under  two  years  of  age.  Cases 
have  heen  reported,  however,  in  sucklings  (nine  months.  Fuller  ;  four  and 
a  half  months.  Ogle),  and  perforation  has  heen  met  with  in  an  infant  five 
days  old.  Epistaxis  ra/cly  occurs  ;  the  rise  in  temperature  is  less  gradual ; 
the  initial  hronchial  catarrh  is  often  ohserved.  The  nervous  symptoms  are 
often  prominent ;  th  ere  are  wakefulness  and  delirium  ;  diarrluea  is  often 
ahsent.  The  rash  may  he  very  slight,  hut  the  most  cojiious  eruption  I 
have  ever  seen  was  in  a  child  of  eight.  The  ahdominal  symptoms  are 
often  mild.  Fatal  haemorrhage  and  perforation  are  rare.  Among  the 
sequelte,  aphasia,  noma,  and  hone  lesions  may  be  mentioned  as  more  com- 
mon in  children  than  in  adults.  The  mortality  of  typhoid  fever  in  chil- 
dren is  low.  In  cases  fatal  early  in  the  disease  only  a  careful  hacterio- 
logical  examination  can  decide  whether  the  swollen  Peyer's  patches  and 
mesenteric  glands — not  uncommon  in  children  with  fever — depend  upon 
infection  with  typhoid  hacilli. 

Typhoid  Fever  in  the  Aged. — After  the  fortieth  year  the  disease  runs  a 
less  favorable  course,  and  the  mortality  is  very  high.  Of  04  fatal  cases, 
7  were  over  forty  years  of  age  ;  1  was  aged  sixty-three,  another  seventy. 
The  fever  is  not  so  high,  but  complications  are  more  common,  particu- 
larly pneumonia  and  heart-failure. 

Typhoid  Fever  in  Pregnancy. — The  disease  is  rare  in  pregnant  women. 
Only  1  case  occurred  in  our  (585  cases.  The  majority  of  the  patients  are  af- 
fected during  the  first  half  of  pregnancy.  Abortion  or  premature  delivery 
follows,  usually  in  the  second  week  of  the  disease — in  100  of  310  cases  col- 
lected by  Sacquin.  The  mortality  in  pregnant  women  with  typhoid  fever 
is  high — 19  in  91  cases  ^i3rieger),  17  per  cent  in  183  cases  collected  by 
Yiiiay.    The  experience   of  Brand  and  of  the  physicians  of  the  Lyons 

*  Hamburger,  Iliemorrhagic  Form  of  Typhoid  (Studies  III). 


86 


SPECIFIC   INFECTIOUS  DISEASES. 


school  would  show  thut  tlio  cold-hiitli  treiitnient  is  not  only  not  contra- 
in(li(!iit('(l,  hut  most  eltioacious. 

Typhoid  Fever  in  the  Fostus. — \V.  Fordyco,  avIio  luis  roofutly  studied 
the  (jucstion  most  th<)i'ou,i,dily,  concludes  us  follows:  (1)  That  typhoid 
tV'Vcr  could  be  comnuiniciited  to  the  lictus  in  ulvro  ;  {"i)  thut  cs  ii  result  of 
tliis  infection  the  f(ctus  nu<,dit  die,  und  ho  expelled  preniiiturely  ;  {'.))  thut 
the  I'u'tus  mi^dit  he  lioni  alive  hut  weakly,  and  evidently  sulfering  from 
the  infection  ;  (4)  that  the  fo'tus  mi;,dit  he  horn  alive  and  healthy,  haviui; 
passed  t'.irou,i,di  the  infection  in  nfrra.  Fiiudly,  tlie  infection  of  the  cliild 
did  not  ne(;essai'ily  follow.  This  last  Avas  the  case  in  a  tu'tus  a^ed  iive 
months,  whoso  mother  died  of  typlioid  fever  in  my  wards.  Flcxner  found 
the  hlood  and  tissues  sterile.  J.  P.  C.  (Irillilh  found  the  W'idal  reaction 
in  a  cliild  seven  weeks  old,  horn  when  the  mother  had  typhoid  fever. 

Relapse. — Kelapscs  vary  in  fre(|uen('y  in  dilt'erent  epidemics,  and,  it 
wuuhl  ai)pcar,  in  different  places.  The  percentagi'S  of  dill'erent  authors 
range  from  '.]  per  cent  (Murchison),  11  per  cent  (Biiumler),  to  15  or  18 
per  cent  (Immermann).  In  Wagner's  clinic,  from  LSS:i  to  lM,S(j,  there 
were  49  relapses  in  501  cases.     In  (585  cases  there  were  5-1  relapses. 

AVe  may  recognize  the  genuine,  tlie  intercurrent,  and  the  spurious  re- 
lapse. 

The  tnie  relapse  sets  in  after  complete  defervescence.  Irving  noted  the 
average  duration  of  the  interval  in  his  cases  as  a  little  over  live  days. 

In  one  case  there  was  complete  apyrexia  for  twenty-tliree  days,  followed 
by  a  relapse  of  forty-one  days'  duration ;  then  apyrexia  for  forty-two  days, 
followed  hy  a  second  relapse  of  two  weeks'  duration.  As  a  rule,  two  of  the 
three  important  symptoms — steplike  temperature  at  onset,  roseola,  rjul  en- 
larged spleen — should  be  present  to  justify  the  diagnosis  of  a  relapse.  The 
intestinal  symptoms  are  variable.  The  onset  may  be  alu-upt  with  a  cliill, 
or  the  temperature  may  have  a  typical  steplike  ascent,  as  shown  in  Chart 
I.  The  numl)er  of  relapses  range  from  3  to  5.  Da  Costa  has  twice  seen 
5  relapses.  The  attack  is  usually  less  severe  and  of  shorter  duration.  Of 
Alurchison's  53  cases,  the  mean  duration  of  the  first  attack  Avas  about 
twenty-six  days;  of  the  relapse,  fifteen  days.  The  mortality  of  the  relapse 
is  not  high. 

The  iiifcrcKn'cnt  relapse  is  quite  common.  A  series  of  cases  will  he 
found  in  our  Studies  in  Typhoid  Fever.  ]\Iany  protracted  cases  are  of  this 
nature.  The  temperature  drops  and  the  4)atient  im])roves ;  hut  after  re- 
maining between  100°  and  10-^°  for  a  few  days,  the  fever  again  rises  and 
the  patient  enters  upoii  another  attack,  wliich  may  he  even  more  severe 
than  the  original  one. 

Spurious  relapses  are  very  common.  They  have  already  been  rcfcrri'd 
to  on  page  K!,  under  post-typhoid  elevations  of  temperature.  They  arc 
recrudescences  of  the  fever  due  to  a  number  of  causes.  It  is  not  always 
easy  to  determine  whether  a  relapse  is  present,  particularly  in  cases  in 
which  the  fever  persists  for  only  five  or  seven  days  without  rose-spots  and 
without  enlargement  of  the  spleen. 

The  relapse  shows  a  reinfection  from  within,  but  of  the  conditions  fa- 


TYPHOID  FEVER. 


37 


the 
on- 
The 
hill, 
luirt 
scon 
Of 

)OUt 

;ip.se 

ho 

his 

■r  VL'- 

and 

ovore 

•ri'ed 

V  are 

ways 

's  in 

and 

s  fa- 


voring its  occnrrcnco  we  as  yet  know  little.  Errors  in  diet  are  somotimea 
hold  rosponsihle  and  occasionally  the  rise  in  tomporature  follows  ahruptly 
upon  some  indiscretioii.  Immunity  in  typhoid  is  ac(piired  sk)wly,  and  wo 
know  that  even  for  a  long  period  after  the  fever  has  disappeared  the  ty- 
phoid bacilli  may  be  found  in  the  stools,  in  the  spleen,  and  in  the  mesen- 
teric glands.  Chiari  suggests  tliat  the  reinfection  may  be  associated  with 
the  persistence  of  bacilli  in  the  bile-passages;  an  indiscretion  in  diet  may 
cause  their  discharge  into  the  intestine. 

Diagnosis. -^Thcre  are  several  points  which  the  physician  should  re- 
member. In  the  first  place,  typhoid  fever  is  the  most  common  of  all  con- 
tinued fevers.  Secondly,  it  is  extraordinarily  variable  in  its  manifesta- 
tions. Thirdly,  there  is  no  such  hybrid  malady  as  typho-malarial  fever. 
And  lastly,  errors  in  diagnosis  are  inevitable,  even  under  the  most  favor- 
able conditions.  In  at  least  4  or  5  cases  in  our  series  the  diagnosis  of 
typhoid  fever  was  not  made  until  autopsy. 

Data  for  Diagnosis. — (a)  General — Xo  single  symptom  or  feature  is 
characteristic.  The  onset  is  often  suggestive,  particularly  the  occurrence 
of  epistaxis,  and  (if  seen  from  the  start)  the  ascending  fever.  The  steadi- 
ness of  the  fever  for  a  week  or  longer  after  reaching  the  fastigium  is  an 
important  point.  The  irregular  remittent  character  in  the  third  week 
and  the  intermittent  features  Avith  chills  are  common  sources  of  error. 
While  there  is  nothing  characteristic  in  the  pulse,  dicrotism  is  so 
much  more  common  early  in  typhoid  fever  that  its  presence  is  always 
suggestive.  The  rash  is  the  most  valuable  single  sign,  and  with  the  fever 
usually  clinches  the  diagnosis.  The  enlarged  spleen  is  of  less  import- 
ance, since  it  occurs  in  all  febrile  conditions,  but  with  the  fever  ami  the 
rash  it  constitutes  the  diagnostic  triad  of  the  disease.  The  absence  of 
leucocytosis  and  the  presence  of  Ehrlich's  reaction  are  valuable  accessory 
signs. 

(h)  Specific. — The  Seriim  Dingnosis. — The  diagnosis  of  typhoid  fever  by 
the  isolation  of  the  bacilli  during  life  is  difficult.  Tapping  of  the  spleen 
for  the  purpose  is  not  a  justifiable  procedure.  Cultures  from  the  blood  give 
positive  results  in  only  a  small  num])er  of  instances,  though  during  the  past 
year  they  have  been  obtained  in  (i  cases  in  my  Avards  (X.  B.  (Jwyn).  Cul- 
tures from  the  typhoid  stools  made  by  the  methods  of  Eisner,  Hiss,  and 
others  are  really  not  suitable  for  general  clinical  purposes.  It  was  accord- 
ingly with  great  satisfaction  that  the  announcement  of  a  comparatively 
simple  method  of  serum  diagnosis  was  received.  In  1894  Pfeitt'er  showed 
that  cholera  spirilla  Avhen  introduced  into  the  peritonaeum  of  an  immu- 
nized animal,  or  when  mixed  with  the  serum  of  immunized  animals,  lose 
their  motion  and  break  up.  This  "  Pfeitfer's  phenomenon  "  of  agglutinii- 
tion  and  immobilization  was  thoroughly  and  systematically  studied  by 
Durham,  in  Gruber's  laboratory.  It  is  well,  as  Welch  has  pointed  out,  to 
bear  in  mind  the  importance  of  this  Avork,  since  by  it  Avas  determined 
the  value  of  the  test  for  the  differentiation  of  bacterial  species  and  for  the 
determination  of  a  previous  attack  of  cholera  or  of  typhoid  fever  ;  and  also 
that  the  immobilization  and  agglutination  Avas  a  specific  effect  of  in- 
.3 


3S 


SPECIFIC  INFECTIOUS  DISEASRS. 


fection  or  intoxication.  Widtil  took  the  metliocl  and  made  it  available  in 
clinical  work. 

Method  of  Application. — The  tests,  as  given  by  Widal,  are  as  follows  :  {a) 
MdcroscopicdL — 'J'he  Ijlood  or  serum  to  be  tested  is  added  either  "  to  a  youn,*; 
bouillon  culture  of  the  typhoid  bacillus  or  to  sterile  bouillon,  which  is  then 
at  once  inoculated  with  the  bacillus.  In  the  former  case  the  reaction  with 
typhoid  serum  ajjpears  usually  within  two  or  throe  hours,  and  consists  in 
clarilication  of  the  previously  turbid  fluid  and  the  fornuition  of  a  clumpy 
sediment  composed  of  accumulated  bacilli.  h\  the  latter  case  the  tube  is 
placed  in  the  incubator,  aiul  within  fifteen  hours  the  reaction  is  numifestcd 
by  growth  of  the  bacilli  in  the  form  of  a  sediment  at  the  bottom  of  the 
tube,  the  fluid  remaining  nearly  or  (piite  clear."  (//)  Microsrojjic  Test. — 
The  blood  or  serum  is  mixed  with  "  a  young  bouillon  culture  or  with  a 
suspension  in  bouillon  or  salt  solution  of  a  fresh  growth  of  the  typhoid 
bacillus,  and  a  drop  or  two  of  the  mixture  is  examined  at  once  under  the 
microscope.  With  a  dilution  of  1  to  10  this  microscopic  typhoid  reaction 
appears,  as  a  rule,  iminediately  or  within  a  few  minutes,  and  is  evidenced 
by  loss  of  motility  and  by  clumping  of  the  bacilli  into  nuisses  of  various 
sizes  and  shapes."  Since  then  various  modifications  have  been  introduced 
and  the  dilution  has  been  increased,  as  a  rule  to  1  to  50  or  even  higher. 
Wyatt  Johnston  introduced  the  use  of  the  dried  blood,  which  is  of  great 
convenience,  and  has  developed  the  method  of  work  in  municij)al  labora- 
tories. For  fuller  details  the  student  is  referred  to  the  text-books  of  bac- 
teriology. 

Results. — The  largest  collection  of  cases  has  been  given  by  Kneass  and 
Stengel  (Gould's  Yearbook,  1898).  Of  2,283  typhoid  cases  the  reaction 
was  present  in  95.5  per  cent.  In  1,305  non-typhoid  cases  there  was  no  re- 
action in  98.4  per  cent.  The  experience  in  my  wards  of  Block  and  Gwyn 
up  to  March,  1898,  shows  that  in  151  cases  the  reaction  was  present  in  144. 
In  i  of  the  negative  cases  the  clinical  course  was  not  certain.  A  very  im- 
portant point  is  the  time  of  appearance  of  the  reaction.  In  only  40  of  the 
last  108  cases  was  the  reaction  obtained  on  the  day  of  admission.  In  only 
26  cases  of  the  series  was  the  reaction  present  before  the  seventh  day  of 
the  disease.  It  may  be  long  delayed.  In  4  cases  it  developed  on  the 
twenty-second,  twenth-sixth,  thirty-fifth,  and  forty-second  days  respectively. 

AVliile  on  the  whole  the  serum  reaction  is  of  very  great  value,  there  are 
certain  difficulties  and  objections  which  must  be  considered.  A  perfectly 
characteristic  case  with  haemorrhages,  rose-spots,  etc.,  may  give  no  reaction 
throughout.  A  case  of  this  sort  has  been  reported  from  my  wards  by  Gwyn, 
in  which  a  so-called  paracolon  bacillus  was  repeatedly  isolated  from  the 
blood.  The  Widal  reaction  Avas  not  present  at  any  time  during  the  course 
of  the  disease  or  after  convalescence.  Brill  has  reported  a  series  of  17 
cases  with  the  clinical  features  of  typhoid  fever,  but  without  the  AVidal 
reaction. 

Common  Sources  of  Error  in  Dip  gnosis. — An  early  and  intense  localiza- 
tion of  the  infection  in  certain  organs  may  give  rise  to  doubt  at  first. 

Cases  coming  on  with  severe  headache,  photophobia,  delirium,  twitching 


TYPHOID  FEVER. 


39 


lo  111 


and 


3rfectly 
eaction 

Gwyn, 
om  the 

course 
of  17 

Widal 


ocaliza- 

t. 

itching 


t 


of  the  muscles  and  retraction  of  the  head  are  almost  invariably  rcfjardod  as 
crrchro-spinal  mcni)i(jitix.  lender  such  circumstances  it  may  for  a  few 
days  be  impossible  to  make  a  satisfactory  diaj^nosis.  I  have  thrice  per- 
formed autopsies  on  cases  of  this  kind  in  wiiicii  no  suspicion  of  typhoid 
fever  had  been  present,  the  intense  cerebro-spinal  manifestations  having 
.dominated  the  scene.  Until  the  appearanc^e  of  al)domimil  symptoms,  or 
the  rash,  it  may  be  quite  impossible  to  determine  the  nature  of  tlie  case. 
Cerebro-spinal  meningitis  is,  however,  a  rare  disease  ;  typlioid  fever  a  very 
common  one,  and  the  onset  with  severe  nervous  symptoms  is  by  no  means 
infrequent.  Fully  one  half  of  the  cases  of  so-called  brain-fever  belong  to 
this  category. 

I  have  already  spoken  of  the  misleading  pulmonary  symptoms,  wliiidi 
occasionally  develop  at  the  very  outset  of  the  disease.  The  bronchitis 
rarely  causes  error,  though  it  may  be  intense  and  attract  the  chief  atten- 
tion. More  difficult  are  the  cases  setting  in  with  chill  and  followed  rapidly 
by  pneumonia.  I  have  brought  such  a  case  before  the  class  one  week  as 
typical  pneumonia,  and  a  fortnight  later  shown  the  same  case  as  undoubt- 
edly one  of  typhoid  fever.  In  another  case,  in  which  '^he  onset  was  with 
definite  pneumonia,  no  spots  developed,  and,  though  there  were  diarrhaui, 
meteorism,  and  the  most  pronounced  nervous  symptoms,  the  doubt  still 
remains  whether  it  was  a  case  of  typhoid  fever  or  one  of  pneumonia 
in  which  severe  secondary  symptoms  developed.  There  is  less  danger  of 
mistaking  the  pneumonia  which  develops  at  the  height  of  the  disease,  and 
yet  this  is  possible,  as  in  a  case  admitted  a  few  years  ago  to  my  wards — 
a  man  aged  seventy,  insensible,  with  a  dry  tongue,  tremor,  ecchymoses 
upon  the  wrists  and  ankles,  no  rose-spots,  eiilargement  of  the  spleen,  and 
consolidation  of  his  right  lower  lobe.  It  was  very  natural,  particularly 
since  there  was  no  history,  to  regard  such  a  case  as  senile  pneumonia  with 
profound  constitutional  disturbance,  but  the  autopsy  showed  the  char- 
acteristic lesions  of  typhoid  fever.  Early  involvement  of  the  pleura  or  the 
kidneys  may  for  a  time  obscure  the  diagnosis. 

Of  diseases  with  w^hich  typhoid  fever  may  be  confounded,  malaria, 
certain  forms  of  pyaemia,  acute  tuberculosis,  and  tuberculous  peritonitis 
are  the  most  important. 

From  malnrud  fevei\  typhoid  is,  as  a  rule,  readily  recognized.  There 
is  no  such  disease  as  typho-malarial  fever — that  is,  a  separate  and  distinct 
malady.  Typhoid  fever  and  malarial  fever  in  rare  instances  may  coexist 
in  the  same  patient.  Of  (586  cases  of  typhoid  fever,  almost  all  with  blood 
examinations,  and  a  majority  of  them  coming  from  malarial  regions,  in  not 
a  single  instance  were  the  malarial  parasites  found  in  the  blood  during 
the  fever.  There  is  now  no  excuse  Avhatever  for  the  continued  use  by 
practitioners  of  the  term  typho-malarial  fever,  and  still  less  for  the  falsifi- 
cation of  vital  statistics  by  death  certificates  signed  with  this  diagnosis. 
The  principle  is  bad  and  the  practice  is  worse,  since  it  gives  a  false  sense 
of  security,  and  may  prevent  proper  measures  of  prophylaxis.  The  au- 
tumnal type  of  malarial  fever  may  present  a  striking  similarity  in  its  early 
days  to  typhoid  fever.     Differentiation  may  be  made  only  by  the  blood 


I 


40 


SPECIFIC  INFECTIOUS  DISEASES. 


cxiiminatlon.  There  may  l>e  no  cliills,  the  remissions  may  be  extremely 
sli^'ht,  there  is  a  liistory  periiaps  of  i»iihn'K<\  weakness,  (liurrlnwa,  and  orne- 
times  vomiting.  The  ton<?ue  is  furred  and  wliito,  the  cheeks  Hushed, 
tlie  spleen  slijjhtly  enlar^'ed,  and  the  temperature  continuous,  or  with  very 
sli<rht  remissions.  The  a'stivo-autumnal  variety  of  the  malarial  j)arasite 
may  not  be  present  in  the  circulating  blood  for  several  days.  Every  year 
we  have  one  or  two  cases  in  which  the  diagnosis  is  in  doubt  for  a  few 
days. 

J'l/fonin. — The  long-continued  fever  of  obscure,  deep-seated  suppura- 
tion, without  chills  or  sweats,  may  simulate  typhoid.  The  more  chronic 
cases  of  ulcerative  endocarditis  are  usually  diagnosed  enteric  fever.  The 
presence  or  absence  of  leucocytosis  is  an  important  aid.  The  Widal  reac- 
tion now  oilers  additional  and  valuable  help. 

Acute  niiliurif  tuberculosis  is  not  infrerjuently  mistaken  for  tyi)hoid 
fever.  The  points  in  diiferential  diagnosis  will  be  discussed  under  that 
disease.  Tubercuhms  peritonitis  in  certain  of  its  forms  may  closely  simu- 
late typhoid  fever,  and  will  be  referred  to  in  another  section. 

Puncture  of  the  spleen  for  the  purpose  of  obtaining  cultures  is  justifi- 
able only  in  exceptional  circumstances. 

Prognosis. — (n)  Death-rate. — The  mortality  is  very  variable,  ranging 
in  private  practice  from  5  to  1^  and  in  hospital  practice  from  7  to  ;^0  per 
cent.  In  some  large  epidemics  the  death-rate  has  been  very  low.  In  the 
recent  outbreak  at  Maidstone,  England,  it  was  between  7  and  8  per  cent. 
In  recent  years  the  deaths  from  typhoid  fever  have  certainly  diminished, 
and,  under  the  influence  of  Brand,  the  reintroduction  of  hydrotherajiy 
has  reduced  the  mortality  in  institutions  in  a  remarkable  manner,  even 
as  low  as  5  or  6  per  cent.  Of  the  085  cases  treated  to  January  1,  1808,  in 
my  wards,  8  per  cent  died.  The  death-rate  since  the  introduction  of  hy- 
drotherapy has  been  7.1  per  cent.  The  Metropolitan  Fever  Hospitals  still 
show  a  high  rate  of  mortality — about  17  per  cent — and  Dresclifeld  gives 
17.18  per  cent  as  the  death-rate  in  the  Monsall  Fever  Hospital  for  the  ten 
years  ending  1894.  The  last  Report  of  the  liritish  Army  Medical  Depart- 
ment (1890)  shows  an  increase  in  both  incidence  and  mortality.  Tn  the 
United  States  army  for  ten  years,  to  1890,  there  was  an  average  annual 
prevalence  of  138.5  cases,  with  mortality  of  19.2  per  cent. 

(/>)  Special  Features  in  Prognosis. — Unfavorable  symptoms  are  high 
fever,  toxic  symptoms  Avith  delirium,  meteorism,  and  haemorrhage.  Fat 
subjects  stand  typhoid  fever  badly.  The  mortality  in  women  is  greater 
than  in  men.  The  complications  and  dangers  are  more  serious  in  the  am- 
bulatory form  in  which  the  patient  has  kept  about  for  a  week  or  ten  days. 
Early  involvement  of  the  nervous  system  is  a  bad  indication  ;  and  the  low, 
muttering  delirium  with  tremor  means  a  close  fight  for  life.  Pro.i;  iiostic 
signs  from  the  fever  alone  are  deceptive.  A  temperature  above  10-4°  may 
be  well  borne  for  many  days  if  the  nervous  system  is  not  involved. 

(r)  Sudden  Death. — It  is  difficult  in  many  cases  to  explain  this  most 
lamentable  of  accidents  in  the  disease.  There  are  cases  in  which  neither 
cerebral,  renal,  nor  cardiac  changes  have  been  found ;  there  are  instances 


TYPnOTD  FEVER. 


41 


is  most 
neither 

istancea 


too  in  which  it  does  not  Bpcm  liki'ly  that  there  could  have  l)cen  a  special 
localization  of  the  toxins  in  the  pueumofj^astric  centres.  McPiiedran,  in 
reporting  a  case  of  the  kind,  in  which  the  post  mortem  showed  no  adf- 
(piate  cause  of  death,  suggests  that  the  experiments  of  McWilliam  on  sud- 
ih'n  cardiac  failure  jjrohabiy  explain  tiie  occurrentte  of  death  in  certain  of 
the  cases  in  whicli  neither  embolism  nor  unemia  is  present.  Under  condi- 
tions of  abnormal  nutrition  there  is  sometimes  induced  a  state  of  dt'Iirium 
ran/is^  wlii(di  may  develop  spontaiu'ously,  or,  in  the  case  of  animals,  on 
slight  irritation  of  thci  heart,  with  the  result  of  extreme  irregularity  and 
linally  failure  of  action.  Sudden  death  occurs  more  frt'tpicntly  in  men 
than  in  woinen,  according  to  Dewevre's  statistics,  in  a  projjortion  of  11-t  to 
2('t.  It  may  occur  at  the  height  of  the  fever,  and,  as  pointed  out  by  (J raves, 
may  also  happen  during  convalescence. 

Prophylaxis. — In  cities  the  prevalence  of  typhoid  fever  is  directly 
proportionate  to  the  inelHciency  of  the  drainage  and  the  water-su}»ply. 
Tlu^re  is  no  truer  indication  of  the  sanitary  condition  of  a  town  than  the 
returns  of  the  number  of  cases  of  this  disease.  AVitii  the  improvement  in 
drainage  the  mortality  in  many  cities  lias  been  reduced  one  half  or  even 
more.  One  of  the  most  striking  instances  is  afforded  by  the  city  of  Munich. 
Cliilds  has  recently  reviewed  the  sanitary  history  of  this  town  as  far  as 
typhoid  fever  is  concern('(l,  and  the  iigures  are  truly  astonishing.  The 
annual  mean  death-rate  per  100,000  inha])itants  was  from  1851  to  LSOO, 
W-iA;  from  18(J1  to  ISTO,  li'i.H;  from  1871  to  1880,  11(5.7;  from  1881  to 
1890,  10;  from  18'J1  to  18i)0,  5.0. 

By  most  rigid  methods  of  disinfection  much  may  bo  done  to  prevent 
the  spread  of  the  infection. 

The  following  procedures,  suggested .  by  CJilman  Thompson,  should  bo 
carried  out  in  hospital  practice,  and,  with  modilications,  in  private  houses : 

1.  The  best  disinfectants  of  typhoid  urine  and  stools  for  practical  use 
arc  (i)  a  1  in  500  acidulated  solution  of  corrosive  sublimate;  (ii)  a  1  in  10 
crude  carbolic-acid  solution;  (iii)  chlorinated  lime. 

2.  Owing  to  the  possibility  of  injury  to  plumbing,  the  carbolic-acid  so- 
lution is  preferable  Avherever  i^lumbing  is  concerned.  The  lime  is  best  for 
country  use  in  privies  and  trenches. 

3.  The  disinfectant  should  be  thoroughly  mixed  with  the  stool  and  left 
in  contact  with  it  for  fully  two  hours.  Enough  of  the  disinfectant  must 
be  added  to  completely  cover  the  stool  Avith  the  solution. 

4.  The  bed-pan  should  be  kept  ready  filled  at  all  times  with  at  least  a 
pint  of  the  disinfectant,  into  which  the  stool  is  at  once  discharged,  and. 
should  be  cleaned,  with  scalding  water  and  one  of  the  disinfecting  so- 
lutions. 

5.  Rectal  therm-ometers,  syringes,  tubes,  and  all  utensils  coming  in  con- 
tact with  any  of  the  fecal  matter  must  be  disinfected  with  the  corrosivo 
sublimate  or  carbolic-acid  solution. 

0.  After  each  stool  the  patient's  perinseum  and  adjacent  parts  should, 
be  washed,  and  sponged  with  a  1  in  2,000  corrosive  sublimate  solution. 

7.  Xurses  and  attendants  should  be  cautioned  to  wash  their  own  hands 


42 


spkcikk;  IXFKCTIurS  diskasks. 


tlioroufiflily  and  immorso  tlioni  in  a  1  in  1,000  corrosivo  Ruhlimato  solution 
iit'tur  iumdlirif,'  tlii!  IxMl-pun,  tiiernionRiter,  syriiiifo,  or  patient,  or  ^'ivinpf 
H])on{^o-  or  tul)-l)iitli.s. 

H.  All  linen  and  bed-clothing'  used  by  the  i)atient  should  bo  soaked  in  ii 
1  in  ^0  ciirbolic-iK'id  solution,  and  subH(M|ucntly  boiled  for  fully  two  hours. 

1).  Disint'ci^tion  of  the  stools  siiould  Ix^  l)e<(un  as  soon  us  the  diaj^nosis 
of  enteric  fever  is  established,  and  should  be  continued  for  ten  days  after 
the  temperature  has  renuiined  at  the  normal. 

10.  In  localities  where  a  proper  drainaj^e  system  is  lacking,  the  stools 
should  either  be  nuxed  with  sawdust  and  crenuited  or  buried  in  a  trench  4 
feet  dee])  after  being  covered  with  chloride  of  lime. 

When  epidemics  are  prevalent  the  drinking-water  and  the  milk  used  in 
families  should  be  boiled.  These  precautions  should  bo  taken  also  by 
recent  residents  in  any  locality,  and  it  is  much  safer  for  travellers  to  drink 
light  wines  or  mineral  water  rather  than  ordiiuiry  water  or  milk.  Care 
should  be  taken  to  thoroughly  cook  oysters  which  have  been  fattened  or 
fresl'.ened  in  streams  contaminated  with  sewage. 

The  physicnan  should  ever  keep  in  mind  the  fact  that  each  individual 
case  of  tjiphoid  fever  is  a  focus  for  the  spread  of  the  disease.  To  carry  out 
effective  measures  of  proj)hijlaxis  is  quite  as  much  apart  of  his  duty  as  the 
care  of  the  patient. 

Antityphoid  Vaccine. — A.  E.  Wright  has  prepared  a  vaccine,  and  at  the 
Army  Medical  School,  Xetley,  and  at  Maidstone,  he  has,  in  conjunction 
with  D.  Semple,  inoculated  a  number  of  persons.  The  i)atients'  blood 
subsequently  gave  the  Widal  reaction,  and  they  believe  them  to  have  been 
rendered  immune  against  typhoid  fever. 

Treatment. — (a)  General  Management. — The  profession  was  long  in 
learning  that  typhoid  fever  is  not  a  disease  to  be  treated  mainly  with 
drugs.  Careful  nursing  and  a  regulated  diet  are  the  essentials  i)i  a  ma- 
jority of  the  cases.  The  patient  should  be  in  a  well-ventilated  room  (or  in 
summer  out  of  doors  during  the  day),  strictly  confined  to  bed  from  the  out- 
set, and  there  remain  until  convalescence  is  well  established.  The  bed 
should  be  single,  not  too  high,  and  the  mattress  should  not  be  too  hard. 
The  woven  wire  bed,  with  soft  hair  mattress,  upon  which  are  two  folds 
of  blanket,  combines  the  two  great  qualities  of  a  sick-bed,  smoothness 
and  elasticity.  A  rubber  cloth  should  be  placed  nnder  the  sheet.  An  intel- 
ligent nurse  should  be  in  charge.  AVhen  this  is  impossible,  the  attending 
physician  should  write  out  specific  instructions  regarding  diet,  treatment 
of  the  discharges,  and  the  bed-linen. 

{/>)  Diet. — Those  forms  of  food  should  be  given  which  are  digested  with 
the  greatest  ease,  and  which  leave  Ijchind  the  smallest  amount  of  residue 
to  form  faices.  Some  regard  should  be  paid  to  the  fancies  of  the  patient. 
Milk  is  the  most  suitable  food.  If  used  alone,  three  pints  at  least  may  be 
given  to  an  adult  in  twenty-four  hours,  always  diluted  with  water,  lime- 
Avater,  or  aiU-ated  waters.  Partially  peptonized  milk,  when  not  distasteful 
to  the  patient,  is  occasionally  serviceable.  The  stools  of  a  patient  on  a 
strict  milk  diet  should  be  examined  with  great  care,  to  see  if  the  milk  is 


TVPlloTI)   FEVr-;i{. 


43 


entirely  di^joated.  Vovcv  piiticntu  oftoii  r:'f'L'ivo  moro  tlmn  thoy  can  utilize, 
ill  which  ciirto  musses  of  eunls  iiro  seen  in  tho  stools,  or  iiiicroscopiciilly  I'at- 
I'orpiiscles  ill  extraonliimry  iihuiidaueu.  Under  these  circuiiistiinces  it  i.i 
best  to  substitute,  for  ])art  of  the  milk,  mutton  or  chicken  broths,  or  beef- 
Juice,  or  a  cU'ar  miisoiinin',  all  of  whicii  may  be  made  very  })alatable  by  tho 
addition  of  fresh  vegotublo  juices.  If,  however,  diarrluea  exists,  animal 
broths  are  apt  to  a^'<?ravato  it.  Some  patients  will  take  whey,  butter- 
milk, kumyss,  or  matzoon  when  the  ordinary  milk  is  distasteful.  Thin 
l)arley-^n-uel,  well  strained,  is  an  excellent  food  for  typhoid-fever  patients. 
Eire's  may  he  ^iven,  either  beaten  u[)  in  milk  or,  better  still,  in  the  form  of 
albumen-water.  This  is  prepared  by  straining  the  whites  of  eggs  through 
a  cloth  and  mixing  them  with  an  equal  quantity  of  water.  It  may  bo  flav- 
ored with  lemon,  and,  if  the  j)atient  is  taking  sj)irits,  whisky  or  brandy  is 
very  conveniently  given  with  it.  Patients  who  are  unable  to  take  milk  can 
subsist  for  a  time  on  this  alone.  Tho  whole  egg  beaten  up  in  milk  or  water 
nuiy  be  used. 

The  patient  should  bo  given  water  freely,  wliich  may  be  pleasantly  cold. 
Iced  tea,  barley-water,  or  lemonade  may  also  be  used,  and  there  is  no  objec- 
tion to  cotfee  or  cocoa  in  juoderato  quantities.  Fruits  are  not,  as  a  rule, 
allowable,  though  the  juice  of  lemon  or  orange  may  be  given.  Typhoid 
patients  should  be  fed  at  stated  intervals  through  the  day.  At  night  it 
depends  npon  the  general  condition  of  the  patient  whether  he  should  be 
aroused  from  sleep  or  not.  In  mild  cases  it  is  not  well  to  disturb  the 
patient.  AVhen  there  is  stupor,  however,  the  patient  should  bo  roused  for 
food  at  the  regular  intervals  night  and  day. 

Alcohol  is  not  necessary  in  all  cases,  but  may  bo  giveii  Avhen  the  weak- 
ness is  marked,  the  fever  high,  and  the  pulse  failing.  In  young  healthy 
adults,  without  nervous  symptoms  ami  without  very  high  fever,  it  is  jiot 
required ;  but  when  the  heart-beat  is  feeble  and  tho  first  sound  becomes 
ol)scure,  if  there  are  a  muttering  delirium,  subsultus  tendinum,  and  a  drv 
tongue,  brandy  or  whisky  should  be  freely  given.  In  such  a  case  from 
eight  to  twelve  ounces  of  good  whisky  in  the  twenty-four  hours  is  a  moder- 
ate amount. 

It  would  be  too  much  like  hoisting  the  teetotaler  with  his  own  petard 
to  attribute  the  high  rate  of  mortality  from  typhoid  fever  at  the  London 
Temperance  Hospital — 15  to  10  per  cent  during  the  ^  cSt  twenty  years — to 
failure  to  employ  alcohol. 

{(')  Hydrotherapy. — The  use  of  water,  inside  and  outside,  was  no  new 
treatmoTit  in  fevers  at  the  end  of  the  last  century,  when  James  Currie  (a 
friend  of  Burns  and  the  editor  of  his  poems),  wrote  his  Medical  Reports  on 
the  Effects  of  Water,  Cold  and  AVarm,  as  a  Remedy  in  Fevers  and  other  Dis- 
eases. In  this  country  it  Avas  used  with  great  effect  and  recommended 
strongly  by  Xathan  Smith,  of  Yale.  Since  1801  the  value  of  bathing  in 
fevers  has  been  specially  emphasized  by  the  late  Dr.  Brand,  of  Stettin. 

Hydrotherapy  may  be  carried  out  in  several  different  ways,  of  which, 
in  typhoid  fever,  the  most  satisfactory  are  by  sponging,  the  wet  pack,  and 
the  full  bath. 


44 


.SPECIFIC   INFKCTIOUS  DISHASKS. 


(a)  fold  Spojif/i)if/. — The  wutcr  iiiiiy  he  t('])i(l,  cold,  or  ice-cold,  nccordin;,' 
(o  tlio  lu'i^^lit  of  tlio  fever.  A  tlioroii;,'li  H|ioii;,'e-l»iitli  Hliould  take  frttiu 
fifteen  to  twenty  minutes.  Tho  iec-coUl  spon^'in;?  is  (juito  as  forniida))lo 
as  tli((  full  cold  bath,  for  which,  when  there  ia  un  iiisuperal)le  objection 
in  i)rivute  ])ractic(%  it  is  an  excellent  alternative.  Mut  fre(|uently  it  is 
ditlicult  to  |(et  the  friends  to  uppreciato  the  advantaj^es  of  the  sponj^in^. 
W  lien  such  is  the  case,  and  in  children  and  (hdic^ato  persons,  it  can  ho 
made  a  little  lesa  formidable  by  spon<jfin^  limb  by  liml)  and  then  the  back 
and  abdonu'ii. 

(/y)  The  ni/(/  pdrk  is  not  so  <;eTu>rally  useful  in  typ]H)id  fi'ver,  but  in 
cases  with  very  ])ronounced  nervous  symj)toms,  if  the  tub  is  not  available, 
the  ])atient  may  be  wrappcul  in  a  sheet  wrun;^  out  of  water  at  (50"  or  05°, 
aiul  then  cold  water  sprinkled  over  liim  witli  an  ordinary  watoiing-pot. 

{c)  The  Jiiith. — Tho  tub  should  i)o  lon<f  etu)U<;h  bo  that  the  ])atient  can 
be  completely  covered  except  his  head.  In  institutions  a  ri;,nd  system  of 
liydi'oiherapy  should  be  ])nictice(l,  rollowini,'  Brand's  instructions,  with 
modilications  to  suit  the  individual  castas.  In  my  clinic,  since  the  practice 
was  introduced  by  Dr.  ]jalleur  the  foUowin,!,'  plan  luis  been  carried  out: 
Every  third  hour,  if  the  temperature  is  above  J 0^3. .5°,  the  patient  is  placed 
in  a  bath  (at  70'  i''alir.),  which  is  wheeled  to  tho  bedside.  \\\  this  he 
reuuiins  from  llfteen  to  twenty  minutes,  and  is  then  taken  out,  wrap])ed 
in  a  dry  sheet,  and  covered  with  a  lifijht  blankest.  Eiu)u,<j:h  water  is  used  to 
cover  the  patient's  body  to  the  neck.  The  head  is  sponjifed  during  the 
oath,  and,  if  there  is  much  torpor,  cold  water  is  pourecl  over  it  from  a 
lieight  of  a  foot  or  two.  ^i'lie  limbs  and  trunk  are  rubbed  thorou^ddy, 
either  with  tlu*  hand  or  witli  a  suitable  "  rul)ber."  Tho  rectal  temjierature 
is  taken  immediately  after  the  bath,  and  again  tlu'ee  quarters  of  an  hour 
later.  The  patient  often  comphuns  bitterly  wlien  in  the  batli,  and  shiver- 
ing and  blueness  are  almost  a  constant  secpience.  Food  is  usually  given 
with  a  stimulant  after  the  bath.  The  only  contra-indications  are  perito- 
nitis ami  luemorrhage.  Neither  bronchitis  nor  pneumonia  is  so  regarded. 
The  accompanying  chart  (Chart  IV)  shows  the  number  of  baths  and  the 
inlluence  on  the  fever  during  two  days  of  treatment.  The  good  effects 
of  the  batlis  are:  (1)  The  reduction  of  tho  fever;  (2)  the  intellect  be- 
comes clearer,  the  stupor  lessens,  and  tho  muscular  twitchings  disap- 
pear ;  (.'5)  a  general  tonic  action  on  the  nervous  system  and  particularly  on 
the  heart ;  (-i)  insomnia  is  lessened,  the  patient  usually  falling  asleep  for 
two  or  throe  hours  after  each  bath ;  and  (5),  most  important  of  all,  the 
mortality  is,  umler  this  plan  of  treatment,  reduced  to  a  minimum.  This 
Jh'dnd  iiiefliod,  as  it  is  called,  has  steadily  advanced  in  favor  both  in  hospi- 
tal and  private  practice,  in  spite  of  the  difficulties  and  tho  unpleasant 
features  necessarily  (connected  with  it. 

The  spongings  frequently  have  to  be  substituted  for  the  tubs  in  cases 
of  extreme  weakness,  or  when  there  is  much  meteorism,  or  when  there  is 
marked  collapse  after  the  baths.  AVhile  a  temperature  at  70°  is  usually 
Avell  borne,  in  the  case  of  children  and  delicate  persons  the  luke-warm  bath 
gradually  cooled  may  be  employed. 


TVI'IIOII)   KKVKIl. 


45 


lUl 


•iituvo 
liour 
livor- 

lorito- 
arded. 
the 
ilt'ects 
(ot  be- 
lisup- 
irly  on 
)ep  for 
1,  tlio 
Til  is 
hospi- 
t'iisunt 

cases 
lere  is 
Lsually 

bath 


The  results  of  liydrothcrapy  are  very  ^'ratifyiii;,'.  Uy  it  in  general  hos- 
pitals from  i\  to  8  patients  in  every  hundred  cases  are  savecl.  In  institu- 
tions in  which  the  expectant  or  other  plans  of  treatment  are  (employed, 
there  is  a  mortality  of  from  \'i  to  ir»  per  <'ent.  In  many  it  is  as  hi;,'h  as  17 
per  cent.  There  is  a  remarkable  uniformity  in  the  death-rate  in  hospitals 
which   carry  out   hydrotherapy.     Since  July,   IHOO,  when  wo  introduced 


IM 

tw 
in 
lot 

lOB 

IM 

103 
IDS 
101 
100 

w 

OR 

07 

06 
Temp. 

Pulse 

Rcsp, 

Stools 

Urine 
Day  of 

DlHflUtU. 


June  It 


JL. 


.:..j.4..|..|..fi.i..i...i...|..:..j...;.,j..j..vi|..;..|.i»!.^..i4)..!J;-..!..|..^« 
.^.;.,i.j.j..i.4..i..i..j,;..i..fv|..;..W|..i..i...i ;»:.•;.  fij..jj|...i...|..Uj...i..i4i...;..i*i...i  .;..!...■... 

,.;..i.;<..;..i..4.;^..|...i..4..;..;....v,..^.»J.;,..^..:..j;;;..i..|Jj..ii^^...;..,..i.3;..i..jA^^ 
:...;.. .;..!.. J. ..:..!  .i..;...;t>;..:...  t)^. I,..'... :..;..;.. .:..i.. .'...:... :..^.j...:.,i...;^l.. ;., .;...! ..|,,;...;.,.l.,i,., I...;. 


•    ■        •    ■-•■'•    ■    '^  ^T%a:. J.. .:/.;..;..;.. .i..|. .;...;.. I..;.,.:..;.. ;«i:A'. .!..;*:..(.. ^., .!,..;.. I... |...:.. 
)j...;.>»<r;..4..i..u-.j..:..i..|4..K.JH--^r>?«<r^»-r^l"i'"li-";--^T?-4 


■\ 


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.;.-.f?-.4. 


;,4■■|«••!••if•••>4v■^^:•■•:♦•i•4■•■|••^•:'^i■4••i••;••4••i••i•4••;p•■•T•^ 
J•■;••;v•••4■'••M••i■■»Vv-*•■i^'■•^••*••^■•■■•:••^•;••••''tf•!••■*•i•^••;^^•  ••l-'^^ 

.:..4..;..|..  ..;.. 44f  ..I. .<.. i..  (..:.. ...;..»..;..*..!■.;.. f.;..i..t..-;..|.»i:,/|...i..|..i..»..^^ 
■  f--y->i  ■/••*■ --i-'-^'J; •.«■••; ..;..;..  i..:  ..j..:  ..i..i..  *...;..*.. 4-.  ...;.. i...;  4... ;..  i  .. I..  J."'-. •♦■■!•••  ii^.-f.-.|...i 

.;-..;..;..i.j.j...iAi..;..l..;...;..4..;--f--i.-^-i--i--i"i.  •'-'----•    '-■--  i--i--i---i  -  ;-:---i --■--:--!--;--•-  1 


J. .;...,..|. .J. ..;..,..■..»...:  ..,..;...,..;. .,...|  ..,..;..,. 


....,...;...,..,.. 


..:...i..|..  i,..:..i..4..  i..;..4.. 


,..|,.,, ...... ..;..,.. 


M.a.H. 


.:^;..i...:..  L. L. . i.. .;.. i. .;!!!.. i. . i. ......i..i...!.^.i..iW.V.i..;..i:..!:;!..i.;.L..i>"?. J.. .:..i.:j..'!..:Ul.j...i^...'. 

■:;;Vi"i  ■•;•■•  •■i••^•v•»"^•i•■  ■•  v-;--f  •■■■••••  :"i  ••:•••••!■  r  •:■••••■;  •■ji4- *■•■•■•■■  i;-v-i"  •  •• 


|6 


17 


I        I        I        I     21        I        I 


IS 


I        I 


lU 


I     I     I 


I    I 


Chart  IV. 

hydrotherapy,  there  have  been  treated  in  my  wards,  to  January  1,  1898, 
058  cases.  The  total  mortality  has  been  7.1  per  cent.  This  includes  all 
cases,  those  admitted  and  dyinj?  within  twenty-four  or  forty-eight  hours, 
and  those  in  which  the  diagnosis  was  only  made  at  autopsy.*  Still  more 
striking  by  contrast  are  the  figures  published  by  F.  E.  Hare  from  the  Bris- 
bane Hospital  (Practitioner,  September,  1897).  Of  1,828  cases  treated  on 
the  general  or  expectant  plan,  the  mortality  was  14.8  per  cent.  Of  1,903 
cases  treated  since  the  introduction  of  hydrotherapy,  the  mortality  was 
only  7.5  per  cent.  Equally  good  results  have  been  obtained  by  J.  C.  Wil- 
son and  Tyson  in  Philadelphia,  by  Oilman  Thompson  in  New  York,  and  at 
numerous  hospitals  in  Germany  and  France.  The  important  question 
comes  up  whether  the  serious  compli(!ations  of  the  disease  are  increased  by 
hydrotherapy.     My  own  statistics  bear  out  Hare's  that  the  remarkable  life- 


*  From  May,  1889,  when  the  hospital  was  oiiened,  to  July,  1890,  the  ordinary  expectant 
plan  was  followed.    The  mortality,  inclusive  of  this  period,  is  8  per  cent. 


40 


Sl'KCIFIC  INFECTIOUS  DISEASES. 


Hiivinj;  ill  liyflrotlicniny  does  not  dopciul  upon  a  dinunution  in  tho  nnnilM'i* 
of  fiitiii  cases  from  perforation  or  from  lin>jnorrlia<,'e.  The  perreiitaj,'!'  of 
]n'rforatioii  eases  in  my  series  was  J.lMl,  wliieli  is  a  little  under  tiie  avera;;e. 
At  UrisharH!  it  wan  5i.it  per  eent,  hotli  before  and  after  the  introduetiou  of 
hathin;,'.  I la'Uiorrha^'o  occurs  in  from  H  to  fi  pi«r  (!ontof  tho  eases.  In  ?nv 
Heries  it  occurred  in  4.1»  per  eent  of  all  castas  since  tin*  introduction  of  liv- 
drotherapy.  'I'he  Urishane  statistics  j,'ive  before  the  introduction  of  hydro- 
therapy I.M  per  cent  of  fatal  cases,  aiul  after  the  introduction  I.".*  \n'\-  cent. 
A  careful  study  of  the  recent  statistics  shows  that  neither  perforation  nor 
ha'inorrha^e  is  njore  friupient  with  liydrotluirapy.  As  to  relapse,  it  is  more 
(Unicuit  to  speak,  the  percentaf,'e  va"ies  so  widely — from  ',]  to  Hi,  It  must 
he  remembered  that  more  cases  are  saved  to  have  rcdapse.  My  percentaj,'e 
of  7.HH  is  sonunvhat  above  the  average,  but  the  increase  in  the  relapses  la 
iu)t  80  ^roat  us  to  seriously  im{)u^n  the  treatment.  Hydrotherapy  does 
not  probably  shorten  the  duration  of  the  stay  in  hospital,  which  was  forly- 
two  days  in  my  series.  We  do  not,  however,  send  out  our  typhoid  cases 
until  they  an;  (piite  strong  and  well. 

(il)  Medicinal  Treatment. — In  hospital  practice  nu'dicinos  are  not  often 
needed.  A  f^reat  majority  of  my  cases  do  not  receive  a  dose.  In  i)rivate 
l)ractico  it  nuiy  bo  safer,  for  the  young  practitioner  especially,  to  order  a 
mild  fever  mixture.  The  (|nestion  of  nuMlicinal  antii)yreti(rs  is  important: 
they  are  used  far  too  often  aiul  too  rashly  in  typhoid  fevcsr.  An  occasional 
dose  of  antifebrin  or  antipyrin  may  <b)  i o  harm,  but  the  daily  us((  of  these 
drugs  is  most  injurious.  Quinine  in  moderate  (b)ses  is  still  nuudi  em- 
ployed. The  local  use  of  guiacol  on  the  skin,  3  88  painted  on  the  tlank, 
causes  a  prompt  fall  in  the  teuMierut  nre. 

A)ilis('j)tir.  Mn/ini/ioii. — Very  laudable  endeavors  have  been  made  in 
numy  (puirters  to  introduce  methods  of  treatnu^nt  directed  toward  tho 
destruction  of  the  typhoid  ])acilli,  or  the  toxic  agent  which  they  produce, 
but  so  far  without  success.  Good  results  have  been  claimed  from  the  car- 
bolic acid  and  iodine  treatment.  Others  advocate  corrosive  sul)linuite  or 
calomel,  ^-luiphthol,  the  salicin  preparations  and  guiacol.  I  can  testify 
to  the  inefficiency  of  the  carbolic  acid  aiul  iodine  and  of  the  /S-naphthol. 
With  the  mercurial  preparations  I  have  no  experieiu^o.  Fortumitely  for 
the  patients,  a  majority  of  these  medicines  meet  one  of  the  two  objects 
whicli  Hippocrates  says  the  physician  should  always  liave  in  view — they  do 
no  harm.  Irrigation  of  the  colon  has  been  recommended,  with  a  view  to 
washing  out  the  toxic  matters  (Mosler,  Seibert). 

{(')  Eliminative  and  Antiseptic  Treatment.— Based  on  the  erroneous 
view  that  the  bacterial  growth  is  chiefly  in  the  intestine  itself.  Thistle  and 
others  have  advocated  what  is  known  as  the  eliminative  and  antiseptic 
treatment.  The  elimination  is  attempted  by  thorough  evacuation  of  the 
bowels  daily,  and  the  other  factor  in  the  treatment  is  the  use  of  intes- 
tinal antiseptics,  of  which  salol  is  recommended.  If,  as  in  cholera,  the 
bacilli  developed  and  produced  the  poison  in  the  intestinal  contents,  there 
might  be  some  reasonableness  in  this  method,  but  the  bacilli  multiply  in 
the  intestinal  walls,  in  the  mesenteric  glands,  and  in  the  spleen.     They 


TYIMTOTD  FKVKR. 


47 


)1U>0US 

iL'  and 
[soptio 
)f  tho 
iiitc's- 
the 
Ithure 
J)ly  in 
I  They 


nro  Hom.'tiincrt  not  fniuid  in  tlm  stooU  nntil  tho  end  of  tho  Hocoiid  wook. 
An  iMi|>ortunt  ol)ji>c>tion  to  tho  uho  of  piir^'iitivt'M  is  tho  fact  that  in  any 
lar;/o  Hcrios  of  cusca  thoHc  with  diarrlio-ii  do  liadly.  (imvcs  rcrnarkctl  that 
"tlif  piitit'iits  who  hav(*  cHcapi'd  afdvc  pur;,'ation  hffdre  adniis,si(»n  will  j^ct 
throu;^'h  the  (li;;i'a.so  with  little  or  no  tynipanitesi."  Tlio  preliminary  eulo- 
iiiel  imr^jo,  ho  much  used,  is  uniHMH^rtmiry. 

(/)  Aiitltoxine  Tr«atment, —  In  spite  of  many  experiinentrt  and  clin- 
ical trials  tho  re.snlt.s  are  Htill  nnsatisraetory.  An  antityphoid  serum  has 
heen  placed  on  the  market,  and  a  few  cases  have  heen  rc|)(»rte(l  with  rapid 
improvement. 

(//)  Treatment  of  tho  Special  Symptoms. — Tlu^  ahdominal  pain  and 
tym[)anite8  aro  host  treated  with  fomentations  or  tiirpeiitino  Btiiiu's.  Tho 
latter,  if  well  applied,  ^dvi'  j;reat  relief.     Sir  William  .Icnner  used  to  lay 


II. 


;.'reat  stress  on  the  atlvaiita<(es  of  a  well-apjilicd  turpentiiu'  stupe, 
dircc'  'd  it  to  \n'  ap[>licu  as  follows:  A  llannci  roller  was  placed  Itcneath 
tho  pi'  .ent,  aiul  then  a  douhh^  layer  of  thin  Ihmnel,  wruu','  out  of  very  hot 
wati'r,  with  a  drac'hni  of  turpentine  mixt'd  with  the  water,  was  a|tplie(|  to 
tlu!  alMlomen  and  coveriMl  with  the  ends  of  the  roller. 

The  vir/i'Diisin  is  a  dilVu'ull  ami  (listressin;f  syp'dom  to  treat.  When 
the  <,nis  is  in  the  lar^e  howcl,  a  tube  may  he  ])asse(l  or  a  tui'pentinc!  oiu'uui 
^'iven.  For  tympanites,  with  a  dry  tonj^uc,  turpentine  was  extcMisively 
used  hy  tho  older  Duhliii  ))hysicians,  and  it  was  introducecl  i.ito  this  coun- 
try hy  tlie  hito  (Jeor<je  15.  Wood.  I'nfort  unately,  it  is  of  very  little  service 
in  tho  Ht'verer  cases,  which  too  often  resist  all  treatment.  Sonictinu'S,  if 
hecf-juico  and  alhumen-wator  aro  substituted  fur  milk,  the  distention 
lessens.     C"har(!oal,  hismuth,  and  y9-naphthol  may  ho  tried. 

For  tho  dittrrlimt,  if  sovoro — that  is,  if  thoro  aro  moro  than  three  or 
four  stools  daily — a  starch  and  opium  ciu'ina  nuiy  ho  jfiven;  or,  hy  the 
mouth,  a  combination  of  hismuth,  in  lar^'e  doses,  with  J)over\s  powder;  or 
tho  acid  diarrhiea  mixture,  acetate  of  lead  (j(rs.  "Z),  dilute  aci^tio  acid 
(TTJ,  15-aO),  and  acetate  of  mor})hia  {\iv.  \-i).  'JMio  stools  should  ho  exam- 
ined to  SCO  that  tho  diarrluea  is  not  ajrjjravated  by  the  prosonce  of  curds. 

Const ipaf inn  is  present  in  many  cases,  and  though  1  hav(!  never  seen  it 
do  harm,  yet  it  is  well  every  third  or  fourth  day  to  give  an  ordinary  enenui. 
Jf  a  hi.xativo  is  needed  during  tho  course  of  tho  disease,  the  llunyadi- 
janos  or  Friedriolishall  watoi*  nuiy  he  given. 

Ifannorrhafie  from  tho  howels  is  hest  treated  with  full  doses  of  acetate 
of  lead  and  o[)ium.  As  ahsoluce  rest  is  essential,  the  greatest  care  should 
be  taken  in  tho  use  of  the  bed-pan.  It  is  perhaps  better  to  allow  the  pa- 
tient to  pass  tho  motions  into  tho  draw-sheet.  Ico  may  be  freely  given,  and 
tho  amount  of  footl  should  be  restricted  for  eight  or  ten  liours.  If  there 
is  a  tendency  to  collapse,  stimulants  should  be  given,  and,  if  necessary, 
hypodermic  injections  of  ether.  Tho  patient  may  be  spared  the  usual 
styptic  mixtures  with  which  he  is  so  often  drenched.  Turpentine  is 
warmly  recommended  by  certain  authors. 

Peritonitis. — In  a  majority  of  tho  eases  this  is  an  inevitably  fatal  com- 
plication, thongh  recovery  is  possible.     If  the  peritonitis  be  duo  to  perfora- 


48 


SPECIFIC   INFKCTIOUS  DISHASHS. 


tioii,  tlic  (|ii('sli()ii  of  liipiirotomy  Hlioiild  hv  iiiuiu'diiitcly  discussed.  Ordors 
slioiiid  1)1!  issiu'd  to  tlio  iiiirsi!,  iiiul  in  liospitids  to  the  house  j)iiysi('iiins,  to 
Wiitch  ciircfully  for  tho  lirst  syinptonis  of  peritonitis.  Tlic^  recent  re- 
sults lire  most  ^ratifyinfi^.  Kinney  (Studies  111)  iind  Keen  have  recently 
reviewed  the  whole  question.  The  latter  has  collected  Ki  cases  with  ItJ 
recoveries.  The  diini^er  of  delay  is  illustrated  by  the  followin<f  fi^aires : 
Of  15  cases  operateil  on  within  twelve  hours,  4  recovered;  of  ^U  c-ases 
operated  on  between  the  twelfth  and  twenty-fourth  hour,  (5  recovered ;  of 
113  cases  ojierated  on  in  the  second  twenty-four  hours  oidy  1  recovered.  A'o 
case  is  so  desperate,  unless  actually  moribund,  as  to  be  without  some  hope 
in  the  hands  of  a  good  surgeon. 

Jione  Lesions. — Tlie  typhoid  periostitis  in  the  ribs  or  in  tho  tibia  does 
not  always  go  on  to  suppuration,  though,  as  a  rule,  it  requires  operation. 
Unless  the  pra(;titioner  is  accnstonied  to  do  very  thorough  snrgical  work, 
he  should  hand  over  the  patient  to  a  competent  surgeon,  who  will  clear 
out  the  diseased  parts  Avith  the  greatest  thoroughness,  llecnrrencc  is  in- 
evitable unless  the  operation  is  complete. 

For  the  progressive  heart-weakness  alcohol,  strychnine  hypodermically 
in  full  doses,  digitalis,  and  hypodermic  injections  of  ether  may  be  tried. 

The  nervous  symptoms  of  typhoid  fever  are  best  treated  by  hydrother- 
apy. One  special  advantage  of  this  plan  is  that  the  restlessness  is  allayed, 
the  delirium  qxiieted,  and  sedatives  are  rarely  needed.  In  the  cases  which 
set  in  early  with  severe  headache,  meningeal  symptoms,  and  high  fever,  the 
cold  bath,  or  in  private  practice  the  cold  pack,  should  be  employed.  An 
ice-cap  may  be  placed  on  the  head,  and  if  necessary  morphia  administered 
hypodermically.  The  practice,  in  such  cases,  of  applying  blisters  to  the 
luipe  of  the  neck  and  to  the  extremities  is,  to  paraphrase  Huxham's  words, 
an  unwholesome  severity,  which  should  long  ago  have  been  discarded  by 
the  profession.  For  the  nocturnal  restlessness,  so  distressing  in  some  cases, 
Dover's  powder  should  be  given.  As  a  rule,  if  a  hypnotic  is  indicated,  it 
is  best  to  give  opium  in  some  form.  Pulmonary  complications  should,  if 
seveie,  receive  appropriate  treatment. 

In  protracted  cases  very  special  care  should  be  taken  to  guard  against 
led-sores.  Al)solute  cleanliness  and  careful  drying  of  the  parts  after  an 
evacuation  should  bo  enjoined.  The  patient  should  be  turned  from  side 
to  side  and  propped  Avith  pillows,  aiul  the  back  can  then  be  sponged 
Avith  spirits.  On  the  lirst  appearance  of  a  sore,  the  Avater-  or  air-bed  should 
be  used. 

(//)  The  Management  of  Convalescence. — Convalescents  from  typhoid 
fever  frc(iuently  cause  greater  anxiety  than  patients  in  the  attack.  The 
(juestion  of  food  has  to  bo  met  at  once,  as  the  patient  develops  a  ravenous 
appetite  and  clamors  for  a  fuller  diet.  .My  custom  has  been  not  to  alloAV 
solid  food  until  the  temperature  has  been  noi-mal  for  ten  days.  This  is,  I 
think,  a  safe  rule,  leaning  perluips  to  the  side  of  extreme  caution ;  but, 
after  all,  Avith  eggs,  milk  toast,  milk  puddings,  and  jellies,  the  patient  can 
take  a  fairly  A'aried  diet.  ^lany  leading  practitioners  alloAV  solid  footl  to  a 
patient  so  soon  as  he  desires  it.     I'eabody  gives  it  on  the  disappearance  of 


TYPIiOTP  FEVER. 


40 


the  ftnor;  tlio  lute  Austin  Flint  was  iilso  in  fiivor  of  f^nvinj;  solid  food 
oiirly.  I  hail  an  early  lesson  in  this  matter  which  1  liavo  never  for^^otti-n. 
A  younj,'  lad  in  the  Montreal  (ieneral  Hospital,  in  whose  ease  I  was  much 
interested,  passed  throu<?h  a  tolerably  sluirp  attack  of  ty[)hoid  fever.  Two 
wecl\s  after  the  eveniiiff  temperature  had  been  iu)rmal,  and  oidy  a  day  or 
two  before  his  intended  disciuirtjfe,  he  ate  several  mutton  chops,  and  within 
twenty-four  hours  was  \n  a  state  of  colla])se  from  perforation.  A  small 
transverse  rent  was  found  at  the  l)ottom  of  an  ulcer  which  was  in  i)rocess 
of  healinj;.  It  is  not  easy  to  say  w'ly  solid  food,  particularly  nu;ats,  should 
disagree,  but  in  so  many  instances  an  indiscretion  in  diet  is  followed  by 
slight  fever,  the  so-called  /WvrAv  caruis,  that  it  is  in  the  best  interests  of  the 
patient  to  restrict  the  diet  for  some  time  after  the  fever  has  fallen.  An 
indiscretion  in  diet  may  indeed  p'-ecipitate  a  relapse.  The  patient  may 
be  allowed  to  sit  up  for  a  short  ti.  j  about  the  ond  of  the  first  w  k  of 
convalescence,  and  the  period  may  be  ])rolonged  with  a  gradual  return  of 
strength.  He  should  move  about  slowly,  and  when  the  weutiier  is  favor- 
able should  be  in  the  open  air  as  mucli  is  possible.  He  should  be  guardi'd 
at  this  period  against  all  unnecessary  excitement.  Emotiomd  disturbance 
not  infrequently  is  the  cause  of  recrudescence  of  the  fever.  C'onstipaticm  is 
not  uncommon  in  convalescence  and  is  best  treated  by  enemata.  A  pro- 
tracted diarrhoea,  which  is  usually  due  to  ulceration  in  the  crolon,  may 
retard  recovery.  In  such  cases  the  diet  shonld  be  restricted  to  milk,  and 
the  patient  should  be  confined  to  bed ;  large  doses  of  bismuth  and  astrin- 
gent injections  will  prove  useful. 

The  recrudescence  of  the  fever  does  not  require  special  measures.  The 
treatment  of  the  relapse  is  essentially  that  of  the  original  attack. 

Among  the  dangers  of  convalescence  may  be  mentioned  tuberculosis, 
which  is  said  by  Murchison  to  be  more  commoii  after  this  than  after  any 
other  fever.  There  are  facts  in  the  literature  favoring  this  view,  but  it  is 
a  rare  sequel  in  this  country. 


I  should 


yphoid 
The 
Ivcnous 
I)  allow 
Ills  is,  I 
li ;  l)ut, 
I'ut  can 
)d  to  a 
lince  of 


11.   TYPHUS   FEVER. 

Definition. — An  acute  infectious  disease  characterized  by  sudden 
onset,  a  maculated  rash,  marked  nervous  symptoms,  and  a  termination, 
usually  by  crisis,  about  the  end  of  the  second  week. 

Etiology. — The  disease  is  known  by  the  names  of  hospital  fever, 
spotted  fever,  jail  fever,  camp  fever,  and  ship  fever,  and  in  (iermany  is 
called  e.V(()it]u'inatic  typhus,  in  contradistinction  to  ahdiiminal  typhus. 

Typhus  is  now  a  rare  disease.  Sporadic  cases  occur  from  time  to  time 
in  the  large  centers  of  population,  but  epidemics  an*  infrequent.  In  this 
country  during  the  past  ten  years  there  have  been  very  few  outbreaks.  In 
New  York  in  l.SSl-S'-i  7:55  cases  were  admitted  into  the  Riverside  Hospi- 
tal ;  in  Philadelphia  a  snuill  epidemic  occurred  in  1883  at  the  Philadelphia 
Hospital. 

The  special  elements  in  the  etiology  of  typhus  are  overcrowding  and 
povert^y.     As  Hirsch  tersely  puts  it,  "  Die  Geschichte  des  Typhus  ist  die 


X^ 


50 


SI'KCIFIC!   INFECTIOUS   DISFASKS. 


(los  mcnsi'liliohon  Klciids."  Overcrowd iiij;,  hick  of  clciinlincss,  iiitorn- 
pcriincc,  ami  liad  food  arc  pnMlis])osinfj:  causes.  The  disease  still  lurks  in 
the  worst  (|uarters  of  London  and  (iliis^j^ow,  and  is  seen  occasionally  in 
New  York  and  I'hiladelphia.  It  is  more  (;omnn)n  in  Grciit  IJritain  and  Ire- 
Lmd  than  in  other  parts  of  Europe.  Durinj,'  lSi)7  tiiero  wore  only  3  eases 
of  typhus  in  Ijondon  fever  hospitals.  Mundiison  lield  that  typhus  niiirht 
ori<,Mnate  s])()ntaneously  under  I'avorahle  conditions.  This  opinion  is  suf;- 
^ested  hy  the  occurrence  of  local  outhreaks  nniler  circuiustances  which 
render  it  ditllcult  to  explain  its  importation,  hut  the  analogy  of  other  in- 
fections discuses  is  directly  a<:fainst  it.  In  1877  there  occurred  a  local  out- 
hreak  of  tyi)hus  at  the  House  of  Kefufj;e,  in  Montreal,  in  whicli  city  the 
disease  had  not  existed  for  many  years.  The  overcrowdiufjj  was  so  .s^reat  in 
the  hasement  rooms  of  the  refu<,'e  that  at  ni<i;ht  there  were  not  more  than 
88  cnhic  feet  of  sj)ace  to  each  person.  Eleven  individuals  were  ullected. 
It  was  not  possil)le  to  trace  the  source  of  infection. 

Ty[)hus  is  one  of  the  most  his^hly  I'ontaijious  of  febrile  affections.  In 
e])i(lcmics  nurses  and  doctors  in  attemhuuH!  upon  the  sick  are  almost  inva- 
riably attacked.  There  is  no  disease  whicdi  has  so  many  victims  in  the 
profession.  In  the  extensive  epidemic  in  the  early  and  middle  part  of  this 
century  many  hundred  physicians  died  in  the  discliargo  of  their  duty. 
Casual  attendance  upon  cases  in  limited  ei)idemics  does  not  ajipear  to  ho 
very  risky,  but  when  the  sick  are  afi:jjfreijated  in  wards  the  poison  a})pears 
concentrated  and  the  danger  of  infection  is  mnch  eiduinced.  Bedding 
and  clothes  retain  the  poison  for  a  long  time. 

The  microbe  of  typhus  fever  luis  not  yet  been  determined.  Strepto- 
bacilli,  diplococci,  and  an  ascimiycete  have  been  described  in  the  blood 
und  tissues,  but  the  question  still  remains  open  for  investigation. 

Morbid  Anatomy. — The  anatomical  changes  are  those  which  resnlt 
from  intense  fever.  The  blood  is  dark  and  fluid  ;  the  muscles  are  of  a  deep 
red  color,  and  often  sliow  a  granular  degeneration,  particularly  in  the 
lieart ;  the  liver  is  enlarged  and  soft  and  may  have  a  dull  clay-like  lustre  ; 
the  kidneys  are  swollen ;  there  is  moderate  enlargement  of  the  spleen,  and. 
a  general  hy})erplasia  of  the  lymph-:'  ^Micles.  Peyer's  glands  are  not  ulcer- 
ated. Bronchial  catarrh  is  usually,  a  d  hypostatic  congestion  of  the  lungs 
often,  present.     The  skin  shows  the  petechial  rash. 

Symptoms. — Incubation. — This  is  placed  at  about  (twelve  days,  but 
it  may  be  less.  There  may  be  ill-delined  feelings  of  discomfort.  As  a  rule, 
however,  the  invasion  is  abrupt  and  marked  by  chills  or  a  single  rigor, 
followed  by  fever.  The  chills  may  recur  during  the  first  few  days,  nd 
there  is  lieadache  with  pains  in  the  back  and  legs.  There  is  early  pros- 
tration, and  the  patient  is  glad  to  take  to  his  bed  at  once.  The  tempera- 
ture is  high  at  first,  and  may  attain  its  maximum  on  the  second  or  third 
day.  The  pulse  is  full,  rapid,  and  not  so  frequently  dicrotic  as  in  typhoid. 
The  tongue  is  furred  and  white,  and  there  is  an  early  tendency  to  dry- 
ness. The  face  is  flushed,  the  eyes  are  congested,  the  expression  is  dull 
and  stupid.  Vomiting  may  be  a  distressing  symptom.  In  severe  cases 
mental  symptoms  are  present  from  the  outset,  either  a  mild  febrile  de- 


TYIMIUS   FEVKH. 


61 


itpm- 
■ks  in 

11 V  ill 

d'  In-- 

ciises 

s  su<;- 
wliii'li 
ler  lu- 
ll out- 
ty  tlio 
roiit  in 
e  than 
[ected. 

IS,  In 
it  in  va- 
in the 
of  this 
r  duty, 
ir  to  bo 
ii])pears 
k'tlding 

^trepto- 
blood 

|i  result 
a  deep 
in  the 
lustre  ; 
in,  and 
It  ulcer- 
lungs 

lys,  but 
a  rule, 
rigor, 
lys,    ud 

]y  pi'os- 

[mpera- 
|r  third 
Qihoid. 
|to  dry- 
is  dull 
|e  cases 
file  de- 


lirium or  an  excited,  u(^tiv(',  almost  muniucal  condition.     Uroncliial  catarrh 


IS  common. 

Stage  of  Eruption. — From  tlie  third  to  the  (H'th  day  the  eruption  iip- 
p(.jii-s — lirst  upon  tin?  ubdonu'n  iind  upper  ])iirt  ol'  the*  chest,  iind  then  upon 
the  extremities  and  face;  developing  so  rapidly  that  in  two  (tr  three  days 
it  is  all  out.  There  are  two  elements  in  the  eruption  :  a  subcuLi(;ular  nu)t- 
tling,  "a  (ine,  irregular,  dusky  red  mottling,  as  ii'  below  the  surface  oi"  tlit^ 
skin  some  little  distance,  and  seen  through  a  8(uni-opa(pie  nusdium  "  (Hu- 
chanan);  and  distinct  ])apular  rose-spots  which  change  to  piitechia;.  in 
Honu^  instances  the  jyetecihial  rash  conu'S  out  with  the  rose-spots,  (.'ollie 
describes  the  rash  as  consisting  of  three  ])arts — rose-(M)lored  sj)ots  which 
disa])pear  on  ])ressure,  dark-red  spots  whi(;h  are  niodilied  by  pressure,  aiul 
})eteciiiie  upon  which  ])ressure  produces  no  elfect.  Jn  children  the  rash  at 
first  may  i)resent  a  striking  resemblance  to  that  of  ineasles,  and  give  as  a 
whole  a  curiously  mottled  appearance  to  the  skin.  TUa  term  mullxsrry  rash 
is  sometimes  api)lied  to  it.  In  mild  cases  the  eru])tion  is  slight,  but  even 
then  is  largely  petechial  in  character.  As  the  rash  is  largely  hn'morrhagic, 
it  is  permaiu'ut  and  does  not  disappear  after  death.  I'sually  the  skin  is 
dry,  so  that  sudaminal  vesi(des  are  not  common.  Jt  is  stated  by  somes 
authors  that  a  tlistinctive  odor  is  ])resent.  During  the  .■iecoiul  week  the 
general  symptoms  are  much  aggravati^d.  The  prostration  becomes  more 
marked,  the  delirium  more  intense,  and  the  fever  rises.  The  patient  lies 
on  his  back  Avith  a  dull  expressionless  face,  flushed  cheeks,  injected  con- 
junctivte,  and  contracted  pu])ils.  The  pulse  increases  in  frequency  and  is 
feebler;  the  face  is  dusky,  and  the  condition  becomes  more  serious.  Ke- 
tention  of  urine  is  common.  Coma-vigil  is  frequent,  a  condition  in  which 
the  patient  lies  with  open  eyes,  but  (piite  unconscious ;  with  it  there  may 
be  subsultus  tendinum  and  picking  at  the  bedclothes.  The  tongue  is  dry, 
brown,  and  cracked,  aiul  there  are  sordes  on  the  teeth.  Respiration  is 
accelerated,  the  heart's  action  becomes  more  and  more  enfeebled,  and  death 
takes  place  from  exhaustion.  Tn  favorable  cases,  about  the  end  of  the 
second  week  occurs  the  crisis,  in  which,  often  after  a  deep  sleep,  the  pa- 
tient awakes  feeling  much  better  and  with  a  clear  mind.  The  tempera- 
ture falls,  and  although  the  prostration  may  b?  extreme,  convalescence  is 
rapid  and  relapse  very  rare.  This  abrupt  termination  by  crisis  is  in  strik- 
ing contrast  to  the  mode  of  termination  in  typhoid  fever. 

Fever. — TIiq  temperature  rises  steadily  during  the  first  four  or  five 
days,  and  the  morning  remissions  are  not  marked.  The  maximum  is  usu- 
ally attained  by  the  fifth  day,  when  the  temperature  may  be  105 ',  100°,  or 
107°.  In  mild  cases  it  seldom  rises  above  103°.  After  reaching  its  maxi- 
mum the  fever  generally  continiies  with  slight  morning  remissions  until 
the  twelfth  or  fourteenth  day,  when  the  crisis  occurs,  during  which  the 
temperature  may  fall  below  normal  within  twelve  or  twenty-four  hours. 
Preceding  a  fatal  termination,  there  is  usually  a  rapid  rise  in  the  fever  to 
108°  or  even  109". 

The  heart  may  early  show  signs  of  Aveakness.  The  first  sound  be- 
comes feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is 


52 


SPECIFIC   INFPX'TIOUS   DISEASES. 


not  infrequent.  Hypostatic  congestion  of  the  lungs  occurs  in  nil  severe 
cuses. 

The  bniin  .symptoms  are  usually  more  pronounced  than  in  typlioid,  and 
the  delirium  is  more  constant. 

The  urine  in  typhus  shows  the  usual  febrile  increase  of  urea  and  urio 
acid.  The  chlorides  diminish  or  disappear.  All)umin  is  present  in  a  largo 
j)roporti()n  of  the  cases,  hut  nephritis  seldom  occurs. 

N'ariations  in  the  course  of  the  disease  are  naturally  common.  There 
are  malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days ; 
the  so-called  typhus  siderans.  On  the  other  hand,  during  ejiidcmics  there 
are  extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent, 
and  convalescence  is  established  by  the  tenth  day. 

Complications  and  Sequelae. -Broncho-pneumonii'i  is  perhaps  the 
most  common  complication.  It  may  pass  on  to  gangrene.  In  certain 
epidemics  gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children 
n(mia  or  cancrum  oris,  have  occurred.  Meningitis  is  rare.  Paralyses, 
Avhich  are  probably  due  to  a  post-febrile  neuritis,  are  not  very  uncom- 
mon. Septic  processes,  such  as  parotitis  and  abscesses  in  ti  e  subcutane- 
ous tissues  and  in  the  joints,  are  occasionally  met  with.  >.'ephritis  is  rare. 
Ilivmatemesis  may  occur. 

Prognosis. — The  mortality  ranges  in  different  epidemics  from  12  to 
20  per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as 
frequently  attacked  as  adults,  rarely  die.  MiQV  middle  age  the  mortality 
is  high,  in  some  epidemics  50  per  cent.  Death  usually  occurs  toward  the 
close  of  the  second  week  and  is  due  to  the  toxa?mia.  In  the  third  week  it 
more  commonly  results  from  pneumonia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the 
disease  presents  distinctive  general  characters.  Isolated  cases  may  be  very 
difficult  to  distinguish  from  typhoid  fever.  While  in  typical  instances  the 
eruption  in  the  two  affections  is  very  different,  yet  taken  alone  it  may  be 
deceptive,  since  in  tyi)hoid  fever  a  roscolous  rash  may  be  abundant  and 
there  may  be  occasionally  a  subcuticular  mottling  and  even  petechias. 
The  difference  in  the  onset,  particularly  in  the  temperature,  is  marked ; 
but  cases  in  which  it  is  important  to  make  an  accurate  diagnosis  are  not 
usually  seen  until  the  fourth  or  fifth  day.  The  suddenness  of  the  onset, 
the  greater  frequency  of  the  chill,  and  the  early  i)rostration  are  the  dis- 
tinctive features  in  typhus.  The  brain  symptoms  too  are  earlier.  It  is 
easy  to  put  down  on  paper  elaborate  differential  distinctions,  which  are 
practically  useless  at  the  bedside,  particularly  when  the  disease  is  not  pre- 
vailing as  an  epidemic.  In  sporadic  cases  the  diagnosis  is  sometimes  ex- 
tremely difficult.  I  have  seen  ^lurchison  himself  in  doubt,  and  more  than 
once  I  have  knoAvn  a  diagnosis  to  be  deferred  until  the  sedio  cadaveris. 
Severe  cerebro-spinal  fever  may  closely  simulate  typhus  at  the  outset,  but 
the  diagnosis  is  usually  clear  within  a  few  days.  Malignant  variola  also 
has  certain  features  in  common  with  severe  typhus,  but  the  greater  extent 
of  the  hemorrhages  and  the  bleeding  from  the  mucous  mendjranes  make 
the  diagnosis  clear  within  a  short  time.     The  rash  at  first  resembles  that 


TYPHUS  FEVER. 


53 


jovere 


1,  and 


(1  uric 

L  lllVgO 


There 

days ; 

J  there 

ihsent, 

ips  the 

certain 

hildren 

nilyses, 

uiiconi- 

cutane- 

is  rare. 

m  12  to 

quite  as 

lortality 

ard  the 

week  it 


of  mcaales,  hnt  in  the  latter  the  eruption  is  hrighter  red  in  color,  often 
cresoentic  or  irregular  in  arrangement,  and  appears  first  on  the  face. 

The  frequency  with  which  other  diseases  are  mistaken  for  typhus  is 
shown  hy  the  fact  that  during  and  following  the  e])idemic  of  ISSl  in  New 
York  lOH  ca>-'  :s  were  wrongly  diagnosed — one  eighth  of  t!ie  entire  number 
— and  sent  t     Jie  Riverside  IFospital  (F.  \V.  Cliapin). 

Treatment. — The  general  management  of  the  disease  is  like  that  of 
typhoid  fever.  Hydrotherapy  should  be  thoroughly  and  systematically 
employed.  Judging  from  the  good  results  which  we  have  obtained  by 
this  method  in  typhoid  cases  with  nervous  symptoms  much  may  be  ex- 
pected from  it.  Certain  authorities  have  spoken  against  it,  but  it  should 
be  given  a  more  extended  trial.  Medicinal  antipyretics  are  even  less  suit- 
able than  in  typhoid,  as  the  tendency  to  heart-weakness  is  often  more 
pronounced.  As  a  rule,  the  patients  ref|uire  from  the  outset  a  supporting 
treatment ;  water  should  be  freely  given,  and  alcohol  in  suitable  doses, 
according  to  the  coiulition  of  the  pulse. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  spe- 
cific medication,  by  sulphocarbolates,  the  sulphides,  carbolic  acid,  etc.,  is 
not  commended  by  those  Avho  have  had  the  largest  experience.  The  spe- 
cial nervous  symptoms  and  the  pulmonary  symptoms  should  be  dealt  with 
as  in  typhoid  fever.  In  epidemics,  when  the  conditions  of  the  climate  are 
suitable,  the  cases  are  best  treated  in  tents  in  the  open  air. 

III.  RELAPSING    FEVER   {Fehrin  reciirrens). 

Definition. — A  specific  infectious  disease  caused  by  the  spirocha^te 
(spirillum)  of  Obermeier,  characterized  by  a  definite  febrile  paroxysm 
which  usually  lasts  six  days  and  is  followed  by  a  remission  of  about  the 
same  length  of  time,  then  by  a  second  paroxysm,  which  may  be  repeated 
three  or  even  four  times,  Avhence  the  mime  relapsing  fever. 

Etiology. — This  disease,  which  has  also  the  names  "  famine  fever  " 
and  "  seven-day  fever,"  has  been  known  since  the  early  part  of  the  eight- 
eenth century,  and  has  from  time  to  time  extensively  prevailed  in  Europe 
especially  in  Ireland.  It  is  common  in  India,  where  the  conditions  for 
its  development  seem  always  to  be  present,  and  where  it  has  been  specially 
studied  by  Vandyke  Carter,  of  Bond)ay.  It  was  first  seen  in  this  country 
in  1844,  Avhen  cases  were  admitted  to  the  Philadelphia  Hospital,  which  are 
described  by  Meredith  Clymer  in  his  work  on  fevers.  Flint  saw  cases  in 
1850-'51.  In  18G9  it  prevailed  extensively  in  epidemic  form  in  New  York 
and  Philadelphia  ;  since  then  it  has  not  appeared. 

The  special  conditions  under  which  it  develops  are  similar  to  those  of 
typhus  fever.  Overcrowding  and  deficient  food  are  the  conditions  which 
seem  to  promote  the  rapid  spread  of  the  virus.  Neither  age,  sex,  nor  sea- 
son seems  to  have  any  special  intluence.  It  is  a  contagious  disease  and 
may  be  communicated  from  person  to  person,  but  is  not  so  contagious  as 
typhus.  Murchison  thinks  it  may  be  transported  by  fomites.  One  attack 
does  not  confer  immunity  from  subsequent  attacks.     In  1873  Obermeier 


64 


SPECIFIC  INFECTIOUS  DISEASKS. 


described  an  orfjaniam  in  the  blood  whieb  is  now  recofjnized  iis  tbc  specific 
agent.  This  si)irilliini,  or  more  correctly  spiroeba'te,  is  from  1}  to  (i  tinu'8 
tbo  len;^tii  of  the  dijimetor  of  ti  red  blood-corpuscle,  and  forms  a  narrow 
spiral  fiiamciit  wbicb  is  readily  seen  m()vin<r  amon<^  the  red  corpuscles  dur- 
iiif^  a  ])ar().\ysiii.  Tbey  are  present  in  tbe  t)lo()d  oidy  dnrin^f  tbe  fever. 
Siiortly  before  tbe  crisis  and  in  tbe  intervals  tbey  are  Jiot  f(jund,  tboiigb 
small  glistening  bodies,  wbicb  are  stated  to  be  tbeir  spores,  appear  in  tbc 
l)lood.  Tbe  disease  lias  been  produced  in  buman  beings  by  inoculation  with 
l)l()od  taken  during  tbe  paroxysm.  It  has  also  been  jiroduced  in  monkeys. 
Hed-bngs  may  suck  out  tbe  spirilla,  and  Tictin  reproduced  tbe  disease  by 
injecting  into  a  healthy  nu)nkey  blood  sucked  by  a  bug  from  an  infected 
monkey.  Nothing  is  yet  known  with  reference  to  tbe  life  history  of  the 
spirocbiV'te.     It  has  not  been  found  in  tbe  secretions  or  excretions. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  appear- 
ances in  relapsing  fever.  If  death  takes  place  during  the  i)aroxysm  tlie 
spleen  is  large  and  soft,  aiul  tbe  liver,  kidneys,  and  heart  show  cloudy 
BAvelling.  There  may  bo  infarcts  in  the  kidneys  and  spleen.  Tbe  bone 
marrow  has  been  found  in  a  condition  of  hyperplasia.  Eccbymoses  are 
not  uncommon. 

Symptoms. — The  inrnhation  appears  to  be  short,  and  in  some  in- 
stances tbe  attack  develops  promptly  after  exposure ;  more  frequently, 
however,  from  five  to  seven  days  elapse. 

The  inr(if<iou  is  abrupt,  with  chill,  fever,  and  intense  pain  in  the  back 
and  limbs.  In  young  persons  there  nuiy  be  nausea,  vomiting,  and  convul- 
sions. Tbe  temperature  rises  rapidly  and  may  reach  104°  on  the  evening 
of  the  first  day.  Sweats  are  common.  The  pulse  is  rapid,  ranging  from 
110  to  130.  There  may  be  delirium  if  the  fever  is  high.  Swelling  of  the 
spleen  can  be  detected  early.  Jaundice  is  common  in  some  epidemics. 
Tbe  gastric  symptoms  may  be  severe.  There  are  seldom  intestinal  symp- 
toms. Cough  may  be  present.  Occasionally  herpes  is  noted,  and  there  may 
be  miliary  vesicles  and  petecbioB.  During  the  paroxysm  the  blood  inva- 
riably shows  the  spirochoete,  and  there  is  usually  a  leucocytosis  (Ouskow). 
After  the  fever  has  persisted  with  severity  or  even  with  an  increasing  in- 
tensity for  five  or  six  days  the  crisis  occurs.  In  the  course  of  a  few  hours, 
accompanied  by  profuse  sweating,  sometimes  by  diarrbcea,  tbe  temperature 
falls  to  normal  or  even  subnormal,  and  tbe  period  of  apyrexia  begins. 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth  ;  it  usually  comes,  however,  about  the  end  of  the  first  week.  In 
delicate  and  elderly  persons  there  may  be  collapse.  The  convalescence  is 
rapid,  and  in  a  few  days  the  patient  is  up  and  about.  Then  in  a  Aveek, 
usually  on  the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills ; 
tbe  fever  returns  and  the  attack  is  repeated.  A  second  crisis  occurs  from 
the  twentieth  to  the  twenty-third  day,  and  again  the  patient  recovers 
rapidly.  As  a  rule,  tbe  relapse  is  shorter  than  the  original  attack.  A 
second  and  a  third  may  occur,  and  there  are  instances  on  record  of  even  a 
fourth  and  a  fifth.  In  epidemics  there  are  cases  Avhich  terminate  by  crisis 
on  the  seventh  or  eighth  day  without  the  occurrence  of  relapse.     In  pro- 


ltHLAF*SIX(}   FKVKR. 


55 


ipocific 
)  tiint'8 
narrow 
it's  (lur- 
)  fever, 
though 
■  in  the 
on  with 
onkeys. 
jcuse  ])y 
nfcctc'd 
J  of  the 

ui)|)i'tir- 
y.sm  the 
yr  cloudy 
lie  hone 
OSes  are 

some  in- 
jquently, 

the  hack 
1  convul- 

evening 
iug  from 

jy  of  the 


tracted  c:;sc8  the  convuloaconoo  is  very  tedious,  as  tlie  jtiiticnt  is  niucli  ex- 
liausrod. 

liehipsing  fever  is  not  a  very  fatal  disease.  Mun  hisou  slates  that  the 
mortality  is  ahout  4  per  cent.  In  the  enfeehled  and  old,  death  may  owwy 
ut  the  height  of  the  first  paroxysm. 

Complications  are  not  frer|ueiit.  In  .some  epidi'iiiics  nephritis  and 
hicmaturia  have  occurred.  Pneumonia  a]»])ears  to  he  rrc(|uent  and  may 
interrupt  the  typical  course  ol'  the  disease.     The  acute  cidargement  of  llio 


lorip 

100  i" 

08G° 
OO'H" 
95U° 


12      3      1      r.      I', 


"<     !t    10    11    VI    K!    II    ir.    it'i   tr    H    I't   •.•<>   •.'! 


I 


miiiiEinyaiosiiRiMHii 

ligiiilllgiiiHIJllBiEfSIIBI 

liHiHiiimiiafismMaiB 
gniBgiiigaimaBmisi 
aigiigasagaBaBiiiBnisaBi 

■MBifaiEggaaBMESSEiyiliES 


Chart  V. — Helapsing  Fever  (Murcliison). 

spleen  may  end  in  rupture,  and  the  ha?morrhage  from  the  stomach,  which 
has  heen  met  with  occasionally,  is  prohahly  associated  with  tliis  enlarge- 
ment. Post-fehrile  paralyses  may  occur.  Ophthalmia  has  followed  cer- 
tain epidemics,  and  may  prove  a  very  tedious  and  serious  complication. 
Jaundice  has  already  heen  mentioned.  In  pregnant  women  ahortion  usu- 
ally takes  place. 

Diagnosis. — The  onset  and  generalsymptoms  may  not  at  first  he  dis- 
tinctive. At  the  heginning  of  an  epidemic  the  cases  are  usually  regarded 
as  anomalous  typhoid ;  hut  once  the  typical  course  is  followed  in  a  case 
the  diagnosis  is  clear.     The  blood  examination  is  distinctive. 

Treatment. — The  paroxysm  can  neither  be  cut  short  nor  can  its 
recurrence  be  prevented.  It  might  be  thought  that  (luinine,  with  its  pow- 
erful action,  would  certainly  meet  the  indications,  ])ut  it  does  not  seem  to 
have  the  slightest  influence.  The  disease  must  be  treated  like  any  other 
continued  fever  by  careful  nursing,  a  regular  diet,  and  ordinary  hygienic 
measures.  Of  special  symptoms,  pains  in  the  ba(!k  and  in  the  limbs  and 
joints  demand  opium.  In  enfeebled  persons  the  collapse  at  the  crisis  may 
1)0  serious,  and  stimulants  with  ammonia  and  digitalis  should  be  given 
freely. 


66 


SPECIFIC  INFECTIOUS  DISEASES. 


m 


IV.  SMALL-POX  (Vm-ioJa). 

Definition. — An  acuto  infectious  ilisonse  clnirnntcrised  by  an  erup- 
tion wliicli  pusses  tlirouj,'h  tlu!  stages  of  i)apule,  vesicle,  pustule,  and 
crust.  The  mucous  nu'nihraues  in  contact  with  the  air  may  also  he 
affected.  Severe  cases  may  be  complicated  with  cutaneous  and  visceral 
ha'morrhafjes. 

Etiology. — It  luis  not  yet  been  determined  in  Avhat  country  small- 
pox originated.  Tlie  disease  is  said  to  liave  existed  in  China  many  centu- 
ries before  Christ.  The  pcslu  inatjna  described  by  (Jalen  (and  of  which 
Marcus  Aurelius  died)  is  believed  to  bo  small-pox.  In  the  sixth  century 
it  i)revailed,  and  subsequently,  at  the  time  of  the  Crusades,  becsame  wide- 
spread. It  Avas  brought  to  America  by  the  S])aniards  early  in  the  sixteenth 
century.  The  first  accurate  account  was  given  by  Khazes,  an  Aral)ian 
physi('ian  who  lived  in  the  ninth  century,  and  whose  admirable  description 
is  available  in  Greenbill's  translation  for  the  Sydenham  Society.  In  the 
seventeenth  century  a  thorough  study  of  the  disease  was  made  by  the  illus- 
trious Sydenham,  who  still  remains  one  of  the  most  trustwortliy  authorities 
on  the  subject. 

Special  events  in  the  liistory  of  the  disease  are  the  introduction  of  in- 
oculation into  Europe,  by  Lady  Mary  Wortley  Montagu,  in  1718,  and  the 
discovery  of  vaccination  by  Jenner,  in  179G. 

Small-pox  is  one  of  the  most  virulent  of  contagious  diseases,  and  per- 
sons exposed,  if  unprotected  by  vaccination,  are  almost  invariably  attacked. 
There  are  instances  on  record  of  persons  insusceptible  to  the  disease.  It  is 
said  that  Diemerbroeck,  a  celebrated  Utrecht  professor  in  the  seventeenth 
century,  was  not  only  himself  exempt,  but  likewise  many  members  of  his 
family.  One  of  the  nurses  in  the  small-pox  department  of  the  Montreal 
General  Hospital  stated  that  she  had  never  been  successfully  vaccinated, 
and  she  certainly  had  no  mark.  Such  instances,  however,  of  natural  im- 
munity are  very  rare.  An  attack  may  not  protect  for  life.  There  are  un- 
doubted cases  of  a  second,  reputed  instances,  indeed,  of  a  third  attack. 

Age. — Small-pox  is  common  at  all  ages,  but  is  particularly  fatal  to  young 
children.  The  fcetiis  in  utero  may  be  attacked,  but  only  if  the  mother 
herself  is  the  subject  of  the  disease.  The  child  may  be  born  with  the  rash 
out  or  with  the  scars.  More  commonly  the  foetus  is  not  affected,  and 
children  born  in  a  small-pox  hospital,  if  vaccinated  immediately,  may  escape 
the  disease ;  usually,  however,  they  die  early. 

Sex. — Males  and  females  are  equally  affected. 

Race. — Among  aboriginal  races  small-pox  is  terribly  fatal.  AV'hen  the 
disease  was  first  introduced  into  America  the  Mexicans  died  by  thousands, 
and  the  Xorth  American  Indians  have  also  been  frequently  decimated  by 
this  plague.  It  is  stated  that  the  negro  is  especially  susceptible,  and  the 
mortality  is  greater — about  42  per  cent  in  the  black,  against  39  per  cent  in 
the  white  (AV.  M.  Welch). 

The  contagium  develops  in  the  system  of  the  small-pox  patient  and  is 
reproduced  in  the  pustules.     It  exists  in  the  secretions  and  excretions. 


SMALL-POX. 


67 


n.  erup- 
lo,  and 
111  so  be 
viscerul 

y  smiill- 

y  centii- 

f  which 

century 

ne  wide- 

ixtecnth 

Arabian 

3cription 

In  the 

the  illus- 

ithoritiea 

ion  of  in- 
,  and  the 

,  and  per- 
attacked. 
ise.     It  is 
/entcenth 
ers  of  his 
Montreal 
iccinated, 
ural  im- 
•e  are  iin- 
tack. 
to  young 
e  mother 
the  rash 
;ted,  and 
ay  escape 


rhen  the 

lousands, 

lated  by 

and  the 

\v  cent  in 

Int  and  is 
ccretions, 


and  in  the  oxhahitions  from  the  iun<;rt  and  the  skin.  The  driod  scaU's  con- 
stitute by  far  the  most  important  ck'ment,  and  as  a  dust-like  })o\vdor  are 
distributed  everywhere  in  the  room  durin<?  convalescence,  becoming  at- 
ta(!hed  to  clothing  and  various  articles  of  furniture.  The  disease  is  proba- 
bly contagious  from  a  very  early  stage,  though  1  think  it  has  not  yet  been 
deterniiiu'd  whether  the  contagion  is  active  before  the  eruption  develops. 
The  poison  is  of  unusual  tenacity  and  clings  to  infected  localities.  Jt  is 
conveyed  l)y  pcuvsons  who  have  been  in  contact  with  the  sick  and  by  fomites. 
During  epidemic^s  it  is  no  doubt  widely  spread  in  street-cars  and  jjublie 
conveyances.  It  must  not  be  forgotten  that  an  un])rotected  jjcrsou  may 
contract  a  very  virulent  form  of  the  disease  from  the  mild  varioloid.  The 
question  of  aerial  transmission,  of  great  importance  in  connection  with  the 
situation  of  hospitals,  can  not  be  regarded  as  finally  settled.  Certain  facts 
are  in  its  favor,  as  those  reported  by  Young.  Of  'M)  cases  which  occurred 
within  500  yards  ol  the  Hastings  small-i)ox  pavilion,  the  jx'rccntage  of 
small-pox  attacks  to  population  ranged  from  4.'4  within  the  100-yard  circle 
to  0.^  in  the  400-  to  500-yard  circle. 

The  disease  smoulders  here  and  there  in  dilTerent  localities,  and  when 
conditions  are  favorable  becomes  epidemic.  Perhaps  the  most  remarkal)le 
instance  in  modern  times  of  the  rapid  extension  of  the  disease  o(!curred  in 
Montreal  in  1885.  8mall-pox  had  been  prevalent  in  that  city  between 
1870  and  1875,  when  it  died  out,  in  part  owing  to  the  exhaustion  of  suit- 
able material  and  in  part  owing  to  the  introduction  of  animal  vaccination. 
The  health  reports  show  that  the  city  Avas  free  from  the  disease  until  1885. 
During  these  years  vaccination,  to  which  many  of  the  French  Camidiaua 
are  opposed,  was  much  neglected,  so  that  a  large  unprotected  population 
grew  up  in  the  city.  On  February  28th  a  Pullman-car  conductor,  who  had 
travelled  from  Chicago,  where  the  disease  had  been  slightly  i)revalent,  was 
admitted  into  the  IIotel-Dieu,  the  civic  small-pox  hospital  being  at  the 
time  closed.  Isolation  Avas  not  carried  out,  and  on  the  1st  of  April  a  serv- 
ant in  the  hospital  died  of  small-pox.  Following  her  decease,  with  a  neg- 
ligence absolutely  criminal,  the  authorities  of  the  hospital  dismissed  all 
patients  presenting  no  symptoms  of  contagion,  who  could  go  home.  The 
disease  spread  like  fire  in  dry  grass,  and  within  nine  months  there  died  in 
the  city,  of  small-pox,  3,1G4  persons. 

The  nature  of  the  contagium  of  small-pox  is  still  unknown.  Weigert 
and  others  have  described  micro-organisms  in  the  pock,  but  they  are  the 
ordinary  pus  cocci,  and  the  part  which  they  play  in  the  affection  is  by  no 
means  certain.  Still  less  definite  are  the  observations  on  the  occurrence 
of  sporozoa  in  the  pocks.  It  is  not  a  little  remarkable  that  in  a  disease 
which  is  rightly  regarded  as  the  type  of  all  infectious  maladies,  the  specific 
virus  still  remains  unknown. 

Morbid  Anatomy. — A  section  of  a  papule  as  it  is  passing  into  the 

[vesicular  stage  shows  in  the  rete  mucosum,  close  to  the  true  skin,  an  area 

in  which  the  cells  are  smooth,  granular,  and  do  not  take  the  staining  fluid. 

This  represents  a  focus  of  coagulation-necrosis  due,  according  to  Weigert, 

to  the  presence  of  micrococci.     Around  this  area  there  is  active  iuflamma- 


58 


SPKCIKIC   IXI-'KCTIOUH   DISKASKS. 


tory  rciu'tion,  luul  in  tin*  v('Hi<'iiliir  stii^jo  tlu'  rcto  mncosum  jn'cscnts  re- 
ticiili,  or  splices,  wliicli  coiitiiiii  scrmn,  leucocytes,  and  lil)riii  lilanients. 
Tlie  ceiilral  drpressioii  or  uml)iliciitioii  correspoiuls  to  the  iireii  of  priiimry 
lUMTosM.  Ill  tli<'  staj,'e  of  miitunitioii  tho  retieuliir  spaces  become  tilled 
with  leui'ocytcs  and  many  of  the  cells  of  tho  reto  miicosum  become  vesicu- 
lar. The  papillic  of  the  true  skin  below  the  ))tistulc  are  swollen  and  intil- 
trated  with  end)ry()ni(^  cells  to  a  varialtle  d(!<,'ree.  If  tlu!  suppuration  ex- 
tends into  this  layer,  scarrin;,'  inevitably  results ;  but  if  it  is  contined  to 
the  in)per  layer,  this  does  not  necessarily  follow.  In  the  ha'morrha<,M(r  cases, 
red  corpuscles  ])ass  out  in  lar^'e  numbers  from  the  vessels  and  occupy  tho 
vesicular  spaces.  They  infiltrate  also  the  deeper  layers  of  tiic  epi<lcrrnis  in 
the  skin  adjacent  to  the  papules.  Fre(|uentiy  a  iiair-follicle  passes  tiirou^'h 
the  centrt^  of  a  i)apule. 

In  tho  mouth  the  pustules  may  be  .seen  upon  the  ton^Mie  and  tho  buccal 
mucosa,  and  on  tho  i)alato.  Tho  eruption  may  bo  abundant  also  in  tiic 
pharynx  and  the  upper  ])art  of  the  (es()])ha;;us.  In  exceptionally  rare  cases 
th((  eru])ti()n  I'Xtends  down  the  (cso[)haj,Mis  and  even  into  the  stomach. 
Swcllinij  of  the  I'eyer's  follicles  is  not  unconnnon ;  tho  pustules  liavo  been 
seen  in  the  rectum. 

In  tho  larynx  tho  eruption  may  bo  associated  with  a  fibrinous  exudate 
and  sometimes  Avith  (i'd(>ma.  Occasionally  the  inflammation  })enetrates 
deeply  and  involves  the  cartilapjc^s.  In  the  trachea  and  bronchi  there  may 
be  ulcerative  erosions,  but  true  pocks,  such  as  aro  soon  on  tho  skin,  do  not 
occur.  There  are  no  special  lesions  of  the  lungs,  biit  congestion  and  bron- 
cho-pneumonia are  very  common.  Tho  liver  is  sometimes  fatty.  A  diffuse 
hepatitis,  associated  with  intense  congestion  of  tho  vessels  and  migration 
of  tho  leucocytes,  has  been  described  ;  Woigert  has  noted  small  areas  of 
necrosis. 

There  is  nothing  special  in  tho  condition  of  tho  blood,  and  even  in  the 
most  malignant  cases  there  aro  no  microscopic  alterations.  In  the  blood- 
drop,  however,  it  will  be  seen  that  tho  corpuscles,  instead  of  forming  rou- 
leaux, are  aggregated  into  irregular  clumps.  An  active  loucocytosis  is 
present.  The  heart  occasionally  shoAVS  myocardial  changes,  parenchyma- 
tous and  fatty ;  endocarditis  and  pericarditis  are  uncommon.  French 
writers  have  described  an  endarteritis  of  tho  coromiry  vessels  in  connection 
with  small-pox.  The  spleen  is  markedly  enlarged.  Apart  from  the  cloudy 
swelling  and  areas  of  coagulation-necrosis,  lesions  of  the  kidneys  are  not 
common.  Nephritis  may  occur  during  convalescence.  Chiari  has  called 
attention  to  the  frequency  of  orchitis  in  this  disease ;  there  are  scattered 
areas  of  necrosis  with  cell  infiltration. 

In  the  luBmorrhagic  form  extravasations  are  found  on  the  serous  and 
mucous  surfaces,  in  the  parenchyma  of  organs,  in  the  connective  tissues, 
and  about  the  nerve-sheaths.  In  one  instance  I  found  the  entire  retro- 
peritoneal tissue  infiltrated  with  a  large  coagulum,  and  there  were  also  ox- 
tensive  extravasations  in  the  course  of  tho  thoracic  aorta,  lla^morrhages 
in  the  bone-marrow  have  also  been  described  by  Golgi.  There  may  be 
haemorrhages  into  the  muscles.     Ponfick  has  described  the  spleen  as  very 


SMAIili-POX. 


59 


cuts  re- 

primiiry 
lu'  lillc'l 
L«  vt'sicu- 
ind  iiilil- 
itioii  ox- 
ilinod  to 

^ric  CllSC'H, 

ciipy  tlu! 
U'l-mis  in 
i  tlirouf^'li 

he  Imccal 
so  in  tlu' 

stoiniich. 
Imve  biH'ii 

s  oxiuliito 
[)eni'tnites 
there  may 
;in,  do  not 
unci  bron- 
\  ditTuse 
niignitiou 
II  ureas  of 

vcn  in  the 
the  bh)od- 
•ining  rou- 
x'vtosis  is 
ireneliynia- 
Freneli 
:onTieetion 
|the  cloudy 
s  are  not 
Ihas  called 
scattered 

terous  and 
tve  tissues, 
litire  retro 
lire  also  ex- 
Imorrhages 
\ce  may  he 
ken  as  very 


lirni  anil  hard  in  ha'tnorrhagie  Hinall-pox,  and  such  waH  the  caHo  in  Hcveii 
instanccH  which  I  exaniine<l.  The  liver  has  been  (h'scrilieil  as  fatly  in 
llu'se  rai)id  cases,  l)ut  in  T)  of  my  T  cases  it  was  of  nurriial  si/e,  (h'lisc,  and 
tirin.  In  'i  it  was  large  and  Tatty;  but  oiu'  man  had  necrosis  of  the  til)ia, 
and  the  otluT  was  a  drunkard.  'I'he  cc<'hyiiioses  are  scatterecl  over  th(» 
iiieninges  of  the  brain  and  cord,  mid  in  one  case  tiu're  was  a  (dot  in  tho 
rigiit  ventrich'.  In  5  of  the  cases  there  were  areas  of  hienu)rrhagic  infarc- 
li(ni  of  tlic  lung.  In  four  instiinces  th(!  pidves  of  the  kidney  were  bhickcd 
witli  (hirk  (d(»ts,  wiiicdi  extended  into  the  caliccs  luid  (h)\vn  the  ureters. 
In  one  instance  tho  (M)atrt  of  the  bladder  were  unilorndy  hu'Uiorrhagic  and 
not  a  trace  of  iu>nual  tissue  could  bo  soon.  The  extravasations  in  tho 
mucous  nuunbrane  of  tlu^  stomaidi  and  intestiiu's  were  nunu'rous  and  large. 
I'eyer's  glands  were  swollen  and  pronnnent  in  four  instances. 

Symptoms. — 'I'hree  forms  of  small-()ox  are  described: 

I.   Vdviitht  vt't'd  :  {(()   Di.screto,  (/>)  Conlluent. 

Ji.  Vnrio/n  /Krinorr/itif/ini  ;  {(i)  Purpura  variolosa  or  bla(;k  small-pox; 
{/))   IlaMuorrhagic  pustular  form,  variola  haunorrhagica  pustulosa. 

;{.   Viin'o/oid.,  or  sinall-pox  modilled  by  vaccination. 

1.  Variola  Vera. — The  alfection  may  be  conveniently  described  under 
various  stages  :  (a)  Incuhitlion. — "  From  nine  to  fifteen  days  ;  ofteiu'sfc 
twcdvc."  I  have  seen  it  dtn'cdoi)  on  the  eighth  day  after  exi»osuro  to  in- 
fection, and  there  are  wcdl-aiithenticated  instances  in  whi(di  tlu*  stage  of 
incubation  has  been  ])rolongc(l  to  twenty  days.  It  is  unusual  for  i)aticnts 
to  cojni)laiu  of  any  symptoms  in  this  stage. 

{!))  [nrasiitn. — In  adults  a  chill  and  in  (diildren  a  convulsion  are  com- 
mon initial  symptoms.  There  nuiy  be  repeated  chills  within  the  first 
twenty-four  hours.  Intense  frontal  heada(du',  severe  lumbar  pains,  and 
vomiting  are  very  constant  feature.-!.  The  pains  in  the  back  and  in  the 
limbs  are  more  si'vere  in  the  initial  stage  of  this  than  of  any  other  erup- 
tive fever,  and  their  cond)ination  with  headache  and  vomiting  is  so  sug- 
gestive that  in  epidemics  precautionary  measures  may  often  be  taken  sev- 
eral days  l)efore  the  eruption  decides  positively  the  nature  of  the  disease. 
The  tempi'rature  rises  (juickly,  and  may  on  the  first  diiy  be  10;5°  or  104". 
The  i)ulse  is  ra})id  ami  full,  not  often  dicrotic.  In  severe  cases  there  may 
111'  marked  delirium,  particularly  if  the  fever  is  high.  The  })atient  is  rest- 
less and  distressed,  the  face  is  ilushed,  and  the  eyes  are  bright  ami  clear. 
The  skin  is  usually  dry,  though  occasionally  there  are  profuse  sw(>ats. 
One  can  not  judge  from  these  initial  symptoms  whether  a  case  is  likely 
to  be  discrete  or  confluent,  as  the  most  intense  backache  and  fever  may 
precede  a  very  mild  attack. 

In  this  stage  of  invasion  the  so-called  initial  rashes  may  occur,  of  wliicdi 
two  forms  can  be  distinguished — the  diifuse,  scarlatinal,  and  the  macular 
or  measly  form ;  either  of  which  may  be  associated  with  petechi.e  aiul  oc- 
cupy a  variable  extent  of  surface.  In  some  instances  they  are  general,  but 
MS  a  rule  they  are  limited,  as  pointed  out  by  Simon,  either  to  the  lower 
abdominal  areas,  to  tho  inner  surfaces  of  the  thighs,  and  to  the  lateral 
thoracic  region,  or  to  the  axilla3.     Occasionally  they  are  found  over  the 


,)■■ 


CO 


Sl'KClI'IC   INFKCTlors   DISKASKS. 


11 


oxtoii.><or  Murfiipos,  pnrtiiiiliirly  in  tlic  ncij^'lihoi'liooil  of  the  kuooH  nnd  clhowH. 
Tlii'.sc  raslicH,  usiiiilly  |iiii|»iiric,  ai-c  often  ass(Miiit('(|  with  iiii  crytlu'timtoua 
or  LM'ysipclatoiiH  Mush.  The  scarlatinal  rash  may  conu'  out  aH  early  aH  tho 
second  (hiy  and  be  art  ditTnso  and  vivid  as  in  u  truu  Hcarhitinu.  The  incuHly 
rash  may  also  he  ditTiise  and  i(h'ntiral  in  chanutter  with  that  of  mcaslua. 
Urticaria  is  only  occasionally  seen.  It  was  present  (»ncc  in  my  Monlreul 
ciwc'S.    Ap[>arently  tliesu  initial  rashe.s  are  mori'  abundant  in  some  epidemica 


11      u      1-.      Ill      ir      iH 


-lOO* 


30'0' 


afltc 


3^  0* 


Iiiiliiil  h'l'vcr  l';ni|itiim. 


Sii|iimriitlvo  I'l'vcr. 
ClI AICT    \'I.— 'I'nic  sI1im1I-|ii).\. 


than  in  othei's;  thus  thoy  were  certainly  nioi'e  luinierons  in  the  Montrciul 
epidemics  between  is^Omid  IHI,")  than  they  were  in  the  more  extensive 
epidemic  in  iSSf).  They  occur  in  from  10  to  1(»  per  cent  of  eases.  In  tho 
eases  under  my  care  in  the  small-pox  department  at  the  Montreal  (ienerul 
Hospital  the  percentap;e  was  IH.*  As  will  be  subsequently  mentioned  these 
initial  rashes  have  considerable  dia<,'nosti{!  value. 

{/•)  Eruption. — (I)  In  the  (/isnr/c  /(iriii,  usually  on  the  fourth  day, 
small  red  spots  ap])ear  on  the  forehead,  particularly  at  the  junction  with 
the  hair,  and  on  the  wrists.  Within  the  lirst  twenty-four  hours  from  their 
appearance  they  occur  on  other  parts  of  the  face  and  on  the  extremities, 
nnd  a  few  are  seen  on  the  trunk.  As  the  rash  comes  out  the  temjjcrature 
falls,  the  ^'eneral  symptoms  subside,  and  the  ])atient  feels  comfortable.  On 
the  fifth  or  sixth  day  the  ])ai)ules  chan_i,'e  into  vesicles  with  clear  summits. 
Kach  one  is  elevated,  circular,  and  presents  a  little  depression  in  the  centre, 
the  so-called  umbilicatioTi.  About  the  ei<?hth  day  the  vesicles  chun<re  into 
l)ustules,  the  umbilication  disappears,  the  flat  top  assumes  a  globular  form 
and  becomes  grayish  yellow  in  color,  owing  to  the  contained  pus.  There 
is  an  areola  of  injection  about  the  i)ustnles  and  the  skin  between  them  is 
swollen.  This  maturation  first  takes  place  on  the  face,  and  follows  tho 
order  of  tho  appearance  of  tho  eruption.  The  temi)erature  now  rises — 
secondary  fever — and  tho  general  symi)toms  return.  The  swelling  about 
the  pustiiles  is  attended  with  a  good  deal  of  tensior  and  jiain  in  the  face  ; 


*  The  Initial  Rashes  of  Sinall-pox.     Canada  Medical  and  Surgical  Journal,  1875. 


SMAM^-I'OX. 


«;i 


1  i'll)<)Wrt. 
cniiitout) 
ly  iiH  tlu) 
('  iiicuHly 

IIU'llsUtH. 

Moll  (null 

|)i(|i'IllU!B 

i:      iH 


Monti'Oiil 
exli'iisivo 
In  the 
(iciienil 
liu'd  these 

iirth  day, 

Ition  with 

om  their 

iciiiitics, 

|i|K'mture 

hie.     On 

Isummits. 

le  centre, 

in<io  into 

lihir  form 

There 

them  is 
llows  the 
w  rises — 
|ig  iihout 

lie  face ; 

1875. 


the  ('yelitls  liecome  swollen  iiiid  closi'il.  'IMicrc  is  ii  wcU-miirki'd  Iciicocyto- 
sis  in  the  Ht;":;e  of  sii|>[Miiiif  ion.  In  the  <lisi'ri'ti'  form  the  t('iii|n'nitiin!  of 
iimturation  <h."H  not  usually  remain  lii^fii  for  more  than  twenty-four  or 
twenty-six  hours,  ao  tluit  on  the  tenth  or  eleventh  day  the  fever  disappears 
,  iind  the  sta^'e  of  eonvalesi'eiiee  hegins.  Tlie  pintiiles  Ciipidly  dry,  lii'st  on 
the  face  and  then  on  tiu^  other  parts,  and  hy  the  fourteeiitli  or  llfteeiilli 
day  des(|Uamation  may  he  far  advanced  on  the  face.  There  nuiy  he  in 
addition  vesicles  in  the  mouth,  pharynx,  and  larynx,  causing  soreiieHs  and 
swelliu};  in  these  parts,  with  loss  of  voice.  Whether  pitting,'  takes  ]ilaeo 
ilepeiids  a  j^ood  deal  upon  the  severity  of  the  disease.  In  a  majitrity  of 
ruses  Syileiihaiii's  statement  holds  ;,food,  that  "  it  is  very  rarely  the  case  that 
the  distinct  siiiall-pox  leaves  its  mark." 

{'i)  I'liti  ('(itijliinit  Fijnii. — With  the  saiiu*  initial  symptoms,  thou^di 
usually  of  1,'reiitcr  severity,  the  rash  appears  on  the  fourth,  or,  aceordin;,'  to 
Sydcnliaiii,  on  the  third  day.  The  more  the  erupt  ion  shows  itself  l)efor(! 
the  fourth  day,  the  more  sure  it  is  to  hei-ome  coiillueiit  (Sydeiiliaiii).  The 
papules  at  lirst  may  he  isolated  and  it  is  only  later  in  the  stage  of  matu- 
ration that  the  eruption  is  coiilliieiit.  Hut  in  severer  i-ases  the  skin  is 
swollen  ami  hypera'mic  and  the  pa [iiiles  are  very  close  together.  On  the 
t'/et  and  hands,  too,  the  papules  are  thickly  set;  more  scattered  on  the 
liiiihs;  and  (luile  discrete  on  the  trunk.  With  the  a{)pearan!'e  of  the 
eruption  the  symptoms  8id)sido  and  the  fever  remits,  hut  not  to  the  same 
extent  as  in  the  discrete  form.  Oeeasionally  t!io  temperature  falls  to  nor- 
mal and  the  patient  may  he  very  comfortahle.  'i'heii,  usually  on  the  eighth 
(l.iy,  tiie  fi'ver  again  rises,  the  vesicles  hegin  to  change  to  luistules,  tli(( 
liy[)era'mia  al)Oiit  them  hecomes  intense,  the  swelling  of  the  face  and 
hands  increases,  and  by  the  tenth  day  the  pustules  have  fully  maturated, 
many  of  them  have  coalesced,  and  the  entire  skin  of  the  head  and  extremi- 
ties is  a  superficial  abscess.  The  fever  rises  to  Wi"  or  10 1",  the  puls((  is 
from  110  to  r^O,  and  there  is  often  delirium.  As  pointed  out  by  Sydcn- 
iniii,  salivation  in  adults  and  diarrluca  in  children  are  conunon  symptoms 
of  this  stage.  There  is  usually  miudi  thirst.  The  eruption  nuiy  also  be 
present  in  the  mouth,  and  usually  the  pharynx  and  larynx  are  involved  and 
the  voice  is  husky,  (ireat  swelling  of  the  cervical  lymphatic  glands  occurs. 
At  this  stage  the  patient  presents  a  terrible  picture,  uiiccpialled  in  any 
oLher  disease;  one  which  fully  justifies  the  horror  and  fright  with  which 
s  nall-pox  is  associated  in  the  public  mind.  Even  when  the  rash  is  con- 
lluent  on  the  face,  hands,  and  feet,  the  pustules  remain  discrete  on  the 
t.unk.  The  danger,  as  pointed  out  by  Sydenham,  is  in  ])roportion  to  the 
irimber  upon  the  face.  "If  ui)ou  the  face  they  are  as  thick  as  sand  it  is 
u  >  advantage  to  have  them  few  and  far  between  on  the  rest  of  the  body." 
In  fatal  eases,  by  the  tenth  or  eleventh  day  the  pulse  gets  feebler  and  more 
rapiil,  the  delirium  is  marked,  there  is  subsultus,  sometimes  diarrho'a,  and 
with  these  symptoms  the  patient  dies.  In  other  instances  between  the 
<  ightli  and  eleventh  day  hieniorrhagic  symptoms  develop.  When  recov- 
ery takes  place,  the  patient  enters  on  the  eleventh  or  twelfth  day  the 
penod  of — 


:-p 


"ji 


62 


SrECIFIC   INFECTIOUS   DISKASI-LS. 


{(f)  Drsirrafion. — Tlie  pustules  l)reiik  aud  tlio  pus  exudes  and  forms 
crusts.  Throu<,'li()ut  the  third  week  the  desiccation  proceeds  and  in  eases 
of  moderate  severity  the  secoiuhiry  fever  subsides ;  l)ut  in  others  it  may 
persist  until  the  fourth  week.  The  crusts  in  confluent  sjnall-pox  adhere 
for  a  long  time  and  the  process  of  scarring  may  take  three  or  four  weeks. 
The  crusts  on  the  face  fall  off,  but  the  tough  epidermis  of  the  hands  and 
feet  may  be  shed  entire.  We  had  in  the  small-pox  department  of  the 
Montreal  Cieneral  Hospital  several  moulds  in  epithelium  of  the  hands  and 
feet. 

2.  Hemorrhagic  small-pox  occurs  in  two  forms.  In  one  the  special 
symptoms  ajjpear  early  and  death  follows  in  from  two  to  six  days.  This 
is  the  so-called  petechial  or  black  small-pox — puvpura  vdriolom.  In  the 
other  form  the  case  progresses  as  one  of  ordinary  variola,  and  it  is  not 
until  the  vesicnilar  or  pustular  stage  that  haemorrhage  takes  place  into  the 
pocks  or  from  the  mucous  membranes.  This  is  sometimes  called  variola 
hmni ')rrlia(jira  jnu-.fahisa. 

Iliemorrhagic  snuill-pox  is  more  common  in  some  epidemics  than  in 
others.  It  is  less  frequent  in  children  than  in  adults.  Of  27  cases  ad- 
mitted to  the  small-pox  dejiartment  of  the  Montreal  General  Hospital 
there  were  3  under  ten  years,  4  between  fifteen  and  twenty,  9  between 
twenty  and  twenty-five,  7  between  twenty-five  and  thirty-five,  3  between 
thirty-five  and  forty-five,  and  1  al)ove  fifty.  Young  and  vigorous  persons 
seem  more  liable  to  this  form.  Several  of  my  cases  were  above  the  aver- 
age in  muscular  development.  Men  are  more  frequently  affected  than 
women ;  thus  in  my  list  there  were  21  males  and  only  0  females.  The 
influence  of  vacciiuition  is  shown  in  the  fact  that  of  the  cases  14  were  un- 
vaccinated,  while  not  one  of  the  13  who  had  scars  had  been  revaccinated. 

The  clinical  features  of  the  forms  of  haemorrhagic  small-pox  are  some- 
what different. 

In  imrpnva  variolosa  the  illness  starts  with  the  usual  symptoms,  but 
with  more  intense  cons^-itutional  disturl)ancc.  On  the  evening  of  the 
second  or  on  the  third  day  there  is  a  dirt'nse  hypenemic  rash,  particularly 
in  the  groins,  with  small  punctiform  lia?mori-hages.  The  rash  extends, 
becomes  more  distinctly  In^morrhagic,  and  the  spots  increase  in  size. 
Ecchymoses  appear  on  the  conjunctiva?,  and  as  early  as  the  third  day 
there  may  be  hannorrhages  from  the  mucous  membranes.  Death  nuiy 
tak(^  place  before  the  rasli  appears.  This  is  truly  a  terriljle  affection  and 
well  developed  cases  present  a  frightful  appeai'ance.  The  skin  may  luive 
a  uniformly  purplish  hue  and  the  unfortunate  victim  may  even  look  plum- 
colored.  The  face  is  swollen  and  large  conjunctival  haemorrhages  with 
the  deeply  s mken  corneae  give  a  ghai-*;ly  appearance  to  the  features.  The 
mind  may  remain  clear  to  the  end.  Death  occurs  from  the  third  to  the 
sixth  day ;  thus  in  thirteen  of  my  cases  it  took  place  on  or  before  this 
date.  The  earliest  death  was  on  the  third  day  and  there  were  no  traces  of 
papules.  There  may  be  no  mucous  haemorrhages  ;  thus  in  one  case  of  a 
most  virulent  character  death  occurred  without  bleeding  early  on  the  fourth 
day.     Iliematuria  is  perhaps  most  common,  next  haematemesis,  and  mela'na 


forma 
11  cases 
it  may 
adhere 
weeks, 
ds  and 
of  the 
ids  and 

special 

.     Tliis 

In  the 

:  is  not 
nto  tlie 
variola 

than  in 
ases  ad- 
iiospital 
between 
between 

persons 
he  aA'cr- 
ed  than 
!S.     The 

:ere  un- 

lated. 
somc- 

)nis,  but 
of  the 
icuhirly 
extends, 
in   size, 
ird  day 
th   niiiy 
ion  and 
ay  luive 
plum- 
es with 
,     The 
to  the 
ore  this 
races  of 
ase  of  a 
c  fourth 
mela'ua 


SMALL-POX. 


03 


(S 


wan,  noticed  in  a  tliird  of  the  cases.  Metrorrlia<?ia  was  present  in  one  only 
of  the  six  females  on  my  list,  lliymoptysis  occurred  in  live  cases.  The 
pulse  in  this  form  of  small-pox  is  rapid  and  often  hard  and  small.  The 
respirations  are  j^reatly  increased  in  fretjuency  and  out  of  all  i)roportion  to 
.the  intensity  of  the  fever.  In  the  case  of  a  negro,  whose  respirations 
the  morning  after  admission  were  32  and  temperature  101°,  after  examin- 
ing the  lungs  and  finding  notliing  to  account  for  the  relatively  rapid 
breathing,  my  suspicions  were  aroused,  and  even  on  the  dark  skin  I  was 
able  on  careful  in  pection  to  detect  hitmorrhages  in  and  about  tlie  papules. 

In  variola jmstulosa  hwinorrhagica  tlie  disease  progresses  as  an  ordinary 
case  of  severe  variola,  and  the  haemorrhages  do  not  develop  until  the  vesicu- 
lar or  pustular  stage.  The  earlier  the  haimorrhage  the  greater  is  the  dan- 
ger. There  are  undoubtedly  instances  of  recovery  when  the  bleeding  has 
taken  place  at  the  stage  of  maturation,  lileeding  from  the  mucous  mem- 
branes is  also  common  in  this  form,  and  the  great  nuijority  of  the  cases 
piuve  fatal,  usually  on  the  seventh,  eighth,  or  ninth  day. 

There  is  a  form  of  hfemorrhagic  small-pox  in  which  bleeding  takes 
place  into  the  pocks  in  the  vesicular  stage  and  is  followed  by  a  rapid 
abortion  of  the  rash  and  a  speedy  recovery.  Six  instaiu'cs  of  this  kind 
came  under  my  ol)servation.*  In  4  the  hasmorrhagc  took  place  on  the 
fourth  day ;  in  3  on  the  fifth  day,  just  at  the  time  of  transition  of  the 
papule  into  the  vesicle.  Extravasation  took  place  chiefly  into  the  pocks 
on  the  lower  extremities  and  trunk,  in  only  two  instances  occurring  in 
those  on  the  arms.  The  eruption  in  all  proved  abortive,  and  no  patients 
under  my  care  with  an  equal  extent  oi  eruption  nuide  such  rapid  recoveries. 
With  these  cases  are  to  be  grouped  those  in  which  the  hannorrhages  occur 
in  the  pustules  of  the  legs  in  patients  who  have  in  their  delirium  got  out 
of  bed  and  wandered  about.  This  modified  form  of  ha^Muori-hagic  small-])ox 
is  also  described  by  Scheby-Iiucli. 

3.  Varioloid. — This  term  is  applied  to  the  modified  form  of  small-pox 
which  affects  persons  who  iuive  been  vaccinated.  It  may  set  in  with 
abruptness  and  severity,  the  temperature  reaching  103°.  More  commonly 
it  is  in  every  respect  mildev  in  its  initial  symptoms,  though  tlie  headache 
and  backache  may  be  very  distressing.  The  papules  ajjpear  on  tlie  even- 
ing of  the  third  or  on  the  fourth  day.  They  are  few  in  number  and  may 
bo  confined  to  the  face  and  hands.  The  fever  droi)s  at  once  and  the  pa- 
tient feels  perfectly  C'Mifortable.  The  vesiculaticm  and  maturation  of  tlir- 
pocks  take  place  rapidly  and  tliere  is  no  secondary  fever.  There  is  rarely 
any  scarring.  As  a  rule,  when  small-pox  ai;tacks  a  person  who  has  been 
vaccinated  within  five  or  six  years  the  disease  is  mihl  1)ut  there  are  in- 
stances in  which  it  is  very  severe,  and  it  may  even  prove        il. 

There  are  several  forms  of  rash  ;  thus  in  what  has  be  ivuown  as  liorn- 
pox,  crystalline  pox,  and  wart-pox  the  papules  come  ou  in  numbers  on  the 
third  or  fourth  day,  and  ])y  the  fifth  or  sixth  day  have  dried  to  a  hard, 
horny  consistence. 

*  Clinical  Notes  on  Sniall-pox.    Montreal,  18TG. 


04 


SPECIFIC   INFECTIOUS  DISEASES. 


AVritors  (lc.s('vil)o  a  varinhi  sine  crupfionr,  which  is  mot  witli  (luviiipf  opi- 
dcniics  in  young  persons  who  hiivo  Ijcen  well  vaccinated,  and  who  present 
simply  the  initial  symptoms  of  fever,  headache,  and  backache.  In  a  some- 
what extensive  experience  in  ^lontreal  I  do  not  remember  to  have  met  Avith 
an  instance  of  this  kind,  or  indeed  to  have  heard  of  one. 

We  do  not  now  see  the  modiiied  form  of  small-pox,  resulting  from  in- 
oculation, in  which  by  tlio  seventh  or  eighth  day  a  pustule  forms  at  the 
seat  of  inoculation  ;  after  this  general  fever  sets  in,  and  with  it,  about  the 
eleventh  day,  appears  a  general  eruption,  usually  limited  in  degree. 

Complications. — Considering  the  severity  of  many  of  the  eases  and 
the  general  character  of  the  disease,  associated  Avith  multiple  foci  of  sup- 
puration, the  complications  in  snudl-pox  are  remarkably  few. 

Laryngitis  is  serious  in  three  ways :  it  may  produce  a  fatal  ojdema  of 
tlie  glottis  ;  it  is  liable  to  extend  and  involve  the  cartilages,  producing 
necrosis;  and  by  diminishing  the  sensibility  of  the  larynx,  it  may  allow 
irritating  particles  to  reach  the  lower  air-passages,  where  they  excite 
bronchitis  or  broncho-pneumonia. 

lironcho- pneumonia  is  indeed  one  of  tlie  most  common  complications, 
and  is  almost  invariably  present  in  fatal  cases.  Lobar  pneumonia  is  rare. 
Pleurisy  is  common  in  some  epidemics. 

The  cardiac  complications  are  also  rare.  Li  the  height  of  the  fever  a 
systolic  murmur  at  the  apex  is  not  uncommon  ;  but  endocarditis,  either 
simple  or  malignant,  is  rarely  met  with.  Pericarditis  too  is  very  uncom- 
mon, ^lyocarditis  seems  to  bo  more  frequent,  and  may  be  associated  with 
eiularteritis  of  the  coronary  vessels. 

Of  complications  in  the  digestive  system,  parotitis  is  rare.  In  severe 
cases  there  is  extensive  pseudo-diphtheritic  angimi.  Vomiting,  Avhich  is 
so  marked  a  symptom  in  the  early  stage,  is  rarely  persistent.  Diarrhoea 
is  not  uncommon,  as  noted  by  Sydenham,  and  is  very  constantly  present 
in  children. 

Albuminuria  is  frequent,  but  true  nephritis  is  rare.  Inflammation  of 
the  testes  and  of  the  ovaries  may  occur. 

Among  the  most  interesting  and  serious  complications  are  those  per- 
taining to  the  nervous  system.  In  children  convulsions  are  common.  In 
adults  the  delirium  of  the  early  stage  may  persist  and  become  violent,  and 
finally  subside  into  a  fatal  coma.  Post-febrile  insanity  is  occasionally  met 
with  during  convalescence,  and  very  rarely  epilepsy.  Many  of  the  old 
writers  spoke  of  paraplegia  v\  connection  with  the  intense  backache  of 
the  early  stage,  but  it  is  probably  associated  with  the  severe  agonising 
lumbar  and  criiral  pains  and  is  not  a  true  paraplegia.  It  must  bo  distin- 
guished from  the  form  occurring  in  convalescence,  which  may  be  due  to 
peripheral  neuritis  or  to  a  diffuse  myelitis  (Westphal).  The  neuritis  may, 
as  in  diphtheria,  involve  the  pharynx  alone,  or  it  may  be  multiple.  Of  this 
nature,  in  all  probability,  is  the  so-called  pseudo-tabes,  or  ataxic  variolique. 
Hemiplegia  and  aphasia  have  been  met  with  in  a  few  instances,  the  result 
of  encephalitis. 

Among  the  most  constant  and  troublesome  complications  of  small-pox 


SMALL-POX. 


G5 


C'pi- 


jnising 
distiu- 
duc  to 

is  may, 
)f  tliis 

\()lirjue. 
result 

lall-pox 


aro  tho.^e  involving?  tlio  skin.  During  convalescence  boils  are  very  fre- 
(|Uont  and  may  be  severe.  Acne  and  ecthyma  are  also  met  with.  Local 
gangrene  in  various  parts  may  occur. 

Arthritis  may  develop,  usually  in  the  period  of  desquamatioTi,  and  may 
pass  on  to  suppuration.  Acute  necrosis  of  the  bone  is  sometimes  mot 
Avith. 

A  remarkable  secondary  eruption  (recurrent  small-pox)  occasionally 
occurs  after  desquamation. 

Special  ScHKcs. — Tlie  eye  affections  Avhieh  were  formerly  so  common 
and  serious  are  not  now  so  frequent,  owing  to  the  care  which  is  given  to 
keeping  the  conjunctiva3  clean.  A  catarrhal  and  purulent  conjunctivitis 
is  common  in  severe  casj...  The  secretions  cause  adhesions  of  the  eyelids, 
and  unless  great  care  is  taken  a  ditfuse  keratitis  is  excited,  which  may  go 
on  to  ulceration  and  perforation.  Iritis  is  not  very  uncoiinuon.  Otitis 
media  is  an  occasional  complication,  and  usually  results  from  an  extension 
of  the  disease  through  the  Eustachian  tubes. 

Prognosis. — In  unprotected  persons  small-pox  is  a  very  fatal  disease. 
In  dilterent  epidemics  the  death-rate  is  from  ^5  to  35  per  cent.  In  >\'il- 
liam  M.  Welch's  report  from  the  ^Municipal  Hospital,  Philadeli)]iia,  of 
2,831  cases  of  variola,  1,534 — i.  e.,  54.18  per  cent — died,  while  of  ;i,lG9 
cases  of  varioloid  only  2S — i.  e.,  1.29  per  cent — died.  The  haMnorrhagic 
form  is  invariably  fatal,  and  a  majority  of  those  attacked  with  the  sevei'er 
confluent  forms  die.  In  young  children  it  is  particularly  fatal.  In  the 
Montreal  epidemic  of  1885  and  188G,  of  3,l(i-4  deaths  there  were  2,717 
under  t.  years.  The  intemperate  and  debilitated  succumb  more  readily 
to  the  disease.  As  Sydenham  observed,  the  danger  is  directly  propor- 
tionate to  the  intensity  of  the  disease  on  the  face  and  liands.  "  When 
the  fever  increases  after  the  appearance  of  the  pitstules,  it  is  a  l)ad  sign  ; 
but,  if  it  is  lessened  on  their  appearance,  that  is  a  good  sign"  (Khazes). 
Very  high  fever,  with  delirium  arid  subsultus,  are  symptoms  of  ill  omen. 
The  disease  is  particularly  fatal  in  pregnant  Avomen  and  abortion  usually 
takes  place.  It  is  not,  however,  uniformly  so,  and  I  have  twice  known 
severe  cases  to  recover  after  miscarriage.  Moreover,  abortion  is  not  in- 
evitable.    Very  severe  pharyngitis  and  laryngitis  are  fatal  complications. 

Death  results  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  the  later  stages  it  usually  occurs  about  the  eleventh 
or  twelfth  day,  at  the  height  of  the  eruption.  In  children,  and  occasion- 
ally in  adults,  the  laryngeal  and  pulmonary  complications  ])rove  fatal. 

Diagnosis. — During  an  epidemic,  the  initial  chill,  followed  by  fever, 
headache,  vomiting,  and  the  severe  pain  in  the  back,  are  symptoms  whicli 
should  put  the  attending  physician  on  his  guard.  Mistakes  arise  in  the 
initial  stage  owing  to  the  presence  of  the  scarlatinal  or  measly  rashes 
which  may  be  extremely  deceptive.  The  scarlatinal  rash  has  not  ahvays 
the  intensity  of  the  true  rash  of  this  disease.  In  my  Montreal  experience 
I  did  not  meet  with  an  instance  in  which  this  rash  led  to  an  error,  though 
I  heard  of  several  cases  in  which  the  mistake  was  made.  These  are  doubt- 
loss  the  instances  to  which  the  older  writers  refer  of  scarlet  fever  and 


I 


till ' 

m 


()() 


SPI'X'IFIO  INPI'XTIOUS   DISEASES. 


sniiill-pox  of'ourriii^'  toj^ctluT.  The  iiiciisl^'  rash  ciin  not  always  bo  dis- 
tiiifruislu'd  from  true  lucaslcs,  instancos  of  which  may  he  mistaken  for  tho 
initial  rasli.  I  found  in  the  ward  ono  morning  a  young  man  wiio  had 
Ikhmi  sent  in  on  the  previous  evening  with  a  diagnosis  of  small-i)()x.  llo 
liad  a  fading  macular  rash  with  distiiu't  small  i)a}>ules,  which  had  iu)t,  how- 
ever, the  shotty  hardness  of  variola.  In  the  evening  this  rash  was  less 
marked,  and  us  I  felt  sure  that  a  mistake  had  been  made,  he  was  disinfected 
and  sent  home.  Jn  another  instance  a  child  believed  to  have  small-pox 
was  admitted,  but  it  proved  to  have  sini])ly  nuiusles.  Neither  of  these  cases 
took  snudl-pox.  In  a  third  case,  wh'ch  I  saw  at  the  City  Hospital,  the 
nu)ttled  papular  rash  was  mistaken  for  small-pox  and  tin;  young  man  sent 
to  the  hospital.  I  saw  him  the  day  after  admission,  Avhen  there  was  no 
question  that  the  disease  was  measles  and  not  variola.  Less  fortunate  than 
the  otluT  cases,  he  took  small-pox  in  a  very  severe  form.  The  general  con- 
dition of  the  patient  and  the  nature  of  the  prodromal  symptoms  are  often 
better  guides  than  the  character  of  the  rash.  In  any  case  it  is  not  Avell,  as 
a  rule,  to  send  a  patient  to  a  small-pox  hospital  until  the  characteristic 
papules  appear  about  the  forehead  and  on  the  wrists. 

In  the  most  malignant  type  of  luemorrhagic  small-i)ox  the  patient  may 
die  before  the  characteristic;  rash  develops,  though  as  a  rule  small,  shotty 
papules  may  be  felt  about  the  wrists  or  at  the  roots  of  the  hairs.  In  only 
one  of  twenty-seven  cases  of  luvmorrhagic  small-jiox,  in  which  death  oc- 
curred on  the  third  day,  did  inspection  fail  to  reveal  the  papules.  In  three 
cases  in  which  death  took  place  on  the  fourth  day  the  characteristic  rash 
was  beginning  to  appear. 

The  disease  may  be  mistaken  for  cerebro-spinal  fever,  in  which  purpuric 
symptoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly 
ill  with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day 
petechi{T3  appeared  on  the  skin.  There  were  retraction  of  the  head,  and 
marked  rigidity  of  the  limbs.  The  haemorrhages  became  more  abundant ; 
UTid  finally  ha?matemesis  occurred  and  the  child  died  on  the  sixth  day.  At 
the  post  mortem  there  were  no  lesions  of  cerebro-spinal  fever,  and  in  the 
deeply  hiBmorrhagic  skin  the  papules  could  be  i-eadily  seen.  The  post- 
mortem diagnosis  of  small-pox  was  unhappily  confirmed  by  the  mother 
taking  the  disease  and  dying  of  it. 

It  might  be  thought  scarcely  possible  to  mistake  any  other  disease  for 
small-pox  in  the  pustular  stage.  Yet  I  had  an  instance  of  a  young  man 
sent  to  me  with  a  copious  pustular  eruption,  chiefly  on  the  trunk  and  cov- 
ered portions  of  the  body,  which,  so  far  as  the  pustules  themselves  were 
concerned,  was  almost  identical  with  that  of  variola ;  but  the  history  and 
the  distribution  left  no  (juestion  that  it  was  a  pustular  syphilide.  It  is  not 
to  be  forgotten,  however,  that  fever,  which  was  absent  in  this  case,  may  be 
present  in  certain  instances  of  diffuse  pustular  syphilis.  Lastly,  chicken- 
pox  and  small-jjox  may  be  confounded.  Indeed,  sometimes  it  is  not  easy 
to  distinguish  between  them,  though  in  well-defined  cases  of  varicella  the 
more  vesicular  character  of  the  pustules,  their  irregularity,  the  short  stage 
of  invasion,  the  slight  constitutional  disturbance,  and  the  greater  intensity 


S^[ALL-POX. 


G7 


lasG  for 


kg  man 


of  the  rash  on  the  trunk,  sliould  make  tlio  diagnosis  clear.  It  is  stated 
that  the  Chicago  case,  whicli  was  tlie  starting-jwint  in  Montreal  of  the 
e])i(lemic  of  iSHo,  was  regarded  as  varicella  and  not  isolated.  Jf  so,  the 
mistake  was  one  wiiich  led  to  one  of  tiie  most  fatal  of  modern  outI)reaks 
of  the  disease. 

(Jlanders  in  the  pustular  form  has  been  mistaken  for  small-pox,  and  I 
know  of  an  instance  (during  an  epidemic)  Avhich  was  isolated  on  the  sup- 
position that  it  was  variola. 

Treatment. — In  the  interests  of  public  health  cases  of  small-]wx 
should  invarial)ly  be  removed  to  special  h(jspitals,  since  it  is  impossil)lo 
to  take  the  proper  precautions  in  private  houses.  The  general  hygienic 
arrangcTnents  of  tiie  room  should  be  suitable  for  an  infectious  disease. 
All  unnecessary  furjiiture  and  the  curtains  and  carpets  should  be  removed. 
The  greatest  care  should  be  taken  to  kee[)  tiie  i)atient  thoroughly  cU'an, 
and  the  linen  should  be  fretiuently  changed.  'J'he  bedclothing  siiould  be 
light.  It  is  curious  that  the  old-fashioned  notion,  which  Sydenham  tried 
so  hard  to  combat,  that  small-pox  patients  should  be  kej)t  hot  and  warm, 
still  prevails;  and  I  have  frequently  had  to  protest  against  the  patient 
being,  as  Sydenham  ex})resses  it,  stifled  in  his  bed.  S})ecial  care  should 
be  taken  to  sterilize  thoroughly  everything  that  has  been  in  contact  with 
the  patient. 

In  the  early  stage  the  pain  in  the  back  and  lind)s  requires  opium, 
Avhich,  as  advised  by  Sydenham,  may  be  freely  given.  The  diet  should 
consist  of  milk  and  broths,  and  of  "  all  articles  which  give  no  trouble  to 
digestion."  Cold  drinks  may  be  freely  given.  Barley-water  and  the 
Scotch  horse  (oatmeal  and  water)  are  both  nutritious  and  palatable. 
After  the  preliminary  vomiting,  which  is  often  veiy  hard  to  check  by 
ordinary  measures,  the  appetite  is  usually  good,  and,  if  the  throat  is  not 
very  sore,  |)atients  with  the  confluent  form  take  nourishment  well.  In 
the  hfemorrhagic  cases  the  vomiting  is  usually  aggravated  and  persistent. 

The  fever  when  high  must  be  kept  within  limits,  and  it  is  best  to  use 
either  cold  sponging  or  the  cold  bath.  When  the  pyrexia  is  combined 
Avith  delirium  and  subsultus,  the  patient  should  be  placed  in  a  bath  at  70°, 
and  this  repeated  as  often  as  every  three  hours  if  the  temperature  rises 
above  103°.  When  it  is  not  practicable  to  give  the  cold  bath,  the  cold 
pack  can  be  employed.  These  measures  are  much  preferable  in  small-pox 
to  the  administration  of  medicinal  antipyretics. 

The  treatment  of  the  eruption  has  naturally  engaged  the  special  atten- 
tion of  the  profession.  The  question  of  the  j)rcvcjitiiig  of  pitting,  so  much 
discussed,  is  really  not  in  the  hands  of  the  physician.  It  depends  entirely 
upon  the  depth  to  which  the  individual  pustules  reach.  After  trying  all 
sorts  of  remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or 
treating  them  with  iodine  and  various  ointments,  I  came  to  Sydenham's 
conclusion  that  in  guarding  the  face  against  being  disfigured  by  the  scars 
"  the  only  effect  of  oils,  liniments,  and  the  like,  was  to  make  the  white 
scurfs  slower  in  coming  off."  There  is,  I  believe,  something  in  p  "tecting 
the  ripening  papules  from  the  light,  and  the  constant  application  on  the 


C8 


SPECIFIC  INFECTIOUS  DISEASES. 


face  and  hands  of  lint  soaked  in  cold  water,  to  which  antiseptics  such  as 
carbolic  acid  or  bichloride  may  bo  added,  is  perhaps  the  most  suitable 
local  treatment.  It  is  very  pleasant  to  the  patient,  and  for  the  face  it  is 
well  to  make  a  mask  of  lint,  which  can  then  bo  covered  with  oiled  silk. 
When  th(!  crusts  be<,nn  to  form,  the  chief  point  is  to  keep  them  tliorouf^ldy 
moist,  wliich  may  be  done  with  oil  or  glycerin.  This  prevents  the  desicca- 
tion and  di (fusion  of  the  flakes  of  epidernus.  Vaseline  is  particularly  use- 
ful, and  at  this  stage  may  l)e  freely  used  upon  the  face.  It  frequently 
relieves  the  itching  also.  For  the  odor,  which  is  sometimes  so  character- 
istic and  disagreeable,  the  dilute  carbolic  solutions  are  probably  best.  If 
the  eruption  is  abundant  on  the  scalp,  the  hair  should  be  cut  short  to 
prevent  matting  and  decomposition  of  the  crusts.  During  convalescence 
frequent  bathing  is  advisable,  because  it  helps  to  soften  the  crusts.  The 
care  of  the  eyes  is  particularly  important.  Tlie  lids  should  be  thoroughly 
cleansed  three  or  four  times  a  day,  and  the  conjunctivie  washed  with  some 
antiseptic  solution.  In  the  confluent  cases,  when  the  eyelids  are  much 
swollen  and  the  lids  glued  together,  it  is  only  by  watchfulness  that  kerati- 
tis can  be  prevented.  The  mouth  and  throat  should  be  kept  clean,  and  if 
crusts  form  in  the  nose  they  should  be  softened  by  frequent  injections. 
Ice  can  be  given,  and  is  very  grateful  Avhen  there  is  much  angina.  In 
moderate  cases,  so  soon  as  the  fever  subsides  the  patient  should  be  allowed 
to  get  up,  a  practice  which  Sydenham  warmly  urged.  The  diarrhoea,  when 
severe,  should  be  checked  with  paregoric.  When  the  pulse  becomes  feeble 
and  rapid,  stimulants  may  be  freely  given.  The  delirium  is  occasionally 
maniacal  and  may  require  chloroform,  but  for  the  nervous  symptoms  the 
bath  or  cold  pack  is  the  best.  For  the  severe  haemorrhages  of  the  malig- 
nant cases  nothing  can  be  done,  and  it  is  only  cruel  to  drench  the  unfortu- 
nate patient  with  iron,  ergot,  and  other  drugs.  Symptoms  of  obstruction 
in  the  larynx,  usually  from  oedema,  may  call  for  tracheotomy.  In  the  late 
stages  of  the  disease,  should  the  patient  be  extremely  debilitated  and  the 
subject  of  abscesses  and  bed-sores,  he  may  be  placed  on  a  water-bed  or 
treated  by  the  continuous  warm  bath.  During  convalescence  the  patient 
should  bathe  daily  and  use  carbolic  soap  freely  in  order  to  get  rid  of  the 
crusts  and  scabs.  He  should  not  be  considered  without  danger  to  others 
until  the  skin  is  perfectly  smooth  and  clean,  and  free  from  any  trace  of 
scabs.  I  have  not  mentioned  any  of  the  so-called  specifics  or  the  inter- 
nal antiseptics,  which  have  been  advised  in  such  numbers ;  so  far  as  I 
know,  those  who  have  had  the  widest  experience  with  the  disease  do 
not  favor  their  use. 


V.  VACCINIA  {Cow-po3-)-W ACCINATION. 

Definition. — An  oruptive  disease  of  the  cow,  the  virus  of  which,  inocu- 
lated into  man  (vaccination),  produc  ~  a  local  pock  with  constitutional 
disturbance,  which  affords  protectioi.^  aore  or  less  permanent,  against 
small-pox. 

The  vaccine  is  got  either  directly  from  the  calf — animal  lymph — in 


VACCINIA— VACCINATION. 


69 


inocu- 

liitional 

igainst 

bli— ill 


P 


which  tilt'  (liscaso  is  jiropnjralcd  at  r('<i;iihir  stations,  or  is  nl)taiiKMl  from 
]K'rsoiis  V!icciiial('(l  (liiiinanizcd  lyiii|>h). 

History.  —  i-'or  cfiiturics  it  liad  Itccii  a  ])()|nilar  hclit'f  aiiioiii^-  t'aniuT 
t'oilc  tliat  cow-pox  protected  aj^^ainst  siiiali-|>ox.  it  is  said  tliat  tlic  notorious 
J)uc1r'Ss  of  C'lt'vckin<l,  rc|tlyin}^  to  some  jol<er  wlio  su;,'<,fested  that  slie  wouhl 
■Jose  her  occupation  if  slie  was  disfi<,nired  witli  small-pox,  said  that  she  was 
not  afraid  of  the  disease,  as  she  had  had  cow-pox.  .Jesty,  a  Dorsetshire 
farmer,  had  iiad  cow-pox,  and  in  ITTl  vaccinated  successl'idly  liis  wife  and 
two  sons,  .riett,  in  llolstein,  in  1T!M,  also  successfully  vaccinated  three 
children.  AVhen  Jenner  was  a  student  at  S()dl)ury,  a  youn>^  girl,  who  came 
for  advice,  when  smal!-pox  was  nu'Utioned,  exclainu'd,  "  I  can  not  take  that 
disease,  for  1  have  had  cow-pox."  Jenner  suhsetpU'Utly  mentioned  the  sul)- 
jcct  to  Hunter,  who  in  reply  gave  the  famous  piece  of  advice:  "  J)o  not 
think,  hut  try;  he  ])atient,  he  accurate."  As  early  as  17S()  the  idea  of  the 
rotective  ])owcr  of  vaccination  was  /irmly  impressed  on  .Tenner's  mind. 
The  ])rohlem  which  occu])ied  his  attention  for  nuiny  years  was  hrought  to 
a  jiractical  issue  when,  on  ^lay  1-1,  ITiX!,  he  took  matter  from  the  hand  of 
a  dairy-maid,  Sarah  Nelmes,  who  had  cow-pox,  and  inoculated  a  hoy  named 
James  Phipps,  aged  eiglit  years.  On  July  1st  matter  was  taken  from  a 
small-])ox  pustule,  and  inserted  into  the  hoy,  ])ut  no  disease  fol]owe(h  In 
17!»(S  a])peared  An  Iiupury  into  the  Causes  and  J^tTects  of  the  Variola 
Vaccina*,  a  Disease  discovered  in  some  of  the  Western  Counties  of  England, 
|»articularly  tHoucestershire,  and  known  hy  the  Xame  of  Cow-pox  (pp.  iv, 
TT),  four  ])lates,  4to.  London,  ITUS).  l''rom  this  time  on  vaccination  si)read 
rai)idly  throughout  the  civilized  world. 

In  the  United  States  vaccination  was  introduced  hy  Ik'ujamin  Water- 
house,  Professor  of  Physic  at  Harvard,  wlio  on  July  8,  1800,  vaccinated 
seven  of  his  children.  President  Jefferson  was  maiidy  instrumental  in 
spreading  the  ])ractice  in  the  Southern  States,  and  John  Pedman  Coxe 
introduced  it  into  Philadelphia. 

The  literature  of  vaccination  has  hecn  greatly  enriched  hy  the  pid)- 
lications  in  connection  with  the  Jenner  centenary.  The  centenary  numher 
id'  the  P)ritisli  IMedical  Journal  is  ]iarticularly  valuahle.  The  report  of  the 
h'oyal  Commission  on  vaccination,  the  exhaustive  article  in  Alll)utt's  System 
l)y  T.  D.  Ackland  and  Copeman,  and  Cory's  recent  numograi)h  on  the 
^^uhjcct  afford  a  large  hody  of  material.  To  the  pnhlic  health  oificials,  who 
wish  for  distrihution  in  handy  sha]ic  Facts  ahout  Small-pox  and  A^accina- 
tion,  the  leaflets  issued  hy  the  Pritish  Afedical  Associalion  (Pritish  Medical 
Journal,  1898,  vol.  i,  p.  632)  will  Ije  of  the  greatest  value. 

Xature  of  Vaccinia. — Ts  cow--pox  a  separate  independent  disease, 
or  is  it  only  small-]iox  modified  hy  passing  through  the  cow?  In  spite  of 
n  host  of  ohscrvations,  this  question  is  not  yet  settled,  as  may  he  seen  in 
ihe  diametrically  opposed  views  expressed  hy  Copeman  in  xMlhutt's  System 
aiul  hy  Prouardel  in  the  Twentieth  Centnry  Practice.  The  experiments 
may  he  divided  into  two  gronps.  First,  those  in  which  tlie  inoculation  of 
the  small-pox  matter  in  the  heifer  produced  pocks  corresponding  in  all 
respects  to  the  vaccine  vesicles.  Lymi)h  from  the  first  calf  ijioculated  into 
a  second  or  third  produced  the  characteristic  lesions  of  cow-pox,  and  from 


TO 


SPKCIFIC  INFECTIOUS  DISEASES. 


llic  I'li'sl,  si'coiid,  or  third  iiiiiiiiiil  Iviiipli  used  to  vaccinntc  iv  cliild  prodiici'd 
a  typical  localized  vacciiic  vesicle  without  any  <»!'  the  <feiu'ralized  luatiirt'S 
of  small-|»ox.  'The  e\|)erimeiits  ol'  I'eely,  (d'  Uahcock,  ami  many  otlior  more 
recent  workers  seem  to  leave  jio  (|iiestioii  whatever  that  typical  vaccinia 
may  be  produced  in  the  call'  by  the  inoculation  ol'  variolous  matter.  A 
^M'cat  deal  of  the  vaccine  material  at  one  time  in  use  in  Mn<;land  was  ob- 
tained in  this  way.  Secondly,  a«;aiiist  tliLs  is  ur^'cd  Cliauveau's  Lyons 
experiments.  Seventeen  younfj;  animals  were  inoculated  with  the  virus  of 
small-pox.  Small  reddish  papides  occurred  which  disappeared  .ra|)i(lly,  but 
the  animals  did  not  acipiire  cow-pox.  l'"iftcen  of  the  seventeen  animals 
were  also  \accinated.  Of  these  only  one  showed  a  typical  cow-])o,\  erup- 
tion. To  delcrniinc  the  nature  of  the  oriiiinal  papules  one  was  excised  and 
inoculated  into  a  iu)n-vaccinated  child,  which  developed  as  a  result  /^t'neral- 
ized  coidliu'nt  small-pox.  A  second  child  inoculated  from  tlu;  primary 
pustule  of  the  (irst  (-liild  developed  discrete  small-pox.  The  French  still 
hold   to   the    Lyons  cx|iei'inients  as  demonstratinii'  the  duality  of  the  (lis 


eases. 

rr 


The  wfjoht  (d'  evidence  favors  the  view  that  cow-])ox  and  liorse-])ox 
are  varioli.  modi(ie(l  by  Iransnnssion;  or,  as  has  been  suj^^fested,  "sniall-po\ 
and  vaccinia  are  both  <d'  them  descended  from  a  common  stock — from  an 
ancestor,  b)r  instance — which  resendiled  vaccinia  far  nuire  than  it  I'csem- 
Med  small-pox  "  (('oi>eniiin). 

Bacteriology  of  Vaccinia. — This,  too,  is  still  unsettled,  (^uist,  .Martin, 
and  Frnst  bave  described  various  micrococci.  Klein  and  Copeman  have 
in(lei)en(lently  found  a  bacillus,  Avliile  I'fi'iU'ei'  and  J{utl'er  liavc  met  with 
bodies  l)elieved  to  be  of  the  nature  of  psorosperms.  Walter  Keed  has  also 
met  with  peculiar  amceboid  bodies  in  the  blood. 

Normal  Vaccination. — Period  of  Inniholioii. — At  first  there  may 
])('  a  little  irritation  at  the  site  of  inoculation,  which  suljsidos.  Period  of 
Erujdion. — On  the  third  day,  as  a  rule,  a  i(a])ule  is  seen  surrounded  by  a 
reddish  zone.  This  tfradually  increases,  and  on  the  fifth  or  sixth  day  shows 
a  delinite  vesicle,  the  margins  of  which  are  raised  while  the  centre  is  de- 
])ressed.  By  the  ei<rhth  day  the  vesicle  has  attained  its  maximum  size.  ]t 
is  round  and  distended  with  a  limi)id  lluid,  the  margin  hard  and  prominent, 
and  the  und)ilication  is  more  distinct.  JJy  the  tenth  day  the  vesicle  is  still 
larj,^e  and  is  suri'ounded  Ijy  an  extensive  areola.  The  contents  have  now  be- 
come imrulent.  The  skin  is  also  swollen,  indurated,  and  often  painful.  On 
the  eleventh  or  twelfth  day  the  hyper.ipmia  diminishes,  the  lymjih  becomes 
more  opacpu'  and  be<iins  to  dry.  \\y  the  end  of  the  second  week  the  vesicle 
is  converted  into  a  brownish  scab,  which  <>radually  be>  omes  dry  and  hard, 
and  in  about  a  week  (that  is,  about  the  twenty-first  or  twenty-fifth  day  from 
the  vaccination)  se])arates  and  leaves  a  circular  ])itted  scar.  If  the  points 
of  inoculation  have  been  close  toji^ether,  the  vesicles  fuse  and  may  form 
a  larpe  i-ombined  vesicle,  ('onstitntional  .sym])tonis  of  a  more  or  less 
marked  dejiree  follow  the  vaccination.  I'sually  on  the  third  or  fourth  day 
the  tem])erature  rises,  and  may  persist,  increasinjr  until  the  eig-hth  or  ninth 
day.  There  is  a  marked  leucocytosis.  In  children  it  is  common  to  have 
with  the  fever  restlessness,  particularly  at  night,  and  irritabilitv;  but  as  a 


iduoetl 
;!iture8 
r  more 
iiccinia 
cr.     A 
fas  ob- 
Lyons 
inis  of 
lly,  l)ut 
uiimixls 
\  cnip- 
st'd  and 
it' n  oral - 
|)iMinary 
icli  stiil 
llic  (lis 

■)rRo-i>ov 
iiall-|)o\ 
I'roiu  ail 
t  rcsciii- 

^Martin, 
an  have 
let  witli 
has  also 

ere  may 
'criod  of 
k'd  hy  a 
IV  shows 


VACCINIA- VACCINATION. 


ih;  is 
size. 


de- 
It 

)inini'iit, 
|e  is  still 
Inow  1)C- 


111. 


On 


bc'comt's 
vesich' 
|id  liard. 
from 


nt^ 


av 


le  poi 


Hv 


or 


form 
less 


rth  dav 

til 


l)r  nm 


to  have 
)ut  as  a 


71 


rule  these  Fyinptonis  are  trivial,  if  the  inocidation  is  made  on  the  arm, 
the  axillary  jrlands  become  larfie  and  sore;  if  on  the  le;:,  the  in^niiiial 
j:lands.  The  duration  of  the  iinniiinity  is  extremely  varialdi',  dilVering 
in  dilVerent  individuals.  Jn  some  instances  it  is  permanent,  hut  a  maj<»rity 
of  peraous  within  ten  or  twelve  years  again  become  s>usce])lible. 

Jicracriiiation  should  be  performed  between  the  tenth  and  fifteenth 
year,  and  whenever  small-po.\  is  epidemic.  The  susceptihility  to  revuc- 
cination  is  curiously  variable,  and  when  small-pox  is  prevalent  it  is  not  well, 
if  unsuccessful,  to  be  content  with  a  sin>;le  attempt.  The  vesicle  in  re- 
vaccination  is  usually  smaller,  has  less  induratit)n  and  hypenvmia,  and  the 
resulting,'  scar  is  le.«s  perfect.  Particn.lar  care  should  be  taken  to  watch 
the  vesicle  of  ri'vaccination,  as  it  not  infre(piently  happens  that  a  spurious 
pock  is  formed,  which  reaches  its  hei;.dit  early  and  dries  to  a  scab  by  the 
eighth  or  ninth  day.  The  constitutional  symptoms  in  revaccination  are 
sometimes  (piite  severe. 

Irregular  Vaccination. — (a)  Local  Variallnns. — We  occasionally 
meet  with  instances  in  whiili  the  vesicle  develoj)S  rapidly  with  much  itch- 
\ng,  has  not  the  characteristic  llattened  appearance,  the  lymph  early  be- 
comes ()[)a(pie,  and  the  crust  forms  liy  the  seventh  or  eighth  day.  The 
evolution  of  the  ])ocks  may  be  abnormally  slow.  In  such  cases  the  operation 
should  again  be  perfoniied  with  fresh  lymph.  The  contents  of  the  vesi- 
cles may  be  watery  and  bloody.  Jn  the  involution  the  bruising  or  irrita- 
tion of  the  jtocks  may  lead  to  ulceration  and  inflammation.  A  very  rare 
event  is  the  recurrence  of  the  ]»ock  in  the  same  place.  Sutton  rei)orts  four 
such  recurrences  within  six  months. 

{[))  Generalized  Vaccinia. — It  is  not  uncommon  to  see  vesicles  in  the 
vicinity  of  the  jjrimary  sore.  Le.«s  common  is  a  true  generalized  ])ustular 
rash,  develoi)ing  in  different  i)arts  of  the  body,  often  beginning  about  the 
wrists  and  on  the  back.  '^Fbe  secondary  ])()cks  may  continue  to  make  their 
appearance  for  five  or  six  weeks  after  vaccination.  In  children  the  disease 
may  prove  fatal.  They  may  be  most  abundant  on  the  vaccinated  limb, 
and  develop  usually  aljout  the  eighth  to  the  tenth  day. 

(c)  Complications. — In  unhealthy  subjects,  or  as  a  result  of  uncleanli- 
ness,  or  sometimes  injury,  the  vesicles  inflame  and  deep  excavated  iilcers 
result.  Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children 
there  may  be  with  this  a  puri)uric  rash.  Acland  thus  arranges  the  dates  at 
which  the  possilde  eruptions  and  complications  may  be  looked  for: 

1.  During  the  first  three  days:  Erythema;  urticaria;  vesicular  and 
bullous  eru])rions:  iuA'accinated  erysipelas. 

2.  After  the  third  day  and  until  the  pock  reaches  maturity:  Urticaria; 
lichen  urticatus,  erythema  multiforme;  accidental  erysipelas. 

3.  About  the  end  of  the  first  week:  (Generalized  vaccinia;  impetigo;  vac- 
cinal ulceration;  glandular  abscess:  se|)tic  infections;  gangrene. 

4.  After  the  involution  of  the  pocks:  Invaccinated  diseases — for  exam- 
ple, syphilis. 

{d)  Transmission  of  Di.9cnse  by  Vaccination. — Syphilis  has  undoubtedly 
been  transmitted  by  vaccination,  but  such  instances  are  very  rare.    A  large 
number  of  the  cases  of  alleged  vaccino-svphilis  must  be  thrown  out.     The 
5 


f 


! 


72 


SPECIFIC  INFECTIOUS  DISRASRS. 


(jui'stion  liiiH  now  Im'((iiih'  really  of  iiiiiior  iiMi»()rtiui('(>  hjiicc  the  widcspn'iid 
use  of  jmiinal  lyinpli.  l>r.  ('dry's  nad  exiicriiiu'iit  may  li»  ic  lie  rt'lVrifd  t<t. 
He  vat'C'iiiaU'd  Jurnr-ir  four  tiiiics  from  syphilitic  cliildrcii.  'I'lu'  lirnt  vnc- 
cinalion  followed,  hut  no  syphilis.  Two  other  a(tem|>ts  (iie^fiitive)  were 
made.  The  fourth  time  he  was  vaeeiiuitid  from  a  child  the  sultject  (d' 
conjreidtal  syphilis.  'J'hc  lymph  was  taken  from  the  child's  nriii  witli  care, 
avoiding'  any  contamimition  with  hlood.  At  two  of  the  jjoints  of  insertion 
ri'd  ]iapules  appeared  on  the  twenty-first  day.  On  the  thirty-ci<,dith  day 
a  little  ulcer  was  found,  which  iMr.  Hutchinson  di-cidcd  was  syphilitic. 
'I'he  diseased  parts  were  then  removed.  J{y  the  liftieth  day  the  constitu- 
tional symittoms  were  well  marked.  Amonj,'  the  diU'erences  hetween 
vaccino-sypliilis  and  vaccination  ulcers  the  most  important  is  perhaps  tiiat 
the  chancre  never  di'Vclops  iiefore  the  (ifteenth  day,  usually  not  until  fiN»m 
thret'  to  live  weeks,  whereas  the  ulceration  of  ordimiry  vaccination  is  j)rcs- 
cnt  by  the  twelfth  or  (ifteenth  day.  The  loss  of  substance  in  the  chancre 
is  usnnlly  quite  supcrlicial  and  the  induration  very  i)archment-like  and 
specific,  with  but  a  slight  iidlammatory  areola.  ^Phe  ^dandular  swellinj;,  too, 
is  constant  and  indolent,  while  in  the  vaccinati(»n  ulcer  it  is  often  absent, 
or,  when  present,  chiclly  iidlammatory. 

I'libcrriilotiis. — '*  No  undoubted  case  of  inva'cinated  tubercle  was 
broujrht  before  tlie  l?oyal  Commission  on  Vaccination"  (Acland).  The  risk 
of  transmittinjf  tuberculosis  from  the  calf  is  so  slij,dit  that  it  need  not  be 
considered.  Tuberculosis  in  the  calf  is  excessively  rare,  and  "  this  almost 
inappreciable  source  of  danger  can  be  avoided  by  the  simjjle  i)recaution  of 
not  using  the  lymph  from  any  calf  until  the  animal  has  been  killed  and 
l)roved  to  be  entirely  free  from  disease  "  (Acland). 

The  transuHssion  oH  leprosy  by  vaccination  is  alj-;)  o|)en  to  serious  doubt. 
In  a  few  instances  tetanus  has  developed  during  vaccination  and  proved 
fatal. 

((')  IiifJiienrc  of  Vdcrinatlnn  vpnii  atlivr  Diseases. — A  quiescent  malady 
may  be  lighted  into  activity  by  vaccination.  This  has  happened  with  con- 
genital syphilis,  occasionally  with  tul)erculosis.  An  old  idea  was  preva- 
lent that  vaccination  had  a  beneficial  influence  upon  existing  diseases. 
Dr.  Archer,  the  first  medical  graduate  in  the  Ignited  States,  recommended 
it  in  whooj)ing-cough,  and  said  that  it  had  cured  in  his' hands  six  or  eight 
cases. 

Choice  of  Ijyinph. — Calf  lym]ih  should  invariably  be  used,  and  it 
can  now  be  obtained  from  ]ierfectly  reliable  sources.  The  ])ractice  of  arm- 
to-arm  vaccination  with  humanized  lym])h  should  be  abandoned.  If  bovine 
lymph  is  not  available,  then  the  humanized  lym])h  should  he  taken  on  the 
eighth  day,  and  only  from  iiorfeetly  formed,  unbroken  vesicles,  which  have 
had  a  typical  course.  Pricking  or  scratching  the  surface,  the  greatest  care 
being  taken  not  to  draw  blood,  allows  the  lymph  to  exude,  and  it  may  be 
collected  on  ivory  points  or  in  capillary  tubes.  The  child  from  which  the 
lymi)h  is  taken  should  be  healthy,  strong,  and  known  to  be  of  good  stock, 
free  from  tuberculoiis  or  syphilitic  taint.  All  possible  sources  of  contamina- 
tion with  ]iyogenic  organisms  are  now  obviated  by  the  use  of  the  glycerin- 
atcd  calf  lymph  which  should  come  into  general  use.    The  Local  Govern- 


VACCINIA- VACCINATION. 


78 


eight 

uid  it 
ann- 
)ovine 
1)11  the 
have 
It  cave 
lay  he 
[h  the 
Istock, 
Imina- 
Iccrin- 


iiicnt  Hoard  has  rocontly  issued  a  valiiahlo  report  on  the  niilijeet  hy  Tliornc 
and  Copeiiian,  ^'ivin^'  lull  dctailH  an  to  the  method  <d'  preparation.     In  it 
the  Htatenu-nt  is  made  that,  whereas  it  was  nsnal  to  make  the  lymph  from 
one  call"  si'rve  for  from  ;;.'(M)  to  .'lOK  vaccinations,  the  glycerinated  lymph  will, 
werve  for  from   l,(H)(»  to  ."»,()(»()  vaccinations. 

Technique. — In  the  |»erl'orinanee  of  the  operation  tliat  part  of  the 
arm  ahont  the  insertion  of  the  deltoid  is  usually  selected.  M(»thers  "  in 
society  "  prefer  to  have  girl  liahies  vaccinated  on  the  leg.  'i'he  skin  should 
he  cleansed  and  juit  upon  the  stretch.  Then,  with  a  lancet  or  the  ivory 
point,  cross-scratches  should  he  made  in  one  or  more  placi-s.  When  the 
lymjih  has  dried  on  the  points  it  is  l)est  to  moisten  it  in  warm  water.  Thi' 
clothing  of  the  child  should  not  he  adjusted  until  the  spot  has  dried,  i\]]t\ 
it  slioultl  lie  protected  for  a  day  or  two  with  lint  or  a  soft  handkerchief. 
If  erysipelas  is  prevalent,  or  if  there  are  casi'S  of  sujipuration  in  tlu!  same 
house,  it  is  well  to  apply  a  pad  of  antiseptic  cotton.  \'accination  is  usually 
perfornu'd  at  the  second  or  third  month.  If  unsuoeessful,  it  should  he  re- 
|>eated  from  time  to  time.  A  person  exposed  to  the  contagion  of  small- 
pox should  always  he  revaccinated.  This,  if  successful,  will  usually  pro- 
tect; hut  not  always,  as  there  are  many  instances  in  wiiicli,  though  the 
vaccination  takes,  variola  also  appears. 

The  Value  of  Vaccination.— Snnitat ion  cannot  account  for  the 
diminution  in  small-pox  and  for  the  low  rate  of  mortality.  Isolation,  of 
course,  is  a  useful  auxiliary,  hut  it  is  no  suhstitute.  \'accination  is  not 
claimed  to  he  an  invariahle  and  ])ermanent  preventive  of  small-pox,  hut  in 
an  immense  majority  of  cases  successful  inoculation  renders  the  person  for 
many  years  insiiscc|)til)le.  ('ommunities  in  which  vaccination  and  revac- 
cination  are  thoroughly  and  systematically  carried  out  are  those  in  which 
small-pox  lias  the  fewest  victims.  On  the  other  hand,  communities  in  whicl 
vaccination  and  revaccination  are  ])ersistently  neglected  are  those  in  which 
c]>idemics  are  most  ])revalent.  In  the  (Jernian  army  the  practice  of  revac- 
cination has  stamjicd  out  the  disease.  Xothing  in  recent  times  has  ])(.'L'n 
more  instructive  in  this  connection  than  the  fatal  statistics  of  Montreal. 
The  epidemic  which  started  in  1870-'71  was  severe  in  Lower  Canada,  and 
persisted  in  Montreal  until  187o.  A  great  deal  of  feeling  had  heen 
aroused  among  the  French  Canadians  hy  the  occurrence  of  several  serious 
cases  of  ulceration,  ]K)ssil)ly  of  syphilitic  disease,  following  vaccination; 
and  several  agitators,  among  them  a  French  physician  of  .some  standing, 
nroused  a  popular  and  widespread  prejudice  against  the  ])ractice.  There 
were  indeed  vaccination  riots.  The  introduction  of  animal  lymph  was 
distinctly  beneficial  in  extending  the  practice  among  the  lower  classes,  l)ut 
com]nilsory  vaccination  could  not  ho  carried  out.  Between  the  years  1870 
and  1884  a  considerable  un]irotected  ])0]mlation  grew  up  and  the  materials 
were  ripe  for  an  extensive  c])ideniic.  The  soil  had  boon  prepared  with  the 
,<;roatest  care,  and  it  only  needed  the  introduction  of  (he  seed,  which  in  due 
lime  came,  as  already  stated,  witli  the  Ptdlman-car  conductor  from  Chi- 
cago, on  the  28th  of  February,  1885.  "Within  the  next  ten  months  thou- 
Piinds  of  persons  were  stricken  with  the  disease,  and  3,1 04  died. 

Although  the  effects  of  a  single  vaccination  may  wear  out,  as  we  say. 


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74 


SPECIFIC  INFECTIOUS  DISEASES. 


and  the  individual  again  become  susceptible  to  small-pox,  yet  the  mortal- 
ity in  such  cases  is  very  much  lower  than  in  persons  who  have  never  l)een 
vaccinated.  The  mortality  in  ])ersons  who  have  been  vaccinated  is  from 
(>  to  y  i)er  cent,  whereas  in  the  inivaccinated  it  is  at  least  35  per  cent. 
Marson  j)ointed  out  some  years  ago  that  there  is  a  definite  ratio  between 
t)ie  nnmber  of  deaths  and  the  number  of  good  vaccination  marks  in  post- 
vaccinal small-pox.  Willi  good  marks  the  mortahty  is  between  3  and  4 
per  cent,  and  with  indifferent  marks  at  icast  lU  or  li  per  cent.  W.  M. 
Welch's  statistics  of  5,000  cases  on  this  point  give  with  good  cicatrices  8 
per  cent;  with  fair  cicatrices,  14  i)er  cent;  with  poor  cicatrices,  21  per  cent; 
])ost-vaccinal  cases,  1(>  i)er  cent;  unvaccinated  case.?,  58  per  cent. 


■%. 


VI.  VARICELLA  {Chicken-pox). 

Definition. — An  acute  contagious  disease  of  childrei.^  characterized 
by  an  eruption  of  vesicles  on  the  skin. 

Etiology.  — The  disease  occurs  in  epidemics,  but  syjoradic  cases  are 
also  met  with.  It  nuiy  i)revail  at  the  same  time  as  smah-pox  or  may  fol- 
low or  ])recede  epidemics  of  this  disease.  An  attack  of  chicken-pox  is  no 
protection  against  small-i)ox.  It  is  a  disease  of  childhood;  a  majority  of 
the  cases  occur  between  the  second  and  sixtli  years.  It  is  rarely  secii  in 
adidts.    The  specific  germ  has  not  yet  been  discovered. 

There  can  l)e  no  tiuestion  that  varicella  is  an  affection  quite  distinct 
from  variola  and  without  at  present  any  relation  whatever  to  it.  An  at- 
tack of  the  one  does  not  confer  immunity  from  an  attack  of  the  other. 
The  case  which  Sharkey  re})orted  is  of  special  importance  in  this  connec- 
tion. A  boy,  aged  five,  was  admitted  to  St.  Thonuis'  Hospital  with  a  vesicu- 
lar erui)tion,  and  was  isolated  in  a  ward  on  the  same  floor  as  the  small-jiox 
ward.  The  disease  was  pronounced  chicken-jiox,  howevei",  by  Sir  liisdon 
Bennett  and  Dr.  Bristowe.  The  patient  was  then  removed  and  vaccinated, 
with  a  result  of  fonr  vesicles  which  ran  a  pretty  normal  course.  On  the 
eighth  day  from  the  vaccination  the  child  l)ecame  feverish.  On  the  fol- 
lowing day  the  ])ai)ules  ai)peared  and  the  child  had  a  well-developed  attack 
of  small-])ox  with  secondary  fever. 

Symptoms. — After  a  period  of  incubation  of  ten  or  fifteen  days  the 
child  becomes  feverish  and  in  some  instances  has  a  slight  chill.  There 
may  be  vomiting  and  pains  in  the  back  and  legs.  Convulsions  are  rare. 
The  erui)tion  \isually  develoi)s  within  twenty-four  hours.  It  is  first  seen 
iipon  the  trunk,  either  on  the  back  or  on  the  chest.  It  may  begin  on  the 
forehead  and  face.  At  first  in  the  form  of  raised  red  papules,  these  are  in 
a  few  hours  transformed  into  hemispherical  vesicles  containing  a  clear  or 
turbid  fluid.  As  a  rule  there  is  no  umbilication,  but  in  rare  instances  the 
})ocks  are  flattened,  and  a  fen-  may  even  be  umbilicated.  They  are  often 
ovoid  in  sliapc  and  look  more  su])erficial  than  tlie  variolous  vesicles.  The 
skin  in  the  neighborhood  is  neither  infiltrated  nor  hy])eraMnic.  At  the 
end  of  thirty-six  or  forty-eight  hours  the  contents  of  the  vesicles  are 
purulent.     They  begin  to  shrivel,  and  during  the  third  and  fourth  days 


ortal- 

from 

cent. 

tween 

post- 
ami  4 

^v.  :m. 

•ices  8 
r  cent; 


VARICELLA. 


75 


;terize(l 

ises  arc 
lay  iol- 
>x  is  no 
ority  of 
seen  in 

distinct 

\n  at- 
e  other, 
connec- 

vesicii- 
nall-pox 

Kisdon 
[cinated, 

On  tlie 
the  fol- 
1  attack 

klavs  the 
There 
lire  rare, 
[rst  seen 
li  on  the 
Le  are  in 
I  clear  or 
Inces  the 
Ire  often 
U.     The 
At  the 
[cles  are 
rth  days 


are  converted  into  dark  browni.-h  crusts,  which  fall  olf  and  as  a  rule  leave 
no  scar.  Fresh  crops  appear  durin«,f  the  first  two  or  liiree  <hiys  of  the  ill- 
ness, so  that  on  tiie  fourth  day  one  can  usually  see  pocks  in  all  stages  of 
develo])inent  and  decay.  They  are  always  discrete  and  the  number  may 
vary  from  eight  or  ten  to  several  hundreds.  As  in  variola,  a  scarlatinal 
rash  occasionally  precedes  the  development  of  the  eruption.  The  erujjtiou 
may  occur  on  the  mucous  membrane  of  the  mouth,  and  occasionally  in  the 
larynx  (D.  II.  Hall). 

Thi-re  are  one  or  two  modifications  of  the  rash  which  are  interesting. 
The  vesicles  may  become  very  large  and  develop  into  regular  bulUu,  look- 
ing not  unlike  ecthyma  or  pemphigus  (varicella  bullosa).  The  irritation 
of  the  rasli  may  be  excessive,  and  if  the  child  scratches  the  pocks  ulcerat- 
ing sores  may  form,  which  on  healing  leave  ugly  scars.  Indeed,  cicatrices 
after  chicken-])ox  are  more  common  than  after  varioloid.  The  fever  in 
varicella  is  slight,  but  it  does  not  as  a  rule  disappear  with  the  ap])ear- 
ance  of  the  rash.  The  course  of  the  disease  is  in  a  large  majority  of  the 
cases  favoral)le  and  no  ill  effects  follow.  The  disease  may  recur  in  the 
same  individual.  There  are  instances  in  which  a  person  has  had  three 
attr.cks. 

In  delicate  children,  particularly  the  tuberculous,  gangrene  (varicella 
escharotica)  may  occui-  about  the  vesicles  (Hutchinson);  or  in  other  parts,, 
as  the  scrotum. 

Cases  have  been  described  (Andrew)  of  luemorrhagic  varicella  with 
cutaneous  ecchymoses  and  bleeding  from  the  mucous  niend)ranes. 

Nephritis  may  occur.  Infantile  hemiplegia  has  develo})ed  during  an 
attack  of  the  disease.  Death  has  followed  in  an  uncomplicated  case  from, 
extensive  involvement  of  the  skin  (Xisbet). 

The  di(if/n(i!<ii<:  is  as  a  rule  easy,  particularly  if  the  ])atient  has  been  seen 
from  the  outset.  AVhen  a  case  conies  under  observation  for  the  first  time 
with  the  rash  well  out,  there  may  be  considerable  dilliculty.  The  abun- 
dance of  the  rash  on  the  trunk  in  varicella  is  most  important.  The  pocks 
in  varicella  are  more  superficial,  more  bleb-like,  have  not  so  deej)ly  an 
infiltrated  areola  al)0ut  them,  and  may  usually  be  seen  in  all  stages  of  de- 
velopment. They  rarely  at  the  outset  have  the  hard,  sliotty  feeling  of  those 
of  sniall-i)ox.  The  general  symptoms,  the  greater  intensity  of  the  onset,  the 
prolonged  jicriod  of  invasion,  and  the  more  frequent  occurrence  of  jjrodro- 
mal  rashes  in  small-i)ox  are  im])ortant  points  in  the  diagnosis. 

Xo  special  liralnicnt  is  rcquirc(h.  If  the  rash  is  aliundant  on  the  face 
great  care  should  be  taken  to  prevent  tlie  child  from  scratching  the  pus- 
tules.   A  soothing  lotion  should  lie  ap])licd  on  lint. 


VII.    SCARLET  FEVER. 

Definition. — An  infectious  disease  characterized  by  a  diffuse  cxan- 
thcm  and  an  angina  of  varia1)le  intensity. 

Etiology. — We  owe  the  recognition  of  scarlet  fever  as  a  distinct  dis- 
ease to  Sydenham,  l)efore  M-liose  time  it  was  confounded  with  measles.     It 


76 


SPECIFIC  INFECTIOUS  DISEASES. 


is  a  wi(lcs])rca(l  alTL'otion,  occurring  in  nearly  all  parts  of  the  globe  and 
attacking  all  races. 

The  di.sea8e  occurs  sporailically  from  time  to  time,  anil  then  under 
unknown  conditions  becomes  widespread.     Epidemics  vary  in  severity. 

Among  jiredisposing  factors  age  is  most  important.  A  large  i)ropor- 
tion  of  the  cases  occur  bufore  the  tenth  year.  Of  an  enormous  number  of 
fatal  cases  tabulated  liy  ^lurchison  over  liU  per  cent  occurred  in  children 
under  this  age.  Adults,  however,  arc  by  no  means  exemjjt.  Very  young 
infants  are  rarely  attacked.  A  certain  number  of  those  coming  in  contact 
with  the  disease  escape.  In  a  family  of  children  all  more  or  less  exposed 
one  or  two  may  not  contract  scarlet  fever,  whereas,  as  a  rule,  in  the  case 
of  measles  all  take  it.  The  suscei)tibility  seems  to  vary  in  families,  and  we 
meet  occasionally  with  sad  instances  in  which  three  or  mo.e  members  of  a 
family  succiimb  in  rapid  succession. 

Males  and  females  are  equally  ail'ected. 

Epidemics  prevail  at  all  seasons,  but  perhaps  with  greater  intensity  in 
autumn  and  winter. 

The  contagion  of  scarlet  fever  is  probably  not  developed  until  the  erup- 
tion appears,  and  is  particularly  to  be  dreaded  during  desquamation.  No 
doubt  the  poison  is  spread  largely  by  the  fine  scaly  particles  which  are 
diffused  with  the  dust  tliroughout  the  room.  Even  late  in  the  disease, 
after  desquamation  has  been  apparently  completed,  a  patient  has  con- 
veyed the  contagion.  The  poison  clings  with  great  persistence  to  cloth- 
ing of  all  kinds  and  to  articles  of  furniture  in  the  room.  In  no  disease  is 
a  greater  tenacity  displayed.  Bedding  and  clothes  which  have  been  put 
away  for  months  or  even  for  years  may,  unless  thoroughly  disinfected, 
convey  contagion.  Physicians,  nurses,  and  others  in  contact  with  the  sick 
may  carry  the  poison  to  persons  at  a  distance.  It  is  remarkable  that  in 
the  case  of  ])hysicians  this  does  not  more  frequently  occur.  I  know  of 
but  one  instance  in  which  I  carried  the  contagion  of  this  disease.  The 
poison  probably  is  not  widely  spread  in  the  atmosphere.  Observations 
have  been  recently  made  which  indicate  that  it  may  be  conveyed  in  milk. 
The  epidemic  investigated  by  Power  and  Klein  in  London  in  1885  was 
traced  by  them  to  milk  obtained  from  a  dairy  at  Ilendon,  in  which  the 
cows  M-ere  found  to  be  suffering  from  a  vesicular  affection  of  the  udder. 
The  nature  of  this  disease  of  the  cow  is  doubtful,  however.  Crookshank 
holds  tiiat  it  was  cow-pox,  and  had  nothing  to  do  with  scarlet  fever. 

Some  writers  maintain  that  scarlet  fever  may  be  associated  with  de- 
fective house-drainage.  Possibly  the  virus  may  occasionally  gain  entrance 
in  this  way. 

One  attack  does  not  necessarily  protect  permanently.  There  are  in- 
stances of  one  or  even  two  recurrences. 

Surgical  and  puerperal  scarlatinas,  so  called,  demand  a  word  under  this 
section.  "While  scarlet  fever  may  attack  a  person  after  operation,  or  a 
Avonian  in  childbed,  the  majority  of  the  cases  described  as  such  belong,  I 
believe,  to  those  of  septicamiia.  In  the  cases  which  I  have  seen  the  red 
rash  was  rarely  so  videspread  as  in  scarlet  fever;  the  tongue  had  not  the 
special  features,  nor  was  the  throat  affected.    Des<piamation  is  no  criterion. 


and 


SCARLET  FEVER. 


77 


'ccted, 
10  sick 

lat  in 
now  of 
The 

ations 
milk. 
85  was 

•h  the 

udder. 

vshaiik 


er  this 
or  a 
Hong,  I 
|he  red 

bt  the 
(terion, 


as  it  occurs  wlienevcr  liyperannia  of  the  skin  has  persisted  for  any  length 
of  time.  It  is  interesting  to  note  that  these  cases  have  become  rare  with 
th^  gradual  disappearance  of  septica'mia.  I.  E.  Atkinson  suggests  that 
in  many  cases  tiieso  raslics  are  due  to  quinine. 

The  specific  germ  is  still  unknown.  Streptococci  are  found  in  the 
skin,  in  tlie  blood  sometimes,  and  in  the  organs  of  fatal  cases.  It  has  even 
been  urged  tluit  the  disease  is  only  a  form  of  streptococcus  infection.  Throat 
lesions  of  the  most  malignant  type  may  occur  without  the  presence  of  the 
bacillus  diphtheria',  but  in  the  infectious  pavilions  of  hos})itals  the  scarlet 
fever  cases  are  very  apt  to  be  complicated  with  true  diphtheria;  much  more 
so  than  in  private  ])ractice.  The  streptococcus  pyogenes  is  the  common 
organism  of  the  otitis  media. 

Morbid  Anatomy. — Except  in  the  hamiorrhagic  form,  the  skin 
after  death  shows  no  traces  of  the  rash.  There  are  no  specific  lesions. 
Tliose  which  occur  in  the  internal  organs  are  due  partly  to  the  fever  and 
partly  to  infection  with  pus-organisms. 

The  anatomical  clianges  in  the  throat  are  those  of  simple  inflamma- 
tion, follicular  tonsillitis,  and,  in  extreme  grades,  of  pseudo-membranous 
angina.  In  severe  cases  there  is  intense  lymphadenitis  and  much  inflai.i- 
matory  cedema  of  the  tissues  of  the  neck,  which  may  go  on  to  su})puration, 
or  even  to  gangrene.  Streptococci  are  found  abundantly  in  the  glands 
and  in  the  areas  of  suppuration.  Of  changes  in  the  digestive  organs^  a 
catarrhal  state  of  the  gastro-intcstinal  mucosa  is  not  uncommon.  The 
liver  may  show  interstitial  changes  (Klein).    The  spleen  is  often  enlarged. 

Endocarditis  and  pericarditis  are  not  infrequent.  Myocardial  changes 
are  less  common.  Tlie  renal  changes  are  the  most  important,  and  have 
been  thoroughly  studied  by  Coats,  Klebs,  "Wagner,  and  others.  The  spe- 
cial nephritis  of  scarlet  fever  will  be  considered  with  the  diseases  of  the 
kidney. 

Affections  of  the  respiratory  organs  are  not  fre([uent.  "When  death 
results  from  the  pseudo-membranous  angina,  broncho-pneumonia  is  not 
uncommon.     Ccrobro-spinal  changes  are  rare. 

Symptoms. — Incubation. — "  From  one  to  seven  days,  oftenest  two  to 
four." 

Invasion. — Tlie  onset  is  as  a  rule  sudden.  It  may  be  preceded  by  a 
slight,  scarcely  noticeable,  indisposition.  An  actual  chill  is  rare.  Vomit- 
ing and,  in  young  children,  convulsions  are  common.  The  fever  is  in- 
tense; rising  rapidly,  it  may  on  the  first  day  reach  104°  or  even  105°. 
Tlie  skin  is  unusually  dry  and  to  the  toucli  gives  a  sensation  of  very  pun- 
gent heat.  The  tongue  is  furred,  and  as  early  as  tlie  first  day  there  may 
be  complaint  of  dryness  of  the  throat.  Cough  and  catarrhal  symptoms 
are  uncommon.  The  face  is  often  flushed  and  the  patient  has  all  the  ob- 
jective features  of  an  acute  fever. 

Eruption. — Fsually  on  tlic  second  day,  in  some  instances  within  twenty- 
four  hours,  the  rash  develops  in  tlie  form  of  scattered  red  points  on  a  deep 
subcuticular  flush.  It  ajipears  first  on  the  neck  and  chest,  and  spreads  so 
rapidly  that  by  the  evening  of  the  second  day  it  may  have  invaded  the 
■entire  skin.    After  persisting  for  two  or  three  days  it  gradually  fades.    In 


1^ 


w 


SPECIFIC  INFECTIOUS  DISEASES. 


pronounced  cases  the  nisli  nt  its  lieiglit  has  a  vivid  scarlet  hue,  quite  dis- 
tinctive and  unlike  tliat  seen  in  any  other  eruptive  disease.  It  is  entirely 
liyperaMiiic,  and  tlie  aniemia  produced  by  ])ressure  instantly  disai^ioars. 
In  a  very  intense  rash  there  may  be  lino  punctil'orni  luvniorrhaf^'es,  which 
do  not  disai)i)ear  on  pressure.  In  some  cases  the  rash  does  not  become 
uniform  but  remains  ])atciiy,  and  intervals  of  normal  skin  separate  largo 
hyperiemic  areas.  Tiny  itapuhir  elevations  may  sometimes  be  seen,  but 
they  are  not  so  common  as  in  measles.  At  the  height  of  the  eruption 
Budaminal  vesicles  may  develo[),  the  iluid  of  which  may  become  turbid. 
Tlie  entire  skin  nuiy  at  the  same  time  be  covered  witli  snuill  yellow  vesi- 
cles on  a  deej)  red  Ijackground.  I'ronounced  cases  of  this  type  were  called 
by  the  older  writers  ficarhiliiui  miliaris.  The  blood  shows  an  early  leuco- 
cytosis,  which  is  often  extreme  in  fatal  cases. 

Occasionally  there  are  petechiie,  which  in  the  malignant  type  of  the 
disease  become  wides^Jiead  and  large.  The  eruittion  does  not  always  ap- 
pear upon  tlie  face.  There  nuiy 
be  a  good  deal  of  swelling  of  the 
skin  which  feels  imcomfortable 
and  tense.  The  itching  is  vari- 
able; not  as  a  rule  intense  at  the 
height  of  the  erui)tion.  The  rash 
can  often  be  seen  on  the  mucous 
niemljranes    of    the    palate,    the 


105-8° 


1040 


102-2' 


cheeks,  and  the  tonsils,  giving  to 


100-4' 


Eruption. 
Chart  VII.— Scarlet  fever  (Striimpcll). 


these  parts  a  vivid  red,   ])uncti- 

form    api)earance.      The    tongue 

at  first  is  red  at  the  tip  and  edges, 

furred  in  the  centre;  and  through 

tlic  white  fur  are  often  seen  the 

swollen   red  papillae,   which  give 

the    so-called    "strawberry"    aj)- 

j)earance    to    the    tongue.      In    a 

few  days  the  "  fur  "'  des(juamates  and  leaves  the  surface  red  and  rough,  and 

it  is  this  condition  which  some  writers  call  the  "strawberry,"  or,  Ijctter, 

the  "  rasi)l)erry  "  tongue.     The  breath  often  has  a  very  heavy,  sweet  odor. 

The  ])liaryiigeal  sym])toms  vary  extremely.    There  may  be — 

1.  Slight  redness,  with  swelling  of  the  pillars  of  the  fauces  and  of  the 
tonsils. 

2.  A  more  intense  grade  of  swelling  and  infiltration  of  these  parts  with 
a  follicular  tonsillitis. 

3.  ^Membranous  angina  with  intense  inflammation  of  all  the  pharyn- 
geal structures  and  swelling  of  the  glands  below  the  jaw,  and  in  very  severe 
cases  a  thick  brawny  induration  of  all  the  tissues  of  the  neck. 

The  fever,  whicli  sets  in  with  such  suddenness  and  intensity,  may  reach 
105°  or  even  10()°.  It  jiersists  with  slight  morning  remissions,  gradually 
declining  with  the  disai^jiearance  of  the  rash.  In  mild  eases  the  tempera- 
ture may  not  reach  103°;  oh  the  other  hand,  in  very  severe  cases  there  may 
be  hyperpyrexia,the  thermometer  registering  108°  or  before  death  even  109°. 


SCARLET  FEVER. 


19 


give 
"    ap- 

In  a 
1,  and 
jctter, 

odor. 

of  the 
us  with 


Tho  pulse  i>re,«eiits  the  ordinary  febrile  characters,  ranging  in  children 
from  120  to  l^O,  or  even  higher.  The  resiiii'ations  ishow  an  increase  pro- 
portionate to  the  intensity  ot  the  fever.  The  uastro-iutcstinal  symptoms 
are  not  marked  alter  the  initial  vomiting,  and  food  is  usually  well  taken. 
In  some  instances  there  are  abdominal  juiins.  The  edge  of  the  spleen  may 
'be  paljjable.  'J'he  liver  is  not  often  enlarged.  W'hh  the  initial  fever  nervous 
symptoms  are  proent  in  a  nuijority  of  the  cases:  but  as  the  rash  comes 
out  the  headache  and  the  slight  nocturnal  wandering  <lisap[)ear.  The 
urine  has  the  ordinary  febrile  characters,  being  scanty  and  high  colored. 
Slight  albununuria  is  by  no  means  infrequent  during  the  stage  of  erup- 
tion. Careful  examination  of  the  urine  should  be  made  every  day.  There 
is  no  cause  for  alarm  in  the  trace  of  albumin  which  is  so  often  present, 
not  even  if  it  is  associated  with  a  few  tube-casts. 

Desquamation. — With  the  di>ai)pearance  of  the  rash  and  the  fever  the 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  upj)er 
layer  of  the  cuticle  begins  to  sejiarate.  The  ])rocess  usually  begins  about 
the  neck  and  chest,  and  Hakes  are  gradually  detached.  The  degree  and 
character  of  the  desquamation  bear  some  relation  to  the  intensity  of  the 
eruption.  When  the  latter  has  been  very  vivid  and  of  long  standing,  large 
flakes  may  be  thrown  off.  In  rai'c  instances  the  hair  and  even  the  nails 
have  been  shed.  ]t  must  not  l)e  forgotten  that  there  are  cases  in  which 
the  desquamation  has  been  i)rolongcd,  according  to  Trousseau,  even  to 
the  seventh  or  eighth  wc(*k.  The  entire  process  lasts  from  ten  to  fifteen  or 
even  twenty  days. 

There  are  cases  of  exc4?ptionr'1  mildness  in  wliich  the  rash  may  be 
scarcely  perceptible.  During  ejtidemics,  when  several  children  of  a  house- 
hold are  afl'ected.  it  sometimes  hap])ens  that  a  child  sickens  as  if  of  scarlet 
fever,  and  has  a  sore  throat  and  the  "  strawberry  tongue  "  without  the  de- 
Aelopment  ot  any  rash.     This  is  the  so-called  srarhiliiia  sine  erupt iane. 

These  nuld  cases  of  scarlet  fever  may  be  followed  by  the  severest  at- 
tacks of  nephritis. 

MALIGNANT   SCARLET   FEVER. 

Atactic  Form.— This  jn-esents  all  the  characteristics  of  an  acute  intoxi- 
cation. The  }»alient,  overwhelmed  by  the  intensity  of  the  i)oison,  may  die 
within  twenty-four  or  thirty-six  hours.  The  disease  sets  in  with  great 
severity — high  fever,  extreme  restlessness,  headache,  and  delirium.  The 
tem])erature  may  rise  to  10T°  or  even  108°,  and  rare  cases  have  been  ob- 
served in  which  the  thermometer  has  registered  even  higher.  Convulsions 
mav  occur  in  children.  The  initial  delirium  rapidly  gives  place  to  coma. 
The  dvsjmiea  may  be  urgx'ut;  the  ]ndse  is  very  rapid  and  feeble. 

Hsemorrhagic  Form. — In  some  instances  hannorrhages  occur  into  the 
skin.  There  are  luem,  turia  and  c])istaxis.  In  the  erythematous  rash  there 
are  at  lirst  scattered  pctechia\  which  gradually  become  more  extensive, 
and  xdtimately  the  skin  may  be  universally  involved.  Death  may  take 
place  on  the  second  or  on  the  third  day.  "While  this  form  is  perhaps 
more  connnon  in  enfeebled  children,  I  have  twice  known  it  to  attack  per- 
sons apparently  in  full  health. 


80 


SPKCIPIC  INFECTIOUS  DISEASES. 


Anginose  Form. — 'Uw  throat  syinptoms  inny  apjjoar  oarly  and  progress 
rapidly.  Tlio  laucus  and  tonsils  are  swollen.  .Menil)ranous  exudation 
oceurs.  It  may  extend  to  the  jxisterior  wall  oi'  the  pharynx,  forward  into 
the  mouth,  and  upward  into  the  nostrils.  The  ghuu'o  oi"  the  neck  rajjidly 
enlarge.  Necrosis  occurs  in  the  tissues  of  the  throat,  the  fcjetor  is  extreme, 
the  constitutional  disturhance  profound,  and  the  child  dies  with  the  clin- 
ical i)icture  of  a  malignant  diphtheria.  Occasionally  the  mendjrane  ex- 
tends into  the  trachea  and  the  bronchi.  The  Eustachian  tubes  and  the 
middle  car  are  usually  involved.  When  death  docs  not  take  jjlace  rapidly 
from  toxicmia  there  nuiy  be  extensive  abscess  formation  in  the  tissues  of 
the  neck  and  sloughing.  In  the  separation  of  deep  sloughs  about  the  ton- 
sils the  carotid  artery  may  be  ojjcned,  causing  fatal  luemorrhage. 

Complications  and  Sequelae. — (a)  iVcphrilis. — At  the  height  of 
the  fever  there  is  often  a  slight  trace  of  albumin  in  the  nrine,  which  is 
not  of  special  significance.  In  a  majority  of  cases  the  kidneys  escape  with- 
out greater  damage  than  occurs  in  other  acute  febrile  alfections. 

Nephritis  is  most  common  in  the  second  or  third  week  and  may  de- 
velop after  a  very  mild  attack.  It  may  be  delayed  until  the  third  or  fourth 
week.  xVs  a  rule,  the  earlier  it  develoi)s  the  more  severe  it  is.  It  varies 
greatly  in  intensity,  and  three  grades  of  cases  may  be  recognized: 

1.  Very  severe  cases  with  suppression  of  urine  or  the  passage  of  a  small 
finantity  of  dark  bloody  nrine  laden  with  albumin  and  tube-casts.  Vomit- 
ing is  constant,  there  are  convulsions,  and  the  child  dies  with  the  symp- 
toms of  acute  urannia. 

2.  Less  severe  cases  without  any  serious  acute  symptoms.  There  is  a 
puffy  appearance  of  the  eyelids,  with  slight  oedema  of  the  feet;  the  urine 
is  diminished  in  quantity,  smoky  in  appearance,  and  contains  albumin 
and  tube-casts.  The  kidney  symptoms  then  dominate  the  entire  case,  the 
dropsy  persists,  and  there  may  be  effusion  into  the  serous  sacs.  The  condi- 
tion may  drag  on  and  become  chronic,  or  the  patient  may  succumb  to 
ura^mic  accidents.  Fortunately,  in  a  majority  of  the  cases  the  disease  yields 
to  judicious  treatment  ami  recovery  takes  place. 

3.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.  The 
urine  contains  albumin  and  a  few  tube-casts,  but  rarely  blood.  The  oedema 
is  extremely  slight  or  transient,  and  the  convalescence  is  scarcely  inter- 
rupted. Occasionally,  however,  in  these  mild  attacks  serious  symptoms 
may  supervene.  (Edema  o^'  the  glottis  may  ]>rove  rapidly  fatal,  and  in  one 
case  of  the  kind  a  child  nnder  my  care  died  of  acute  effusion  into  the 
pleural  sacs. 

Occasionally  aMlema  occnrs  without  albuminuria  or  signs  of  nejdiritis. 
Possibly  in  some  of  these  case  the  cx'dcma  may  be  Invmic  and  due  to  the 
anamia;  but  thcio  are  instances  in  which  marked  changes  have  been  found 
in  the  kidney  after  dcatli,  even  when  the  nrine  did  not  show  the  features 
characteristic  of  nephritis. 

(h)  AiihrHis. — During  the  subsidence  of  the  fever,  rarely  at  its  height, 
pains  and  swellings  in  the  joints  may  develop  and  present  all  the  charac- 
teristics of  acute  rheumatism.  In  all  probability  it  is  not,  however,  true 
rheumatism,  but  is  analogous  to  gonorrhceal  arthritis.     The  effusion  may 


SCARLET  FEVER. 


81 


urine 

burn  in 

aso,  tlie 

condi- 

unil)  to 

yields 

The 

oedema 

inter- 

nptoms 

in  one 

ito  the 

jdiritis. 
to  the 
found 

leatures 

height, 
:harac- 
|r,  true 
In  may 


j)ass  on  to  suppuration,  in  wliicli  case  it  most  commonly  involves  only  a 
fc^ingle  joint. 

(f)  Cardiac  Coniplicalions. — Simi»le  endueardilid  is  not  uncommon, 
and  many  cases  of  chronic  valvular  disease  originate  prol)ably  in  a  latent 
endocarditis  during  this  disease,  ^lalignant  endocarditis  is  rare.  Peri- 
carditis is  pr(»l)alily  not  more  freipient,  hut  is  less  likely  to  be  overlooked 
tiian  endocarditis.  It  usually  develops  during  convalescence;  the  elfusioii 
may  be  sero-llhrinous  or  })urulent.  The  cardiac  com[)lications  are  some- 
times found  in  as.^ociation  with  arthritis.     Myocarditis  is  not  uncommon. 

(d)  Pleurisy  may  follow  pneumonia,  though  this  is  rare.  ^lore  often 
it  occurs  during  convalescence,  is  insidious  in  its  course,  and  as  a  rule 
l)urulent.  This  sericnis  complication  of  scarlet  fever  is  not  sullicu-ntly 
recognized.  Jt  was  one  upon  which  my  teacher,  K.  1*.  Howard,*  in  ^lon- 
treal,  specially  insisted  in  his  lectures.  Sheriff,  in  a  number  of  the  same 
Journal,  reports  two  cases,  occurring  at  the  same  time  in  brothers,  one  of 
whom  died  suddeidy  after  a  slight  exertion. 

{c)  Ear  Ctiiiipliralinns. — These  are  common  and  serious.  They  are 
due  to  extension  of  the  inilammation  from  the  throat  through  the  Ku- 
stachian  tubes,  and  rank  among  the  most  frecpient  causes  of  deafness.  The 
severe  forms  of  iuend)ranous  angina  are  almost  always  associated  with  in- 
ilammation of  the  nuddle  ear,  which  goes  on  to  sup})uration  and  to  ])er- 
foratiou  of  the  drum.  The  suppuration  may  extend  to  the  labyrinth  and 
rapidly  produce  deafness.  In  other  instances  there  is  suppuration  in  the 
mastoid  cells.  In  the  necrosis  which  follows  the  middle-ear  disease,  the 
facial  nerve  may  be  involved  and  i)aralysis  follow.  Later,  still  more  seri- 
ous comi)lications  may  follow  the  otitis,  such  as  thrond)osis  of  the  lateral 
sinus,  meningitis,  or  abscess  of  the  brain. 

(/)  Adenitis. — In  comjiaratively  mild  cases  of  scarlet  fever  the  sub- 
maxillary lymph-glands  may  be  swollen.  In  severer  cases  the  swelling  of 
the  neck  becomes  extreme  and  extends  beyond  the  limits  of  the  glands. 
Acute  phlegmonous  inflammations  may  occur,  leading  to  wides])read  de- 
struction of  tissue,  in  which  vessels  may  be  eroded  and  fatal  liaMnorrhage 
ensue.  The  su|)purative  processes  may  also  involve  the  irtro-])haryngeal 
tissues. 

The  swelling  of  the  lym])h-glands  usually  subsides,  and  within  a  few 
weeks  even  the  most  extensive  nlargement  gradually  disappears.  There 
are  rare  instances,  however,  in  which  tlio  lymphadenitis  becomes  chronic, 
and  the  neck  remains  with  a  glandular  collar  which  almost  obliterates  its 
outline.  This  nniy  prove  intractable  to  all  ordinary  measures  of  treat- 
ment. A  case  came  under  my  observation  in  which,  two  years  after  scar- 
let fever,  the  neck  was  enormously  enlarged  and  surrounded  by  a  mass  of 
firm  brawny  glands. 

{(j)  Xcrrans  Complications. — Chorea  occasionally  develops  in  connec- 
tion with  the  arthritis  and  endocai'ditis.  Sudden  convulsions  followed  by 
hemiplegia  may  occur.  Progressive  paralysis  of  the  limbs  with  wasting 
may  devclo]>  with  the  features  of  a  subacute,  ascending  spinal  paralysis. 

*  Canada  Medical  and  Surgical  Journal,  December,  1872. 


!  ^' 


82 


Sl'KCIFIC  INFhX'TIOUS  DISEASES. 


.:.,), 


Tliroiiibosis  of  tliu  C(Mvl)ral  veins  may  occur.  Mental  svnii)tonis,  mania  ami 
melani'liojia,  have  been  descrihed. 

(/»)  Other  rare  coinplicationH  and  He(|uela'  are  (edema  of  the  eyelids, 
without  ne|iliritis  (S.  riiilips),  symmetrical  ^ningrene,  enteritis,  nonui,  and 
jterforation  of  the  soft  ]»alate  ((Joodall).  I'earsoii  and  Littlewood  have 
reported  a  case  of  dry  jfaiij,'reiie  after  scarlet  fever  in  a  hoy  of  four,  whieh 
develo|)ed  on  the  ninth  day  of  the  disease,  and  involved  hoth  legs,  neces- 
sitating amputation  at  the  upper  third  of  the  thighs.    The  child  recovered. 

Diagnosis. — The  diagnosis  of  scarlet  fever  is  not  diiVicult,  l)ut  there 
are  eases  in  which  the  true  nature  of  the  disease  is  for  a  time  douhtful. 
The  following  are  the  most  common  conditions  with  which  it  may  be 
confounded: 

1.  Aciile  ExfollaCitKj  Dermatitis. — This  pseudo-exanthem  simulates  scar- 
let fever  very  closely.  It  has  a  sud<len  onset,  with  fever,  'J'he  eruption 
spread.s  rai)idl3',  is  uniform,  and  after  persisting  lor  live  or  six  days  begins 
to  fade.  Even  hefore  it  has  entirely  gone,  desciuanuition  usually  hegins. 
Some  of  these  cases  can  not  he  distinguished  from  scarlet  fever  in  tlie 
stage  of  erui)tion.  The  throat  sym[)toms,  however,  are  usually  absent,  and 
the  tongue  rarely  shows  the  changes  which  are  so  marked  in  scarlet  fever. 
In  the  des(inanuitiou  of  this  affection  the  hair  and  nails  are  commonly 
aifected.  It  is,  too,  a  disease  liahle  to  recur.  Some  of  the  instances  of 
second  and  third  attacks  of  scarlet  fever  have  been  cases  of  this  form  of 
dermatitis. 

2.  Measlc'^,  which  is  distinguished  by  the  hjnger  })eriod  of  invasion, 
the  characteristic  rature  of  the  prodromes,  and  the  later  ai)pearance  of  the 
rash.  The  greater  intensity  of  the  measly  rash  ujion  the  face,  the  more 
])apular  character  and  the  irregular  crescentic  distribution  are  distinguish- 
ing features  in  a  majority  of  the  cases.  Other  i)oints  are  the  abseiice  in 
measles  of  the  sore  throat,  the  peculiar  character  of  the  desquamation,  and 
the  absence  of  leiicocytosis. 

3.  Tiiithchi. — The  rash  of  ru])ella  is  sometimes  strikingly  like  that  of 
scarlet  fever,  but  in  the  great  majority  of  cases  the  mistake  could  not  arise. 
In  cases  of  doubt  the  general  sym^jtoms  are  our  best  guide. 

4.  Septicannia. — As  already  mentioned,  the  so-called  puerperal  or  sur- 
gical scarlatina  shows  an  eruption  which  may  be  identical  in  ajjpearance 
with  that  of  true  scarlet  fever. 

5.  Diyhthcriu. — The  practitioner  may  Ijc  in  doubt  whether  he  is  deal- 
ing with  a  case  of  scarlet  fever  with  intense  membranous  angina,  a  true 
dii)htheria  with  an  erythematous  rash,  or  coexisting  scarlet  fever  and 
di[ihtlieria.  In  the  angina  occurring  early  in,  and  during  the  course  of 
scarlet  fever,  though  the  clinical  features  may  be  those  of  true  diphtheria, 
Loelller's  bacilli  are  rarely  found.  On  the  other  hand,  in  the  membranous 
angini  occurring  during  convalescence,  the  bacilli  are  usually  ])resent.  The 
rash  iji  diiditheria  is,  after  all,  not  so  common,  is  limited  usually  to  the 
trunk,  is  not  so  persistent,  and  is  generally  darker  than  the  scai-latinal  rash. 

Scarlatina  and  di]»htlieria  may  coexist,  but  in  a  case  ])resenting  wide- 
spread erythema  and  extensive  memljranous  angina  with  Loeffler's  bacilli, 
it  would  puzzle  Hippocrates  to  say  whether  the  two  diseases  coexisted,  or 


SC'AULKT   FKVKU. 


83 


u 


at  of 


arise. 


deal- 
a  trucj 
anil 
iirso  ol 
theria, 
)ranoiis 
,  The 
to  the 
\\  rash, 
widt'- 
jacilli, 
ted,  or 


wliether  it  was  only  an  intense  searUitinai  ni.sU  in  diphtheria.  Desciuania- 
ti(»n  occurs  in  either  case.  The  stre|>tocoet  lis  angina  is  not  so  apt  to  e.\- 
tend  to  the  hirvnx,  nnr  are  recurrences  &.;  connnon;  Init  it  is  well  to  l)ear 
in  mind  that  ^^  iieral  infection  may  oecnr,  tiuit  tlie  membrane  may  spread 
(h)\vn\vard  with  ^neat  rapidity,  and,  lastly,  that  all  the  nervous  setiuda.'  of 
the  Klel)s-Loclllcr  diphtheria  nuiy  follow  the  streptococcus  form. 

(J.  Jfni;/  L'dslirs. — 'j'hese  are  partial,  and  seldom  more  tinin  a  transient 
hy[)era'mia  of  the  >kiii.  Occasionally  they  are  dilfuse  and  intense,  and  in 
such  cases  very  deceptive.  Tiiey  are  not  assf»ciated,  however,  with  the 
characteristic  symptoms  of  invasion.  There  is  no  fever,  and  with  care  the 
distinction  can  usually  hi'  made.  They  are  most  apt  to  follow  the  use  of 
belladonna,  (pdniuc,  and  iodide  of  jiotassium. 

Copxislpure  nf  oilier  Piffcdscs. — Of  4S,;}(!(i  eases  of  scarlet  fever  in  the 
^[etropolitan  Asylum  IJoard  Hospitals  which  were  com|)licated  by  some 
other  disease,  in  l.diil  cases  the  secondary  infection  was  diphtheria,  in  8!MJ 
cases  chicken-pox.  in  tif'.i  measles,  in  4.0  1  whoopin^'-cou<,di,  in  oo  erysipelas, 
in  11  enteric  fever,  and  in  1  typhus  fever  (F.  F.  Cai^'iT). 

JIiiw  Ion;/  is  a  Child  I iifcrlire? — Usually  after  des(|uamation  is  com- 
])lete,  in  four  or  five  weeks  the  danj^er  is  over,  but  the  occurrence  of  so-called 
'"return  cases"  show  that  )»atients  remain  infective  even  when  free  from 
desquamation.  In  IS!) J,  with  ^,.VJ3  patients  from  the  (;ias<jow  fever 
hosi)itals  sent  to  tlu'ir  homes  convalescent,  fre.'h  cases  appeared  in  TO 
of  the  houses  (Chalniers).  With  15,000  cases  submitted  to  an  avera<^c 
pei'iod  of  isolation  of  forty-nine  days  or  inider,  the  percentage  of  return 
cases  was  l.SG;  with  an  average  period  of  fifty  to  iifty-six  day.s,  the  per- 
centage was  1.1".^;  where  the  isolati(,.i  extended  to  between  fifty-seven  and 
sixty-five  days,  the  percentage  of  return  cases  was  1  (Xeech).  This 
author  suggests  eight  weeks  as  a  nunimum  and  thirteen  weeks  as  a  maxi- 
mum. 

Prognosis. — Fpidemics  differ  in  severity  and  the  mortality  is  ex- 
tremely variable.  Among  the  better  classes  the  death-rate  is  much  lower 
than  in  hosoital  ))ractice.  There  are  physicians  who  have  treated  consecu- 
tively a  I'lUnlred  or  more  cases  without  a  death.  On  the  other  hand,  in 
hospitals  and  among  the  })oorer  classes  the  death-rate  is  considerable, 
ranging  from  o  to  10  per  cent  in  mild  e])idemics  to  '20  or  30  per  cent  in 
the  very  severe. 

The  younger  the  child  the  greater  the  danger.  In  infants  under  one 
year  the  death-rate  is  very  high.  The  great  proportion  c  atal  cases 
occurs  in  children  under  six  years  of  age. 

The  unfavorable  sym])toms  are  very  high  fever,  early  mental  disturb- 
ance with  great  jactitation,  the  occurrence  of  hemorrhages  (ctitaneous  or 
visceral),  intense  membranous  angina  with  cervical  ])ubo,  and  signs  of 
laryngeal  obstruction. 

Xephritis  is  always  a  serious  com])lication  and  when  setting  in  with 
suppression  of  the  urine  may  quickly  prove  fatal.  It  is  noteworthy,  how- 
ever, that  a  large  majority  of  the  cases  of  scarlatinal  nephritis  recover. 

Treatment. — The  disease  can  not  he  cut  short.  In  the  presence  of 
the  severer  forms  we  are  still  too  often  helpless.    There  is  no  disease,  how- 


84 


SPKCIKIC  ixfk(;tious  diskasks. 


ever,  in  wliicli  the  sucoossful  issue  nnd  the  nvoidnnce  of  CDmitlirntiniis  de- 
j)eiul8  more  upon  the  pkilled  jiulginent  ol'  the  iihysieian  nnd  the  care  with 
which  his  instructions  are  carried  out. 

The  child  sh(»uld  he  isohited  nnd  [tlaccd  in  chai^'e  of  n  ronipetcnt 
nurse.  The  tcin|terature  ol'  the  room  should  he  constant  and  the  ventila- 
tion thorough.  The  cluld  should  wear  a  light  llannel  night-gown,  and 
the  hedelothing  should  not  he  too  Jieavy.  The  diet  should  consist  of  milk, 
hroths,  and  fresh  fruits;  water  should  hi;  freely  given.  With  the  fall  of 
the  teni|)eratiire,  the  diet  may  he  increased  and  the  child  may  gra(lu;illy 
return  to  ordinary  fare.  When  desiiuanuition  hegins  the  child  should  ho 
thoroughly  ruhhed  every  day,  or  every  second  day,  with  sweet  oil,  or  car- 
bolated  vaseline,  or  a  C-per-cent  hydro-iuiphthcd  soap,  which  prc'vents  the 
drying  and  the  ditfusion  of  the  scales.  An  occasioiuil  warm  hath  may 
then  be  given.  At  any  time  during  the  attack  the  skin  may  be  sponged 
M'ith  Avarni  water.  The  ]»atient  may  be  allowed  to  get  up  after  the  tcm- 
jierature  has  been  normal  for  ten  days,  but  for  at  least  three  weeks  from 
this  tin\e  great  care  shoidd  be  exercised  to  jjrevent  exposure  to  cold.  It 
must  not  he  forgottiMi,  also,  that  the  rciud  complications  are  very  apt  to 
develop  during  the  convalescence,  and  after  all  danger  is  ap})arently  i)ast. 
Ordinary  eases  do  not  require  any  medicine,  or  at  the  most  a  simple  fever 
mixture,  and  during  convalescence  a  bitter  tonic.  The  l)owels  should  be 
carefully  regulated. 

Special  sym])toms  in  the  severe  cases  call  for  treatment. 

When  the  fever  is  above  103°  the  extrenuties  nuiy  be  sponged  with 
tepid  water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this  will 
not  sudice,  and  more  thorough  measures  of  hydrotherapy  should  be  ])rac- 
tised.  With  ])ronounced  delirium  and  nervous  sym])toms  the  cold  })ack 
should  bo  used.  AVhen  the  fever  is  rising  rapidly  but  the  child  is  not 
delirious,  he  should  be  ])laced  •a  a  warm  bath,  the  tem[)erature  of  which 
can  be  gradually  lowered.  The  Ijath  with  the  water  at  80°  is  beneficial. 
In  giving  the  cold  pack  a  rubber  sheet  and  a  thick  layer  of  blankets  should 
be  s[)read  upon  a  sofa  or  a  bed,  and  over  them  a  sheet,  wrung  out  of  cold 
water.  The  naked  child  is  then  laid  upon  it  and  wrapjied  in  the  blankets. 
An  intense  glow  of  heat  quickly  follows  tlie  preliminary  chilling,  and  from 
time  to  time  the  blankets  may  be  unfolded  and  the  child  sprinkled  with 
cold  water.  The  good  effects  which  follow  this  plan  of  treatment  arc 
often  striking,  particularly  in  allaying  the  delirium  and  jactitation,  and 
procuring  (piiet  and  refreshing  sleep.  Parents  will  object  less,  as  a  rule,, 
to  the  warm  bath  gradually  cooled  than  to  any  other  form  of  ]iydrothera]>y. 
The  child  may  be  removed  from  the  warm  bath,  placed  upon  a  sheet 
Avrung  out  of  tolerably  cold  water,  and  then  folded  in  blankets.  The  ice- 
cap is  very  useful  and  may  be  kept  constantly  ajiplied  in  cases  in  which 
there  is  high  fever,  ^fedicinal  antipyretics  are  not  of  much  service  in 
coni]iarison  with  cold  water. 

The  throat  symptoms,  if  mild,  do  not  require  much  treatment.  If 
severe,  the  local  measures  mentioned  under  diphtheria  should  be  used. 
Cold  applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  some- 
times difficidt  to  get  a  child  to  submit  to  them.     In  connection  with  the 


MKASLES. 


85 


tliroiit,  tlic  curs  should  be  npcoinlly  lookt'u  oftur,  and  a  careful  disinfectiitii 
(d'  the  nu)Utli  and  I'auces  l»y  suitable  auliseptic  solutions  should  bo  iiruc- 
tised.  When  tlic  inllanuuation  extends  tlir(Ui;,di  the  tuljes  to  the  luiddh; 
ear,  the  iiractitiiincr  shoidil  cither  liiuis('l"  cxannnc  (biily  the  condition  ol' 
the  drum,  or,  when  a\ailablc,  a  specialist  should  be  called  in  to  assist  him 
ill  the  ease.  The  careful  watchinjr  of  this  uiend)rane  day  by  day  aiul  tlu; 
puneturiuf^  of  it  if  the  tension  beconu's  too  <freat  may  save  the  hearing'  of 
the  child.  With  the  aid  of  cocaine  the  drum  is  readily  puiu'tured.  The 
operation  may  be  repeated  at  inteis'als  if  the  jiain  and  distention  return. 
No  complication  of  the  disease  is  more  serious  than  this  exteiision  of  the 
intlammatory  process  to  the  ear. 

The  nephritis  should  be  dealt  with  ns  in  ordinary  cases;  indications 
for  tr(>atment  will  be  found  under  the  appro|M'iate  section.  It  is  worth 
nlentionin^^  howe\i,'r,  that  daceoud  insir-ts  upon  the  great  value  of  milk  diet 
in  scarlet  fever  n-i  a  preventive  of  nephrif-s. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  weak- 
ness, which  is  usually  the  result  of  the  direct  action  of  tlu'  poison,  and  is 
liest  met  by  stimulants. 

^lany  si)eci(ics  have  been  vaunted  in  scarlet  fever,  but  th"V  are  all 
useless. 

Vin.  MEASLES. 


d  with 
'lis  will 
e  prac- 
1  i>ack 
is  not 
which 
leficial. 
shoidd 
of  cold 
ankets. 
(1  from 
d  with 
•nt  arc 
n,  and 
a  rule, 
lerapy, 
sheet 
le  ice- 
which 
ice  in 

it.  If 
used, 
sonie- 

tth  the 


Definition. — An  acute,  highly  infectious  disorder,  characterized  liy 
an  initial  coryza  aiul  a  rai)i(lly  spreading  eruj)tion. 

Etiology. — 'J'Iil;  infection  of  measles  is  very  intense  and  immunity 
iiga'iist  attack  not  nearly  so  common  as  in  scarlet  fever,  J.  is  a  disease  of 
cliiklliood,  but  unprotected  adults  are  liable  to  the  infection.  Indeed, 
measles  is  more  freijuent  in  a<hdts  than  is  scarlet  fever.  Within  the  first 
fix  months  of  life  the  liability  is  not  so  marked,  though  infants  of  a  month 
er  three  M'ceks  may  be  attacked.  The  sexes  are  eiiually  alTected.  The  con- 
tagion is  communicated  by  the  breath  and  by  tlu  secretions,  particularly 
those  of  the  nose.    It  may  be  conveyed  by  u  third  person  and  by  fomites. 

The  disease  is  ]»ractically  endemic  in  large  centres  of  population,  and 
from  time  to  tiuu'  spreads  and  ]»revails  epidemically.  It  occurs  at  all  sea- 
suns,- but  ])revails  more  extensively  during  the  colder  months.  There  is 
no  infectious  disease  in  ■»hich  recurrence  is  more  frequent.  There  may 
lie  a  second,  third,  or  even  a  fourth  attack. 

The  contaijium  of  the  disease  is  unknown.  Xo  one  of  the  various  organ- 
isms which  have  been  described  meets  the  requirements  of  Koch's  law. 

Morbid  Anatomy. — ]\Ieasles  itself  rarely  kills,  but  the  conijdica- 
tions  and  scquehe  combine  to  make  it  a  very  fatal  affection  in  children. 
There  are  no  characteristic  post-mortem  a])]iearances.  The  skin  changes 
iu'c  those  associated  with  an  intense  hypera'mia. 

There  is  a  catarrhal  condition  of  the  mucous  membranes,  particularly 
of  the  bronchi.  The  fatal  cases  show  almost  invariably  either  broncho- 
I'lieumonia,  ca])illary  bronchitis  Mith  patches  of  collapse,  or  less  frequently 
lobar  pneumonia.    The  bronchial  glands  are  invariably  swollen.     Pleurisy 


!!: 


80 


SPECIFIC  INFECTIOUS  DISEASES. 


* 


IS  less  c'oiuinoii.  During  convak'scence  from  measles  there  is  a  special  lia- 
hility  to  tuberculous  invasion,  and  tuberculous  broncho-pneumonia  claims 
a  liir;^e  number  of  victims.    The  bronchial  glands  may  also  be  all'ected. 

The  gastro-intestinal  mucosa  nuiy  l)e  hypenemic.  Swelling  of  Peycr's 
glands  is  not  at  all  uncommon  and  may  reach  u  very  intense  grade  iu  the 
l»atciies. 

Symptoms. — Incubation. — "  From  seven  to  eighteen  days;  oftenest 
fourteen."  The  disease  has  been  frequently  inoculated.  In  such  cases 
the  incul)ation  period  is  less  than  ten  days. 

Invasion. — Tlie  'Msease  usually  begins  with  symptoms  of  a  feverish 
cold.  'I'licre  are  shiverings  (not  often  a  detinite  chill),  marked  coryza, 
sneezing,  running  at  the  nose,  redness  of  the  eyes  and  lids,  with  photo- 
pli')i,ia,  and  within  twenty-four  hours  cough.  These  early  catarrhal  sym])- 
touis  are  more  marked  in  measles  than  in  any  other  infectious  disease  of 
children.  There  nuiy  be  the  symi)toms  so  commonly  associated  with  an 
on-coming  fever — nausea,  vomiting,  and  headache.  The  tongue  is  furred. 
Examination  of  the  throat  may  show  a  reddish  hypera'mia  or  in  some  in- 
stances a  distinct  ])unctiform  rash. 
1       2345678        Occasionally  this  s])reads  over  the 

whole  mucous  membrane  of  the 
mouth  Avitli  the  exception  of  the 
tongue.  The  tem])erature  at  this 
stage  is  visually  high, reaching  from 
1();5°  to  104°,  ascending  gradually 
through  the  second  and  third  days. 
Eruption.  —  Usually  on  the 
fourth  day,  when  the  fever  and 
general  symi)toms  have  reached 
their  height,  the  rash  appears 
upon  the  cheeks  or  forehead  in 
the  form  of  small  red  papules, 
which  increase  in  size  and  spread 
over  the  neck  and  thorax.  When 
the  eruption  becomes  well  devel- 
oped the  face  is  swollen  and  cov- 
ered Avith  reddish  blotches,  which 
often  have  rounded  or  crescentic  outlines.  Here  and  there  is  an  intervening 
portion  of  unatt'ected  skin.  At  this  stage  the  cervical  lymph-glands  may 
be  slightly  swollen  and  sore;  sometimes  also  the  glands  in  the  groins, 
axilhc,  and  at  the  ell)ows.  The  papules  can  now  be  felt  with  the  finger. 
Sonu'times  they  are  ([uite  shotty,  but  do  not  extend  deep  into  the  skin.  On 
the  trunk  and  extremities  the  swelling  of  the  skin  is  not  so  noticeable, 
the  color  of  the  rash  not  so  intense  and  often  less  uniform.  The  mottled, 
blotchy  character  of  the  rash  appears  most  clearly  on  the  chest  or  the  abdo- 
men. The  rash  is  hypera-mic  and  disapjiears  on  i)ressurc,  but  in  the  more 
malignant  cases  it  may  become  hamiorrhagic.  The  general  symptoms  do 
not  abate  with  the  occnrrence  of  the  eruption.  They  persist  until  the  end 
of  the  fifth  or  the  sixth  day,  when  in  the  majority  of  the  cases  all  the  symp- 


1040' 


102-2' 


100- 4* 


98  e* 


96'8* 


1 

mtmfmm 

■ 

Initial  Fever. 
Chart  YIII.- 


Eruptive  Fever. 
EnipUon. 

-Jlcaslcs  (Striiinpell), 


MEASLP^S. 


87 


ial  lia- 
clainis 
tod. 

Foyer's 
in  the 

)ftonest 
h  cases 

foverish 
coryza, 
photo- 
.1  syinj)- 
soase  of 
with  an 
i  furred, 
iome  in- 
rm  ras^h. 
iver  tlie 
of   the 
I  of  the 
■  at  this 
ing  from 
[radually 
ird  days, 
on     the 
;ver   and 
reached 
appears 
ihead   in 
papules, 
spread 
When 
dev  el- 
and cov- 
-svhich 
ervening 
nds  may 
groins, 
finger, 
km.    On 
ticeuble, 
mottled, 
he  ahdo- 
lie  more 
)toms  do 
the  end 
he  symp- 


toms l)e^ome  n'itigalcd.  Among  tlio  pocnliaritics  of  the  rasli  may  ho  moii- 
tioiu'd  the  (It'VclopiiR'iit  of  mimoroiis  mihary  vesiok'S  and  tiic  ooeiirrcneo  of 
lietechiu',  which  niv  soon  oc<'asionally  ovoii  in  oases  of  moderate  sovorily. 

Desquamation. — After  persisting  for  two  or  tiiroe  days  the  rasli  grad- 
ually fa(h's  and  dcsijUiiiniition  occurs  ir^  the  i'orm  of  very  line  branny  scales, 
whicdi  may  ho  dilUcult  tu  see  aud  are  wholly  ujilike  tiie  coarse  exfoliation 
in  scarlet  fovcr.  -  ^. 

'fho  catarrhid  symptoms  gradually  disappear  and  oijuvalescence  is 
ra]>idly  ostahlishcd. 

Jn  oj)idojnics  of  measles  atypical  cases  are  common.  The  rash  may 
a])poar  early,  within  thirty-six  hours  of  the  onset  of  the  symptoms;  or,  on 
the  other  hand,  it  iiuiy  Ijo  delayed  until  the  sixth  day.  As  in  other  oxan- 
thoms,  when  many  cases  occur  ii  a  household,  one  of  the  children  may 
have  all  the  initial  symptoms  and  "sicken  for  the  disease,"  as  it  is  said, 
hut  no  oru})tion  apijoars. 

The  most  sei'ioiis  variety  of  measles  is  that  in  which  lueinoi'rhagos  oc- 
cur— the  viurbilli  liaiiiorrhayici.  In  general  practice  those  cases  are  very 
uiu'ommon.  Occasionally  in  institutions,  ])articularly  when  the  hygienic 
surroundings  ai'c  liiid,  one  or  two  oases  dovolop  during  an  epidemic,  it  has 
heen  frecpiontly  t^vvi\  in  camjis  ami  wlien  the  disease  is  freshly  imported 
into  a  native  |io|iulation,  as  in  the  Fiji  Islands.  During  the  civil  war, 
as  shown  by  Smart's  statistics,  some  cases  occurred. 

In  this  form  the  disease  sets  in  with  much  greater  intensity,  the  rash 
becomes  ])otochial,  luomorrhagos  occur  from  the  mucous  momhranos,  the 
constitutional  depression  is  very  great,  and  death  occurs  early  from  tox- 
a'una. 

Complications  and  Sequelae. — The  existing  bronchitis  is  apt  to 
extend  into  the  >iiialler  tidjos  and  lead  to  collapse  and  broiu'ho-ijneumonia. 
\\'hen  limited  in  extent,  this  causes  only  aggravation  of  the  cough  and  ])er- 
sistence  of  the  fever  (sym])tom.  which  gradually  abate),  and  convalescence 
is  rapid;  but  in  debilitated  children,  more  particularly  in  institutions  and 
among  the  lower  classes,  this  complication  is  extronudy  grave  and  is  re- 
sponsible for  tlie  liigh  death-rate  from  measles  in  the  community.  In 
some  instances  the  clinical  ])i(ture  is  that  of  a  suffocative  catarrh,  the 
result  of  a  widos])rcad  involvement  of  the  smaller  tubes.  The  descri})tion 
of  the  condition  will  be  found  under  T)roncho-])ncunionia.  Lobar  ])nou- 
nionia  is  loss  common  and  ])orhaps  loss  dangerous. 

Laryngitis  is  not  uncommon:  the  voice  l)ecomos  husky  and  the  cough 
crou]iy  in  character.  (Ldonui  of  the  glottis  is  very  rare.  P.seudo-mem- 
branous  inflammation  of  the  ])harynx  and  larynx  may  occur  and  ])rove 
fatal.  In  debilitated  infants  severe  stomatitis,  cancruin  oi-is,  or  ulcerative 
vulvitis  may  develop. 

Catarrhid  inflammation  of  the  middle  ear  is  not  very  uncommon,  and 
may  ]n'occed  to  su]ii)uration  and  to  ]U'rforation  of  the  drum.  The  con- 
junctival catarrh  rarely  leads  to  further  trouble,  though  occasionally  the 
inflammation  becomes  purulent. 

Intestinal  catarrh  is  common  in  some  epidemics,  and  there  may  be  the 
symptoms  of  acute  colitis. 
6 


il 


88 


SPECIFIC  INFECTIOUS  DISEASES. 


Nephritis  is  an  exceed in<.';ly  rare  complication. 

Of  the  sequela}  oi'  measles,  tuberculosis  is  the  most  important — either 
an  involvement  of  the  bronchial  glands,  a  miliary  tuberculosis,  or  a  tuber- 
culous broncho-pneumonia.  Arthritis  is  rare.  1  have  known  anchylosis  of 
the  jaw  to  follow  measles  in  a  child  of  four  years. 

Among  the  rarer  secjuche  are  paralyses.  Hemiplegia  is  very  rare,  but 
eases  of  ])ara|)legia  have  been  described.  Thomas  Jiarlow  reports  a  fatal 
case  in  which  the  symptoms  occurred  early,  the  ])aralysis  exteiulcd  rn|)idly 
and  involved  the  upper  lindjs,  and  death  took  i)lace  on  the  eleventh  day. 
Marked  vascular  changes  were  found  in  the  gray  matter  of  the  sj)inal  cord, 
and  were  believed  to  depend  on  an  early  disseminated  myelitis.  Examina- 
tion of  the  i)<n"ii)heral  nerves  was  not  made.  "While  some  of  these  cases  are 
due  to  an  ascending  myelitis,  others  are  probably  the  result  of  a  post- 
febrile polyneuritis. 

Diagnosis. — From  scarlet  fever,  with  which  it  is  most  likely  to  be 
confounded,  measles  is  distinguished  by  the  longer  initial  stage  with  char- 
acteristic sym])toms,  and  the  blotchy  irregular  character  of  the  rash,  which 
is  so  unlike  the  diffuse  uniform  erythema  of  scarlet  fever.  Occasionally 
in  measles,  when  the  throat  is  very  sore  and  the  eruption  pretty  diffuse, 
there  may  at  first  be  difficulty  in  determining  which  disease  is  present,  but 
a  few  days  should  suffice  to  make  the  diagnos-s  clear.  As  a  rule  there 
is  no  leucocytosis.  It  may  be  extremely  difficult  to  distinguish  from  rothcln. 
I  have  more  than  once  known  practitioners  of  large  experience  unable 
to  agree  upon  a  diagnosis.  The  shorter  prodromal  stage,  the  slighter  fever 
in  many  cases,  are  perhaps  the  most  imi)ortant  features.  It  is  difflcidt  to 
speak  definitely  about  the  distinctions  in  the  rash,  though  perhaps  the 
more  uniform  distribution  and  the  absence  of  the  crescentic  arrangement 
are  more  constant  in  rotheln.  In  Africans  the  disease  is  easily  recognized, 
even  in  the  black;  the  papules  stand  out  with  great  plainness,  often  in 
groups;  the  hypera-mia  is  to  be  seen  on  all  but  the  very  black  skins.  The 
distribution  of  the  rash,  the  coryza,  and  the  rash  in  the  mouth  are  impor- 
tant points. 

The  conditions  under  Avhich  measles  may  be  mistaken  for  small-pox 
have  already  been  described.  Of  drug  eruptions,  that  induced  by  copaiba 
is  very  like  measles,  but  is  readily  distinguished  by  the  absence  of  fever 
and  catarrh. 

Prognosis. — The  mortality  bills  of  large  cities  show^  Avhat  a  serious 
disease  measles  is  in  a  community.  Among  the  eruptive  fevers  it  ranks 
third  in  the  death-rate.  The  mortality  from  the  disease  itself  is  not  hisrh. 
but  the  pulmonary  complications  render  it  one  of  the  most  serious  of  the 
diseases  of  children. 

In  some  cjiidcmics  the  viisease  is  of  great  severity.  In  institutions  and 
in  armies  the  death-rate  is  often  high.  The  fever  itself  is  rarely  a  source 
of  danger.  The  extension  of  the  catarrhal  symptoms  to  the  finer  bronchial 
tubes  is  the  most  serious  indication. 

Treatment. — Confinement  to  bed  in  a  well-ventilated  room  and  a 
light  diet  are  the  only  measures  necessary  in  cases  of  uncomplicated  measles. 
The  fever  rarely  reaches  a  dangerous  height.    If  it  does  it  may  be  lowered 


RUBELLA. 


89 


-cither 
tuber- 
osis  of 

•0,  but 
a  fatal 
rapidly 
;h  day. 
il  cord, 
amina- 
ises  are 
a  post- 

^  to  be 
h  char- 
,  which 
sionally 
di  it'll  sc, 
3nt,  hut 
ie  there 
rotholn. 

unahle 
cr  fever 
ficult  to 
aps  the 
igcment 

gnized, 

ten  in 

The 

nnpor- 

lall-pox 
copaiba 
)f  fever 

serious 
t  ranks 
)t  high, 
of  the 

ons  and 

source 

ronchial 

and  a 
measles, 
lowered 


by  sponging  or  l)y  the  tepid  batli  gradually  reduced.  If  the  rash  docs  not 
come  out  well,  warm  drinks  and  a  hot  bath  will  hasten  its  maturation. 
The  bowels  should  be  freely  oj)ened.  If  the  cough  is  distressing,  pare- 
goric and  a  mixture  of  ipecacuanha  wine  and  scpiills  should  be  given.  The 
})atient  should  be  kept  in  bed  for  a  few  days  after  the  fever  subsides.  Dur- 
ing des(|iianintion  the  skin  should  be  oiled  daily,  and  warm  batiis  given 
to  facilitate  the  process.  The  convalescence  from  measles  is  the  most 
imi)ortant  stage  of  the  disease.  Watchfulness  and  care  may  prevent  seri- 
ous pulmonary  com})lications.  The  frequency  with  which  the  mothers 
of  children  witli  simple  or  tuberculous  broncho-pneuuionia  tell  us  that 
"the  child  caught  cold  after  measles,"  and  the  contemplation  of  the  mor- 
tality bills  should  make  us  extremely  careful  in  our  management  of  this 
ail'ection. 

IX.   RUBELLA  (liotheln,  Oerman  Measles). 

Tills  exanthem  has  also  the  names  of  rubeola  notha,  or  epidemic  rose- 
ola, and,  as  it  '«<  su])i)oscd  to  present  features  common  to  both,  has  been  also 
known  as  h_;  ^rid  measles  or  hybrid  scarlet  fever.  It  is  now  generally 
regarded,  however,  as  a  sejjarate  and  distinct  affection. 

Etiology. — It  is  propagated  l)y  contagion  and  spreads  with  great 
rapidity.  It  frequently  attacks  adults,  and  the  occurrence  of  either  measles 
or  scarlet  fever  in  childhood  is  no  protection  against  it.  The  epidemics 
of  it  are  often  very  extensive. 

Symptoms. — These  arc  usually  m'M,  and  it  is  altogether  a  less  seri- 
ous affection  than  measles.  Very  exccpti».nally,  as  in  the  epidemics  studied 
by  Cheadle,  the  symptoms  are  severe. 

The  stage  of  incubation  ranges  from  ten  to  twelve  days. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in  the 
back  and  legs,  and  coryza.  D.  II.  Hall  insists  that  slight  sore  throat  is  a 
constant  symptom,  on  which  account,  indeed,  it  was  that  it  was  originally 
regarded  as  a  hybrid,  having  the  sore  throat  of  scarlet  fever  and  the  rash 
of  measles.  There  may  be  very  slight  fever.  In  30  per  cent  of  Edwards's 
cases  the  tem])eraturc  did  not  rise  above  100°.  The  duratio.;  of  this  stage 
is  somewhat  variable.  The  rash  usually  a])poars  on  the  first  day,  sonie 
writers  say  on  the  second,  and  others  again  give  the  duration  of  the  stage 
of  invasion  as  three  days.  Griffith  places  it  at  two  days.  The  eruption 
comes  ont  first  on  the  face,  then  on  the  chest,  and  gradually  extends  so 
that  witliin  twenty-four  hours  it  is  scattered  over  the  whole  body.  It  may 
be  the  first  symptom  noted  by  the  mother.  The  eruption  consists  of  a 
number  of  round  or  oval,  slightly  raised  spots,  pinkish-red  in  color,  usually 
discrete,  but  sometimes  confluent. 

The  color  of  the  rash  is  somewhat  brighter  tlian  in  measles.  The 
patches  are  less  distinctly  crcsccntic.  After  persisting  for  two  or  three 
days  (sometimes  longer),  it  gradually  fades  and  tliere  is  a  slight  furfura- 
ceous  desquamation.  The  rash  persists  as  a  rule  longer  than  in  scarlet 
fever  or  measles,  and  the  skin  is  sliglitly  stained  after  it.  The  lymphatic 
glands  of  the  neck  are  frequently  swollen,  and,  when  the  eruption  is  very 
intense  and  diffuse,  the  lymph-glands  in  the  other  parts  of  the  body. 


f: 


90 


SPECIFIC  INFECTIOUS   DISEASES. 


There  arc  no  spcchil  coiiipliciilioiis.  'IMie  (liseii,<o  usually  i»i()grossos 
favorably;  hut  in  rare  instnnccs,  as  in  those  reported  hy  Cheadle,  the 
pyniploins  are  ol'  i;i'eater  severity.  Alhiiniiiiuria  may  occur  ami  even 
nephritis.  I'neumonia  and  colitis  have  been  prest'nt  in  some  epidiMuics. 
Icterus  has  lieen  seen. 

Diagnosis. — 'IMie  mildness  of  the  case,  the  sli<i-litness  of  the  ])rodromal 
sym})toius,  the  iinlducss  or  the  absence  ol'  the  fevi'i',  the  more  diU'use  char- 
acter of  the  I'ash,  its  rose-red  color,  and  the  early  enlargement  of  the 
cervical  jilands,  ai'e  the  cliief  ])oint,s  of  distinction  between  rilthelu  and 
laeash's. 

'J'he  treatment  is  that  of  a  simple  febrile  altection.  It  is  well  to 
keep  the  child  in  bed,  though  this  mav  be  dillicult,  as  the  jiatient  rarely 
feels  ill. 

X.    EPIDEMIC    PAROTITIS  (Mumps). 

Definition. — An  infections  disease,  characterized  by  inflammation  of 
the  parotid  gland.  The  testes  iu  males  aiid  the  ovaries  and  breasts  in 
females  are  sometimes  involved. 

Etiology. — 'i'he  nature  of  the  virus  is  unknown. 

The  aU'ection  has  all  the  characters  of  an  epidemic  disease.  It  is  said 
to  be  endemic  in  certain  localities,'  and  ])robably  is  so  in  large  centres  of 
])opulation.  At  certain  seasons,  ])articularly  in  the  spring  and  autumn 
months,  the  nuudier  of  cases  inci'cases  rapidly.  It  is  met  most  frequently 
in  childhood  and  adolescence.  A'ery  young  infants  and  adults  are  seldom 
;attacked.  ]\Iales  are  somewhat  more  frequently  affected  than  females.  Jn 
institutions  and  .~chools  the  disease  has  been  known  to  attack  over  !)0  ])cr 
cent  of  all  t!  e  children.  It  mav  be  curiouslv  localized  in  a  citv  or  district. 
The  disease  i.-   'ontagious  and  s])reads  from  patient  to  patient. 

A  remarkaiMi'  idio])athic,  non-s])ecific  ])arotitis  may  follow  injury  or 
disease  of  the  abdominal  or  ])elvic  organs  (see  Diseases  of  the  Salivary 
Glands). 

Symptoms. — The  ]ieriod  of  incubation  is  from  two  to  three  Aveeks, 
and  there  are  rarely  any  symptoms  during  this  stage.  The  invasion  is 
marked  by  fever,  which  is  usually  slight,  rarely  rising  ahove  101°,  hut  in 
e.\ce])tionally  severe  cases  going  u])  to  103°  or  104°.  The  child  com])lains 
of  ])ain  just  below  the  ear  on  one  side.  Here  a  slight  swelling  is  noticed, 
which  incrc  js  gradually,  until,  within  forty-eight  hours,  there  is  great 
enlargement  of  the  neck  and  side  of  the  cheek.  The  SAvclling  passes  for- 
Avard  in  front  of  the  ear,  and  back  beneath  the  sterno-cleido  muscle.  The 
other  side  usually  hecomcs  atfected  within  a  day  or  two.  The  other  sali- 
vary glands  are  rarely  involved.  The  greatest  inconvenience  is  experi- 
enced in  taking  food,  for  the  patient  is  unable  to  open  the  mouth,  and 
even  sjieech  and  deglutition  become  difticult.  There  may  he  an  increase 
in  the  secretion  of  the  saliva,  hut  the  reverse  is  sometimes  the  case.  There 
is  seldom  great  pain,  hut,  instead,  an  unjdeasant  feeling  of  tension  and 
tightness.  There  may  he  earache,  even  otitis  media,  and  slight  impairment 
of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually 


El'IDEMIC   PAltOTITIS. 


91 


preat 


I 


i 


subsides  and  tlic  child  ra|ti(ll\  ropiiiis  his  strength  and  health.  lJela[ise 
rarely  ii'  ever  occurs. 

Occasionally  the  disease  is  very  severe  and  characterized  l)y  high  lever, 
delirium,  and  great  prostration.  The  patient  may  even  la[)so  into  a  typhoid 
condition. 

Oirliilis. —  Kxcessively  rare  before  ])id)erty,  W  develops  usually  as  the 
parotitis  subsides,  or  indeed  a  week  or  ten  days  later.  Oni'  or  both  testicles 
may  be  involved.  The  swelling  may  be  great,  and  occasionally  elVusioii 
takes  place  into  the  tuinca  vaginalis,  'i'he  orchitis  may  develop  before 
the  jmrotitis,  or  in  rare  instances  may  be  the  oidy  manil'estatio-i  of  the 
infection  {(iniillis  ixirolidvtt).  The  inllammalion  increases  b)r  three  or  four 
days,  and  resolution  takes  place  gradually.  There  may  be  a  muco-purulent 
discharge  from  the  urethra.  In  severe  eases  atrophy  may  follow,  foi'tunately 
as  a  rule  only  in  one  organ:  occui'ring  in  both  before  puberty  the  natural 
development  is  usually  checked.  lOven  when  both  testicles  are  atrophied 
and  small,  se.xnal  vigor  may  be  retained.  The  proportion  of  eases  of  orchitis 
varies  in  dilTi'rent  epidemics;  "1 1  cases  oeeurred  in  (i!)!)  cases,  and  lOo  case.s 
of  ati'ophy  b)ll()wed   l(i;)  instances  of  orchitis  (Condiy). 

A  vulvo-vaginitis  sometimes  occurs  iu  gii'ls,  and  the  breasts  may  be- 
come eidarged  and  teuder.  ^lastitis  has  been  seen  in  l)oys.  Involvement 
of  the  ovaries  is  rare. 

Complications  and  Sequelae. — Of  these  the  cerebral  affections 
are  perhaps  the  most  serious.  As  already  mentioned,  there;  uuiy  be  de- 
lirium and  high  fever.  In  rare  instances  uuMiiugitis  has  bei'U  found. 
Hemiplegia  aiul  conui  uuiy  also  occur.  xV  majority  of  the  fatal  cases  aro 
associated  with  meningeal  symptoms.  These,  of  course,  are  very  rare  in- 
comparison  with  the  frequency  of  tlie  disease;  yet,  in  the  Index  Catalogue, 
under  this  caption,  thei'e  are  six  fatal  eases  mentioned.  In  some  epi- 
demics the  cerebral  com])lications  are  much  more  nuirked  than  in  others. 
Acute  mania  has  occurred,  and  there  are  instances  on  record  of  insanity 
following  the  disease. 

Arthritis,  albuminuria,  even  acute  uraemia  Avith  convulsions,  endocar- 
ditis, facial  ])aralysis,  hemi])legia,  and  jieripheral  neuritis  are  occasioiuil 
complications. 

Su])]uiration  of  the  gland  is  an  extrc'uudy  rare  complication  in  genuine 
idiopathic  mum])s.  Gangrene  has  occasionally  occurred.  '^Phe  special 
senses  may  be  seriously  involved.  ]\lauy  cases  of  deafness  have  been  de- 
scribed in  connection  with  or  following  mumps.  It,  unfortunately,  may 
be  permanent.  AfTections  of  the  eye  are  rare,  but  atrophy  of  the  optic 
nerve  has  been  described.     The  lachrymal  glands  may  be  involved. 

T»ela])se  may  occur,  even  two  or  three,  and  chronic  hypertrophy  of  the 
gland  may  follow. 

The  diagnosis  of  the  disease  is  usually  (>asy.  The  ]>osition  of  the 
swelling  in  front  of  and  below  the  car  ami  the  elevati(ui  of  th(>  lol)e  on  the 
affected  side  definitely  fix  the  locality  of  the  swelling.  In  children  in- 
flanimation  of  the  jiarotid.  apart  from  ordinai'y  mum|)s,  is  excessively  rare. 

Treatment. — It  is  well  to  keeii  the  ]iaticnt  in  bed  during  the  height 
01  the  disease.    The  bowels  should  be  freely  opened,  and  (he  patient  given 


02 


SPECIFIC  INFECTIOUS  DISEASES. 


a  li<^lit  li(|iii(l  (lic't  No  iHcdiciiR'  is  nMniircd  unless  tlio  feviT  is  lii^li,  in 
uliicli  Ciisi'  acoiiiti'  may  he  ^iven.  Cold  compresses  may  he  phiced  on  liio 
gland,  hut  children,  i\s  n  rnle,  i)rt'l"t'r  hot  upijlications.  A  |iad  of  cotton 
Mad(]ing  oovered  with  oiled  silk  is  the  hest  application.  Suppuration  it» 
hardly  ever  to  ])e  dreaded,  even  thon<::h  the  <:land  hecome  very  tense.  Shoidd 
redne.^s  and  tenderness  dcveloi),  leeches  may  '.'  used.  With  delirium  and 
head  .symi)toms  the  ice-cap  may  ho  applied.  In  a  rohust  suhject,  unless 
the  signs  of  constitutional  depression  arc  extreme,  a  free  venesection  may 
do  good.  For  the  orchitis,  rest,  with  support  and  protection  of  the  swollen 
gland  with  cotton-wool,  is  usually  sullicient.  * 


XI.  WHOOPING  COUGH. 

Definition. — A  specific  affection  characterized  by  convulsive  cough 
and  a  long-drawn  insjiiration,  during  which  the  "  whoop"  is  produced. 

Etiology. — The  disease  occurs  in  epidemic  form,  hut  s])oradic  cases 
apjjcar  in  a  conimunity  from  time  to  time.  It  is  directly  contagious  from 
])erson  to  person;  l)ut  dwelling-rooms,  houses,  school-rooms,  and  other 
h)calities  may  be  infected  by  a  sick  cliild.  It  is,  however,  in  this  way  less 
infectious  than  other  diseases,  and  is  probably  most  often  taken  by  direct 
contact.  Ko])lik,  ('za])lewski,  and  Ilensel  I'ave  described  a  bacillus  in  the 
sputum,  which  may  ])robably  be  the  specific  organism.  The  ])acilli  are  pres- 
ent in  the  mucous  clumj)s,  with  other  forms  as  a  rule,  l)ut  they  can  be  sepa- 
rated by  proper  means.  Ko])lik  found  them  in  13  of  16  cases  of  wliooi)ing- 
cough.  It  is  a  small  bacillus  with  rounded  ends,  a  little  larger  than  the 
influenzj  bacillus.  It  is  a  facultative  anaerobe,  and  is  pathogenic  for  mice. 
There  are  still  doubtful  points  regarding  the  organism.  Epidemics  prevail 
for  two  or  three  months,  usually  during  the  winter  and  spring,  and  have 
a  curious  relation  to  other  diseases,  often  preceding  or  following  epidemics 
of  measles,  less  frequentl}  of  scarlet  fever. 

Children  between  the  first  and  second  dentitions  are  commonly  affected. 
Sucklings  are,  however,  not  exem])t,  and  I  have  seen  very  severe  attacks 
in  infants  under  six  weeks.  It  is  stated  that  girls  are  more  subject  to  the 
disease  than  boys.  Adults  and  old  peojde  are  sometimes  attacked,  and  in 
the  aged  it  may  be  a  very  serious  aflPection.  ]\fany  persons  possess  immu- 
nity against  the  disease,  and,  though  frequently  cx]ioscd,  escape.  As  a 
rule,  one  attack  protects.  Delicate  anfimic  children  with  nasal  or  bron- 
chial catarrh  are  more  subject  to  the  disease  than  others.  According  to 
the  Ignited  States  Census  Reports,  the  disease  is  more  than  twice  as  fatal 
in  the  negro  race  than  in  others. 

Morbid  Anatomy. — Whooping-cough  itself  has  no  special  patho- 
logical changes.  In  fatal  cases  pulmonary  complications,  particularly 
broncho-pneumonia,  are  usually  present.  Collapse  and  compensatory  em- 
physema, vesicular  and  intersti^""!,  are  found,  and  the  tracheal  and  bron- 
chial glands  are  enlarged. 

Symptoms. — Catarrhal  and  paroxysmal  stages  can  1)6  recognized. 
There  is  a  variable  period  of  incubation  of  from  seven  to  ten  days.     In 


wuooi»iN(i-couaii. 


1)3 


iho  rnlavrhdJ  sfnr/r  tlio  cliild  lins  the  s}'ni])t()iii?'  of  nn  ordinary  cold,  wliicli 
may  \n"/\u  witli  sli^lit  tVvcr,  riiiiiiinj;'  at  the  iiosc,  injection  of  llie  oyi's, 
and  ii  hi'oMcliial  coiijiii,  usually  ilry,  and  soinL'tinics  ^ivin^^  indications  of  a 
sjiasniodic  charai'tcr.  'JMio  fever  is  usually  not  lii^li,  and  sli;^dit  attention 
is  paid  to  the  syniptoins,  which  are  tliou<fht  to  be  those  of  a  simple  catarrh. 
After  lastiiif^  for  a  week  or  ten  days,  instead  of  subsiding,  the  con<;li  be- 
comes worse  and  more  convulsive  in  character. 

'I'he  paro.ri/siiKil  situ/e,  marked  by  the  characteristie  cough,  dates  from 
the  first  n})pearancc  of  the  "  whoop.''  The  fit  l)egins  with  a  series  of  from 
fifteen  to  twenty  short  coughs  of  increasing  intensity,  and  then  with  a 
deep  ins|)iration  the  air  is  drawn  into  the  lungs,  making  the  "  whoop," 
which  may  be  heard  at  a  distance  and  from  which  the  disease  takes  it.s 
name.  This  k)ud  insjjiratory  sound  may  sometimes  precede  the  series  of 
.'spasmodic  cx])iratory  efforts.  Several  coughing-fits  may  succeed  each  other 
until  a  tenacious  mucus  is  ejected.  This  nuiy  be  small  in  amount,  but 
after  a  series  of  coughing-fits  a  considerable  (piantity  may  be  expec- 
torated. Not  infrequently  it  is  brought  up  by  vomiting  or  by  a  combina- 
tion of  cough  and  regurgitation.  There  may  be  only  four  or  five  of  these 
attacks  in  the  day,  or  in  severe  cases  they  nuiy  recur  every  half-hour.  Dur- 
ing the  i)aroxysm  the  thorax  is  very  strongly  compressed  by  the  powerful 
exi)iratory  efforts,  and,  as  very  little  air  passes  in  through  the  glottis,  there 
are  signs  of  defective  aeration  of  the  blood;  the  face  becomes  swollen  and 
congested,  the  veins  arc  prominent,  the  eyeballs  protriule,  and  the  con- 
junctiva' become  dee])ly  engorged.  Suffocation  iiuleed  seems  imminent, 
when  with  a  dee]),  crowing  insi)iration  air  enters  the  lungs  and  the  color 
is  quickly  restored.  Children  are  usually  terrified  at  the  onset,  and  run 
at  once  to  the  mother  or  nurse  to  be  supported  during  the  attack.  Few 
diseases  are  more  ])ainful  to  witness.  In  severe  ])aroxysms  vomiting  is 
frequent  and  the  sphincters  may  be  ojiened.  The  urine  is  said  to  be  of 
high  specifi  -  gravity  (1022-1032),  pale  yellow,  and  to  contain  much  uric 
acid. 

An  ulcer  nnder  the  tongue  is  a  very  common  event,  and  was  thought 
at  one  time  to  be  the  canse  of  the  disease. 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective 
in  the  ex]uratory  stage,  full  and  clear  during  the  deej),  crowing  inspiration; 
but  on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur 
heard,  owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glot- 
tis.   r)ronchial  r.^iles  are  occasionally  heard. 

Among  circumstances  which  ])recipitate  a  paroxysm  are  emotion,  such 
as  crying,  and  any  irritation  about  the  throat.  Even  the  act  of  swallowing 
sometimes  seems  suflficicnt.  In  a  close  dusty  atmosphere  the  coughing- 
fits  are  more  frequent.  After  lasting  for  three  or  four  weeks  the  attacks 
become  lighter  and  finally  cease.  In  cases  of  ordinary  severity  the  course 
of  the  disease  is  rarely  under  six  weeks. 

The  conijdications  and  sequelre  of  whooping-cough  are  important.  Dur- 
ing the  extensive  '  onous  congestion  haemorrhages  are  very  a])t  to  occur 
in  the  form  of  petechijT',  particularly  about  *'  ('  forehead,  ecchymosis  of 
the   conjunctivne,   epistaxis,   and    occasionally    iuvmoptysis.      ITiBmorrhagc 


y-A 


SPECIFIC   INFECTIOUS  DISEASES. 


from  tilt!  bowels  ih  nirc.  Convulsions  iwo  ?iot  very  iinfotnmon,  (hie  porlinps 
to  till'  cxtri'iiic  ('nji()i';.;ciii('iit  of  the  ctTi'liriil  cortex.  \'ery  rarely  lieiiii|»le^iii 
or  iiioiio|»le;,Mii  I'dllows.  Sudden  deatli  lias  been  caused  Ity  extensive  suh- 
(liiial  liiciiiorrlni^ie.  \\'liooiiin<j-c()n<fli  iiiiist  lie  regarded  as  a  \('vy  iiiiiisiiul 
cause  of  ci'rehral  palsy  in  children.  It  was  associated  with  .'5  <d'  uiy  series 
of  Iv'O  cases,  hut  in  none  of  them  did  the  liemipleiiia  come  on  diirin^f  the 
paroxysm,  as  in  a  case  reported  by  S.  West,  ilernhardt  has  described  an 
acutely  developing'  spastic  paraple«,da. 

Tho  persistent  vomitin<,f  may  induce  marked  anaMiiia  and  wastin;,'.  The 
j)ulmonary  com|ilications  which  follow  whoopinii-cou,u;h  are  extremely  seri- 
ous. l)uriii«;'  the  sevei'i'  couj^hin<;-spells  interstitial  emphysema  may  \w 
induced,  more  rarely  ])iu'Uinotliorax.  I  saw  one  instance  in  which  rupture 
occurred,  evidently  lU'ar  the  root  of  the  Innjjf,  and  the  air  passed  alon^'  (he 
trachea  and  reaclietl  the  subcutaneous  tissues  of  the  ueck,  a  (;ondition 
which  has  been  known  to  become  jfcneral.  Uronclio-piU'umonia,  with  its 
accompanying'  collapse,  is  the  most  fre(pient  pulmonary  complication  and 
carries  olt'  a  lar^^e  luiniber  of  children.  It  may  be  simple,  but  in  a  c(ui- 
siderable  pro[)ortion  of  the  cases  the  ]>rocess  is  tuberculous,  i'leurisy  is 
^ioiuetinu's  met  with  and  occasionally  lobar  ])neumonia.  Knlar^-ement  of 
the  bronchial  <;lands  is  very  common  in  wlioopin,i,''-con^h  and  has  been 
thought  to  cause  the  disease.  It  may  scunt'tinies  be  sullicient  to  pi'oduce 
dnlne,«s  over  tho  numnbrium.  l)urin<;  the  spasm  the  radial  \n\he  is  small, 
the  right  heart  engorged,  and  during  and  after  the  attack  the  cardiac  action 
is  very  much  disturbed.  Sci'ious  damage  may  result,  and  possibly  some 
of  the  cases  of  severe  valvidar  disease  in  children  who  luive  had  neither 
rheumatism  nor  scarlet  fever  may  be  attributed  to  the  terrible  heart  strain 
during  a  ])rolonged  attack  of  whooping-cough.  Koi)lik  regards  the  swi'lling 
about  the  face  and  eyes  as  an  important  sign  of  the  heart  strain.  Serious 
renal  complications  are  very  uncommon,  hut  albumin  not  infre(pu'ntly 
and  sugar  occasionally  is  found  in  the  urine.  An  unusually  marked  leuco- 
cytosis  a])pcars  early,  chiefly  of  the  lyni])hocytes  (ikninier). 

Diagnosis. — So  distinctive  is  the  "whoop"  of  the  disease  that  tho 
diagnosis  is  very  easy;  hut  occasionally  there  are  doubtful  cases,  jjarticu- 
larly  during  epidemics,  in  which  a  series  of  expiratory  coughs  occurs  with- 
out any  inspiratory  crow. 

Prognosis. — Taken  with  its  complications,  whooping-cough  must  he 
regarded  as  a  very  fatal  alTection.  According  to  Dolan,  it  ranks  third 
among  the  fatal  diseases  of  children  in  Juigland,  where  the  death-rate  per 
1,000,000  fiom  this  disease  is  5,000  annually.  The  younger  the  infant 
the  greater  is  the  prol)al)ility  of  serious  complications.  The  deaths  are 
chiefly  among  children  of  the  poor  and  ainong  delicate  infants. 

Treatment. — Barents  should  be  Avarned  of  the  serious  nature  of 
whooping-cough,  the  gravity  of  which  is  scarcely  appreciated  by  the  ]iuh- 
lic.  Particular  care  should  he  taken  that  children  suspected  of  the  disease 
are  not  sent  to  the  ])ul)lic  schools  or  ex]iosed  in  any  way  so  tluit  other  chil- 
dren can  hecome  contaminat(Hl.  There  is  more  reprehensihle  neglect  in 
connection  with  this  tlian  with  any  other  disease.  The  patient  should  ho 
isolated,  and  if  the  paroxysms  are  at  all  severe,  at  rest  in  bed.     Fresh  air, 


INFLUENZA. 


95 


niulit  find  fliiy,  is  n  most  csscnliiil  I'lfiiictit  in  tlio  trcntiiicnt  of  tlio  disciisc. 
'riio  iiicdiciiiiil  trciitiiiciit  of  wlinopin^r-coii^^h  is  most  iiiisntisfactorv.  In 
th(!  ciitnrriud  slii^rc  when  tiicrc  is  fever  (lie  cliild  siioidd  he  in  hed  and  ii 
Sidine  fever  mixture  iidnniiislei-ed.  If  tlie  coiioji  is  distrossinjr,  ipec  lu  iiiinliii 
wine  and  |)are<;orie  may  l)e  ^iiveii.  I^'or  tlie  paroxysnud  sla^'e  u  suspiciously 
ionji;  list  (){'  remedies  lias  been  reediiiineiided,  twenty-two  in  one  popular 
text-hook  on  llierapeiities.  if  the  disease  is  (\[\v,  as  seems  prol)al)le,  to  a 
f^erin  ^M'owiiin-  upon  and  irri(atin<,'  the  hronchial  iiiueo,-.a,  a  jierniieidal  plan 
of  treatment  seems  jii<,dily  rational,  and  persistent  attempts  should  he  maile 
to  discover  a  suitahle  remedy.  (^)uiiiiiie  is  one  of  the  hest  dru,<rs.  Oiu; 
sixth  of  a  orain  may  he  ^jiveii  three  times  a  day  for  each  mouth  of  a.uo, 
and  U  .ui'ain  for  each  year  in  clii'dreii  'iiider  li\('  years.  Hesorciii 
in  a  l-pci'-ceiit  solution,  swahhe<l  fi'cipieiitly  on  the  tlii'oal;  ".'  or  ;{  <;'raiiis 
of  iodoform  to  an  ounce  of  starch  powder;  a  sprav  of  carholic  acid 
— have  all  hei'u  warmly  recommended.  ,1.  Lewis  Smith  advises  the  use  of 
the  steam  atomizer  with  a  solution  of  carholic  acid,  chlorate  of  potassium, 
and  hroniide  of  potassium  in  glycerin,  llroinofoi'iii.  in  doses  of  1  to  5 
minims  suspended  in  syrup,  lias  heeu  warmly  recoiiiuieiided  of  late.  Jacoiii 
rcf^ards  hclladoiina  as  the  most  satisfactory  remedy.  He  ^ives  it  in  full 
doses,  as  much  as  one  sixth  of  a  iiraiit  of  the  exti'act  to  a  child  of  six  or 
eijiiit  months  three  times  a  day.  It  should  he  uiveii  in  siinicient  <ioses  to 
])i'oduce  the  cutaneous  Hush.  l'"or  the  nervous  elemciit  in  the  disease  aiiti- 
])yrin  has  heeu  used  with  apparent  success. 

After  the  sevei'ity  of  the  attack  has  passed  ami  couvalesceuce  has 
lje<,nin,  the  child  should  lie  watched  with  tlie  frreatest  care.  It  is  just  at 
this  period  that  the  fatal  hi'onclio-pncumoiiias  are  apt  to  develop.  Tin? 
cough  sometimes  persists  for  months  and  the  child  remains  weak  and  deli- 
cate. Chancre  of  air  should  1)(>  tried.  Such  a  patient  should  be  fed  with 
care,  and  given  tonics  and  cod-liver  oil. 


XII.    INFLUENZA  (/.«  (/ripp,'). 

Definition. — A  ])andemic  disease,  appearing  at  irregular  iiitervrds, 
characterized  hy  extraordinary  rajiidity  of  extension  and  the  large  niimher 
of  peo])le  attacked.  Following  the  jiandemic  there  a-e,  as  a  rule,  for  sev- 
eral years  endemic  or  epidemic  outbreaks  in  dilTerent  regions.  Clinically, 
the  disease  has  ]-»rotean  as]iects,  but  with  a  special  tendency  to  attack  the 
respiratory  mucous  membranes. 

History. — (!reat  pandemics  have  beeii  recognized  since  th(>  sixteenth 
century.  There  have  been  four  with  th-'ir  sncceeding  e])idemics  during 
the  present  century— is;')()-';i:5,  18:](;-";5r,  1847-MS.  and  ]SS!)-!)().  The 
last  pandemic  began,  as  others  had  done  before,  in  some  of  the  distant  pi'ov- 
inces  of  Russia  (hence  th(>  name  Russian  fever)  in  October,  ami  by  the 
beginning  of  Xoveniber  it  had  reached  'Moscow,  \\y  the  middle  of  Xovcin- 
ber  Berlin  was  attacked.  V>y  the  middle  of  I)ecember  it  was  in  London, 
and  hy  the  end  of  the  month  it  had  invaded  Xew  York,  and  was  widely 
distributed  over  the  entire  continent.  Within  a  year  it  had  visited  nearly 
all  parts  of  the  earth. 


**p— ■■ 


96 


SI'KCIFIC  l\l'M<:(TI()rS   DISKASKS. 


The  (hirntioii  of  nii  ciii'lcitiic  in  iiiiy  niic  locality  is  Trom  si\  to  ci^^'lil 
vccks.  With  I  lie  i-xct'iilioii,  pcrhnps,  of  (Icii^Mic,  tlicrc  is  no  disease  wliicli 
allarks  iiKliscriiiiinati'ly  so  lai';;'i'  a  proportion  of  tlio  inhal)itiints.  l-'or- 
Innalcly,  as  in  (Icnj^nic,  llic  rati'  of  mortality  is  very  l<»\v,  l»nt  the  last  cpi- 
dcniii'  taii^clit  lis  to  ivco^Miizc  in  inlhicn/.a,  particularly  its  sctpicls  and  coni- 
jdii-ations,  one  of  the  nioKt  scrioUH  of  all  spccilii'  diseases.  'I'lie  opportunity 
for  studying;  tlio  disease  in  the  last  epideiiue  has  thrown  much  lij,dit  upon 
many  proi)lenis.  Anion<^  the  most  notahle  product  ions  were  the  work  of 
I'feill'cr  in  discoverinj,'  the  spi-eillc  ^'crni,  the  elal)orate  Uerlin  report  hy  von 
Leyden  and  Senator,  and  tlu  Locid  ({overnnient  Moard's  report  hy  Parsons, 
licichtenstern's  artielo  in  Nolhiiaijers  JIandhuch  is  the  most  masterly  and 
systematic  consideration  of  the  disease  in  (he  literature. 

Etiology.— -What  relation  has  the  epidemie  influenza  to  the  ordinary 
inlluenza  cold  or  catarrhal  fever  (commonly  also  called  the  (jrijiiic),  which 
is  constantly  present  in  the  community!''  Leichtenstern  answers  this  (jues- 
tion  Ity  makin<;  the  following'  divisions:  (1)  Kpideinie  in/liicina  vera,  caused 
hy  ri'eitl'er's  hacillus;  {'2)  endemic-epidemic  iii/liicn-ji  vera,  which  often 
devi'lops  for  several  years  in  succession  after  a  pandemic,  also  causi'd  hy  the 
same  hacillus;  (',\)  endenuc  iiifhiiina  nostras,  pseudi^-inlluenza  or  catarrhal 
fi'ver,  coinnioidy  called  tlic  tjrippe,  which  is  a  spocinl  disease,  still  of  un- 
kiu)wn  etiology,  and  which  hears  the  same  relation  to  the  true  inlluenza  as 
choh'ra  nostras  does  to  Asiatic  cholera. 

The  epidemics  which  followed  the  groat  |)andeniic  of  ISSO-'OO  during 
the  years  1891  to  1895  varied  in  intensity  and  extent  in  ditlVrent  localities. 

The  disease  is  highly  contagious;  it  spreads  with  reniarkahle  rapidity, 
which,  however,  is  not  greater  than  modern  methods  of  conveyance.  In 
the  great  jiandemic  of  188!)-'IH)  sonu'  of  the  large  ])risons  escaju'd  entirely. 
The  outhreak  of  e])idemics  is  indei)endent  of  all  seasonal  and  meteorological 
conditions,  though  the  worst  have  heen  in  the  colder  seasons  of  the  year. 
One  attack  does  not  necessarily  protect  from  a  sidjsequent  one.  A  few 
persons  a]i])cnr  not  to  he  liahle  to  the  disease. 

Bacteriology. — In  1892  PfeiU'er  isolated  a  bacillus  from  the  nasal 
and  bronchial  secretions,  which  is  recognized  as  the  cause  of  t'le  disease. 
It  is  a  small,  non-motile  organism,  which  stains  well  in  LoeiTler's  methylene 
blue,  or  in  a  dilute,  ]iale-rcd  solution  of  carbol-fuchsin  in  water.  On  cul- 
ture media  it  grows  only  in  the  ]>rcsence  of  hannogloljin.  The  bacilli  are 
present  in  enormons  numbers  in  the  nasal  and  bronchial  secretions  of 
]\'^itients,  in  the  latter  almost  in  pnre  cultures.  They  persist  often  after 
the  severe  symptoms  have  subsided. 

The  much-discussed  question  whether  during  the  presence  of  an  e])i- 
demic  human  influenza  attacks  animals  must  be  answered  in  the  negative. 
In  great  pandemics  of  influenza  the  general  rule  holds  good  that  other 
diseases  do  not  prevail  to  the  same  extent.  Anders  has  brought  forward 
statistics  to  indicate  that  the  outbreaks  of  malaria  are  very  much  dimin- 
islu'd  during  the  ]U"evalence  of  influenza. 

Symptoms. — The  incubation  period  is  "from  one  to  four  days;  often- 
e?t  three  to  four  days."  The  onset  is  usually  abrupt,  with  fever  and  its 
associated  phenomena. 


INFLUKNZA. 


V>7 


Types  of  the  Disease. — The  imiiiifcstaliniis  arc  ho  cxtrnonliiiarily 

r()iii|ilc\  llint  il  is  Itcsi  tu  dt'scrilK'  tlicm  iimlcr  Ivpt's  ul'  the   liscasf. 

1.  livsjiifohini. — 'I'lic  iiiiicoiis  iiifiiiliniiic  ol'  tlic  respiratory  trad  frum 
tilt'  iiosc  to  lln'  air-cells  of  the  Imij^s  may  he  re^ninU'M  as  tlie  seal  of  eleelioii 
of  the  iiilliieiiza  Itacilli.  In  the  simple  forms  the  disease  sets  in  with  eoryza, 
and  presents  the  features  of  an  aente  catarrhal  fever,  with  perhaps  rather 
more  prostration  and  dehility  than  is  nsnal.  in  other  cases  the  catarrhal 
symptoms  persist,  hronehitis  ilevclops,  the  fever  conlinnes,  there  is  de- 
lirium and  much  prostration,  and  the  pict.ire  nuiy  even  l)e  that  of  severe 
typhoid.  The  ^M'aver  resjiiratory  conditions  are  hronehitis,  plcnri.-y,  and 
pnenmonia.  The  hronehitis  has  really  no  special  peculiarities.  Tile  sputum 
is  supposed  hy  many  to  he  rlistinctive.  Sometimes  it  is  in  extraordinary 
amounts,  very  thin,  and  containing,'  purulent.  nuisscH.  I'feiU'er  re^oirds 
s|)ntum  of  a  ^ncenish-yellow  color  and  in  coin-like  lumps  as  almost  char- 
acteristic of  iidliienza.  in  other  cases  there  nuiy  he  a  dark  red,  hloody 
sputum.  One  of  the  most  distrcssinj,'  setinels  of  the  iidluenza  hronehitis 
is  diU'use  hronchiectasis,  of  which  1  have  seen  at  least  one  instanei!.  It 
occasionally  happens  that  the  hronehitis  is  of  ^M'cat  intensity  and  reached 
the  liner  tuhes,  so  thai  the  patient  heconies  cyanoscd  (»r  even  asphyxiated. 

Inllucn/u  piuMimonia  is  one  of  the  most  serious  nuinifestations,  and  nuiy 
de])end  upon  IM'cilVer's  hacillus  itself,  or  is  the  result  of  a  niixe(|  infection. 
The  true  inlluenza  ])n(Mimonia  is  most  commonly  lohiilar  or  catarrhal,  les.s 
often  croupous.  Much  of  Ww.  mortality  of  the  disease  depends  upon  the 
fatal  character  of  this  complication.  The  clinical  course  of  the  cases  is 
ol'leii  irre<j;ular  and  the  syniptoms  are  ohscuro  or  masked. 

Inlluenza  jjloiirisy  is  more  rare,  hut  cases  of  primary  involvement  of  the 
pleura  arc  reported.  It  is  very  apt  to  lead  to  empyema.  I'ulnionary 
tuherculosis  is  usually  much  aj^jfravated  hy  an  attack  of  inlluenza. 

2.  Xcrvous  Form. — Without  any  catarrhal  syniptoms  there  may  be 
severe  headache,  ])ain  in  the  back  and  joints,  with  profound  prostration, 
^lany  remarkable  nervous  manifestations  were  noted  during  the  last  epi- 
demic. Amonjij  the  more  serious  may  be  mentioned  nienini,ntis  and  en- 
cephalitis, the  latter  leading  to  hemiplegia  or  monoplegia.  Abscess  of  the 
brain  lias  followed  in  acute  cases.  All  forms  of  neuritis  are  not  uncom- 
mon, and  in  some  cases  are  characterized  by  marked  disturl)ance  of  motion 
and  sensation.  Judging  from  the  acconnts  in  the  literature,  almost  every 
form  of  disease  of  the  nervous  system  may  follow  inlluenza. 

To  involvement  of  the  nerves  may  be  ascribed  some  of  the  commo.i 
cardiac  symjitoms,  such  as  ])ersistent  irregularity,  tachycardia  or  brady- 
cardia, and  attacks  of  angina  pectoris.  Among  the  most  important  of  the 
nervons  seqnelae  are  depression  of  spirits,  melancholia,  and  in  some  cases 
dementia. 

3.  Gastro-infesfinal  Form. — "With  the  onset  of  the  fever  there  may  be 
nansea  and  vomiting,  or  the  attack  may  set  in  with  abdominal  pain,  profuse 
diarrhoea,  and  collapse.  In  some  epidemics  jaundice  has  been  a  common 
symptom.  In  a  considerable  number  of  the  cases  there  is  enlargement  of 
the  spleen,  dej^ending  chiefly  u]ion  the  intensity  of  the  fever. 

4.  Febrile  Form. — The  fever  in  influenza  is  very  variable,  but  it  is 


^1 


08 


SI'KCII'K"   INI'KCTIors   DISK  ASKS. 


iiii|iortiii)t  to  r(<('i)H;Mi/*>  tlnit  it  tuny  Ih'  tli*'  mily  iiiiinircstiitinn  of  tlio  dis- 
(•ii>c.  It  is  soiiirtiiiirs  iiuii'krilly  I't'iii i t ti'iit ,  wiili  I'iiilis;  or  in  riir<>  (■iih(>h 
llicn'  is  II  iirolniclcd.  ((iiitiiiiii'd  lever  of  Hovorul  wtrks  diiratioii,  wliiili 
(-iiiiidiitt's  ty|ilioid  closely. 

W'llilt'  tlli'sc  lire  |terliii|is  tlie  most  eomilioll  fofllis  with  their  eoiiiplieil- 
tiolis,  t'jelH'  ill't'  iimiiy  otiiel's,  iiliioii;;  which  iiiiiy  he  iiieiit  ioiied  the  I'ollow- 
iii;r:  N'lirioijs  reiud  nlVectioiis  have  lieeii  noted,  (i.  |{iinin,::iirten  hits  culled 
lltletitiot)  to  the  lCe(|ll('ney  of  ne|tlicitis  in  the  I'ecent  e|)idelilie.  Ol'iJiitls 
has  iteeii  iilso  seen.  I'lndocardilis  and  pericarditis,  |)hlehilis  and  throinhosis 
of  the  variiMis  vessels  are  reported.  Herpes  is  conniioii.  A  dilVnse  erythema 
soinet  iiin's' occurs,  occasionally  purpura.  Catarrhal  con  jniict  ivitis  is  a  i'rc- 
(pieiit  event.  Iritis,  and  in  line  instances  (tptic  neuritis.  Iia\e  heeii  met 
with,  .\ciite  otitis  incdia  was  a  <'omiiion  ('(Miiplicalion.  I  lia\e  seen  severe 
and  persistent  verti;:o  follow  inlliieii/a,  proli'dily  fi'oin  iinoheineiit  of  the 
laliyriiith. 

Since  llie  late  severe  epidemics  it  has  heeii  the  fashion  lo  date  various 
ailnieiils  or  chronic  ill-licalth  fioiii  inllnenza.  In  many  cases  this  is  cor- 
rect. It  is  astonishing,'  the  iilimher  of  people  who  have  hecii  crippled  in 
heallli   for  years  after  an  attack. 

Diagnosis.  —  Dnrin^f  a  pandemic  the  cases  oll'er  hut  sli;:hl  ditriciilty. 
'The  profoundness  of  the  prost  riition.  out  of  all  proportion  to  the  intensity 
of  the  diseasi'.  is  one  of  the  most  characteristic  featiiivs.  the  respiratory 

foi'iii  the  diagnosis  may  he  maile  hy  the  hacterio|o,L;ical  examination  of  the 
sputum,  a  procedure  which  should  he  resorted  to  early  in  a  suspected  epi- 
demic. The  ditlVreiiliation  (d'  the  various  forms  has  ln'cii  already  sulli- 
cielitly  considered. 

Treatment. — Isohition  should  he  practised  when  possil)le.  and  old 
people  should  he  u'lii'^ed  a<zainst  all  possihle  sources  of  infection.  The 
secretions,  nasal  and  hrou'hial,  .-hould  he  thoronnidy  disinfeetiMl.  In  evei'y 
case  the  disease  should  he  rejfiirded  as  serious,  and  the  patient  should  he 
confined  to  bed  until  the  fever  lias  completely  disa])peared.  In  this  way 
alone  can  serious  complications  l)e  avoided.  From  the  (uitset  the  treatment 
should  he  support in<r,  and  the  patietd  should  be  carefully  fed  and  well 
nurpod.  'J'he  I.owels  sliould  be  openeil  by  a  dose  of  calomel  or  u  saline 
draiifilit.  At  niffi.*-  10  jjrrains  of  Dover's  ])ow(ler  may  be  ;;iven.  At  the 
onset  a  warm  bath  is  sometimes  prraleful  in  relieving,''  the  pain  in  the  back 
and  limbs,  but  <:reat  care  should  be  taken  to  have  the  bi'd  well  wanned, 
aiul  th(>  patient  should  be  fi'iven  after  it  a  drink  of  hot  lemonade.  If  the 
fever  is  hi,L;h  and  there  is  delirium,  small  doses  of  antipyrin  may  be  oiven 
and  an  ice-eap  applied  to  the  head.  The  medicinal  antipyretics  slionld  be 
used  Avith  caution,  as  ]irofound  prostration  sometimes  develops  in  these 
cases.  Too  mnch  stress  should  not  be  hiid  upon  the  mental  features.  De- 
lirium may  lie  marked  even  with  sliuht  fever.  Tn  the  cases  with  ;^reat  car- 
diac weakness  stimnlants  should  be  oiven  freely,  and  dm'ini:'  convalescence 
strychnia  in  full  doses. 

TUo  intense  bronchitis,  pneumonia,  and  other  complications  slionld 
receive  their  appropriate  treatment.  The  convalescence  re(]nires  careful 
management,  and  it  may  he  weeks  or  months  before  the  patient  is  restored 


th 


DKNdUE. 


UD 


to  full  liciilth.  A  j.'n(M|  milrilioiis  diet,  cliiin^rc  of  iiir,  an. I  |>I('iisiiiil  Hiir- 
riiiiii(liii;.fs  arc  csscnlial.  Tlic  «lr|in'ssioii  n\'  sjiirits  Inllnwiii^  llii-  discasu 
).•«  (till*  of  its  must  iin|il«'asaiit  aii*l  <il)>tiiial«'  iVaniri-s. 


(.1(1 
The 

CI'V 

)e 

WiiV 

ii"t 

veil 

iiu; 

1(! 

iiick 
ii('(l, 
llir 
\('ii 
»(' 
Kse 
IK- 
car- 
neo 

>ul(1 
I'lil 


XIII.  denguf:. 

Definition.-  Am  aciiti'  inlVctiinis  disease  n\'  triipieal  and  siditrojiieal 
ii';:i()ns,  eliaiactei'i/ed  liy  I'eltrile  ,  aroxvsms,  |»ains  in  the  joints  and  iiiiu- 
<'les,  an  initial  erytlietnattnis,  and  a  lerniinal  |iidyni()r|)liiins  ei-M|)tiiin. 

It  is  known  as  Inrdk-hinic  lever  I'idni  the  atrocicMis  character  of  iju'  [tain, 
and  ildiuhj  fnrr  from  the  still',  dandilied  piit.  'I'lie  word  dcn^iiie  is  >u\)- 
|i(i>ed  to  he  derived  i'roni  a  Spanish,  or  pos-ild)'  I lindoostance,  ctjidvalcnt  of 
the  word  dandy. 

History  and  Geographical  Distribution.  Tiie  disease  was  first 
recoil, i/ed  ill  \',]'.t  in  Cairo  and  in  .)a\a.  where  Hryloii  descril»e(l  tn.  -nt- 
iircak  in  liatavia.  The  description  hy  Itcnjainin  K'nsh  (d'  the  cpidennc 
in  l'liiladcl|iliia  in  1*S()  is  due  of  the  first,  and  one  of  the  very  Ix'st  ac- 
counts (d' tlie  disease,  lietwccn  l.S'.'l  and  iS'jS  it  was  prevalent  a!  intervals 
in  India  and  in  thi'  Sonthern  Stales.  S.  II.  |)icks(tM  ^dvcs  a  frrapliic  de- 
scription ol'  the  disease  as  il  appeared  in  Charleston  in  l.S'JS,  Sinct;  that 
date  there  liavc  hecii  I'onr  or  live  widespread  epidenucs  in  lro|)ical  coun- 
tries and  on  this  continent  aloni;-  the  (Jnll'  States,  the  lust  in  the  siiiiiiiier 
ol'  IS!)7.  None  (d'  the  receid  epidenucs  have  extended  into  the  .Xorthcin 
States,  hut  in   ISSS  il   prevailecl  as  I'ar  north  as  \'ir;iinia. 

Etiology.— The  rapidity  of  dill'nsion  and  the  pandemic  character  aro 
the  two  most  iniportaid  features  of  dciiji'ne.  There  is  no  disease,  not  even 
iidluenza,  which  attatdvs  so  larf^c  a  proportion  of  the  po|Hdation.  In  (ialves- 
ton,  in  ISDT.  v'O. (>()()  people  were  attacked  within  two  nionths.  It  iippears 
to  helonj,^  to  the  ^M'oiip  of  e.xanthcmatic  fevers,  and  has  their  hi^ddy  infec- 
tious characters.  A  micrococcus  has  heen  found  in  the  bloofl  of  patients  by 
]\reLau^Iilin,  (d'  Te.xas. 

As  the  disease  is  rarely  fatal,  no  oliscrvations  have  been  made  u])on  its 
patliolo.u'ical  nnatomy. 

Symptoms. — The  period  of  incubation  is  from  Ihree  to  live  days, 
durinjf  which  the  patient  b'cls  well.  The  attack  sets  in  sinhleidy  with 
headache,  chilly  feelinj>s,  and  inteiiso  aeliiiiff  pains  in  the  joints  and  mus- 
cles. 'JMie  temperature  rises  <iradually,  and  may  reach  KKi"  or  1(»T°.  The 
]tulso  is  rapid,  and  there  arc  the  other  ])henomena  associated  with  acute 
fever — loss  of  a])|)etite,  coated  tonirue,  sliirht  nocturnal  delirium,  and  con- 
centrated urine.  The  face  has  a  sulTused.  bloated  appearance,  tli(»  eyes  an; 
injected,  and  the  visible  mucous  mend)ranes  are  flushed,  '^riiere  is  a  con- 
gested, erythematous  state  of  the  skin.  IJush's  descri|)tion  of  the  jtains  is 
worth  (piotinji',  as  in  it  the  epithet  break-l)one  occurs  in  the  literature  for 
the  first  time.  "The  pains  which  accompanied  this  fever  were  exipiisitely 
severe  in  the  head,  back,  and  lind)s.  The  pains  in  the  head  were  sometinu's 
in  the  hack  parts  of  it.  and  at  other  times  they  occupied  only  the  eyeballs. 
In  some  peo]»le  the  pains  were  so  acute  in  their  backs  id  hips  that  they 
•could  not  lie  in  bed.    In  others,  the  pains  afTected  the  neck  and  arms,  so 


t 


I 


100 


SPECIFIC  INFECTIOUS  DISEASES. 


as  to  })ro(Uico  in  one  instance  a  dilliculty  of  moving  the  fingers  of  the  right 
liand.  Tlicy  all  complained  more  or  less  of  a  soreness  in  the  seats  of  these 
])iiiiis,  [)articularly  wlieii  they  occupied  the  head  and  eyehalls.  A  few  com- 
j)iaiiied  of  their  llcsh  being  sore  to  the  touch  in  every  \n\vt  of  the  body. 
From  these  circumstances  the  disease  was  sometimes  believed  to  be  a  rheu- 
anatisnijbut  its  more  general  name  among  all  classes  of  peojjle  was  the  break- 
bone  fever."  The  large  and  small  joints  are  all'ectcd,  sometimes  in  suc- 
cession, and  become  swollen,  red,  and  painful.  In  some  cases  cutaneous  hy- 
l)eriesthesia  has  been  noted.  Jhemorrhage  from  the  mucous  meml)ranes  was 
noted  by  l?ush.    Black  vomit  has  also  been  described  by  several  observers. 

The  fever  gradually  reaches  its  maximum  by  the  third  or  fourth  day; 
the  ])atient  tlu-.i  enters  njujn  the  apyretic  |)eriod,  which  may  last  from  two 
to  four  days,  and  in  which  he  feels  prostrated  and  stilt'.  A  second  paroxysm 
of  fever  then  occurs,  and  the  i)ains  return.  In  a  large  number  of  cases  an 
eruption  is  common,  which,  judging  from  the  description,  has  nothing 
distinctive,  being  sometimes  macular,  like  that  of  measles,  sometimes  dif- 
fuse and  scarlatiniform,  or  })ai)ular,  or  lichen-like.  In  other  instances  the 
rash  has  been  described  as  urticarial,  or  even  vesicidar.  Certain  writers 
describe  inflammation  and  hy])eni>mia  of  the  mucous  membrane  of  the 
nose,  mouth,  and  pharynx.  Enlargement  of  the  lymph-glands  is  not  un- 
common, and  nuiy  ])ersist  for  weeks  after  the  disap])earance  of  the  fever. 
Convalescence  is  often  protracted,  and  there  is  a  degree  of  mental  and 
physical  ] prostration  out  of  all  proportion  to  the  severity  of  the  primary 
attack.  The  pains  in  the  joints  or  muscles,  sometimes  very  local,  may  per- 
sist for  weeks.  Kush  refers  to  the  former,  stating  that  a  young  lady  after 
recovery  said  it  should  be  called  break-heart,  not  break-bone,  fever.  The 
average  duration  of  a  moderate  attack  is  from  seven  to  eight  days.  Dengue 
is  very  seldom  fatal.    Dickson  saw  three  deaths  in  the  Charleston  epidemic. 

Com])lications  are  rare.  Insomnia  and  occasionally  delirium,  resem- 
bling somewhat  the  alcoholic  form,  have  been  observed,  and  convulsions 
in  children.    A  relapse  may  occur  even  as  late  as  two  weeks. 

The  diagnosis  of  the  disease,  prevailing  as  it  does  in  epidemic  form 
and  attacking  all  classes  indiscriminately,  rarely  offers  any  special  difficulty. 
Isolated  cases  might  be  mistaken  at  first  for  acute  rheumatism.  The  im- 
portant question  of  the  differentiation  between  yellow  fever  and  dengue 
will  be  considered  later. 

Treatment. — This  is  entirely  symptomatic.  Quinine  is  stated  to  be 
a  prophylactic,  but  on  insufficient  grounds.  Hydrotherapy  may  be  em- 
ployed to  reduce  the  fever.  The  salicylates  or  antipyrin  may  be  tried  for 
the  pains,  which  usually,  however,  require  opium.  During  convalescence 
iodide  of  potassium  is  recommended  for  the  arthritic  pains,  and  tonics  are 
indicated. 

XIV.  CEREBRO-SPINAL    MENINGITIS. 

Definition. — A  specific  infectious  disease,  occurring  sporadically  and 
in  epidemics,  caused  by  the  diplococcus  intracellularis,  characterized  by 
inflammation  of  the  cerebro-spinal  meninges  and  a  clinical  course  of  great 
irregularity. 


CEREBRO-SPINAL  MENINGITIS. 


101 


Migiie 


Migiie 


;o  be 
em- 
'd  for 
eence 
}s  are 


and 
d  hy 
sreat 


i 


The  affection  is  also  known  )>}•  the  names  of  malignant  })ur[)ui'ic  fever, 
petechial  fever,  and  spotted  fever. 

History. — Vieussenx  iir.st  described  a  small  outbreak  in  (Jeneva  in 
1805.  In  180(j  L.  Danielson  and  E.  ;Mann  (^ledical  and  Agricultural 
Register,  IJoston)  gave  an  account  of  "a  singi'^-u-  and  very  mortal  disease 
which  lately  made  its  ap[)earance  in  Medford,  Mass.'" 

The  disease  attracted  much  attention  and  was  the  subject  of  several 
very  careful  studies.  The  Massachusetts  ;^[edical  Society,  in  I  SOU,  ap- 
])ointed  James  Jackson,  Thomas  Welch,  and  J.  C.  Warren  to  investigate  it. 
Klisha  North's  little  book  (IHll)  gives  a  full  account  of  the  early  epi- 
demics. Stille's  monograj)]!  (18(57)  and  the  elaborate  section  in  vol.  i  of 
Joseph  Jones'  works  contain  details  of  the  later  American  outbreaks.  The 
liistory  of  the  disease  in  Eurojje  and  elsewhere  is  to  be  found  in  Ilirsch's 
Geographical  Pathology,  and  a  detailed  statement  of  the  epidemics  in  the 
United  Kingdom  is  given  as  an  ai)pendix  by  Ormerod  in  his  article  in  All- 
butt's  System.  Ilirscli  divides  the  outbreaks  into  four  periods:  From  1805 
to  1830,  in  which  the  disease  was  most  prevalent  tliroughout  the  United 
States;  a  second  i)eriod,  from  1837  to  1850,  when  the  disease  prevailed  ex- 
tensively in  France,  and  there  were  a  few  outbreaks  in  the  United  States; 
a  third  period,  from  1854  to  1874,  when  there  were  outbreaks  in  Europe 
and  several  extensive  e})idemics  in  this  coimtry.  During  the  civil  war 
there  were  com])aratively  few  cases  of  the  disease.  It  prevailed  extensively 
in  the  Ottawa  A^alley  early  in  the  seventies.  In  the  fourth  period,  from 
1875  to  the  jjrescnt  time,  the  disease  has  broken  out  in  a  great  many 
regions.  There  was  a  serious  epidemic  in  western  ]\Iary]and  in  1892  and  in 
Xew  York  in  1893.  From  the  spring  of  189G  to  the  date  of  writing,  April, 
1898,  the  disease  has  prevailed  in  Boston  and  the  neighboring  towns,  and 
lias  been  made  the  sul)ject  of  careful  study  by  Councilman,  ]\Iallory,  and 
Wright,  whose  monograph,  issued  by  the  Massachusetts  State  l^oard  of 
Health,  is  the  most  important  contribution  made  in  this  country  to  the 
pathology  of  epidemic  meningitis. 

Etiology. — Cerebro-s]iinal  meningitis  presents  several  remarkable 
peculiarities.  The  outbreaks  are  localized,  occurring  in  certain  regions, 
and  are  rarely  very  widespread.  As  a  rule,  country  districts  have  been 
more  afflicted  than  cities.  The  epidemics  have  occurred  most  frequently  in 
the  winter  and  spring.  The  concentration  of  individuals,  as  of  troo])s  in 
large  barracks,  seems  to  be  a  special  factor,  and  epidemics  on  the  Conti- 
nent show  how  liable  recruits  and  young  soldiers  are  to  the  disease.  In 
civil  life  children  and  young  adults  are  most  susceptible.  Over-exertion, 
long  marches  in  the  heat,  de]>ressing  mental  and  bodily  surroundings,  and 
the  misery  and  squalor  of  the  large  tenement  houses  in  cities  are  predis- 
posing causes.  The  disease  seems  not  to  be  directly  contagious,  and  is 
probably  not  transmitted  by  clothing  or  the  excretions.  It  is  very  rare 
to  have  more  than  one  or  two  cases  in  a  house,  and  in  a  city  epidemic  the 
distribution  of  the  cases  is  very  irregular.  Councilman  has  found  five  in- 
stances in  which  the  same  individual  is  reported  to  have  had  the  disease 
twdce. 

Sporadic  cases  occur  from  time  to  time  in  the  larger  cities  and  country 


102 


SPECIFIC  INFECTIOUS  DISEASES. 


districts  on  tiiis  roiitint'iit.  Al'lcr  liic  (ir.st  t'|ti(k'niic  in  Montreal  in  1873 
oi'casional  instances  occmitcmI.  In  l'liiia(lci[»liia,  since  its  appearatice  in 
l.si;;!,  there  liave  been  casi'S  re[>orte(l  every  year  in  tlie  nioi'taiity  hills. 
Without  autopsy  the  diagnosis  ui'  jnany  oi'  these  is  extrejni'iy  doubtlul;  i»ut 
tiuTo  can  be  no  (lueslion  tiuit  tlie  disease,  tiion^h  rare,  still  lin<rers.  Jud^^- 
in;X  I'roMi  my  own  e.\|iei'ience  in  three  of  the  hospitals  of  thai  city,  in 
Avhich  in  live  years  I  saw  oidy  three  instances,  I  woidd  I'e^ard  it  as  very 
much  less  l're(|uent  than  the  reports  of  the  Health  OHice  would  seem  to  in- 
dicate. 

It  is;:rt'atly  to  be  desired  that  observers  herearter  pay  very  special  atten- 
tion to  thesi'  cases,  particularly  to  the  bacteriolo<,ncal  study,  in  order  to 
determine  the  character  oi'  the  excitinti:  orjianism. 

Bacteriology.  —  In  1S8T  Weichselbaum  described  an  organism,  the 
J)ljil(irnrrits  iiilnicclhihtris  ineiiiiKjilidis,  which  was  probably  the  same  as 
one  pi't'viously  I'ouiid  by  Leichtenstern.  In  the  tissues  the  or^-anism  is 
almost  constantly  within  the  polynuclear  leucocytes.  In  cultures  it  has 
wt'll-charactt'i'ized  features,  and  is  distinguishable  from  tlu'  pneuniococcus. 
SiiU'c  \\'eicliselbaum"s  observations  this  is  the  or<ianism  which  has  usually 
bei'U  met  with  in  the  carefully  studied  epidenucs  of  the  disease,  particu- 
larly by  .lii<ier.  In  the  recent  IJoston  outbreak,  in  35  of  the  cases  on  which 
])ost-niortem  examinations  were  made,  the  diplococci  were  demonstrated  in 
all  but  4,  in  one  of  which  they  had  jtreviously  been  found  in  lluid  withdravi'n 
by  s])inal  puncture.  The  other  3  cases  Mere  chronic.  Cultures  may  fail  to 
i^ive  the  organism  even  when  abundantly  jjresent,  as  shown  on  cover-slii)s. 
in  T  cases  the  ])neumocot-cus  was  found  in  connection  with  the  di])lococ- 
cus  intracellularis,  and  t)nce  i-'riedliinder"s  bacillus.  Lnnd)ar  puncture  was 
performed  in  55  eases,  in  38  of  which  diplococci  were  found. 

Morbid  Anatomy.  —  in  malignant  cases  thei-e  may  he  no  characteris- 
tic changes,  the  brain  and  spinal  cord  showing  only  extreme  congestion, 
which  was  the  lesion  described  by  Vieusseux.  In  a  majority  of  the  acutely 
fatal  cases  death  occurs  within  the  first  week.  There  is  intense  injection  of 
the  )iia-arachnoi(l.  The  exudate  is  usnally  fil)rino-])nrulent,  most  nuirked  at 
the  base  of  the  brain,  where  the  meninges  may  be  greatly  thickened  and 
])lastered  over  with  it.  On  the  cortex  there  may  be  much  lym|)h  along 
the  larger  fissures  and  in  llu'  sulci;  sometimes  the  entire  cortex  is  covered 
witli  a  thick,  ])urulent  exu(hite.  It  deserves  to  be  recorded  that  l^anielson 
and  ^iann  made  five  auto])sies  and  were  the  first  to  describe  "a  lluid  resem- 
bling ])us  between  the  dura  and  pia  mater."  The  cord  is  always  involved 
Avith  the  brain.  The  exudate  is  nu)re  abundant  on  the  posterior  surface, 
and  involves,  as  a  ride,  the  dorsal  and  lumbar  regions  more  than  the  cervical 
portion. 

In  the  more  chronic  cases  there  is  general  thickening  of  the  meninges 
and  scattered  yellow  ]iatches  mark  where  the  exudate  has  been.  The  ven- 
tricles in  the  acute  cases  are  dilated  and  contain  a  turbid  fluid,  or  in  the 
jiosterior  cornua  pnre  pus.  In  the  chronic  cases  the  dilatation  may  be  very 
great.  The  brain  substance  is  usually  a  little  softer  than  normal  and  has 
a  ])inkish  tinge;  foci  of  luvinorrhage  and  of  encephalitis  may  be  found. 
The  cranial  nerA^es  are  usually  involved,  particularly  the  second,  fifth,  sev- 


CEREBRO-SPIXAL  MENINGITIS. 


103 


l.icc, 
•vical 

inges 
Ycn- 

Ihe 
very 

has 
lund. 

sev- 


enth, and  ci^lilli.     Tlic  spinal  nerve  roots  are  also  round  iiid)eddeJ  in  the 
exudate. 

.Mientseopicidlv,  the  exudate  eonsists  largely  of  |iolynuelear  leiieoeytc!* 
elosely  packed  in  a  lihrinous  material.  Klexiier  and  liaiker  deserihe  larger 
eells,  t'l'oni  two  to  eight  times  the  diameter  of  a  K'ueoeyte.  The  lesions  in 
the  tissue  of  the  hrain  anil  cord,  aeeording  to  Councilman,  are  more  marked 
in  this  than  in  other  I'orms.  They  consist  chielly  in  infiltration  of  the 
tissue  with  ])us  cells,  which  extend  downward  in  the  perivascular  spaces,  lii 
some  instances  there  are  foci  oi'  ])urulent  iniiltration   and   ha'inorrhage. 


f|M 


lie  lU'uroglia  cells  are  swollen,  witli  large,  clear,  and  vesicular  nui'lei. 
The  ganglion  cells  show  less  marked  changes.  Diplococci  are  found  in 
varialtle  iniudiers  in  the  exudate,  heing  more  numerous  in  the  hrain  than  in 
the  cord. 

Liesions  in  Other  Parts. — In  one  of  the  Boston  cases,  examination 
of  the  nasal  secretion  during  life  showed  di|)lococci,  and  in  this  instance 
there  \vas  found  ])ost  mortem  a  ])urulent  iniiltration  of  the  mucous  niem- 
hrane.     In  two  other  cases  this  mend)rane  was  normal. 

Luiifis. —  I'lu'umonia  and  ])leurisy  luive  been  desci'ihed  in  the  disease. 
Councilman  reports  that  in  the  recent  epidemic  in  13  cases  there  v/as  con- 
gestion with  (edema,  in  7  hroncho-pneumonia,  in  2  ciniracteristic  croupous 
pneumonia  with  pneumococci;  in  iS  j)neumonia  due  to  the  (li|)lococ'CUs  intra- 
cellnlaris  was  |iresent. 

Spleen. — The  organ  varies  a  good  deal  in  size.  In  only  three  of  the 
I'oston  fatal  cases  was  it  found  much  enlarged.  '^Fhe  liver  is  rarely  al)normal. 
Acute  iiri)lirili>i  is  sometimes  present.  The  intestines  show  sometimes  swell- 
ing of  the  follicles,  hut  this  was  not  present  in  any  of  the  IJoston  cases. 

Symptoms. — Cases  dill'er  remarkably  in  their  characters.  Many  dif- 
ferent fcjrms  have  l)een  described.  These  are  perhaps  best  grouped  into 
three  classes: 

1.  Malignant  Form. — This  fuhninant  or  apoplectic  tyi)e  is  found  with 
variable  frecpicncy  in  e[)idenucs.  It  may  occur  s|)oradically.  The  onset 
is  sudden,  usually  with  violent  chills,  headache,  somnolence,  spasms  in  the 
muscles,  great  (h'pression.  moderate  elevation  of  tem])erature,  and  feeble 
l)ulse,  which  may  fall  to  fifty  or  sixty  in  the  minute.  Csually  a  jinrpnric 
rash  develops.  In  a  l'hiladeli)hia  case,  in  1888,  a  young  girl,  api)arently 
qiute  well,  died  within  twenty  hours  of  this  foi'in.  There  are  casi's  on 
record  in  which  death  has  occurred  within  a  shorter  time.  Stille  tells  of 
a  child  of  five  years,  in  whom  death  occurred  after  an  illness  of  ten  hours; 
and  refers  to  a  case  reported  by  Cordon,  in  which  the  entire  dui'ation  of 
the  illness  Avas  only  live  hours.  Two  of  Vieusseux's  cases  died  within 
twenty-four  hours. 

2.  Ordinary  Form. — The  stage  of  incubation  is  not  known.  The  dis- 
ease usually  sets  in  suddenly.  There  may  be  premonitory  symptoms: 
headache,  ]iains  in  the  back,  and  loss  of  ap])etite.  ^lorc  commonly,  the 
onset  is  with  headache,  severe  chill,  and  vomiting.  The  temperature  rises 
to  101°  or  10'^°.  The  pulse  is  full  and  strong.  An  early  and  important 
sym])tom  is  a  painful  stiffness  of  the  muscles  of  the  neck.  The  headache 
increases,  and  there  are  photo])hobia   and   great   sensitiveness   to   noises. 

7 


5v 


104 


SPECIFIC  INFECTIOUS  DISEASES. 


(.'liiklrt'ii  bucunie  very  irritaMo  and  iTstk'ss.  In  sovcro  cases  the  contrac- 
tion ol*  the  nuisck'S  oi"  the  neck  sets  in  early,  the  head  is  drawn  l)ack,  and, 
wlien  the  nuisck's  of  the  hack  are  also  involved,  there  is  orthotouos,  which 
is  more  coninion  than  ojtistliotonos.  The  pains  in  the  back  and  in  the 
limbs  may  be  very  severe.  The  motor  syni|)tonis  are  most  characteristic 
Tremor  of  the  muscles  may  be  present,  with  t(jnic  or  clonic  spasms  in  the 
arms  or  legs.  Jiigidity  oi"  the  muscles  oi"  lii.e  l)ack  or  neck  is  very  com- 
mon, and  the  i)atient  lies  with  the  body  stilt"  and  the  head  drawn  so  far 
back  that  the  occii)ut  nuiy  be  between  the  shoulder-blades.  Excei)t  in 
early  childhood  convulsions  are  not  common.  Strabismus  is  a  frequent 
and  important  symptom.  Spasm  of  the  muscles  of  the  face  may  also 
occur.  Cases  have  been  described  in  which  the  general  rigidity  and  still"- 
ness  was  such  that  the  body  could  be  moved  like  a  statue.  Paralysis  of 
the  trunk  muscles  is  rare,  but  paralysis  of  the  muscles  of  the  eye  and  the 
face  is  not  uncommon. 

Of  sensory  symptoms,  headache  is  the  most  dominant  and  persists  from 
the  outset.  It  is  chicHy  in  the  back  of  the  head,  and  the  ])ain  extends 
into  the  neck  and  back.  There  may  be  great  sensitiveness  along  the  spine, 
and  in  many  cases  there  is  marked  hypera?sthcsia. 

The  psychical  symptoms  are  pronounced.  Delirium  occurs  at  the  onset, 
occasionally  of  a  furious  and  maniacal  kind.  The  patient  may  display  at 
the  start  marked  erotic  sym])toms.  The  delirium  gives  place  in  a  few  days 
to  stupor,  which,  as  the  ell'usion  increases,  dee])ens  to  coma. 

The  temperature  is  irregular  and  variable.  Ilemissions  occur  frequently, 
and  there  is  no  uniform  or  typical  curve  during  the  disease.  In  some  in- 
stances there  has  been  little  or  no  fevjr.  In  others  the  temperature  may 
reach  105°  or  10G°,  or,  before  death,  108°.  The  pulse  may  be  very  rapid 
in  children;  in  adults  it  is  at  first  usually  full  and  strong.  In  some  cases 
it  is  remarkaldy  slow,  and  may  not  be  more  than  fifty  or  sixty  in  the  minute. 
Sighing  respirations  and  Cheyne-Stokes  breathing  are  met  with  in  some 
instances.  Unless  there  is  pneumonia  the  respirations  are  not  often  in- 
creased in  frequency. 

The  cutaneous  symptoms  of  the  disease  are  important.  Herpes  occurs 
with  even  greater  frequency  than  in  pneumonia  or  in  intermittent  fever. 
The  petechial  rash,  which  has  given  the  name  spotted  fever  to  the  dis- 
ease, is  very  variable.  Stille  states  that  of  98  cases  in  the  Philadel- 
phia Hospital,  no  eru])tion  was  observed  in  37.  In  the  INlontreal 
cases  petechife  and  purple  spots  Mere  common.  They  appear  to  have  been 
more  frequent  in  the  epidemic*  on  this  continent  than  in  Europe.  The 
]ietcchia^  may  be  numerous  and  cover  the  entire  skin.  An  erythema  or 
dusky  mottling  may  be  present.  In  some  instances  there  have  l)een  rose- 
colored  hyiierannic  spots  like  the  typhoid  rash.  Urticaria  or  erythema  no- 
dosum, ecthyma,  pemphigus,  and  in  rare  instances  gangrene  of  the  skin 
have  been  noted. 

There  is  a  leucocytosis,  a  point  which  may  help  in  the  diagnosis  from 
typhoid  fever.  In  the  recent  Boston  epidemic  blood  counts  were  made  in 
33  cases.  The  highest  number  of  leucocytes  in  any  one  was  31,000.  The 
increase  is  chiefly  in  the  polynuclear  variety. 


luv 


CERKBRO-SPIXAL   JFENINGITIS. 


lo: 


hila 
lont 


Iciiia  or 


As  alrciidy  .^tilted,  vomiting'  may  bo  u  special  IVaUire  at  tlio  onset;  but, 
as  a  ruli',  it  ^n'adiially  siiljsides.  In  sonio  instances,  liowovcr,  it  i)ersists 
and  becoiiies  the  most  serious  and  distressiii<^  ol'  the  syni|)toins.  JJiarrluea 
is  not  coiiunou.  The  bowels  are  usually  conliued.  The  abdomen  is  not 
tender.     In  the  acute  i'oi'ui  the  spleen  is  usually  enlar«i:ed. 

The  urine  is  sometimes  albumim)us  and  the  (pumtity  may  be  iiici'easi'd. 
Glycosuria  has  been  noted  in  some  instances,  and  in  the  niali«inant  types 
luvinatufia. 

The  course  of  the  disease  is  extrenudy  variable.  Ilirsch  ri<ihtly  states 
that  it  may  ran^a'  between  a  lew  hours  and  several  months.  .More  than 
hair  of  the  deaths  occur  within  the  first  five  days.  In  favorable  cases, 
after  the  syiuptoms  have  persisted  for  five  or  six  days,  imi)rovenient  is  in- 
dicated by  a  lessenintr  of  tlie  s])asni,  reduction  of  the  fever,  and  a  return 
of  the  intelli<ience.  A  sudden  fall  in  the  temperature  is  of  bad  omen.  Con- 
valescence is  extremely  tedious,  and  may  be  interrupted  by  complications 
and  secjuelie  to  be  noted. 

3.  Anomalous  Forms. 

(a)  AhiirUre  Type. — The  attack  sets  in  with  great  severity,  but  in  a 
day  or  two  the  symi)toms  sul)side  and  convalescence  is  rapid.  Striimpell 
would  distinguish  between  this  abortive  variety,  which  begins  with  sutdi 
intensity,  and  the  mild  andnilant  cases  described  by  certain  writers.  He 
reports  a  case  in  which  the  nuuiingeal  symptoms  set  in  with  the  greatest 
intensity  and  persisted  for  four  days,  the  temperature  rising  to  4U.i)°  C 
On  the  fifth  day  the  patient  entered  upon  a  rapid  and  satisfactory  con- 
valescence. In  the  mild  cases,  as  distinguished  from  the  abortive,  the  pa- 
tients complain  of  headache,  nausea,  sensations  of  discomfort  in  the  back 
and  lindjs,  and  stilTness  in  the  neck.  There  is  little  or  no  fever,  and  only 
moderate  vouuting.  These  cases  could  be  recognized  only  during  the 
prevalence  of  an  epidemic. 

{]))  All  I iilcniiillenf  Ti/pe  has  been  observed  in  many  ejiidemics,  and  is 
recognixed  by  von  Ziemsscn  and  Stillc.  It  is  characterized  by  exacerba- 
tions of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  a  curve 
of  an  intermittent  or  remittent  character.  The  pyrexia  resembles  that  of 
pyajmia  rather  than  malaria. 

(c)  Chronic  Form. — Ileubner  states  tliat  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recognized  by  many  writers  on  the 
subject.  An  attack  may  be  protracted  for  from  two  to  five  or  even  six 
months,  and  nmy  cause  the  most  intense  marasmus.  It  is  characterized  by 
a  series  of  recurrences  of  the  fever,  and  may  present  the  most  complex 
symptonmtnlogy.  It  is  not  improbable  that  tliese  jirotracted  cases  depend 
upon  chronic  hydroce])lialns  or  abscesses  of  the  brain.  This  form  differs 
distinctly  from  the  intermittent  type.  A  very  remarkalde  instance  of  it  is 
described  by  "Worthington,  in  which  the  disease  lasted  for  fourteen  weeks. 
Complications. — Pleurisy,  pericarditis,  and  ])arotitis  are  not  un- 
ecfmmon. 

Pneumonia  is  described  as  frequent  in  certain  outbreaks.  Immermann 
found,  during  the  Erlangen  epidemic,  many  instances  of  the  combination 
of  pneumonia  with  meningitis,  but  it  does  not  seem  possible  to  determine 


1(»6 


SIM'X'IFIC   INFECTIOUS   DISKASES. 


uIictlitT,  in  siicli  cases,  |)iu'iimi)iiiii  is  the  priiiiiii'V  disciisc  iiiid  (lie  mcniiiifitis 
H'cdiidiiry,  or  rice  irrsa.  'J'iu'  rr('{|iicnc_v  willi  wliicli  iiilliiiiiiiinlion  ol'  tlie 
mcniiiffcs  of  the  hi'aiii  coiiiiilicalcs  |iiiciiiii((iiia  is  well  known,  ('ouiicil- 
nmn  su<i:<,''('sls  tinit  llic  pncnnionia  ol'  tlii'  disc^asc  Is  not  the  true  cronpons 
lorni,  Init  due  to  tlii'  diplococciis  ni('nin<iilidis.  'I'liis  was  I'oiind  in  ci^lit 
of  the  lioslon  casi's,  and  in  one  it  was  so  extensive  tinit  it  eonld  liavi'  i)cen 
mistaken  I'or  the  oidinary  eronpous  pneninonia.  Arthritis  lias  heen  tiie 
most  ri('((ueid  coniplicalion  in  ceitain  epideniies.  ^lany  joints  are  all'ected 
simultaneously,  and  there  are  s\vellinj,%  pain,  and  exudation,  sonietinies 
serous,  sonietimes  purulent.  This  was  iii'st  observed  by  .lames  Jackson,  Sr., 
in  the  epidciuic  which  he  di'scrihed.     Enteritis  is  rare. 

lieadache  may  persist  ior  months  or  years  after  an  attack.  Chronic 
liydroce])halus  (le\'eloi)8  in  certain  instances  iu  children.  'Die  symptoms 
ol'  this  are  "  paroxysms  of  severe  headache,  pains  in  the  neck  and  I'xtremi- 
ties, vomitin<:,  loss  of  consciousness,  convulsions,  and  involuntai'y  discharges 
of  fji'ces  and  urine  "  (von  Ziemsscn).  \'on  Ziemssen  re<;ards  chronic  hydro- 
cephalus as  liy  no  means  a  rare  seqnela.  Mental  feebleness  and  aphasia 
have  occasionally  been  noted. 

J'araly-is  f)f  individual  cranial  nerves  or  of  the  lower  extremities  may 
])ersist  for  some  time.  Jn  some  of  these  cases  there  may  be  i)eripheral 
]icuiilis,  as  ^lills  sufrf^csted. 

Special  Senses. — l'']ir. — These  arc  due  to  three  causes:  First,  neuritis 
following'  involvement  of  the  nerve  in  the  exudation  at  the  base.  This  may 
alfect  the  third  nerve  or  the  o|)tic  nerves,  leading  to  acute  ])apillitis,  which 
Avas  found  in  (i  out  of  10  cases  examined  by  Randolph.  Secondly,  the 
inllammation  may  extend  directly  into  the  eye  along  the  ])ia-arachnoid  of 
the  optic  nerve,  causing  purulent  choroido-iritis  or  even  keratitis.  Thirdly, 
a  neuritis  of  tlie  fifth  nerve  may  be  followed  by  keratitis  and  ])uruleut 
conjunctivitis. 

luir. —  Deafness  very  often  follows  indamniation  of  the  labyrinth.  Otitis 
media,  with  mastoiditis,  may  develo])  from  direct  extension.  In  (i-t  cases 
of  meningitis  which  recovered,  ^Moos  found  that  .jo  per  cent  were  deaf.  JFe 
suggests  that  the  abortive  form  of  the  disease  may  be  responsible  for  many 
cases  of  early  acipiircd  deafness.  In  children  this  not  infrequently  leads 
to  deaf-mutism.  A'on  Ziems.scn  states  that  in  the  deaf  and  dumb  institutions 
of  I>and)erg  and  Xuremberg,  in  LSv  I,  a  majority  of  the  ])U])ils  had  become 
deaf  from  e])i(lemic  cerebro-s])inal  meningitis. 

Nnse. — Coryza  is  not  infrc(|uent  early  in  the  disease,  and  Striimpell  says 
that  in  many  of  his  cases  nasal  catarrh  preceded  the  meningitis.  He  sug- 
gests that  the  latter  may  be  caused  by  infection  from  the  nose.  Certainly 
the  nasal  secretion  ajjpears  frecpiently  to  contain  the  diplococci — in  IS  cases 
examined  by  Scherrcr,  and  in  10  out  of  15  of  the  ]3oston  cases. 

Diagnosis. — Is  cerebro-spinal  meningitis  i)resent?  This  is  not  always 
easy  to  answer.  Tn  certain  n)anifestations  typhoid  fever,  typhus  fever,  and 
])n('umonia  closely  simulate  cerebro-spinal  meningitis.  I  am  (piite  certain 
that  many  cases  re])ortcd  to  the  health  boards  as  the  last-named  disease 
belong  to  the  cerebral  form  of  typhoid  fever  or  ])neumonia.  Such  cases 
present  high  fever,  delirium,  I'etraction  of  the  neck,  tremor,  and  rigidity 


c'i:in:Hi{u-si'i\Aii  mknincjitis. 


107 


Old  of 

lirdly, 

iruk'iit 

Olitirf 

cases 

f.    He 

iiiiiny 

leads 

\itions 

x'come 

'11  says 
[('  siij;-- 
lainly 
S  cases 

always 
er,  and 
certain 
disease 
h  cases 
ri.cidity 


of  the  iimsclcs,  and  a  cerlain  dia<j;nosis  may  only  lie  made  at  auto|>sy. 
Stokes'  statenii'nt,  that  "there  is  no  sin;.de  nervous  syin|itoni  wliicli  may 
not  and  does  imt  oecnr  independently  of  any  appreeiahle  lesion  ol'  the  hrain, 
nerves  or  spinal  cord,"  can  not  he  too  (d'ten  icpeated.  I  have  already  re- 
I'eiTed  to  the  i'aet  that  the  inalignaiit  I'orm  of  sniall-pox  may  l)e  mistaki'ii 
for  eei'ehi'o-spinal  meningitis. 

'I'he  second  ([nest  ion.  Is  the  disease  cerebi'o-spinal  fever?  is  iisnally  easy 
to  answer  when  an  epidemic  is  prevailing,',  as  the  prat-l  ilioner  then  soon 
learns  to  reeo;;'nizc  the  ditl'erent  types  of  which  I  have  spoken.  'I'he  chief 
diiru'idty  is  in  diU'erent  iat  in^'  sporadic  eases  i>\'  fer<'l)ro->pinaI  lever  lidni 
other  forms  of  menin^'itis.  Thi'  matlei'  is  of  inip<iilance  ehielly  wilh  refer- 
ence to  the  pi'oLinosis,  which  is  so  much  more  favoralile  in  cereln'o-spinal 
fever.  Neither  the  tnlierculons  nor  the  streptococcus  forms  olVer.  as  a  rule, 
special  diniculties.  "^I'lie  p  eumococcus  meninizitis  may  occur  alone  or  as  a 
complication  of  a  pneumo  lia.  latent  or  manifest.  Leiehtenstcrn  stales  that 
"in  mciiinnitis  followin<i  pnenmonja  contraciion  of  the  mnscK'S  of  the 
neck  is  often  ahsent,  while  in  epi<lemic  meninjiitis  it  is  almost  invariably 
|)resent.  Pnenmonia-menin<:itis  soon  leads  to  delirium  and  coma,  while 
in  the  epidenuc  foi'm  the  seiisorium  may  he  normal  thi'oULihout  the  entire 
conrse.  J'neunionia-meninji'itis,  moreover,  is  rapidly  fatal,  while  the  e])i- 
denuc  form  is  freiiuently  recovered  from."  Councilman  concludes  that  the 
diiference  hetween  the  clinical  history  of  pneumococeus  menin;:itis  as  com- 
])arGd  with  the  epidemic  form  is  the  ahsence  or  slight  (levelo|)ment  in  tlu; 
former  of  symptoms,  pointing  to  extensive  infection  of  the  mer)inu:es  of  the 
cord  and  of  the  roots  of  the  spinal  and  ci'anial  nerves.  I'rohahly  the  most 
reliable  method  in  dia<,mosis  is  (^luncke'.s  lund)ar  puncture,  which  is  easily 
l)erl'ormed  and  free  from  dan<i'er.  In  the  recent  IJoston  epidennc  it  was 
carried  out  in  55  cases,  and  diplococci  were  found  in  ."^S.  '^I'he  ne.srative  cases 
were  ehielly  early  in  the  outbreak.  '^Foward  the  end  of  the  epidemic  there 
were  no  ncfrative  results  when  the  spinal  ]iuncture  was  made  early,  and  tlu; 
tubes  were  inoculated  with  a  lar<ie  amount  of  )naterial.  TIk'  puncture 
should  he  nuule  1)etween  the  .second  and  third  or  the  third  and  fourth  lum- 
bar vertebi'a'  with  an  ordinary  exploratory  or  '*  antitoxine  "  needh;.  At  a 
depth  of  about  4  cm.  in  children  and  7  or  S  cm.  in  adults  the  needle  ])asses 
throu<:h  the  nu'iidn'anes,  and  the  fluid  comes  out  drop  by  drop,  it  is  not. 
as  a  rule,  necessary  to  n.sc  aspiration.  For  bacteiMolotiical  study  fnun  5  to 
10  cc.  should  pass  into  a  pei'fect'y  sterilized  test-tube,  which  should  then 
be  sto|>|)ered  M'ith  cotton.  The  I'xperience  of  !•".  II.  Williams  and  of  Went- 
worth  in  I'oston  shows  that  puncture  is  not  only  harmless,  I)ut  the  results 
are  sonu'times  ]iositively  benelicial.  Ilereaftei"  this  ))rocedure  should  be 
used  (>arly  in  all  sporadic  cases,  and  cai'cful  studies  matle  of  the  oriianisms. 

Prognosis. — llirsch  states  that  the  mortality  has  ran.ucd  in  various 
epidemics  from  ?0  to  75  ])er  cent.  In  children  the  death-rate  is  much 
hiuher  than  in  adults.  Cases  with  deep  coma,  repeated  convulsions,  and 
hi<,di  fev(>r  rarely  recover.  The  outlook  in  the  protracted  cases  is  not  ,c:ood, 
thouph  Ilenhner  gives  an  instance  of  a  lad  of  seven,  who  was  ill  from  the 
end  of  February  imtil  the  end  of  June,  with  repeated  recurrences,  was 
worn  to  a  skeleton,  and  yet  completely  recovered. 


1^ 


108 


SPECIFIC  INFKCTIOUS  DISHASHS. 


Treatment. — 'I'ho  lii^li  mlo  df  mortulily  which  hiis  existed  in  most 
I'liideiiiics  iiidiciites  liic  futility  of  the  various  liicrnpculicid  ii^^i-iits  which 
huve  been  reconiniended.  When  we  consider  the  nature  of  the  local  dis- 
ease and  the  fact  that,  so  I'ar  as  we  know,  simple  or  tulx-ri'ulons  cerehro- 
sjiinnl  nienin<,dtis  is  invariably  fatal,  we  may  wonder  rather  that  recovery 
I'ullows  in  any  well-developed  case. 

In  strong  robust  patients  the  local  abstraction  of  blood  by  wet  cuj)8 
on  the  nape  of  the  neck  relieves  the  pain.  (Jeneral  bloodletting  is  rarely 
indicated.  Cold  to  the  liead  and  spine,  which  was  used  in  tlu!  first  epi- 
denucs  by  Kew  lOngland  ])hysicians,  is  of  great  service.  A  jjladder  of  ice 
to  the  head,  or  an  ice-cap,  and  the  spinal  ice-bag  may  be  continuously  em- 
ployed. The  latter  is  very  beneficial.  Judging  from  the  remarkable  effecta 
of  the  general  bath  in  tyi)hoid  with  pronounced  cercbro-spinal  symptoms, 
hydrotherapy  should  be  systematically  employed  if  the  temperature  is  above 
l(i"-i.r)°.  ]n  |)rivate  ])ractice  the  cold  })ack  or  s])onging  may  be  sul)stituted. 
If  any  counter-irritation  is  thought  necessary,  the  skin  of  the  back  of  the 
neck  may  be  lightly  touched  with  the  Paciuelin  thermocautery.  JMisters, 
which  have  been  used  so  much,  are  of  d(nd)tful  benefit.  Of  internal  reme- 
dies opium  nuiy  l)e  given  freely,  best  as  morphia  hypodermically.  Stille 
recommends  giving  a  grain  of  o])ium  every  liour  in  severe  cases  or  every 
two  hours  in  cases  of  moderate  severity;  von  Ziemssen  advises  the  hypo- 
dermic injection  of  morjihia,  from  one  third  to  one  half  grain  in  adults. 
]\Icrcury  has  no  special  inllu.nce  on  meningeal  inflammation.  Iodide  of 
l)()tassium  is  Avarndy  recommended  by  some  writers.  Quinine  in  large  doses, 
ergot,  belladonna  and  Calabar  bean  have  had  advocates.  Bromide  of  potas- 
sium may  be  cm])loyed  in  the  milder  cases,  but  it  is  not  so  useful  as  mor- 
])hia  to  control  the  spasms. 

The  diet  should  be  nutritious,  consisting  of  milk  and  strong  broths 
while  the  fever  persists.  Many  cases  are  very  difTicult  to  feed,  and  Ileubner 
recommends  forced  alimentation  with  the  stomach-tube.  The  cases  seem  to 
bear  stimulants  well,  and  Avhisky  or  brandy  may  be  civen  freely  when  there 
are  signs  of  a  failing  heart. 


XV.    LOBAR    PNEUMONIA. 

{Croupous  or  Fibrinous  Pneumonia ;  Pneumonitis ;  Lung  Fever.) 

Definition. — An  infectious  disease  characterized  by  inflammation  of 
the  lungs,  to,\a>mia  of  varying  intensity,  and  a  fever  that  terminates  ab- 
rn])tly  by  crisis.  Secondary  infective  ])rocesses  are  common.  The  micro- 
coccus lanccolatus  of  Fraenkel  is  present  in  a  large  pro])ortion  of  the  cases. 

Incidence. — Pneumonia  is  the  most  Avides])read  and  the  most  fatal 
of  all  acute  diseases.  In  the  United  States  during  the  census  year  1890 
there  died  of  it  TH.-lOfi,  a  death-rate  per  100,000  of  population  of  18G.94. 
"  ^fore  deaths  are  attributed  to  it  than  to  any  single  form  of  disease  except 
consum]ition  "  (Census  Report).  During  the  year  1897  there  died  of  pneu- 
monia in  Baltimore  044  persons.  It  came  next  on  the  list  to  pulmonary 
tuberculosis.    The  Census  Reports  of  1870,  1880,  and  1890  show  that  pneii- 


LORAIl  PNEUMONIA. 


lOU 


inonia  iis  a  cmise  of  dcatli  lias  iut'ivasi'd  hut  slightly.  ('.  F.  Folsoni  has 
hroiii^ht  forward  cvidoiuo  to  bIiow  that  in  tlio  Stuto  t»l'  Massuchutit'tta  thoro 
has  hi'cii  Im'Iwi'cu  l>>')'-i  and  1S!)4  a  iiroj^'ressivt'  incrcasL'  in  tlio  duath-rato 
IVoiii  i»iicuiii(iiiia.  'I'iic  suiiH'  is  true  for  the  city  ol'  (ihis_<f()\v.  On  tlic  other 
hand,  in  England  there  is  a  sli{,dit  diminution.  Jlospital  statistics  ishow 
that  the  ratio  of  pneumonia  to  otlicr  a(hnisi:*ioU8  is  in  the  proportion  ol'  ^U 
to  ;?()  per  1,()()0. 

Etiology. — Af/c. — To  the  sixth  year  the  predisposition  to  pneumonia 
is  marked;  ii  (Hnnnislios  to  tiio  tifteeiitii  year,  hut  then  for  cacli  sul)se(iuent 
decade  it  increases.  For  chihlreii  Jlolt's  statistics  of  oUO  cases  give:  First 
year,  1.")  per  cent;  fiom  the  second  to  the  sixth  year,  G::i  per  cent;  from  the 
seventh  to  tiie  eleventh  year,  5J1  \)er  cent;  from  the  twelfth  to  the  four- 
teenth year,  l>  per  cent.  Jiohar  ])neuni()nia  has  heen  nu't  with  in  the  lu'w- 
l)()rn.  'J'he  relation  to  age  is  well  shown  in  the  last  Census  Keport.  The 
death-rate  in  persons  from  fifteen  to  forty-five  years  was  10U.05  ])er  100,000 
of  jjopnlation;  from  forty-live  to  sixty-five  years  it  was  ::iJ()3.15i;  and  in  \k'1'- 
sons  sixty-live  years  of  age  aiul  over  it  was  733.77.  Pneumonia  may  well 
be  called  the  friend  of  the  aged.  Taken  oil'  l)y  it  in  an  acute,  short,  not 
often  painful  illness,  the  old  nuxn  escapes  those  "cold  gradations  of  decay" 
80  distressing  to  himself  and  to  his  friends. 

Sex. — Males  are  more  frccpiently  aU'ected  tluin  females.  The  Census 
Rei)ort  for  JS!)0  gives  -l"^,73;)  males  against  33,7r)7  females. 

Ji'ace. — In  this  country  ])nenmonia  is  more  fatal  in  the  colored  race  than 
among  the  whites,  the  death-rate  being  278.1)7  against  182.24. 

Social  Condition. — The  disease  is  more  conmion  in  the  cities.  The 
census  figures  give  234.07  deaths  per  100,000  of  jiopulation  for  the  cities 
against  141.0!>  for  rural  districts.  Individuals  who  are  much  exposed  to 
hardship  and  cold  are  particidarly  liable  to  the  disease.  Xew-coniers  and 
immigrants  are  stated  to  be  loss  suscejitihle  than  native  inhabitants. 

Persanal  ('undition. — Debilitating  causes  of  all  sorts  render  individuals 
more  susceptible.  Alcoholism  is  ])erhaps  the  most  ])otent  ])redisj)osing 
factor.    lJol)ust.  healthy  men  are,  however,  often  attacked. 

Previous  Mind-. — Xo  acute  disease  recurs  in  the  same  individual  with 
such  frccpu'iicy.  Instances  are  on  record  of  individuals  who  have  had  ten 
or  more  attacks.  The  ])ercentage  of  recurrences  has  been  ])laced  as  high 
as  50.  Netter  gives  it  as  31,  and  he  has  collected  the  statistics  of  eleven 
observers  who  place  the  ])ercentage  at  2fi.8.  Among  the  highest  figures  for 
recurrences  are  those  of  l?eujamin  Kush,  28,  and  Andral,  Ifi. 

Tirninia. — Occasionally  the  disease  directly  follows  an  injury,  particu- 
larly of  the  chest.  Litton,  who  has  described  those  routusion-pneuinoniiv, 
^aw  14  cases  in  the  course  of  six  3'oars.  Jiirgensen,  however,  mot  with  only 
one  case  among  7^8  pneumonia  patients.  There  can  bo  no  question  that  an 
acute  inflammation  of  the  lungs  may  follow  immediately  upon  injury  to 
the  chest  without  fracture  of  the  ribs.  Harris  has  reported  a  remarkable 
case  in  which  a  ])neumonia  of  this  kind  appears  to  have  boon  infected  from 
obsolescent  tuberculous  foci  in  the  same  lung.  Workers  in  certain  phos- 
phate factories,  where  they  breathe  a  very  dnsty  atmosphere,  according  to 
Ballard,  are  particularly  prone  to  pnenmonia. 


110 


Sl'lX'Il'lC   1NFH(TI()L'S  DISKASKS. 


('(//(/  has  hcfii  I'di' yi'iirs  rcpirdcd  us  an  iiii|t()rtaiit  etiological  ['actor.  'I'lu) 
lici|iiciit  occurrence  of  an  initial  diill  has  heen  one  reason  Tor  tliirt  vvitli'- 
fipi'cail  liclit  r.  As  to  the  cUwL' uasuc'iation  of  |iiieiiiiionia  with  ex|)(Wiire  llu're 
can  lie  no  (iiieslion.  Wo  see  tlii'  disease  occur  either  [(ronipll)'  ai'li'r  u  svet- 
tin.i;'  or  a  chilhu;;'  due  to  sonic  unusual  exposure,  or  come  on  after  an  ordi- 
nary catarrh  of  onu  or  two  (lays'  duration.  Cold  is  now  rc^iarded  simply 
a.*  a  factor  in  lowering  the;  jvsislauce  of  the  hronchial  and  i)ulinorary 
tissues. 

('Ilnidlc  (iiid  Si'dsan. — Climate  does  not  appear  to  liavo  very  much  iii- 
lluence,  as  pneumonia  |»i'evails  ('(jually  in  hot  and  cold  countries.  It  is 
stated  to  he  more  prevalent  in  the  Southern  than  in  the  Northern  States, 
hut  an  examination  of  the  last  Census  Kepurt  shows  that  tlu're  i>  very  little 
diirerence  in  tlu-  various  State  groups. 

]\luch  more  important  is  the  inllncnce  of  scasnii.  Statistics  are  unaui- 
nuuis  in  placing  the  highest  incidence  of  the  disease  in  the  winter  ami 
f.pring  months.  In  Montreal  .Innuai'V,  the  coldest  nmnth  (d'  the  year,  hut 
Ml. I.  steady  temperatui'c,  has  usually  a  comi)aratively  low  death-rale  from 
|>ncunionia.  The  large  statistics  of  Seit/,  from  Munich  and  of  Seihert  of 
New  ^'o|•k'  i:ive  the  liiizhest  percentage  in   l''ehruaiT  and  March. 

Bacteriology  of  Acute  Lobar  Pneumonia. — (a)  The  Mln-ococ- 
ciis  hiiiccdhihis,  I'licuiiKicorcus  or  Dlplococciis  /'iicniinuiin',  of  FritcnkeL — 
In  Septend)er,  ISSO,  Sti'rnherg  inoculated  rahhits  with  his  own  saliva  and 
isolated  a  nueroeoccus.  The  puhlication  was  not  made  until  Api'il  'M),  ISSI. 
I'asfeur  discovered  the  same  organism  in  the  saliva  of  a  child  dead  of  hydro- 
])h()hia  in  Deci'iuher,  hSMO,  and  the  priority  of  the  discovery  belongs  to  him, 
as  Ins  puhlication  is  dated  January  LS,  1S81.  There  was,  liowever,  no  sus- 
])i('ion  that  this  organism  was  concerned  in  tlie  etiology  of  loliar  ]menmonia, 
and  it  was  not  really  until  April,  1884,  that  A.  I'raenkel  determined  that 
the  organism  found  l)y  Sternberg  and  Pastenr  in  the  saliva,  and  known  as 
the  coccus  of  sputum  septicaMuia,  was  the  most  frequent  organism  in  acute 
])neumonia.  At  first  there  was  a  good  deal  of  confusion  l)etween  this  and 
the  organism  described  by  Friedliinder,  November,  188;'),  and  which  is  now 
known  as  the  ])neumo-bacillus.  '^Fhe  subsequent  investigations  of  Fraenkel 
and  those  of  Weichselbaum  have  demonstrated  that  in  a  very  large  pro- 
])ortion  of  all  cases  of  croui)ous  ])ni'umonia  the  diplococcus  is  ])resent. 

'^i'he  organism  is  a  somewhat  elli])tical,  lance-shaped  coccus,  usually 
occurring  in  |»airs;  hence  the  term  diplococcus.  It  is  n-adily  demon- 
strated in  cover-glass  })reparations  with  the  usual  solutions  and  by  the 
Gram  method.  About  the  organism  in  the  sputum  a  ca])sule  can  always 
be  demonstrated.  Its  cultural  and  l)iological  ])roperties  ])resei'.t  many 
variations,  for  a  consideration  of  which  the  student  is  referred  to  the  text- 
books on  bacteriology.  Scarcely  any  peculiarity  is  constant.  A  large  num- 
ber of  vnrieiies  have  been  cultiA'ated.  Its  kinshi]i  to  the  streptococcus 
pyogenes  is  regarded  by  many  as  very  close. 

Disfrilniiion  in  tlio  Bodi/. — Tn  the  bronchial  s(>cretions  and  in  the  af 
fected  lung  it  is  readily  demonstrated  in  cover-sli])s,  and  in  the  latter  in 
sections.    During  life  in  cases  of  pneumonia  the  organism  has  been  isolated 
from  the  blood  in  a  number  of  cases,  in  4  out  of  32  by  Kohn. 


LOlJAlt  PNKI'MONIA. 


Ill 


Microromis    huKrnliiliis    iimhr    ullirr    ('i)iiililiiiiis. —  In    tliis    rDiuu'cliou 


O  sus- 

IDDJil, 

that 

)\vn  as 

acute 

and 

now 
Mikol 

pro- 
it. 

uially 

'luon- 

the 

ihvays 

many 

tcxt- 
iiuin- 
•occus 


a  vt'i'y  ini|Hirt;nit   |Miint  is  the  iircscncf 


llu'  iir;:jini^ui  in   llif  niniiih  and 


linnichial   H'cri'tions    (if    iiiNiltliy    individuals — »'<>    pfi-   crnt,    accurdin;,'    lu 

persists  for  nionllis  or  cmii  tor  years  in  the  .--aliva 


xNelt 
oi'i 


er  s  oliservations. 


lersons  will)  Inivt' 


It 

had 


pneunionui. 


//(  (///((■/•  Discdsi'H. — The  or-iiinisni  is  very  widt'ly  ilistribuled,  and  i.s 
I'mind  in  many  other  eimilitions  i)(>si<los  cronpous  pneunmnia.  It  ha>  hcen 
met  uilli  in  pnre  enltiires  in  the  inilaniniatiuns  of  the  serous  mendu'anes — 
ph'iirisy,  pericarditis,  meninLiilis,  peritonitis,  acute  synovitis,  and  in  endo- 
carditis, I'tc. 

An  acute  general  infection  with  the  micrococcus  huieoolatus  without 
locan/e(|  i'oci  may  prove  rapidly  fatal,  constituting^  a  I'liriiiiutrorrits  f<rjili- 
nniild  comparai)le  to  the  typhoid  septiea'inia  already  descrihed.  'rowiisend 
has  reported  a  remarkahh;  case  of  a  <:irl  a^cd  six,  who  had  pain  in  the  ahdo- 
nien,  Miinitin^',  and  a  temperature  of  JOL'-i°.  '^^riicre  was  no  exudate  in  the 
throat,  'i'wenty-four  hours  fr(un  the  hej^innin^jj  of  the  syin|)tonis  she  had 
a  convulsion  and  dii'd  six  hours  later,  'i'hert;  was  huind  a  ;:('neral  infection 
with  the  pneumococcus,  which  occurreil  in  the  hlood,  lun^^s,  spleen,  and 
kidneys.  In  l-'lexiier's  study  of  terminal  infections  the  micrococcus  laneeo- 
latus  was  f(Uind  four  times  in  acute  peritonitis,  eleven  tinu'S  in  acute  peri- 
carditis, live  times  in  acute  endocarditis,  three  times  in  acute  pleurisy,  and 
three  tinu'S  in  acute  menin;iitis. 

OitlKide  llie  hudy  the  organism  has  been  found  in  the  dust  and  sweepings 
of  rooms. 

{h)  Thc'BaiiUus  piiriiniiniid'  of  Fru'dliimlcr. — This  is  a  larger  organism 
than  the  ])neumococcus,  and  ai"»])ears  in  the  form  of  small,  short  rods.  It 
also  shows  a  capsule,  hut  presents  marked  l)iological  and  culti.r;;!  dilfer- 
enees  from  Fraenkel's  |)neumococcus.  ]t  is  not  foumi  nearly  so  often 
in  the  lung  as  the  ])neuniocoocus.  It  occurred  in  9  of  W'eichselbaum's  I'i'J 
cases.    Its  etiological  relation  to  the  disease  is  still  in  (piestion. 


{(■)  Oilier  Ori/duisiiis. — In  a  variable  number  of  cases  of  ])neumoniu 
the  stai)hylococcus  and  the  stre[)tocoecus  pyogenes  occur,  rarely  alone,  nsu- 
ally  in  association  with  the  ])neumococcus.  '^i'he  streptococcus  |)yogenes 
may  be  the  only  organism  ]iri>sent,  ])arti<'ularly  in  children,  hut  this  type  of 
])nennu)nia  ])robal)ly  dill'ers  from  the  true  librinous  form.  Other  organisms 
iuive  been  nu't  wiili  in  pneumonia — the  bacillus  typhosus,  the  bacillus  diph- 
theria', and  the  influenza  l)acillus. 

Clinically,  the  iiifcrllovs  luilinr  of  pnenmonia  was  recognized  long  before 
yvQ  knew  anything  of  the  jineumococcus.  Among  the  features  which 
favored  this  view  were  the  following:  I'^irst,  the  disease  is  similar  to  other 
infections  in  its  mode  of  ontbreak.  It  may  occur  in  endemic  form,  local- 
ized in  certain  houses,  in  barracks,  jails,  and  schools.  As  many  as  ten 
occu]iants  of  one  bouse  have  been  attacked,  and  in  hospital  ])ractice  it  is 
not  in  frequent  to  have  2  or  3  cases  admitted  from  the  same  house.  I  have 
peen  three  mend)ers  of  a  family  consecutively  attacked  with  a  most  malig- 
nant type  of  pneumonia.  Among  the  more  remarkable  endemic  outbreaks 
is  that  reported  by  ^Y.  V>.  Eodman,  of  Frankfort,  T\y.  In  a  prison  with 
a  ])0])ulation  of  735  there  occurred  in  one  year  IIS  cases  of  pneumonia 


112 


SPKCll'IC   INFKCTIOUS   DISKASKS. 


witli  ',i!)  (Ic'iitlis.  At  tlic  |M'iiiti'iitiiiry  at  AiiiIhtj,'  (lurinj;  a  ]H'rin(l  of  llvo 
inuiitliH  tluTi;  wwii  I'il  casfH  with  ii  inortnlit y  altuvc  '^'S  iicr  cciit.  Tlic 
(lincasc  may  assiinic  ('iiidciiiic  |»ru|M)rii()iis.  In  tlu!  Mi(l(lli'sl)(»roii|:li  ciii- 
(Ifiiiic,  h(»  (iircliilly  sliiilictl  by  iJallanl,  tlicrc  were  HH'i  porHoiirt  attacked 
with  a  iimrlality  (»i'  '-.M  |)t'r  triit.  Duriiij,'  hoiiic  yi'Hr«  piu'iiinoiiia  in  ho  pivva- 
li'iit  that  it  iw  practically  paiidciiiic.  Direct  coiitaj,Mon  Ih  mi^rjicHted  liy  the 
i'act  that  a  patient  in  the  next  hcd  to  a  pneumonia  case  may  take  the  din- 
ease,  or  '^  uv  '.i  cases  may  follow  in  rapid  succession  in  a  ward.  It  Ih  very 
t'.\eepti(»nal,  however,  for  nnrsen  or  doetorn  to  hu  attacketi. 

St'condiy,  the  clinical  course  of  the  iliseane  la  that  of  an  acute  infection. 
It  is  the  very  type  of  a  self-limited  disease,  iMinninj,'  a  definite  cycle  in  a 
way  seen  only  in  infections  disordi'rs. 

Thirdly,  as  in  other  acute  infections,  the  constitntional  symptoms  may 
hear  no  jtroportion  whatever  to  the  severity  of  the  local  lesion.  As  is  well 
known,  a  patient  may  have  a  very  small  ajiex  pneumonia  which  does  not 
seriously  impair  the  hreathin^'  capacity,  hut  which  nuiy  he  accompanied 
with  the  most  intense  toxic  fiyiturcs. 

I tiiDniiiUii  (111(1  Sd-iiiii  'rhviutjtji. — The  observations  of  the  Klemperers, 
l''oa,  Washltourn,  and  others  on  the  |)rodnction  of  immunity  and  on  the 
cure  of  the  disease  arc  of  <frcat  importance.  'I'he  Klemperers  found  that 
immunity  was  readily  obtained  in  animals  either  by  subcutaneous  or  intra- 
venous injections  of  larj^'c  (piantities  of  the  filtered  bouillon  cidtures,  or 
by  the  injection  of  the  f,dycerinc  extract.  The  immunity,  tliou^di  rarely 
lasting'  more  than  six  months,  was  transmitte<l  to  the  o(Tsprin;,f  born  within 
this  |»eriod.  Still  more  interesting'  are  tli'r  observations  upon  the  cure 
of  the  experimentally  produced  disease.  They  found  that  the  serum  and 
fluids  of  the  body  of  ;in  animal  which  had  been  rendered  immune  liad  the 
pro|)erty  not  only  of  iJroducinfr  immunity  when  introduced  into  the  circu- 
lation of  another  susceptil)le  animal,  but  actually  of  curinf;  the  disease 
after  infection  had  been  in  |»ro<fress  for  some  time.  In  infected  animals 
with  a  body  temperature  of  from  40°  to  11°  (\,  the  fever  fell  to  normal 
in  twenty-four  hours  after  the  injection  of  serimi  i>om  another  animal 
■which  possessed  immunity.  They  believe  that  the  pneumococcus  ])roduces  a 
])oisonous  all)umin  (pncumotoxin)  which  when  introduced  into  the  circu- 
lation of  an  aninuil  causes  elevation  of  tem])erature  and  the  subsc(pu'nt 
])roduction  in  the  body  of  a  substanec  (antipnenmotoxin)  which  possesses 
the  ])ower  of  neutralizin<i  the  poisonous  albumin  which  is  formed  by  the 
bacteria.  Tn  man  they  hold  that  durinfi^  the  pneumonic  ])rocess  there  is  a 
constant  abs()r])tion  into  the  circulation  of  this  poisonous  albumin  ])ro- 
duced  by  the  bacteria  in  the  lun<;s.  This  continues  until  eventually  the 
same  antidotal  substance  is  produced  in  the  circulation  that  has  been  seen 
to  occur  ex))erinu'ntally.  It  is  then  that  the  crisis  occurs.  The  bacteria 
are  neither  destroyed  nor  is  their  ])ower  to  jirnduce  the  poisonous  albumin 
lessened;  but  the  third  factor,  the  antitoxic  element,  now  exists  and  neu- 
tralizes the  toxie  snbstances  as  they  are  ])roduced.  They  demonstratecT 
that  the  serum  of  the  blood  of  patients  after  the  crisis  of  ])neumonia  con- 
tained the  antitoxic  substance  and  was  capable,  in  a  fair  nnml)er  of  cases, 
of  curing  the  disease  when  injected  into  infected  animals. 


tli( 

^ri 

th 

so 

are 

bio 

a  1  v( 

tiss 

as 

wil 

cas( 

rcd( 

obf; 

tine 

hep; 

til.. 

a(l\-i 

////// 

tin  id 

of  ;•( 

and 

the 


LOhAU   PN'KrMoNIA. 


113 


livo 

'■I''- 
icki'tl 

ly  tl»o 
0  (Us- 
i  very 

'(•tion. 
e  in  a 

IS  limy 
irt  woU 
){'s  not 
i|ii\nio(l 

ipC'lTfH, 

on  tlui 

nd  that 

ir  intni- 

urcs,  of 

11  rari'ly 

\  within 

[ho  cnri' 

nni  i»n<l 

had  tho 

\(>  circu- 

(list'Jisi' 

aninialri 

)  nonnal 
nnintiil 
odiu't'S  ii 
ic  circu- 
sc(in('nt 
nospcsscs 
1  l)y  tho 
hero  is  a 
nin   ]>vo- 
ually  the 
ccn  seen 
hactc'ria 
;  alhinnin 
and  n cu- 
ll nstratc'd 
lonia  con- 

■i-  of  cases, 


Xot  niiK  li  prnpross  has  ns  yet  lu'cn  mane  in  <'slalilishin;;  a  sati-sfadory 
Hcrnni  tlitiii|i\  lor  the  (Mmusc  in  nn-n.  \Va>hl»oMrn  has  ohtaincd  hiii;t'  tjiian- 
titics  of  till'  .Ti'iini  hy  iiiiiiiiini/'in^'  )ioni<>s,  hut,  ho  I'ar  as  1  can  ascertain,  u 
trust w oil liy  iiiiti|iiiciiniococcic  Horiiin  Ik  at  pfcscnt  not  in  the  inurkot. 

Morbid  Anatomy.  Since  th(>  time  oi'  Lacnncc,  patholoMjists  havo 
rcco;;iiizcd  iliirc  sialics  ill  the  inllanicd  hiii^'-  ('n;;or^ciiicnl,  red  hepati/a- 
tion,  and  ^ray  hc|iati/,atioii. 

In  the  stii;^('  of  nKjiinji'nii'iil  liic  hin^'  tissue  is  (h'c|)  red  in  coh)r,  firmer 
to  tlic  touch,  and  iiuir*!  solid,  and  on  section  tiie  sinrace  is  liaiiied  with 
hiood  and  seriiin.  It  still  cre|iitates,  thoii^di  .tot  so  distinctly  as  healthy 
lunj;,  and  excised  [lortioiis  lloat.  The  air-cells  can  he  dilated  hy  insiillla- 
tion  lidiii  llic  lironchus.  Microscopical  examination  shows  the  lapillary 
vessels  to  he  <,neatly  distended,  the  alveolar  epithelium  swollen,  and  tho 
air-cells  occupied  liy  a  variahle  nundicr  ol'  hlood-corpiiscles  and  detached 
alveolar  cells.  In  the  stiijre  of  red  lirjidlizdliini  the  liiii;;  tissue  is  solid,  linn, 
and  airless.  If  the  entire  lohe  is  involved  it  looks  voluminous,  and  sho"s 
indentations  of  the  rihs.  On  section  tlie  surface  is  dry,  reddish  hrown  in 
color,  and  lias  lost  the  deeply  coii<,fesled  a|»pcarance  of  the  lirst  staj^'e.  One 
of  the  most  rciiiarkahle  features  is  the  friahility;  in  stiikinjf  (.'ontrast  to 
the  healthy  liiii;:,  which  is  torn  with  clilhculty,  a  hepati.  "  orpin  can  he 
readily  hrokeii  hy  the  lin^'er.  Careful  inspection  shows  that  the  surface 
is  distinctly  granular,  the  /,'raniilations  represcntiiif^  flhrinous  ))liiifs  lilliiii,' 
the  air-cells.  The  distinctness  of  this  appearance  varies  ;,M-eatly  with  the 
size  of  the  alveoli,  which  arc  iiliout  O.lO  nun.  in  diameter  in  the  infant, 
O.lo  or  O.K'  in  the  adult,  and  from  ().'?()  to  O.ti.")  in  old  nj^e.  On  scrapinfj; 
the  surface  with  a  knife  a  reihlish  viscid  serum  is  removed,  containing;  small 
^n'aniilar  masses.  The  smaller  hronchi  often  contain  fihrinoiis  jilu^^s.  If 
the  lim^f  has  hcc  •einoved  hcfore  the  heart,  it  is  not  uncommon  to  liiid 
solid  moulds  of  clot  tilling  the  hlood-vessels.  Microscopically,  tho  air-cells 
are  seen  to  he  occupied  hy  coaffulated  fihrin  in  the  meshos  of  vvhieh  are  rod 
hlood-corpiiscles,  polynuclear  leucocytes,  and  alveolar  e])itheliiim.  Tho 
alveolar  walls  are  infiltrated  and  leucocytes  are  seen  in  the  interlohiilar 
tissues.  Cover-^lass  jirepa  rat  ions  from  the  exudate,  and  thin  sections  show, 
as  a  rule,  the  diplococci  already  referred  to,  many  of  which  are  contained 
within  cells.  Staphylococci  and  streptococci  may  also  bo  seen  in  some 
cases.  Tn  the  stauc  of  f/raj/  lirpalizaHon  the  tissue  has  chanfred  from  a 
reddish-hrown  to  a  ^n-ayish-whito  color.  The  surface  is  moister,  the  exiidato 
obtained  on  pcra])in<r  is  more  turbid,  the  granules  in  the  acini  nro  less  dis- 
tinct, and  the  lung  tissue  is  still  more  friable.  Histologically,  in  gray 
h(>iiatization,  it  is  seen  that  tho  air-cells  are  densely  filled  with  leucocytes, 
the  fibrin  network  and  the  red  Itlood-corpuscles  have  disapiieared.  A  moro 
advanced  condition  (tf  gray  hc])atization  is  that  known  as  jiiinilnit 
iiipllrafion,  in  which  the  lung  tissue  is  softer  and  bathed  with  a  jiurulent 
fluid. 

The  stage  of  gray  he]>atization  ajipears  to  bo  the  first  step  in  the  process 
of  rcsi)hili()ii.  The  exudate  is  softened,  the  cell  elements  are  disintegiatod 
and  rendered  capable  of  absorption.  When  the  purulent  infiltration  of 
the  lung  tissue  reaches  the  grade  sometimes  seen  post  mortem,  it  is  prob- 


lU 


sriOCIFIC  INFECTIOUS  DISEASES. 


able  tliat  resolution  t-oiild  not  take  place.  Small  abscess  cavities  may  arise, 
and  Ity  their  fusion  lar<ier  ones.  Ol'teii  in  one  lunj^-,  or  even  in  one  lobe, 
the  various  stages  of  the  ])roeess  may  be  seen,  and  I  lie  passage  oL'  the  en- 
gorgement into  red  he[)ati/at ion  and  o[  llie  iattt'r  into  the  gray  stage  can 
be  readily  traced. 

The  general  details  of  the  morbid  anatomy  of  pneumonia  may  be 
gathered  from  the  following  facts,  based  on  JOO  auto[)sies,  made  by  me  at 
the  (u'ucral  lios[)ital,  .Montreal:  In  -VI  cases  the  right  lung  was  airocted; 
in  3".',  the  left;  in  JT,  both  organs.  In  27  cases  the  entire  lung,  Mith  the 
exception,  perhaps,  of  a  narrow  margin  at  the  apex  and  anterior  border, 
\vas  consolidated.  In  3-1  cases,  the  lower  lobe  alone  was  involved;  in  13 
cases,  the  upper  lobe  alone.  When  ch)uble,  the  lower  lobes  were  usually 
aU'ectocl  together,  but  in  three  instances  the  lower  lobe  of  one  and  tlu' 
upper  lobe  of  the  other  were  attacked.  In  three  cases  also,  both  uj)per 
lobes  were  aU'ected.  Occasionally  the  disease  involves  the  giH-ater  part  of 
both  lungs;  thus,  in  one  instance  the  li'ft  organ  with  the  exception  of  the 
anterior  border  was  uniforndy  hepatized,  while  the  right  was  in  the  stage 
of  gray  hej)atizati()n,  except  a  still  smaller  ])ortion  in  the  corresi)onding 
region.  In  a  third  of  the  cases,  red  and  gray  hepatization  existed  together, 
in  :^v'  instances  there  was  gi'ay  hej)atization.  As  a  rule  the  unalfected  por- 
tion of  the  lung  is  congested  or  tedematous.  "When  the  greater  portion  of 
a  lobe  is  attacked,  the  uninvolved  ])art  may  be  in  a  state  of  almost  gelati- 
nous u'deuia.  The  unalfected  lung  is  usually  congested,  jtarticularly  at 
the  posterior  jiart.  This,  it  must  be  renuMubered,  may  be  largely  due  to 
post-mortem  subsidence.  The  uninflamed  portions  are  not  always  con- 
gested and  (edi'matous.  I'he  upper  lobe  may  be  dry  and  bloodless  when 
the  lower  lobe  is  uniforndy  consolidated.  The  average  weight  of  a  normal 
lung  is  about  GOO  grammes,  while  that  of  an  intlamed  organ  may  be  1,500, 
2,000,  or  even  2,500  grammes. 

The  bronchi  contain,  as  a  rule,  at  the  time  of  death  a  frothy  serous 
fluid,  rarely  the  ten.icious  mucus  so  characteristic  of  pneumonic  sputiim. 
The  mucous  nuMubrane  is  usually  reddened,  rarely  swollen.  In  the  airocted 
areas  the  smaller  bronchi  often  contain  fdjrinous  plugs,  which  may  extend 
into  the  larger  tubes,  forming  perfect  casts.  The  bronchial  glands  are 
SM-ollen  and  may  even  be  soft  and  pulpy.  The  pleural  surface  of  the  in- 
tlamed lung  is  invariably  involved  w^.^n  the  process  becomes  su])erficial. 
Commonly,  there  is  only  a  thin  sheeting  of  exudate,  producing  slight 
turbidity  of  the  membrane.  In  only  two  of  the  hundred  instances  the 
])leuTa  was  not  involved.  In  some  cases  the  fd)rinous  exudate  may  form  a 
creamy  layer  an  inch  in  thickness.  A  serous  exudation  of  variable  amount 
is  not  uncomnum. 

Lesions  in  other  Organs. — The  heart  is  distended  with  firm,  tenacious 
coagula,  wliich  can  be  M-ithdrawn  from  the  vessels  as  dendritic  moulds. 
Tn  no  other  acute  disease  do  we  meet  with  coagula  of  such  solidity  and 
firmness,  'fbe  distention  of  the  right  chambers  of  the  heart  is  ]iarticu- 
larly  marked.  The  left  chaml)ers  are  rarely  distended  to  the  same  degree. 
The  spleen  is  often  enlarged,  though  in  only  35  of  the  100  cases  was  the 
weight  above  200  grammes.     The  kidneys  show  parenchymatous  swelling. 


LOBAR   I'N  K  U  MON I  A. 


115 


lU'U 

)riuiil 
,500, 

rous 
itmn. 
ectetl 
xtend 
i  are 
e  in- 
[Icial. 
slig-lit 
s  the 
irm  a 


nt 


nou 


icioiis 
and 

i(rr  00. 


the 


lllin 


turbidity  of  tlie  cortex,  and,  in  a  very  considerable  proportion  of  the  cases 
— 'iti  per  cent — chronic  interstitial  changes. 

IVricarditis  is  not  infrcciucnt,  and  occurs  more  ])articularly  with  ])neu- 
nionia  of  tiie  left  side  anil  with  double  pneumonia.  In  o  of  tlic  lOO  autop- 
sies it  was  j)rcsent,  and  in  4  of  them  tiie  laj>pct  of  lung  overlying  thr  peri- 
cardium with  its  pleura  was  involved.  Endocarditis  is  nuire  freijuent  aiul 
occurred  in  10  of  the  100  cases.  In  5  of  these  the  endocarditi.s  was  of  tlie 
i!im|)lc  character;  in  11  the  lesions  were  ulcerative.  Fatty  degeneration 
of  the  iieart  is  not  connnon  exce])t  in  i)rotracted  cases. 

^Icningitis  is  not  infrequently  found,  and  in  nuiny  cases  is  associated 
with  nudignant  endocarditis.  It  was  })resent  in  8  of  the  100  autopsies. 
Of  20  cases  of  meningitis  in  idcerative  endocarditis  15  occurred  in  pneu- 
monia.    The  meningeal  inllammation  in  these  cases  is  nsually  cortical. 

Croupous  or  di})htlieritic  inflammation  may  occur  in  otiier  parts.  A 
croupous  colitis,  as  pointed  ont  by  Jiristowe,  is  not  very  uncommon.  Jt 
occurred  in  5  of  my  100  post-mortems.  It  is  nsually  a  thin,  flaky  exuda- 
tion, most  marked  on  the  tops  of  the  folds  of  the  mucous  mend)raiie.  In 
1  case  there  was  a  patch  of  crou])ous  gastritis,  covering  an  area  of  12  by 
S  cm.,  situated  to  the  left  of  the  cardiac  orifice. 

The  liver  shows  itarcnchymatous  changes  and  often  extreme  engorge- 
ment of  the  hepatic  veins. 

Symptoms. — Course  of  the  Disease  in  Ti/piral  Cases. — We  know  but 
little  of  the  incubation  i)eriod  in  lobar  })neumonia.  It  is  probably  very 
short.  There  are  sometimes  slight  catarrhal  symptoms  for  a  day  or  two. 
As  a  rule,  the  disease  sets  in  abruptly  with  a  severe  chill,  which  lasts  from 
fifteen  to  thirty  minutes  or  longer.  In  no  acute  disease  is  an  initial  chill 
so  constant  or  so  severe.  The  patient  may  be  taken  abrn])tly  in  the  midst 
of  his  work,  or  may  awaken  out  of  a  sound  sleep  in  a  rigor.  The  temi)era- 
tnre  taken  during  the  chill  shows  that  the  fever  has  already  begun.  If 
seen  shortly  after  the  onset,  the  patient  has  nsually  features  of  an  acute 
fever,  and  complains  of  headache  and  general  ])ains.  "Within  a  few  hours 
pain  in  the  side  develops,  often  of  an  agonizing  character;  a  short,  dry, 
painful  congh  begins,  and  the  respirations  are  increased  in  frequency. 
When  seen  on  the  second  or  third  day,  the  picture  in  typical  ])neumonia 
is  (piite  pathognomonic;  more  so,  perha])s,  than  that  presented  by  any 
other  acute  disease.  The  ])atient  lies  flat  in  bed,  often  on  the  afTected 
side;  the  face  is  flushed,  particularly  one  or  both  cheeks;  the  breathing  is 
hurried,  accompanied  often  with  a  short  expiratory  grunt;  the  ahv  nasi 
dilate  with  each  inspiration;  herpes  is  usually  ])rescut  on  the  lips  or  nose; 
the  eyes  are  bright,  the  expression  is  anxious,  and  there  is  a  frequent  short 
cough  which  makes  the  patient  wince  and  hold  his  side.  The  expectora- 
tion is  blood-tinged  and  extremely  tenacious.  The  temperature  may  he 
104°  or  10.")°.  The  ])ulse  is  full  and  bounding  and  the  pulse-respiration 
ratio  much  disturbed.  Examination  of  the  lung  shows  the  physical  signs 
of  consolidation — blowing  breathing  and  fine  rales.  After  persisting  for 
from  seven  to  ten  days  the  crisis  occurs,  and  with  a  fall  in  the  temperature 
the  patient  passes  from  a  condition  of  extreme  distress  and  anxiety  to  one 
of  comparative  comfort. 


nJ 


116 


SPECIFIC   IXFECTIOUS   DISEASES. 


Special  Features. — The  fever  rises  rapidly,  and  tlio  lioight  nmy  be 
101°  or  105°  witliiu  twelve  lioiirs.     Having  readied  the  fastigium,  it  is 


Jnn.  in 


licKp. 


76 


70 


SS 


SO 


Bfi 


SO 


^b 


10 


39 


30 


25 


20 


IS 


10 


Pulse 
190 


180 


170 


100 


150 


110 


130 


120 


110 


100 


90 


80 


70 


60 


60 


10 


Temp. 

lot 

108 

107 

100 

lOB 

101 

103 

102 

101 

lOO 

99 

98 

97 

9C 
Temp, 

Pulse 

Resp 
Stools 

Urine 

)ay  of 

DisL'ii 


10 


11 


12 


13 


14 


BLACK,   TEMPERATURE  ;  RED,    PULSE  I  BLUE,   RESPIRATION. 

CiiAKT  IX. — Fever,  pulse,  and  respirations  in  lobar  pneumonia. 

remarkably  constant.    Often  the  two-hour  temperature  cliart  will  not  show 
for  two  davs  more  than  a  defjree  of  variation.     In  children  and  in  cases 


LOBAR  PNEUMONIA. 


117 


witliont  oliill  tlip  rise  is  more  gradual.  Tn  old  persons  and  in  drnnkards  the 
1cm|)('ratiiro  range  is  lower  than  in  eliildreii  and  in  healthy  individuals; 
indeed,  one  oeeasionall}'  meets  witli  an  afebrile  [)neunu)nia. 

The  Crisis. — After  the  fever  lias  persisted  for  from  live  to  nine  or  ten 
days  there  is  an  ahrupt  drop,  known  as  the  erisis,  which  is  jterliaps  tlie 
most  characteristic  feature  of  lobar  ])neumonia.  Tlie  day  of  the  erisis  is 
variable.  It  is  very  uncommon  before  tiie  thii'd  day,  and  rare  after  the 
twelfth.  I  have  twice  seen  it  as  early  as  the  third  (hiy.  From  the  lime  of 
]Ii|)pocratos  it  has  been  thought  to  be  nmre  frequent  on  the  uneven  days, 
])artieularly  the  fifth  and  seventh.  A  i)recritical  rise  of  a  degree  or  two 
may  occur.  In  one  case  the  temperature  rose  from  10.5°  to  nearly  107°,  and 
then  in  a  few  hours  fell  to  normal.  Not  even  after  the  chill  in  malarial 
fever  do  we  see  such  a  ])rompt  and  ra])id  dro])  in  the  temperature.  The 
nsual  time  is  from  five  to  twelve  hours,  but  often  in  an  hour  there  may 
occur  a  fall  of  six  or  eight  degrees  (S.  West).  The  temperature  may  be  sub- 
normal after  the  crisis,  as  low  as  Dti"  or  i)7°.  Vsually  with  the  ci'isis  there  is 
an  abundant  sweat,  and  the  ])atient  sinks  into  a  comfortable  sleep.  The 
day  after  the  erisis  there  may  be  a  slight  ])ost-critical  rise.  A  ])seu(lo- 
crisis  is  not  very  uncommon,  in  which  on  the  fifth  or  sixth  day  the  temjjera- 
ture  dr()])s  from  104°  or  105°  to  I0^°,  ami  then  rises  again.  When  the  fall 
takes  i)lace  gradually  within  twenty-four  hours  it  is  called  a  ]>rotracted 
crisis.  If  the  fever  persists  beyond  the  twelfth  day,  the  fall  is  likely  to  bo 
by  lysis.  In  children  this  mode  of  termination  is  common,  and  occurred 
in  one  third  of  a  series  of  IS',]  cases  reported  by  Morrill.  Occasionally  in 
debilitated  individuals  the  temperature  drops  ra])idly  just  before  death; 
more  frequently  there  is  an  ante-mortem  elevation.  In  cases  of  delayed 
resolution  the  fever  may  persist  for  wet'ks.  The  crisis  is  the  most  remark- 
able single  ])henomenon  of  pneumonia.  With  the  fall  in  the  fever  the 
res])irations  become  reduced  almost  to  nornud.  the  ])ulse  slows,  and  the 
])atient  ])asses'fr()m  ])erha])s  a  state  of  extreme  hazard  and  distress  to  one 
of  safety  and  comfort,  ami  yet,  so  far  as  the  ])hysical  examination  indicates, 
there  is  with  the  crisis  no  special  change  in  the  local  condition  in  the  lung. 

I'aiii. — On  the  afl'ected  side  there  is  early  a  shar]i,  agonizing  ])ain,  gen- 
erally referred  to  the  region  of  the  nip])le  or  lower  axilla.  It  is  much  aggra- 
vated on  deep  inspiration  and  on  coughing.  It  is  associated  with  the  ac- 
com])anying  dry  pleurisy  of  the  disease.  It  is  absent  in  central  pneumonia, 
and  much  less  fre([uent  in  a])ex  imeumonia.  In  exce])tional  cases  the  ])ain 
is  in  the  abdomen,  and  I  have  twice  known  the  sus])icion  of  appendicitis 
raised  by  the  sudden  acute  onset  of  the  ])ain,  once  in  the  region  of  the  navel 
and  once  low  on  the  right  side.  The  pain  may  be  severe  enough  to  re(pnre 
a  hyi)odermic  injection  of  morphia. 

Di/spDnn  is  an  almost  constant  feature.  Even  early  in  the  disease  the 
res])irations  may  be  30  in  the  minute,  and  on  the  second  or  third  day  be- 
tween 40  and  50.  The  movements  are  shallow,  evidently  restrained,  and 
if  the  ])atient  is  asked  to  draw  a  dee])  ])reath  he  cries  out  with  the  ])ain. 
Z.vjiiration  is  frequently  interru])ted  by  an  audible  grunt.  At  first  with  the 
increased  res])iration  there  may  be  no  sensation  of  distress.  I^ater  this 
may  be  present  in  a  marked  degree.     In  cliiklren  the  respirations  may  bo 


118 


SPECIFIC  INFECTIOUS  DISEASES. 


80  or  even  lUU.  ]\Iaiiy  fnctors  conihine  to  i)ro(liicc  the  shortness  of  hrcath — 
the  pain  in  tiio  side,  the  toxa'tnia,  the  fever,  and  the  h)ss  of  function  in  a 
conHideral)le  area  of  the  luns?  tissue.  Soinetinies  tliere  appear  to  he  nerv- 
ous factors  at  \vori\.  That  it  does  not  depend  ui)on  tlie  consolidation  is 
siiown  hy  the  fact  that  after  the  crisis,  witiiout  any  cluui^'e  in  tlie  local 
condition  of  the  lun^f,  the  nuniher  of  respirations  may  (lro[)  to  normal. 
The  ratio  hetween  the  res])iration8  and  the  pulse  may  he  1  to  2  or  even  1  to 
1.5,  a  disturhance  rarely  so  marked  in  any  other  disease. 

Coiu/li. — This  usually  comes  on  with  the  ])ain  in  the  side,  and  at  first  is 
dry,  hard,  and  without  any  ex|)ectoration.  Later  it  hecomes  very  charac- 
teristic— frequent,  short,  restrained,  and  associated  with  great  ])ain  in  the 
side.  Jn  old  persons,  in  drnnkards,  in  the  terminal  pneumonias,  and  some- 
times in  young  children  there  nuiy  be  no  cou^ii.  After  the  crisis  the  cough 
nsually  l)ecomes  much  easier  and  the  ex])ectoration  more  easily  expelh'd. 
The  cough  is  soiuetimes  persistent,  continuous,  and  hy  far  the  nuist  aggra- 
vated and  distressing  sym])tom  of  the  disease.  Paroxysms  of  coughing  of 
great  intensity  after  the  crisis  suggest  a  ])leural  exudate. 

iSpiihim. — A  brisk  luemoptysis  nuiy  be  the  initial  sym])tom.  At  first 
the  sputum  may  be  mucoid,  but  usually  after  twenty-four  hours  it  becomes 
blood-tinged,  viscid,  and  very  tenacious.  At  first  (piite  red  from  the  un- 
changed blood,  it  gradually  i)econies  rusty  or  of  an  orange  yellow.  The 
tenacious  viscidity  of  the  sputum  is  rennu'kal)le;  it  often  has  to  be  wiped 
from  the  li])s  of  the  patient,  and  a  s])it-cup  half  full  nuiy  he  inverted  with- 
out spilling.  In  low  ty])es  of  the  disease  the  sputum  may  be  fluid  and  of 
a  dark  brown  color,  resend)ling  prune  juice.  The  amount  is  very  variable. 
In  children  and  in  ohl  people  there  n'  ly  be  none,  and  even  in  adults  cases 
are  not  very  nnconunon  in  which  from  beginning  to  close  there  is  no  ex- 
])ectoration.  A  common  anu)unt  is  from  150  to  300  cc.  daily.  After 
the  crisis  the  quantity  is  varial)le,  abnndant  in  some  cases,  al)sent  in  others. 

IMicroscopically,  the  s])utum  consists  of  leucocytes,  mucus  corpuscles, 
red  l)lood-cor])uscles  in  all  stages  of  degeneration,  and  bronchial  and  alve- 
olar epithelium.  IlaMiiatoidin  crystals  are  occasionally  met  with.  Of  micro- 
organisms the  pneumococcus  is  nsually  present,  and  sometimes  Friedlander's 
bacillus.  Very  interesting  constitnents  are  small  cell  moulds  of  the  alveoli 
and  the  fd)rinous  casts  of  the  bronchioles;  tlie  hitter  may  l)e  very  ])lainly 
visible  to  the  naked  eye,  and  sometimes  may  form  good-sized  dendritic 
casts.  Chemically,  the  expectoration  is  particularly  rich  in  calcium  chloride. 

Physical  Signs. — Tnspecfion. — The  ]iosition  of  the  patient  is  not 
constant.  He  nsually  rests  more  comfortably  on  the  affected  side,  or  he 
is  ]iro])i)ed  w\)  with  the  s])ine  curved  toward  it.  Ortliopna\a  is  not  nearly 
so  frequent  as  in  heart-disease. 

Insiiection  of  the  thorax  may  show  at  first  no  differences  between  the 
tMo  sides;  nsnally  if  the  lower  lobe  of  a  lung  is  involved  the  movement  is 
less  on  the  affected  side.  Later  this  deficient  expansion  is  marked,  and 
may  be  lioth  seen  and  felt.  The  comiiensatory  increased  movement  on 
the  sonnd  side  is  sometimes  very  noticeable  even  before  the  patient's  chest 
is  bared.  The  intercostal  s]iaccs  are  not  usually  obliterated.  "When  the 
cardiac  lappet  of  the  left  upper  lobe  is  involved  there  may  be  a  marked 


LOBAR  PNEUMONIA. 


Hi) 


iable. 

cashes 
10  cx- 

Aftcr 

tlicrs. 
clcs, 
ilvo- 
icro- 
(lor's 
vooli 
liiily 
ritic 

irido. 
not 

Dr  lie 
oarly 

the 
'ut  is 

and 
t  on 
chest 

tho 
irked 


increase  in  tho  area  of  visil)le  cardiac  ])ulsation.  Pulsation  of  the  alTecled 
liin^'  may  cause  a  marked  movement  of  tlie  elu-st  wall  ((iraves).  Other 
points  to  be  noticed  in  the  inspi'ction  ai'e  the  freciueney  of  the  respiration, 
the  action  of  the  accessory  muscles,  such  as  the  sterno-cleido-mastoids  and 
scaleni,  and  the  dilatation  of  the  nostrils  with  each  inspiration. 

Mciisiinilidii  may  sliow  a  delinite  increase  in  the  volume  of  the  siih; 
alfected,  rarely  more,  however,  than  1  or  IJ  cm. 

ralpaliun. — The  lack  of  expansion  on  the  alfected  side  is  sometimes 
more  readHy  perceived  by  touch  than  by  si<,dit.  The  ph  ural  friction  may 
be  felt.  On  askin*,'  the  jjatient  to  count,  the  voice  frenutus  is  greatly  in- 
creased in  comparison  with  the  corresponding  point  on  the  healthy  side. 
It  is  to  be  remend)ere(l  that  if  the  bronchi  are  tilled  with  thick  si'cretion, 
or  if,  in  what  is  known  as  nuissive  pneumonia,  they  are  tilled  with  lil)rinous 
exudate,  the  tactile  fremitus  may  be  diminished.  It  is  always  well  to  ask 
the  patient  to  cough  before  testing  the  frenutus. 

rcrcussiun. — Jn  the  stage  of  engorgement  the  note  is  higher  pitched 
and  nuiy  have  a  somewhat  tympanitic  cpudity,  the  so-called  Skoda's  reso- 
nance. This  can  often  be  obtained  over  the  lung  tissue  just  above  a  con- 
solidated area.  When  the  lung  is  he})atized,  the  percussion  note  is  dull, 
the  quality  varying  a  good  deal  from  a  note  which  has  in  it  a  certain  tym- 
panitic (pudity  to  one  of  absolute  llatness.  There  is  not  the  wooden  llat- 
ness  of  elfusion  and  the  sense  of  resistance  is  not  so  great.  During  resolu- 
tion the  tympanitic  quality  of  the  percussion  note  usually  returns.  For 
weeks  or  months  after  convalescence  there  nuiy  be  a  liiglier-i)itched  nott> 
on  the  alfected  side.  Among  variations  to  be  noticed  are  that  Wint rich's 
change  in  the  percussion  note  when  the  mouth  is  o])en  may  be  very  well 
marked  in  i)neumonia  of  the  up])er  lobe.  Occasionally  there  is  an  almost 
metallic  quality  over  the  consolidated  area,  and  when  this  exists  with  a 
very  pronounced  amphoric  quality  in  the  breathing  the  presence  of  a  cavity 
may  be  suggested.  In  deep-seated  pneununiias  there  may  be  for  several 
days  no  change  in  the  percussion  note,  and  in  a  few  rare  cases  percussion 
shows  no  change  throughout  the  disease. 

Avsnillalioi). — Quiet,  su])])ressed  breathing  in  the  affected  part  is  often 
a  marked  feature  in  the  early  stage,  and  is  always  suggestive.  Very  early 
there  is  heard  at  the  end  of  ins])iration  the  fine  crepitant  rale,  a  series  of 
minute  cracklings  heard  close  to  the  ear,  and  perhaps  not  audible  until  a 
full  breath  is  drawn.  This  is  ])robably  a  fine  pleural  crepitus,  as  J.  K. 
Learning  maintained;  it  is  usually  believt'd  to  be  produced  in  the  air-cells 
and  finer  bronchi  by  the  separation  of  tho  sticky  exudate.  At  this  stage, 
before  consolidation  has  occurred,  the  breath-sounds  may  be,  as  before  men- 
tioned, much  feebler  than  in  liealth,  but  on  drawing  a  long  breath  they 
may  have  a  harsh  quality,  to  which  the  term  broncho-vesicular  has  been 
applied.  In  the  stage  of  red  he])atization  and  when  dulnoss  is  well  de- 
fined, tho  respiration  is  tubular,  sinn'lar  to  that  heard  in  health  over  the 
larger  bronchi.  "With  this  blowing  breathing  there  may  l)e  no  rilles,  and 
it  mav  present  an  int(>nsity  unknown  in  any  other  ])ulmonary  affection. 
It  is  sinijtlv  the  propagation  of  the  laryngeal  and  tracheal  sounds  through 
the  bronchi  and  the  consolidated  lung  tissue.     The  permeability  of  the 


*•: 


■<•■■: 
Si- 

1^ 


120 


SPECIFIC  INFECTIOUS  DISEASES. 


liroiiclii  is  Cf^scntial  to  ils  ]tro(luoti()n.  Tiil)iiliir  breathing  is  absent  in  cer- 
tain casi's  of  massive  pneumonia  in  w  bicli  the  hirger  bronelii  are  completely 
iilled  with  exu(hition.  Wlien  resolution  begins  mucous  niles  oi'  all  sizes  can 
be  heard.  At  lirst  they  are  small  and  have  been  ealled  tlie  n'(ln.i-crci)ilus. 
The  voice-sounds  are  transmitted  through  the  consolidated  lung  with  great 
intensity.  'J'liis  bronchophony  may  have  a  curious  nasal  (pialily  to  which 
the  term  a'gophony  has  been  given.  There  are  cases  in  which  the  consoli- 
dation is  deeply  si-atcd — so-called  central  pneumonia,  in  which  the  phys- 
ical signs  are  slight  or  even  absent,  yet  the  cougli,  the  rusty  expectoration, 
and  general  features  nudce  the  diagnosis  certain. 

Circulatory  Symptoms. — During  the  chill  the  jnihe  is  small,  but  in 
the  succeeding  lever  it  becomes  full  aiul  bounding.  In  cases  of  nmderate 
severity  it  ranges  from  KiU  to  IIG.  It  is  not  often  dicrotic.  In  strong, 
healthy  individuals  and  in  children  there  may  be  no  sign  of  failing  ])ulse 
throughout  the  attack.  AVith  extensive  consolidation  the  left  ventricle 
may  receive  a  very  much  dinunished  amount  of  blood  and  the  pulse  in 
conse(pU'nce  may  be  small.  In  the  old  and  feeble  it  may  be  small  and 
rapid  from  the  outset.  The  juilse  jnay  be  full,  soft,  very  deceptive,  and  of 
no  value  wliatever  in  ]»rognosis.  The  heart-soiuuh  are  usually  loud  and 
clear.  During  the  intensity  of  tlie  fever,  ])articularly  in  children,  hriiiln 
are  not  uncommon  both  in  the  mitral  and  in  the  ])ulmonic  areas.  The 
second  sound  over  the  pulmoiuiry  artery  is  accentuated.  Attention  to  this 
sign  gives  a  valuable  iiulication  as  to  the  condition  of  the  lesser  circula- 
tion. AVitli  distention  of  tlie  right  chambers  aiul  failure  of  the  right  ven- 
tricle to  ein[)ty  itself  com])lctely  the  pulmonary  second  sound  becomes  much 
less  distinct.  When  the  right  heart  is  engorged  there  may  be  an  increase 
in  the  didness  to  the  riuht  of  the  sternum.  With  gradual  heart  weakness 
and  signs  of  dilatation  the  long  pause  is  greatly  shortened,  the  sounds 
a]i]»roach  eacli  other  in  tone  and  have  a  ftptal  character  (embryocardia). 

There  may  be  a  sudden  early  collapse  of  the  lieart  with  very  feeble, 
rapid  ])ulse  and  increasing  cyanosis.  I  have  known  this  to  occur  on  the 
third  day.  Even  when  these  symptoms  are  very  serious  recovery  may  take 
])lace.  I  saw  with  Dr.  Ilollyday  a  robust  man  of  thirty-six  who  at  the  end 
of  the  second  week  of  a  severe  ])neumonia  had  two  serious  attacks  of  heart 
weakness,  in  which  the  ])ulse  became  exceedingly  feeble,  scarcely  percepti- 
ble; there  was  marked  pallor,  an  ashy  ajipearance  of  the  face,  and  ])rofuse 
sweating.  I^oth  attacks  appeared  to  be  most  critical,  but  he  recovered 
perfectly.  In  other  instances  without  any  special  warning  death  may 
occur  even  in  robust,  previously  healthy  men.*  luidocarditis  and  pericar- 
ditis will  be  considered  under  complications. 

Blood. — Anamiia  is  rarely  seen.  Bollinger  has  called  attention  to  an 
oliga'mia  due  to  the  large  amount  of  exudate,  and  thinks  that  the  collapse 
features  are  in  part  due  to  it.  There  is  in  most  cases  a  leucocytosis,  which 
appears  early,  ]iersists,  and  disappears  with  the  crisis.  The  leucocytes  may 
number  from  12.000  to  -10,000  or  50,000,  or  even  more,  per  cubic  millimetre. 
The  fall  in  the  leucocytes  is  often  slower  than  the  drop  in  the  fever,  par- 


I 


1 


*  For  illustrative  cases  see  Procjnosis  in  Pneumonia,  Am.  Jr.  Med.  Sci.,  Jan.,  1807. 


LOBAR  PNEUMONIA. 


121 


ticalorly  when  resolution  is  dt'layod.  The  annexed  chart  from  J.  S.  Billings' 
l)ai>or  (J.  II.  11.  lUdlt'tiii,  No.  43)  shows  well  the  coincident  drop  in  tho 
I'cvtr  and  in  tlie  miinhor  oi"  tho  h'ucocytcs.  A  point  of  considerable  prog- 
nostic importance  is  that  in  nialijrnant  pneumonia  the  leucocytosis  may 
be  absent,  and  in  any  case  the  continuous  absence  may  be  regarded  as  an 
unfavorable  sign.     Of  50  cases  shown  in  my  clinic  during  tho  sessions  of 


bericar- 


to  an 


?olla 


pse 


w 


•Inch 


fos  may 
I  i  metro, 
par- 


Fub.,  1803 

16         1        17        1        18         1        19        1        20        1        21        1        22 

0    III    0    12    S    in   0    12    0    in   6    Vi    G    in    0    12    0    ni  6    12    0    in    8    12    8     in  8 

100 

105° 

104° 

103° 
102° 
101° 

100° 
99° 

98° 

60,000 
10,000 
30,000 

20,000 
18,000 
18,000 
11,000 

12,000 
10,000 
8,000 

«,oqo__ 

1,000 
2,000 

1 

I 

V 

\ 

\ 

/ 

I 

I 

^ 

\ 

-■ 

\/ 

1 

y 

\ 

V 

I 

T 

\ 

A 

A 

\ 

-^ 

J^ 

t 

/ 

\. 

.    !  1 

-' 

... 

— 

- 

-- 

-- 

... 

... 

- 

> 

■- 

... 

- 

-■ 

-- 

-- 

-- 

r' 

: 

1 

1 

1 

1 

1 

1 

1 

1 

1 

' 

1 

1 

1 

1 

1  i 

-- 

-- 

... 

-- 

1 

■- 

- 

-- 

-- 

- 

-- 

... 

... 

__ 

- 

— 

-- 

■- 

— 

- 

— 

- 

.-. 

1 

i  1 

807. 


Chart  X. 

189G-97  and  1897-'98,  the  highest  leucocytosis  was  63,000,  the  lowest 
10,200.  A  striking  feature  in  the  blood-slide  is  the  richness  and  density  of 
tho  fibrin  network.     This  corresponds  to  the  great  increase  in  the  fd)rin 


122 


SPECIFIC   INFECTIOUS  DISEASES. 


ek'UK'Hts.  wliicli  has  Imig  lu'cn  known  to  dcciir  in  pncnnionin,  tlio  propor- 
tion risin«f  from  I  to  1<)  parts  per  tlionsiind.  Ilavcni  dcsfrilics-  tlif  hlood- 
jilak's  as  ifrcatly  increased.  Tlu'  micrococei  can  very  rarely  he  dcnion- 
i<trati'd  in  tlio  Mood. 

Digestive  Organs. — The  t(jn;,nie  is  wliite  and  furred,  and  in  severe 
toxic  cases  rapidly  heeonies  dry.  A'oinilin<,f  is  not  nncoininon  at  tiie  onset 
in  cliihlren.  The  appetite  is  h)st.  C'()nsti|)ation  is  more  common  tiian 
diarrhu'a.  A  distressing  and  sometimes  (huigerous  symptom  is  meteorisni. 
Oil  several  occasions  1  have  seen  great  distress  from  the  enlarged,  tym- 
])anitic  al)d()inen  pushing  up  the  diaphragm.  The  spleen  is  usually  en- 
larged, and  the  edge  can  he  felt  during  a  deep  inspiration.  With  extreme 
engorgement  of  the  right  heart  there  may  be  perceptible  increase  in  the 
volume  of  the  liver. 

Skin. — Among  cutaneous  syniptoins  one  of  the  most  interesting  is  the 
association  of  herjjes  with  j)neum()nia.  Not  excepting  malaria,  we  see 
lal)ial  herpes  more  frequently  in  this  than  in  any  other  disease,  occurring, 
as  it  does,  in  from  1;^  to  40  per  cent  of  the  cases.  It  is  supposed  to  be  of 
favorable  prognosis,  and  figures  have  been  quoted  in  i)roof  of  this  asser- 
tion. It  may  also  occur  on  the  nose,  genitals,  and  anus.  Its  significance 
and  relation  to  the  disease  are  unknown.  It  is  scarcely  necessary  to  men- 
tion the  theory  which  has  been  advanced,  that  it  is  an  external  expression 
of  a  neuritis  which  involves  the  pneumogastric  and  induces  the  pneumo- 
nia. At  the  height  of  the  disease  sweats  are  not  common,  but  at  the  crisis 
they  may  be  profuse.  Redness  of  one  cheek  is  a  phenomenon  long  recog- 
nized in  connection  with  jjueumonia,  and  is  usually  on  the  same  side  as 
the  disease. 

Urine. — Early  in  the  disease  it  j)resents  the  usual  febrile  characters 
of  high  color,  high  specific  gravity,  and  increased  acidity.  A  trace  of  albu- 
min is  very  common.  There  may  he  tube-casts  and  in  a  few  instances  the 
existence  of  albumin,  tube-casts,  and  blood  indicate  the  presence  of  an 
acute  nephritis.  In  a  large  proportion  of  all  cases  the  albumin  is  a  febrile 
or  toxic  feature.  The  urea  and  uric  acid  are  usually  increased  at  first,  but 
may  be  much  diminished  before  the  crisis,  to  increase  greatly  with  its  onset. 
The  chlorides  are  absent  or  greatly  reduced  during  the  height  of  the  fever, 
owing  to  the  amount  exuded  in  the  hepatized  lung.  At  the  crisis  there  may 
be  a  marked  increase  in  the  amount  of  urine,  which  is  heavily  laden  with 
urates  and  extractives.  "When  jaundice  occurs  there  is  bile  pigment.  I 
saw  profuse  ha?maturia  on  the  seventeenth  day  of  a  severe  pneumonia.  The 
boy  had  recently  had  gonorrhoea. 

Cerebral  Symptoms. — Headache  is  common.  Convulsions  occur 
frequently  at  the  outset  in  children.  Apart  from  meningitis,  which  will 
be  considered  separately,  one  may  grouji  the  cases  with  marked  cerebral 
features  into — 

First,  the  so-called  cerebral  pneumonias  of  children,  in  which  the  dis- 
ease sets  in  Avith  a  convulsion  and  there  are  high  fever,  headache,  delirium, 
great  irritability,  muscular  tremor,  and  perhaps  retraction  of  the  head 
and  neck.  The  diagnosis  of  meningitis  is  usually  made,  and  the  local 
afToction  may  be  overlooked. 


! 


I 


LOBAR  rXKl'MOXIA. 


128 


Socoiully.  tlio  cases  with  iiiniiincal  s\  inptoins.  These  nuiy  ocenr  at  the 
very  outset,  and  1  (Hice  |)crt'(iriiic<l  an  aiilo|isy  mi  a  case  in  which  there  was 
n(t  siis|»ici(>ii  wliatever  that  tiie  disease  was  other  than  acute  mania.  Tiie 
liouse  |ihysieian  shouhl  ;:ive  instructions  to  the  tuirses  to  watch  such  cases 
very  carerully.  On  March  2'i,  lS!l|,  a  iiatieiit  who  had  heen  (h)in;,f  very 
well,  with  the  e\(e|ilion  of  sli;,dit  (h'liriuni,  whih'  the  (U-ih'i'Iy  was  out  of  the 
room  for  a  lew  moments,  <,'ot  up,  I'aised  the  window,  and  jumped  out,  sus- 
taining,' a  fracture  of  tiie  h'<^  and  of  tlie  uppei-  lumhar  veitehra',  of  which 
he  died. 


'I'hirdlv,   ah'oholic   eases    with    the    features   of   delirium    tremen.- 


It 


should  111'  an  iinariahle  rule.  e\('n  if  l\'ver  !je  not  ]iresent,  to  examine  the 
lun<:s  in  a  case  of  iiKiiiid  a  pulii. 

Fourthly,  cases  with  toxic  features,  resemhlin;;  ratluT  those  of  ura'una. 
Without  a  chill  and  without  con;:h  or  pain  in  the  side,  a  patient  may  de- 
velop fever,  a  little  shortness  of  hri-ath,  and  then  ,<i:radually  <;row  dull  men- 
tally, and  within  three  days  he  in  a  condition  of  profound  toxa'inia  with 
low,  mutterini:  delirium. 

It  is  stated  that  apex  ])neunu)nia  is  more  often  accompanied  with  severe 
delirium.  Occasionally  the  c'erel)ral.  symptoms  develoj)  imnu'diately  after 
the  crisis.     ^leiital  disturliance  mav  persist  dui'in'r  and  after  convalescence, 


a  I 


id  in  a  few  instances  delusional  insanity  follows,  the  out 


ooK  in  wnicn  is 


avoranle 


Complications." — Compared  with  tyi)hoid  fevi'r,  |)iieunionia  has  hut 
U'w  complications  and  still  fewer  sequeliv.  The  most  important  are  the 
following: 

Plciirisi/  is  an  inevitable  event  when  the  inllammation  reaches  the  sur- 
face of  the  luiiu',  and  thus  can  scarcely  lie  termed  a  complication.  I>ut  there 
are  cases  in  which  the  pleuritic  features  take  the  first  place — cases  to  which 
the  term  ]»leuro-|)neumonia  is  applicahh".  '^I'he  exudation  may  l)c  sero- 
tihrinous  with  copious  elfusion,  dilTcrinif  from  that  of  an  ordinary  acute 
pleurisy  in  the  <,n'eater  richness  of  the  tihrin,  which  may  form  thick, 
li'iiacioiis,  curdy  layers.  I'neunioiiia  on  one  side  with  extensive  pleurisy 
en  the  other  is  sometimes  a  jjuzzlin*-'  conii)lication  to  dia.iiiiose  and  an 
aspirator  needle  uiay  he  reciuired  to  settle  the  (piestion.  The  hacterioloj^ical 
examination  of  the  fluid  has  demonstrated,  in  a  lar^ye  numher  of  cases,  the 
presence  of  the  ]>iieuniococcus.  Kmpyema  frecpiently  follows  pneumonia. 
The  pleurisy  caused  hy  the  stre])tococcus  is  much  more  dan*:"erous  and  is  a 
not  infrequent  fatal  complication.  Klfusion  may  not  have  heen  susi)ected 
diirin,!,'  the  height  of  the  disease,  hut  after  the  temperature  lias  heen  normal 
I'nr  some  days  a  slight  rise  occurs  and  an  irreii'ular  fi'vcr  persists.  Dulness 
iiintinues  at  the  hase,  or  may  have  extended.  The  hreathiim  is  feehle 
mid  there  are  no  rales.  Such  a  condition  may  he  closely  sinndati.'d,  of 
course,  hy  the  thickened  pleural  layers  which  are  so  commonly  found  after 
the  ]mennionia.  The  question  should  he  settled  at  once  hy  tiie  introduc- 
tion of  the  needle.  Tt  is  hy  no  means  an  uncommon  com])lication,  and 
many  cases  of  empyema  sui^posed  to  he  primarv  are  in  reality  secondary  to 
n  sli<iht  pneumonia.     The  persistence  of  the  leucocytosis  is  an  important 

point. 

8 


124 


SPECIFK'   INFKCTIOUS   I)ISF':ASKS. 


J'rrirdnlills  is  more  (■(iii)iii<»ii  in  the  init'iiiiioiiin  of  cliililrcii,  imrtion- 
liirly  wIh'M  (ioiiliic,  nnd  it  is  siiid  willi  the  i>iu'iiiiioiiia  (if  the  left  side.  It 
is  particiiliirly  apt  to  i'nildw  or  to  lie  associntt'*!  with  acute  rliciiinatisiii.  It 
was  prc'si'iit,  as  1  statfd,  in  .')  of  my  !<»<»  autopsies.  'riioii;,di  usually  plastic, 
there  may  he  much  serous  ell'iision.  'i'liere  is  rarely  any  dilliculty  in  the 
diagnosis,  but  when  the  pneuinoniu  involves  the  portion  of  Inn;,'  coverinj; 
the  pericardium,  there  nuiy  he  dilliculty  in  determining,',  hy  physical  signs, 
the  existence  of  fluid.  The  increase  in  the  dyspud-n,  the  greater  feebleness 
of  the  pulse,  and  the  gradual  suppression  of  the  heart-sounds  will  give  the 
most  valuable  indications.  Jn  some  instances  the  lluid  is  purulent.  'JMiough 
a  very  serious  event,  it  is  surprising  how  often  recovery  takes  place  even 
in  till'  most  desperate  cases  of  pneumonia  com[)licated  with  pericarditis, 
a  point  to  which  1  have  heard  ]\lurchison  refer. 

J'JiKldcardilis  is  still  more  fre(pient,  and  in  my  1(»(>  autopsies  was  pres- 
ent in  Ki.  1  called  attention  in  the  (Julstonian  lectures  for  LSS.")  to  the 
great  freiiuency  of  this  C'onii)lication.  Of  20\y  cases  of  malignant  endo- 
carditis collected  from  the  literature,  54  occurred  in  this  disease.  Sub- 
secpu'nt  observations  have  fully  confirmed  this  statemi'iit.  Kanthack  found 
an  antecedent  pneumonia  in  1  [.'^i  per  cent  of  all  instances  of  infective  endo- 
carditis. It  is  much  more  common  ii\  the  left  heart  than  in  the  right. 
It  is  ])articulnrly  liable  to  attack  persons  with  old  valvular  disease.  The 
jmeuniococcus  has  been  fo.md  in  the  vegetations.  There  may  be  no  symp- 
toms indicative  of  this  complication  even  in  very  severe  cases.  It  nuiy, 
however,  be  sus])ected  in  cases  (1)  in  which  the  fever  is  jirotracted  nnd 
irregular;  {2)  when  signs  of  septic  mischief  arise,  such  as  chills  and  sweats; 
{[])  when  end)olic  ])lienomena  ai)pcar.  The  frecpient  complication  of 
meningitis  with  the  endocarditis  of  jineumonia,  which  has  already  been 
mentioned,  gives  jirominence  to  the  cerebral  symptoms  in  these  cases.  The 
jihysical  signs  may  be  very  deceptive.  There  are  instances  in  which  no 
cardiac  murmurs  have  been  heard.  In  others  the  development  under 
observation  of  a  loud,  rough  murmur,  particularly  if  diastolic,  is  extremely 
suggestive. 

Myoranlifis  is  rare. 

Heart-clots. — Ante-mortem  coagula  are  unconnnon  in  pneumonia,  even 
in  extreme  grades  of  dilatation  of  the  right  chamber.  In  not  a  single  in- 
stance of  my  auto])sies  were  there  globular  thrombi  in  the  auricles  or  in 
the  apices  of  the  ventricles.  In  ])rotracted  cases  thrombi  occasionally  form 
in  the  veins.  A  rare  com])lication  is  emhoUsm  of  one  of  the  larger  arteries. 
1  saw  in  ]\Iontreal  an  instance  of  end)olism  of  the  femoral  artery  at  the 
height  of  ])ncumonia,  Avhich  necessitated  amputation  at  the  thigh.  The 
]iatient  recovered.  Aphasia  has  been  met  with  in  a  few  instances,  setting 
in  ahrnjjtly  with  or  without  hemi])legia. 

Menimjitis  is  porha])S  the  most  serious  com])lication  of  pneumonia.  It 
varies  very  much  at  dilTercnt  times  and  in  different  regions.  j\Iy  Montreal 
experience  is  rather  exceptional,  as  8  iier  cent  of  the  fatal  cases  had  this 
complication.  It  usually  comes  on  at  the  height  of  the  fever,  and  in  the 
majorit"  of  the  cases  is  not  recognized  unless,  as  hefore  mentioned,  the 
base  is  involved,  which  is  not  common.    j\Icningitis  may  develop  later  in 


LOMAU   PXHl'MOXIA. 


12: 


itirticu- 
(!c.  It 
siu.  It 
]»lusti(', 
ill  tilt' 
ovorinti 
il  !<ijins, 

I'lili'lli'Srt 
vivc  tlu' 
'riinii-rli 
ICO  even 
eurilitif*, 

ras  prt'S- 
5  to  the 

lit     C'IhIk- 

0.     Sul)- 
fk  found 
ive  cndo- 
lio  ri^lit. 
ISO.     The 
no  pynip- 
It  may, 
icted  and 
d  sweats; 
tion    of 
idy  hoon 
SOS.    The 
Inch  uo 
lit   under 
xtremely 


nia,  even 
iingle  in- 
■k's  or  in 
ully  form 
arteries. 
i-y  at  tlie 
lr"h.  Tlie 
<,  settinjr 

Ionia.     It 

hlontrcal 

had  this 

id  in  the 

^med,  the 

later  in 


the  disease,  and  is  then  iiiorc  easily  dia^rnosed.  In  some  cases  it  is  associ- 
nted  with  inTective  endoeanlilis.  The  pneiimocoecus  has  hceii  t'nund  in 
the  exudate. 

Peri  phi' nil  nrinltis  is  a  rare  romplication,  (d'  which  several  eases  liave 
been  dcscril)ed.  1  saw  one  well-maiketl  instance  following  piu'umoiiia  and 
influenza  in  the  spring  of  l.siMi.  'I'here  was  neuritis  of  the  left  arm  with 
coiisiderahle  wasting. 

(Iiislrir  citttijiliciilliiuH  are  rare.  A  ornnjious  gastritis  has  already  hi'en 
mentioned.  The  cvoupDUx  rnlllls  may  indiic(>  severe  diarrlnea.  .Jiiuiiilin' 
is  one  of  the  most  interesting  coniplications  of  |tneumonia  and  occurs  with 
curious  irregularity  in  dilVerent  oiithreaks  of  the  disease,  it  sets  in  early, 
is  rarely  very  intense,  and  has  not  the  eharaeters  of  ohstructive  jaundice. 
There  are  cases  in  which  it  assumes  a  very  si-rious  form.  The  niotle  of  |»ro- 
ductioii  is  not  well  ascertained.  It  does  not  appear  to  hear  any  dclinite 
relation  to  the  degree  of  hepatic  engorgement  and  it  is  certainly  not  due 
to  catarrh  of  the  ducts.    I'ossihly  it  may  he,  in  great  part,  Inematogenons, 

I'ltrolills  occasionally  occurs,  ('(ininioiily  in  association  with  endocar- 
ditis.   Jn  children  middle-ear  disease  is  not  an  infretpient  complication. 

Ih'i(/hrs  disease  does  not  often  follow  pneumonia.     I'i'rilniiitis  is  ex- 


ceedingly rare. 


The  relations  of  rhniiDfiUsni  and  ])neiinionia  are  very  interesting.  'J'lie 
arthritis  may  precede  the  onset,  and  the  piieimionia,  possihiy  with  endo- 
carditis and  pleurisy,  may  occur  as  a  complication  of  the  rheumatism.  Jn 
other  instances  at  the  height  of  an  ordinary  pneumonia  one  or  two  joints 
may  become  red  and  sore.  On  the  other  hand,  after  the  crisis  has  occurred 
pains  and  swelling  may  come  on  in  the  joints. 

Kelapse. — There  are  cases  in  which  from  the  ninth  to  tlie  eli'vciith 
day  the  fever  subsides,  and  after  the  temperature  has  been  normal  for  a 
day  or  two  a  rise  occurs  and  fever  may  jiersist  for  another  ten  days  or  even 
two  weeks.  Though  this  might  be  termed  a  relapse,  it  is  more  correct  to 
regard  it  as  an  instance  of  an  anomalous  course  of  delayed  resolution. 
Wagner,  who  has  studied  the  subject  carefully,  says  that  in  'iis  large  ex- 
perience of  1,100  cases  he  met  with  only  3  doubtful  cases.  Vs'hen  it  does 
occur,  the  attack  is  usually  abortive  and  mild.  In  the  case  of  Z.  R.  (Medical 
Xo.  42"^3),  with  pneumonia  of  the  right  lower  lobe,  crisis  occurred  on 
the  seventh  day,  and  after  a  normal  tem])eratiire  for  thirteen  days  he  was 
discharged.  That  night  he  had  a  shaking  chill,  followed  by  fever,  and  he 
had  recurring  chills  with  reappearance  of  the  pneumonia.  In  a  second 
case  CMedical  No.  4538)  crisis  occurred  on  the  third  day,  and  there  was 
recurrence  of  pneumonia  on  the  thirteenth  day. 

Eccnrrence  is  more  common  in  pneumonia  than  in  any  other  acute 
disease.  Rush  gives  an  instance  in  which  there  were  28  attacks.  Other 
authorities  narrate  cases  of  8,  10,  and  even  more  attacks. 

Convalescence  in  pneumonia  is  usually  ]ironipt  and  ra])id,  and  sequeliv 
are  rare.  Some  authors  speak  of  a  sudden  fatal  colla])se  when  the  patients 
are  allowed  to  get  up  and  go  about  too  soon.  With  the  onset  of  fever  and 
persistence  of  the  leucocytes  the  affected  side  should  be  very  carefully 
examined  for  pleurisy.     With  a  persistence  of  the  dulness  the  physical 


I'^O 


SI'KCIFU'  INFKCTIor.H  DISKASKS. 


hi;.MiH  iiiiiv  lie  oliscuri',  lutt   the  \\>v  of  n  siiinll  fvplonilory  nt'c(llt>  will  lio 

ImIIIkI     \rlV    Mlt  i'flK'tdl'V. 

Clinical  Varieties.  I.  I.ncal  viirintiini  mi'  rrs|iuiihil»li'  |f)r  SMiuc  III' 
till'  iiiii>t  iiiiirkt'd  <l(viiitiuMs  Iniiii  tlif  ii>iiiil  tv|u>. 

Ajir.r  iniiiihnmia  is  miiil  to  lir  iimrL'  ol'tcii  assofiiitod  with  ndynninic 
I'nitiircrt  iiikI  with  iiiiirki-cl  ccri'lirnl  syiiiiitoms.  The  (•xpcctdrntiiin  niul 
tiiii;:h  iiiny  1)1'  !-li;:lit.  I  ciiii  nut  >\\\  lliut  in  iiiv  ('Xiu'ricMcf  ilic  ccivhrai 
t-yiii|it(iiiiH  in  iidiilts  liiivc  hccii  more  niiirkcd  in  tlii.s  i'onn,  noi'  do  i  think 
it  nt'ccsciirily  |ini\fr  tliiin  if  silniitcd  nl  llic  l)«t?i'. 

M iiliiilnri/  or  iri'i'iniii/  jiiiciiiiiniiid,  a  I'orni  which  HUCcoHsivoly  involves 
nnt'  Inhc  al'tcr  the  otlicr. 

piiiililr  /inriniiiiiiid  has  no  pi'i-nliarities  otluT  than  tho  givatcr  daiigor 
(•onnccti'd  w  itii  it. 

Mafxim  pnt'innoiiUi  is  a  rare  form,  in  which  not  alon(!  tho  air-r-clls  hnt 
the  hronchi  of  an  cntin'  loho  or  even  of  a  \n\\)i  arc  lillcd  with  the  lihrinons 
cMidatc.  The  anscnltalory  hij^ns  ai'e  ahscnl;  lln-re  is  neilher  freniiliis  nor 
tnltular  hreathin^',  and  on  |H.'rcu>iHion  the  Innjj  \^  ahsolutely  Hat.  it  closely 
re>enililes  pleurisy  with  olVnsion.  'I'lie  moulds  of  the  hronchi  may  lie  ex- 
pectorated in  violent  (its  of  couuhin^r- 

Cfiilnil  I'liriiiiiniiid. — 'i'lie  inllanuual ioi)  may  lie  deep-seated  at  llie 
root  of  the  lunji'  or  centrally  placed  in  a  lolte,  and  for  several  days  the  diaj;- 
nosis  nuiy  he  in  doidit.  It  may  not  lie  until  the  thii'd  or  fourth  day  that  a 
jileural  friction  is  detec'led,  or  that  dulness  c>r  hlowin;;  hreathini^  and  nUes 
ari'  rec(»;:nized.  I  saw  recently  with  l)r.  lleni'y  Adier  and  l)r.  Chew  an 
instaiU'c  in  which  at  the  end  of  the  fourth  day  in  a  yonnir,  thin-chestei] 
jjiil  all  the  usual  symptoms  of  pneunxmia  were  present  without  any  phys- 
ical sitrns  other  than  a  few  clicking,'  ri'des  at  the  left  a|)ex  hehind.  The  thin- 
ness of  the  ]iatient  j^icatly  facilitated  the  examination.  The  ;:-eneral  fea- 
tures of  pneumonia  coiitinnt'd,  and  the  crisis  occurred  on  the  seventh  day. 

v'.  riiciiiiKniid  III  Infants. — It  is  sometimes  seen  in  tho  newhorn.  In 
infants  it  very  often  sets  in  with  a  convulsion.  The  sninmit  of  the  \\\\\'^ 
seems  more  fi'e(piently  involved  than  in  adnlts.  and  llu'  cerehral  symptoms 
are  more  marked.  The  tor])or  and  coma,  ]mrticularly  if  they  follow  con- 
vnlsions,  and  the  preliminary  static  of  excitement,  may  lead  to  the  diag- 
nosis (if  meningitis.     Pneumonic  sputum  is  rarely  seen  in  children. 

?>.  I'nriinionid  in  IJir  Ai/i'i]. — The  disease  may  he  latent  and  set  in  Avith- 
<iiit  a  chill:  the  cough  and  exi)ectoration  are  slight,  tli(>  ])liysical  signs  ill- 
delined  and  changeahle,  and  the  constitutional  symptoms  out  of  all  \m)- 
jiortion  to  tho  extent  of  tho  local  lesion. 

-I.  I'nriiidniild  In  Alcoholic  Siihjcrls. — Tho  onset  is  insidious,  the  <ymp- 
toms  masked,  the  fever  slight,  and  the  clinical  ]>ictnre  usually  that  of 
delirium  tremens.  The  thermometer  alone  may  indicate  the  ])resence  of 
an  acute  disease.  Often  the  local  condition  is  overlool-ced,  as  the  ])atient 
makes  no  complaint  of  jiain,  ami  (here  may  he  very  little  shortness  of 
breath,  no  cough,  and  no  s]iutum. 

.").  Trnnhidl  rnmninnla. — The  wards  and  the  post-mortem  room  show 
a  very  striking  contrast  in  their  ])neuni<inia  statistics,  owing  to  (he  occnr- 
rcnco  of  what  may  he  called  terminal   i)neumonia.     During  tho  winter 


J 


i 


LoUAll   I'N'KL'MON'IA. 


127 


ivill  l»o 

iilllt'    of 

ymui\i*' 
III  uikI 
•cirhnil 
I  tliink 


(}lVL'ri 


HV 


(1iiM;j:i'r 

•oils  l)Ut 
ihriiums 
ilus  iii»r 
I  clost'ly 
y  1)0  ex- 

iit  the 
[he  (liii.u- 
\\  that  11 
md  vi'iles* 
Chew  ail 

l-(.'lU'StO«l 

iiy  l»hys- 
'hc  thiii- 
cral  I'ra- 
ith  (hiy. 
i>rn.  In 
tlu'  lunjj; 
vinptoms 

low    Cdll- 

hc  (liag- 
II. 

in  Avith- 
Isiiiiis  ill- 
all  i)ro- 

iic  <yini>- 

that    "f 

'st'iice   ni 

jo  ijatient 

Irtne^s  of 

join  show 
he  oooiiv- 
\o  wintov 


inontliH  pnticnts  with  clirunic  |tiihiii»iiary  tiilicrciiinHlM,  nrtcrio-sckToKiH, 
iifiirt  (lis('Hi*o,  Uri;,Mit*H  (liKi-asc,  ainl  dialictes  iiic  not  iiilri'iinrnily  ciirrii'il 
nil"  hy  II  i»ii('iiiiiiiiiiii  wliicii  iiiny  jiive  tVw  or  no  hij-iis  of  its  |iiv>t'ni'L'.  Tlun; 
may  lu-  a  sliirlit  clfvation  of  t('iii|H'nitiirc,  with  iiicn'iisc  in  the  n's|tiratioiH, 
hut  till'  juiticiit  is  iirar  the  cikI  ami  |ii'i'|ia|is  not  in  a  comlitioii  in  wliicli 
a  tli(iroii;ili  |iliysi(al  cxaminalion  (-in  he  niailt'.  Tlic  autopsy  nuiy  slmw 
|imiimniiia  of  tlic  ^^rcatcr  |iai't  of  one  lower  'ulic  m-  of  tlic  a|M'\,  vvliidi  liad 
riitircly  csfiiiM'd  notice.  In  diabetic  |tiitieiitJ  the  disease  uflcii  niiis  a  rapid 
and  severe  course,  and  may  end  in  altscess  cr  ii;an;.'r"iie. 

Some  of  the  most  remai'kaiile  varialioiis  in  llie  (dinical  cniirM'  of  piini- 
iiiiiiiia  (Irpeiid  proiiahly  upon  llie  .-cverily.  pnssilily  iipnii  llic  iialnre  nl  the 
infective  a^t'iil.  l-'iirlliei-  investijiiitioii  may  eiialde  us  to  say  how  I'lir  tlie 
T'^sociated  orj^aiiisms,  >o  often  ]>re»;'!'.;,  may  he  respoiisilile  for  the  dilTcr- 
I'lices  in  tlie  clinical  course. 

(!.  Sirdiiddni  I'liniiiKuiltis. — These  arc  met  willi  chielly  in  the  specilic 
h'Ncrs,  pail  iculiii  ly  diphtheria,  typhoid  fe\er,  typhus,  intliieii/a.  and  the 
phiLiUe.  Anatomically,  they  rarely  present  the  typical  form  of  red  or  ^ray 
licpati/atioii.  The  surface  is  smoother,  not  so  dry,  and  it  is  often  a  pseiido- 
lohar  condition,  a  consolidation  caused  hy  clusely  set  areas  of  lohiilar  iii- 
Milvemciit.  Jlistolo^neally,  they  are  charaeteri/.eil  in  maiiy  instances  hy  a 
more  ei'llnlar,  less  (ihrinons  exudate,  which  may  also  inliltrate  the  alveolar 
walls.  Uaeteriolo<:iciilIy,  a  lar<,'e  niiinher  of  dilVereiit  oiyanisms  have  heeit 
found,  the  s])ecilic  niicrohe  of  the  primary  disease,  usually  in  association 
with  the  >treplococciis  pyo^'eiies  or  the  staphylococcus;  in  some  iii-taiices 
the  Colon  hacillus  has  heeii  iiresent.  I'inkler  has  attempted  to  separate  a 
special  form,  which  he  calls  the  dciilr  rrlhihtr  /iiii'KiiKiiiio,  to  which  most  of 
these  secondary  types  conform  and  which  have  the  liistolo^icul  characters 
already  referred  to  (Die  Aeuten  Lun^'enentzimdiiiiiien,  1S!»1). 

The  syni])tonis  of  the  secondary  pneumonias  (d'ten  lack  the  strilsini,' 
definiteness  of  the  primary  croupous  pneumonia.  I'he  pulmonary  features 
may  he  latent  or  masked  alto<i'ether.  There  may  he  no  couj^li  and  only  a 
slight  increa.se  in  the  luimlier  of  respirations.  Tlie  lower  lohe  of  one  lunjij 
is  most  commonly  involved,  and  the  iihysical  sifins  are  ohsenre  and  rarely 
amount  to  more  than  imjiaired  resonance,  feehle  breathing,  and  a  few 
(racklinji  nlles.  In  some  instances  when  the  consolidation  is  o.\tensiv(>  the 
hreathinj^  is  distinctly  tuhnlar. 

7.  EjtHleiiilc  pncvnuinia  has  already  heen  referred  to.  It  is,  as  a  rule. 
more  fatal,  and  often  dis])lays  minor  com]»lications  which  diU'er  in  dilTer- 
ent  outbreaks.  Tn  some  the  cerebral  manifestations  are  very  marked;  in 
others,  the  cardiac;  in  others,  a,train,  the  ••■astro-intestinal. 

8.  Larval  Pneumonia. — "Mild,  ahortivo  ty])es  are  seen,  ])articnlarly  in 
institntions  when  ])nenmonia  is  prevailing  extensively.  A  jiatient  may 
have  the  initial  i^ymptoms  of  the  disease,  a  slijrht  chill,  moderate  fever, 
a  few  indefinite  local  si<rns,  and  herpes.  The  whole  process  may  only  last 
for  two  or  three  days:  some  anthors  recognize  even  a  one-day  pneumonia. 

9.  Asllirnir,  Tn.vir,  or  'fi/phoid  Pneumonia. — The  toxa^mic  featnres 
dominate  the  scene  thronghont.  The  local  lesions  nay  he  slight  in  extent 
and  the  sidijectivc  ])henomcna  of  the  disease  ahsent.     The  nervons  .cym]i- 


5:f 


1^ 


128 


SPECIFIC  INFECTIOUS  DISEASES. 


tuins  usuully  prtHloiiiiiiate.  There  arc  delirium,  ])rostration,  and  early 
Mi-akness.  \  ery  i'rcHjUcntly  tiiei'e  is  jaundice.  Ua.stnj-intestinal  i?yni|tt()iu3 
may  Ije  present,  particularly  diarriuea  and  meteorism.  Jn  such  a  case,  seen 
al)()ut  tlie  end  of  the  iirst  week,  it  luay  be  dillicult  to  say  whether  the  con- 
dition is  one  of  asthenic  i)neunionia  or  one  of  ty})hoid  fever  which  has  set 
in  with  early  localization  in  the  lung.  Here  the  Widal  reaction  would  bo 
an  important  aid.  In  these  cases  there  is  really  a  i)neumococeus  septi- 
ca-iuia,  and  the  or'i'anisms  juay  sometimes  be  isolated  from  the  blood. 
l*()ssil)ly,  too,  there  is  a  mi.xed  infection,  and  the  streptococcus  pyogenes 
nuiy  be  in  large  j)art  res[)onsible  for  the  toxic  features  of  the  disease. 

10.  Assoridlidn  of  I'liciiiitonia  with  vUier  Diseases. — (a)  With  Malaria. 
— A  malarial  pneumonia  is  described  by  many  observers  and  thought  to  be 
]»artieularly  prevalent  in  some  })arts  of  this  country.  One  hears  of  it,  in- 
deed, even  where  true  malaria  is  rarely  seen.  With  our  large  experience  in 
malaria,  amounting  now  to  nearly  2,000  cases,  and  a  considerable  nuud)er 
of  pneumonia  ])atients  every  year,  we  have  only  had  a  few  cases  in  which 
tlie  latter  disease  has  developed  during  malarial  fever,  or  vice  versa,  lu 
either  case  the  malaria  yields  prom])tly  to  the  action  of  quinine.  So  far  as 
tlie  Southern  States  are  concerned,  the  cpiestion  of  a  special  form  was 
thrashed  out  years  ago  in  a  discussion  between  Manson  and  W.  T.  Howard, 
and  was  decided  in  the  negative.  A  form  of  pneumonia  directly  dei)endent 
upon  the  malarial  i)arasite  is  unknown.  "We  have  not  been  able  to  recog- 
nize here  a  pneumonia  which  is  influenced  in  any  way  by  the  malarial 
poison.  Such  a  case  as  the  following  we  see  occasionally:  A  patient  was 
admitted,  ]\Iarch  IG,  18!)4,  Avith  tertian  malarial  fever.  The  lungs  were 
clear.  A  ])neumonia  began  thirty-six  hours  after  admission.  Quinine  was 
given  that  evening,  and  the  malarial  organisms  rapidly  disappeared  from 
the  blood.  There  was  successive  involvement  of  the  right  lower,  the  middle, 
ami  the  left  lower  lobe.  The  temi)erature  fell  by  crisis  on  the  24th,  and 
there  were  no  features  in  the  disease  whatever  suggestive  of  malaria.  In 
other  instances  we  have  found  a  chill  in  the  course  of  an  ordinary  pneu- 
monia to  l)e  associated  with  a  malarial  infection,  and  quinine  has  ra])idly 
and  i)rouiptly  caused  the  disap])earance  of  the  jiarasites  from  the  blood. 

(7;)  Piiraiiioiiia  and  Anile  I'heanintisDi. — "We  have  already  spoken  under 
comi>]ications  of  this  association,  which  is  uiore  frequently  seen  in  children. 

(r)  Pneumonia  and  7'uhercuhsis. — ^lany  subjects  of  chronic  pulmonary 
tid.)erculosis  die  of  an  acute  croupous  pneumonia.  A  point  to  be  specially 
borne  in  mind  is  the  fact  that  acute  tuberculous  pneumonia  may  set  in 
with  all  the  features  and  physical  signs  of  fibrinous  pneumonia  (see  i)ago 
21)0). 

For  the  consideration  of  the  association  of  pneumonia  with  typhoid 
fever  and  influenza,  the  reader  is  referred  to  the  sections  on  those  diseases. 

11.  Posl-Dperalion  Pnenmnnia. — ?)efore  the  days  of  ann:^sthesia,  lobar 
pneumonia  was  a  well-recognized  cause  of  death  after  surgical  injuries  and 
operations.  Xorman  Cheevers,  in  an  early  number  of  the  Guy's  Hosjiital 
T?e])orts,  calls  attention  to  it  as  one  of  the  most  frequent  causes  of  death 
after  surgical  procedures,  and  Erichsen  states  that  of  41  deaths  after  sur- 
gical injuries  23  cases  exhibited  signs  of  pneumonia.     The  lobular  form 


i   ^0 

I 


i 


LOBAR  PNEUMONIA. 


129 


A  early 
luptoiua 
ISC,  scon 
the  fon- 
i  has  set 
\-ov\U\  ho 
lis  scpti- 
e  hh)(Hl. 
pyogenes 

JC. 

Malaria. 
rht  to  ho 
ol"  it,  in- 
ricnce  in 
;  munljcr 
in  which 
crsa.  In 
So  far  as 
forni  was 

Howard, 
lopendcnt 

to  rccog- 
)  mahirial 
itient  was 
nigs  were 
iiiine  was 
ired  from 

c  middle, 
24th,  and 

aria.  In 
ary  pn on- 
us rapidly 

)lood. 

en  under 
children. 

)\dmonary 
specially 

lay  set  in 

(see  page 

typhoid 
diseases, 
'sia,  lohar 
juries  and 
Hospital 
of  death 
after  snr- 
ular  form 


is  the  most  frequent.    I  have  already  referred  to  the  contusion-pneumonia 
descrihed  hy  Litten. 

12.  I'JtIicr  rneuinonia. — The  question  of  a  direct  rehition  hetween  ether 
narcosis  and  jjiicunionia  has  l)ot'n  much  discussed  within  the  jiast  year, 
having  heen  raised  hy  Mr.  Luca.s,  of  liuy's  Hospital.  The  statistics  are  hy 
no  means  unanimous.  Troscott,  of  Boston,  in  40,000  cases  found  only  3 
of  acute  lohar  pneumonia.  The  London  ana'sthetists,  ])articularly  Hewitt 
and  Silk,  seem  also  to  have  had  a  fortunate  experience.  Silk  having  found 
among  5,000  cases  13  of  pneumonia;  8  of  these  were  tongue  or  jaw  cases. 
The  (ierman  experience  is  very  diU'erent.  Von  Beck  states  that,  owing  to 
the  injurious  after-eU'ects  upon  the  respiratory  tract,  the  use  of  ether  has 
heen  largely  restricted  in  Czerny's  clinic.  Gurlt  reports  52,177  cases,  with 
'.]()  cases  of  ])neumonia  and  15  deaths.  On  the  surgical  side  of  the  Johns 
Hopkins  Hospital,  I)r.  Bloodgood  tells  mo  there  have  heen  15  cases  of 
])neumonia  following  amosthosia;  12  of  those  have  heen  hroncho-jipcu- 
monias;  7  deaths  and  8  recoveries;  79  per  cent  of  the  cases  follo\ved  ah- 
dominal  soctujn  or  hernia  operations.  Czerny  suggests  that  the  relation 
of  llieso  ether  i)neumonias  to  ahdominal  oi)orations  is  associated  with  tlio 
pain  on  coughing,  which  leads  to  an  accumulation  of  secretion,  and  through 
this  to  retention  or  aspiration  pneumonia.  Amon^^  the  various  views 
hrought  forward  to  account  for  it  are  the  rapid  ovapoiation  of  the  ether, 
causing  chilling  of  the  pulmonary  tissues,  chilling  of  lie  patient  at  the 
time  of  operation,  infection  from  the  iidialor,  and  direct  action  of  the 
other. 

The  prohahility  is  that  the  prolonged  etherization  lowers  the  vitality 
of  the  tissues  of  the  finer  hronchi  and  permits  the  ])athogonic  organisms 
(which  are  almost  alw.ays  present)  to  do  their  work.  The  ])noumonia  is 
more  frequently  lohular  than  lohar.  Xouwerck,  and  suhsocpiontly  Wiiitnoy, 
have  suggested  thorough  disinfection  of  the  mouth  and  L.iroat  heforo 
operation. 

13.  Dchn/ed  TiCsnlitlion  in  rncumonla. — The  lung  is  restored  to  its  nor- 
mal state  ])artly  hy  the  expectoration  of  tlio  exudate,  ])artly  hy  its  licpiefac- 
tion  and  al)sor])tion.  There  are  cases  in  which  resolution  takes  jdaco  rapidly 
without  any  increase  in  or,  indeed,  without  any  ex])ectoration;  on  the 
other  hand,  during  resolution  it  is  not  uncommon  to  find  in  the  sputa  the 
little  i)lugs  of  fihrin  and  leucocytes  which  have  1)cen  loosened  from  the 
air-cells  and  expelled  hy  coughing.  In  a  majority  of  cases  hoth  processes 
are  prohahly  at  work.  A  variahle  time  is  taken  in  the  restoration  of  the 
lung.  Soiuetimes  within  a  week  or  ten  days  the  dulness  is  greatly  dimin- 
ished, tlie  hroath-sounds  hecome  clear,  and,  so  far  as  physical  signs  are 
any  guide,  the  lung  seems  perfectly  restored.  It  is  to  he  rememhered  that 
in  any  case  of  pneumonia  Avith  extensive  pleurisy  a  certain  amount  of 
dulness  will  persist  for  months,  oAving  to  thickening  of  the  pleura. 

Delayed  resolutiou  is  a  condition  which  causes  much  anxiety  to  the 
physician.  Wliile  it  is  perhaps  more  frequent  in  dehilitated  persons,  yet 
it  is  met  with  in  robust,  previously  healthy  individuals,  and  in  cases  which 
have  had  a  very  typical  onset  and  course.  The  condition  is  stated  to  he 
most  frequent  in  apex  pneumonia.     Venesection  has  heen  assigned  as  a 


130 


SPECIFIC  INFECTIOUS  DISEASES. 


cause.  There  is  no  question  tliat  tlie  solid  exudate  can  persist  for  weeks 
and  yet  the  intc,i:i'ily  ol'  tlie  ]un<i-  may  idtiniatciy  be  restored.  Grissole  de- 
scribes tlie  lung  ironi  a  patient  who  died  on  the  sixtieth  day,  in  which  the 
alTected  ])art  showed  n  condition  not  unlike  that  of  the  acute  sta<;e. 

C'linicalh',  there  are  several  <,n'oups  of  cases:  i'irst,  those  in  which  the 
crisis  occurs  naturally,  the  teiuperature  falls  and  remains  normal,  but  the 
local  features  ]iersist — well-nuirked  llatness  with  tubular  breathing  aud 
ndes.  iicsolulion  may  occur  ^■ery  slowly  and  gradually,  taking  from  two 
to  three  M'eeks.  Jn  a  second  group  of  cases  the  temperature  falls  by  lysis, 
and  with  the  ])ersistence  of  the  local  signs  there  is  shght  fever,  sometimes 
.'tweats  and  rapid  pulse.  The  condition  may  ])ersist  for  three  or  four  weeks, 
or,  as  in  one  of  my  cases,  for  eleven  weeks,  and  ultimately  perfect  resohition 
occur.  During  all  this  time  there  may  be  little  or  no  sputum.  The  prac- 
titioner is  naturally  much  exercised,  and  he  dreads  lest  tuberculosis  should 
sui)ervene.  In  a  third  group  the  crisis  occurs  or  the  fever  falls  l)y  lysis, 
but  the  consolidation  ])ersists  and  there  may  be  intense  bronchial  breath- 
ing, with  few  or  no  rilles,  or  the  fever  may  recur  and  the  patient  may  die 
exhausted.  In  1  of  my  100  autopsies  a  i)aticnt,  aged  fifty-eight,  had 
died  on  the  thirty-second  day  from  the  initial  chill.  The  right  lung  Avas 
solid,  grayish  in  color,  firm,  and  presented  in  places  a  translucent,  semi- 
homogeneous  aspect.  In  these  areas  the  alveolar  walls  were  thickened,  and 
the  plugs  filling  the  air-cells  Avere  undergoing  transformation  into  new 
connective  tissue.  This  fibroid  induration  may  proceed  gradually  and  be 
associated  with  shrinkage  of  the  aifected  side,  and  the  gradual  production 
of  a  cirrhosis  or  chronic  interstitial  pneumonia. 

Ordinary  fibrinous  pneumonia  never  terminates  in  tuberculosis.  The 
instances  of  caseous  pneumonia  and  softening  which  have  followed  an 
acute  pneumonic  process,  have  been  ivoni  the  outset  tuberculous  (see  page 
290). 

14.  Tcrminailnn  in  Abscess. — This  occurred  in  4  of  my  100  autopsies. 
Usually  the  lung  breaks  down  in  limited  areas  and  the  abscesses  are  not 
large,  but  they  may  fuse  and  involve  a  considerable  proportion  of  a  lobe. 
The  condition  is  recognized  by  the  sputa,  which  is  usually  abundant  and 
contains  |)us  and  elastic  tissue,  sometimes  cholesterin  crystals  and  hivma- 
toidin  crystals.  The  cough  is  often  paroxysmal  and  of  great  severity; 
usually  the  fever  is  remittent,  or  in  ])rotracted  cases  intermittent  in  char- 
acter, and  there  may  be  ])ronounced  hectic  sym]itoms.  "When  a  case  is 
seen  for  the  first  time  it  may  be  difficidt  to  determine  whether  it  is  one 
of  abscess  of  the  lung  or  a  local  em])y;vma  which  has  ])erforated  the 
lung. 

15.  Gangrene. — This  is  most  commonly  seen  in  old  debilitated  persons. 
It  Mas  ])resent  in  3  of  my  100  auto]isies.  It  very  often  occurs  with  abscess. 
The  gangrene  is  associated  with  the  growth  of  the  saprophytic  bacteria  on 
a  soil  made  favorable  by  the  ])resence  of  the  pnenmococcns  or  the  strepto- 
coccus. Clinically,  the  gangrene  is  rendered  very  evident  by  the  horribly 
fetid  odor  of  the  expectoration  and  its  characteristic  features.  In  some 
instances  the  gangrene  may  be  found  ]iost-mortem  when  clinically  there 
has  not  been  any  evidence  of  its  existence. 


or  weeks 
issole  du- 
•hich  the 
{-■e. 

■Inch  tlie 
,  but  the 
ling  ami 
from  two 

hv  Ivr-is, 
oim.'tim<-'= 
u;-  weeks, 
resolution 
rhe  jji'ia- 
?is  should 
i  by  lysis, 
111  breath- 
t  may  die 
iji-ht,   had 

lung  was 
ent,  semi- 
:ened,  and 

into  new 
,ly  and  be 
)roduction 

)sis.  Tlie 
lowed  an 
(see  page 

autopsies. 

s  are  not 

of  a  lobe. 

ulant  and 

nd  h  anna- 
severity; 

t  in  char- 
a  case  is 
it  is  one 

)rated   the 

d  persons, 
nth  abscess, 
lacteria  on 
je  strepto- 
|e  horribly 
In  some 
[ally  there 


i 


LOBAR   rXEUMUNIA. 


181 


, 


Prognosis. — Pneumonia  is  the  most  fatal  of  all  acute  diseases,  killing 
more  than  diphtht-ria,  and  ranking  next  to  consumption  as  a  cause  of  death. 

Jlosjiilal  statistics  show  tliat  the  mortality  ranges  from  ^'()  to  40  per 
cent.  ()i  1,012  cases  at  the  Monti'eal  (ieneral  llos|)itid,  the  morlalily 
was  'vMl.l  ]»er  cent.  It  api)ears  to  be  somewhat  more  fatal  in  southern 
climates.  Of  3,U(it)  eases  treated  at  the  Charity  Hospital,  Xew  Orleans,  the 
death-rate  was  JJS.Ol  \wv  cent.  Of  the  first  Vii  cases  admitted  to  or  devel- 
oping in  the  Johns  Hopkins  Hospital,  oT  died,  a  mortality  of  "^U.S  per  cent. 
Ju  704  cases  at  the  J'ennsylvania  J]os])ital  the  mortality  was  2d  \wv  cent. 
At  the  i)Oston  City  Hospital  in  l,llo  eases  the  mortality  was  'i\).\  [)er  cent. 
It  has  been  urgi'd  that  the  mortality  in  this  disease  has  been  steadily  in- 
creasing, and  attempts  have  been  nuule  to  coniu'ct  this  increase  with  the 
expectant  i)lan  of  treatment  at  })resent  in  vogue.  lUit  the  careful  and  thor- 
ough analysis  by  C.  X.  Townsend  and  A.  Coolidge,  Jr.,  of  1.000  cases  at 
the  ^lassaehusetts  CJeiieral  Hos[)ital  iiidieates  clearly  that,  when  all  cir- 
(iinistances  are  taken  into  consideration,  this  conelusion  is  not  justified. 
I'liey  found  that  when  all  fatal  cases  over  iil'ty  years  of  age  were  omitted, 
and  those  patients  who  were  delicate,  intemperate,  or  the  subject  of  some 
com[)lication,  there  was  very  little  vai'iation  fnun  decade  to  decade,  and 
that,  excluding  these  cases,  the  rate  was  but  little  over  10  per  cent.  Hi 
answer  to  the  assertion  that  the  modilied  treatment  is  in  part  res[)onsi1)le 
iov  the  increased  mortality,  these  authors  show  clearly  that  the  rise  in 
death-rate  took  place  in  the  })eriod  prior  to  18G0,  when  the  treatment  was 
entirely  or  in  great  part  heroic. 

Act'ording  to  the  analysis  of  708  cases  at  St.  Thomas's  Ifospital  ])y 
Hadden,  H.  W.  (J.  .McKenzie,  and  W.  W.  Ord,  the  mortality  progres.^ively 
increases  from  the  twentietli  year,  rising  from  S.T  ]>er  cent  under  that  age 
to  'Z'l  ])er  cent  in  the  third  decade,  30.8  ])er  cent  in  the  fourth,  47  i)er  cent 
in  the  fifth,  51  per  cent  in  the  sixth,  05  \)QV  cent  in  the  seventh  decade. 
Of  2"-?3,T30  cases  collected  by  Wells  from  various  sources,  40,*^Tn  died,  a 
mortality  of  IS.l  i)er  cent. 

The  mortality  in  ])rivate  ]n-actice  varies  greatly.  1\.  P.  Howard  treated 
170  cases  with  only  G  per  cent  of  deaths.  Fussell  has  recently  reported  134 
cases  with  a  mortality  of  17.9  per  cent.  The  mortality  in  children  is  some- 
times very  low.  Morrill  has  recently  re])orted  G  deaths  in  1:^3  cases  of  frank 
pneumonia.     On  the  other  hand,  Goodhart  had  25  deaths  in  120  cases. 

The  following  are  among  the  circumstances  which  influence  the  prog- 
nosis: 

A(je. — As  Sturges  remarks,  the  old  are  likely  to  die,  the  young  to  re- 
cover. Under  one  year  it  is  more  fatal  than  between  two  and  five.  Fus- 
sell lost  5  out  of  8  cases  in  3'earlings.  At  abont  sixty  the  death-rate  is  very 
high,  amounting  to  GO  or  80  per  cent.  So  fatal  is  it  in  tliis  country,  at  least, 
that  one  may  say  that  to  die  of  ])neumonia  is  the  natural  end  of  old  people. 

As  already  stated,  the  disease  is  more  fatal  in  the  negro  than  in  the 
white  race. 

Previous  habits  of  life  and  the  condition  of  bodily  health  at  the  time 
of  the  attack  form  the  most  imi)ortant  factors  in  the  prognosis  of  pneu- 
monia.   In  analyzing  a  series  of  fatal  cases  one  is  very  much  imi)ressed  with 


132 


SPECIFIC  INFECTIOUS  DISEASES. 


the  munl)cr  of  cases  in  wliicli  the  organs  sliow  signs  of  tlegencratlon.  In 
2o  of  my  lUU  autopsies  at  the  Montreal  (jenenil  liosi)itul  tiie  kidneys 
showed  extensive  interstitial  changes.  Individuals  debilitated  from  sick- 
ness or  poor  food,  iiard  drinkers,  and  that  large  class  of  hospital  patients, 
comi)osed  of  rohnst-looking  laborers  between  the  ages  of  forty-five  and 
sixty,  wiiose  organs  show  signs  of  wear  and  tear,  and  who  have  by  excesses 
in  alcoiiol  weakened  tiie  reserve  i)ower,  fall  an  easy  ]nvy  to  the  disease. 
Very  few  fatal  cases  occur  in  robust,  healthy  adults.  Some  of  the  statistics 
given  by  army  surgeons  show  Ijctter  than  any  others  the  low  mortality 
from  jineumonia  in  healthy  ])icked  men.  Tlie  death-rate  in  the  (lernian 
army  in  over  '1(»,()()()  cases  was  only  ;5.(j  ])er  cent. 

Certain  compUcations  and  terminations  are  particularly  serious.  The 
meningitis  of  jjiieumonia  is  i)robably  always  fatal.  Endocarditis  is  ex- 
tremely grave,  much  more  so  than  ])ericarditis.  Apart  from  these  serious 
complications,  the  fatal  event  in  i)neumonia  is  due  either  to  a  gradual 
toxiemia  or  to  mechanical  interference  with  the  respiration  and  circulation. 

Toxwrnia  is  the  important  prognostic  feature  in  the  disease,  to  which  in 
a  majority  of  the  cases  the  degree  of  pyrexia  and  the  extent  of  consolidation 
are  entirely  subsidiary.  It  is  not  at  all  j)roportionate  to  the  degree  of  lung 
involved.  A  severe  and  fatal  toxtemia  may  develoj)  with  the  consolidation 
of  only  a  small  ])art  of  one  lobe.  On  the  other  hand,  a  patient  with  com- 
plete solidification  of  one  lung  may  have  no  signs  of  a  general  infection. 
The  (piestion  of  individual  resistance  seems  to  be  the  most  important  one, 
and  one  sees  even  nu)st  robust-looking  individuals  fatally  stricken  within 
a  few  days. 

Much  stress  has  been  laid  of  late  upon  the  factor  of  leiicocytosis  as  an 
element  in  tlie  ]irognosis.  A  very  slight  or  com])lete  absence  of  a  leuco- 
cytosis  is  regarded  as  very  unfavorable.  Of  the  22  cases  from  my  wards 
reported  by  killings,  only  1  sluiwed  a  comj)lete  absence  during  the  entire 
course  of  the  disease.  In  6  fatal  cases  there  was  an  absence  of  leucocytosis 
at  some  period  of  the  disease.  As  a  rule,  it  may  be  said  that  the  continuous 
absence  of  leucocytosis  is  unfavorable. 

Death  from  direct  interference  with  the  function  of  res])iration  is  rare. 
It  may  hap]icn  in  extensive  double  pneumonia,  but  even  with  involvement 
of  a  very  large  section  of  both  lungs  recovery  may  take  place.  A  very  im- 
])ortant  element  in  the  prognosis  is  the  condition  of  the  lieart,  from  failure 
of  which  (|uite  as  many  die  as  from  the  intoxication.  The  heart  weakness 
may  be  due  either  to  the  s])ecifie  action  of  the  poison,  to  the  prolonged  fever, 
or  to  over-distcntion  of  the  right  chambers.  All  three  factors  may  be  at 
work  together.  I  have  already  referred  to  the  sudden  onset  of  serious  car- 
diac weakness;  more  commonly  there  is  a  gradually  increased  rapidity  w'ith 
increasing  weakness  of  the  heart  muscle.  The  pulse  is  not  always  a  safe 
guide;  since,  as  T  mentioned  before,  it  may  he  full  and  soft  and  not  very 
rapid  within  a  few  hours  of  a  fatal  termination,  even  in  cases  without  pro- 
nounced tox.Tmia. 

Diagnosis. — Xo  disease  is  more  readily  recognized  in  a  large  majority 
of  the  cases.  The  external  characters,  the  sputa,  and  the  physical  signs 
combine  to  make  one  of  the  clearest  of  clinical  pictures.     After  a  study 


LOBAR   PNEUMONIA. 


i;j3 


n.     In 

iclncys 

1  sick- 

itit'uts, 

,e  and 

xcessos 

lisoase. 

atistics 

Di-tulity 

Icnuan 

i.     The 
i  is  ex- 
serious 
gradual 
idation. 
rhich  in 
ilidation 
of  lung 
ilidation 
th  com- 
ifection. 
ant  one, 
1  within 

■is  as  an 
a  leuco- 
y  wards 
e  entire 
■ocytosis 
titinuous 

is  rare. 

Iilvement 

k-ery  im- 

\\  failure 

•eakness 

mI  fever, 

ly  be  at 

lous  car- 

ity  with 
[s  a  safe 
liot  very 
|out  pro- 

iiajority 

Jal  pigns 

a  study 


in  the  i)ost-niortem  room  of  my  own  and  others'  mistakes,  I  think  that 
the  ordinary  loliar  pneumonia  of  adults  is  rarely  overlttoked.  Krrors  are 
jiai'licuhirly  liable  to  oecur  in  the  intercurrent  pneuiv.onias,  in  those  coin- 
plit-ating  chronic  alfections,  and  in  the  disease  as  met  with  in  children,  the 
i'.ged,  and  drunkards.  Tubcrculo-pneumonic  i)hthisis  is  frequently  con- 
lounded  with  pneumonia.  IMcurisy  with  ell'usion  is,  I  believe,  not  often 
mistaken  except  in  children.  The  diagnostic  i>oints  will  he  referred  to 
under  })leurisy. 

In  diabetes,  Bright's  disease,  chronic  heart-disease,  pulmonary  idithisis, 
and  cancer,  an  acute  })neumonia  often  ends  the  scene,  and  is  frequently 
overlooked.  In  these  cases  the  temperature  is  perhaps  the  best  index, 
and  should,  more  i)articularly  if  cough  develops,  lead  to  a  careful  examina- 
tion of  the  lungs.  The  absence  of  expectoration  and  of  pidmonary  symp- 
toms may  make  the  diagnosis  very  difficult. 

In  children  there  are  two  sjjecial  sources  of  error;  the  disease  may  be 
entirely  nuisked  by  the  cerebral  symi)toms  and  the  case  mistaken  for  one 
of  meningitis.  It  is  renuirkable  in  these  cases  how  few  indications  there 
are  of  ])ulmonary  trouble.  The  other  condition  is  pleurisy  with  effusion, 
which  in  ^•hildren  often  has  deceptive  physical  signs.  The  breathing  may 
l)e  intensely  tubular  and  tactile  fremitus  may  be  i)resent.  The  exjjloratory 
needle  is  sometimes  recjuired  to  decide  the  question.  In  the  old  and  de- 
l.)ilitated  a  knowledge  that  the  onset  of  ])neuni()nia  is  insidious,  and  that 
tlie  symptoms  are  ill-defined  and  latent,  should  put  the  i)ractitioner  on  his 
guard  and  nuike  him  very  careful  in  the  examination  of  the  lungs  in  doubt- 
ful cases.  In  chronic  alcoholism  the  cerebral  symptoms  may  ])redominate 
and  com])letely  nuisk  the  local  process.  As  mentioned,  the  disease  may 
assume  the  form  of  violent  mania,  but  more  commonly  the  sym])toms  are 
tliose  of  delirium  tremens.  In  any  case  ra])id  pulse,  rapid  respiration,  and 
fever  are  sym])toms  which  should  invarialily  excite  su'^])icion  of  inflannna- 
lion  of  the  lungs.  Tnder  cerebro-sjunal  meningitis  will  be  found  tlie  points 
<if  dilferential  diagnosis  between  ])neumonia  and  that  disease. 

Pneumonia  is  rarely  confounded  witli  ordinary  consum])tion,  but  to 
dilfcrentiate  acute  tuberculo-pneumonic  ])hthisis  is  often  difficult.  The 
case  may  set  in  with  a  chill.  It  may  be  impossible  to  determine  which 
coiuliti'  is  present  until  softening  occurs  and  clastic  tissue  and  tubercle 
bacilli  appear  in  the  sjiutum.  A  similar  mistake  is  sometimes  made  in 
cliildren.  With  tyjdioid  fever,  pneumonia  is  not  infrequently  confounded. 
There  are  instances  of  ]meumonia  with  the  local  signs  well  marked  in 
wliich  the  patient  ra])idly  sinks  into  wliat  is  known  as  the  typhoid  state, 
with  dry  tongue,  rapid  ]uilse,  and  diarrluea.  T'nlcss  the  case  is  seen  from 
ilu'  outset  it  may  be  very  difficult  to  determine  the  true  nature  of  the 
malady.  On  the  other  hand,  there  are  cases  of  typhoid  fever  which  set  in 
with  sym]itoms  of  loliar  ])neumouia — t1ie  so-called  jineumo-typlius.  It  may 
bo  impossible  to  make  a  dilferential  diagnosis  in  sucli  a  case  uidess  the 
oliaracteristic  eruption  develops  or  the  "Widal  reaction  be  found. 

Prophylaxis. — The  (|uestion  of  the  prevention  of  pneumonia  is  a 
•liflioult  one,  which  has  hardly  yet  come  within  the  sphere  of  practical 
]:ii(iwledge.     More  care  should  be  taken  with  pneumonic  sputum  than  has 


.it: 


:|; 


134 


SPECIFIC  INFECTIOUS  DISEASES. 


1)0011  (lone  liorotoforo,  iiinl  it  slioiild  be  caroriilly  (lisiiil'cotod.  Individuals 
wlio  liavo  had  piioiiiiHUiia  should  he  spooially  caroi'ul  to  koop  tho  mouth 
and  throat  tiiorouiihly  oloansod,  and  any  Jiouso  in  wliich  sovoral  casos  of 
piu'iinionia  iiavc  ocoui'iod  in  rapid  .succession  shouhl  hi'  thoroughly  dis- 
int'cctcd. 

Treatment.— I'nounionia  is  a  solt'-liniitod  disoaso,  whiih  can  neither 
he  ahoi'led  \u\v  cut  siiort  hy  any  known  means  at  our  command.  J'^M'U 
nndiT  the  most  unl'aNorahle  circumstances  it  may  terminate  al)ruptly  and 
naturally,  without  a  dose  of  medicine  having  heen  administered.  A  patient 
Avas  admitted  into  the  IMiiladdpIiia  Hospital  oji  the  evening  oJ'  the  seventh 
day  after  the  chill,  in  Avliich  he  had  been  seen  hy  one  of  my  assistants,  who 
had  ordered  him  to  go  to  a  hospital,  lie  remained,  however,  in  his  house 
alone,  without  assistance,  taking  nothing  hut  a  little  milk  and  hre/.d  and 
whisky,  and  was  brought  into  the  hospital  by  the  |)olice  in  a  condition  of 
active  delirium.  That  night  his  tem|)erature  was  1().">°  and  his  i)ulse  above 
1^0.  In  his  delirium  he  came  near  esca])ing  through  the  window  of  the 
ward.  The  f(jllowing  morning — the  eighth  day — the  crisis  occurred,  iMid 
at  ward  class  his  temperature  was  below  IKS".  The  entire  lower  lobe  of  the 
right  side  was  found  involved,  and  he  entered  upon  a  rapid  convalescence. 
So  also,  under  the  favoring  circumstances  of  good  nursing  and  careful 
diet,  the  exjjerience  of  many  physicians  in  dilferent  lands  has  shown  that 
jnicumonia  runs  its  course  in  a  definite  time,  ternunating  sometimes  spon- 
taneously on  the  third  or  the  llfth  day,  or  continuing  until  the  tenth  or 
twelfth. 

There  is  no  sjiecific  treatment  for  ])neumonia.  The  young  ])ractitioner 
may  bear  in  mind  that  ])atients  are  more  often  damaged  than  heljied  hy 
the  promiscuous  drugging,  which  is  still  only  too  prevalent. 

1.  (Icnernl  Maiiaficnieid  of  a  Case. — The  same  careful  hygiene  of  the 
jjcd  and  of  the  sick-room  should  he  carried  out  as  in  tyjihoid  fever.  Tho 
]jatient  should  not  he  too  much  hundled  up  witli  clothing.  For  the  heavy 
flannel  uiulershirts  should  he  suhstituted  a  thin,  light  flannel  jacket,  o])en 
in  front,  whicli  enahles  the  physician  to  make  his  examinations  without 
unnecessarily  disturbing  the  patient.  The  room  should  be  hright  and 
light,  letting  in  the  sunshine  if  possible,  ai  1  thoroughly  well  ventilated. 
Only  one  or  two  ])ersons  should  he  allowed  in  the  room  at  a  time.  Even 
when  not  called  for  on  account  of  the  high  fever,  the  ])atient  shoiild  he 
carefully  sponged  each  day  with  te])id  water.  This  should  he  done  with 
as  little  disturhancc  as  ])ossible.  Special  care  should  be  taken  to  keep  the 
mouth  and  gums  cleansed. 

2.  Diet. — Plain  water,  a  ])leasant  tahi«  water,  or  lemonade  should  1)e 
given  freely.  "When  the  patient  is  delirious  tlie  water  should  he  given  at 
fixed  intervals.  The  food  should  he  liquid,  consisting  chiefly  of  milk, 
either  alone  or,  hettor,  mixed  with  food  prepared  from  some  one  of  the 
cereals,  and  eggs,  either  soft  hoiled  or  raw. 

3.  Sprrinl  Trcaimeni. — Certain  measures  are  heliovcd  to  have  an  influ- 
ence in  arresting,  controlling,  or  cutting  short  the  disease.  It  is  very  diiri- 
cult  for  the  practitioner  to  arrive  at  satisfactory  conclusions  on  this  ques- 
tion in  a  disease  so  singularly  variahle  in  its  course.    How  natural,  when 


LOBAR  PNEUMONIA. 


135 


of  the 

ir.     The 

e  heavy 

t,  open 

ivitliout 

lit   and 

tilated. 

Even 

)  11.1(1  be 

lie  ^vith 

eep  the 

nild  he 
Kven  at 
If  milk, 
of  the 


hi 


inflii- 
y  diffi- 
^s  qiies- 

when 


on  the  third  or  J'ourtii  day  the  crisis  occurs  and  convalescence  set  in,  to 
attribute  the  luijtpy  result  to  tlic  cll'cct  of  some  special  medication!  J  low 
easy  to  I'or^ct  that  the  same  uncxitcctcd  early  recoveries  occur  under  other 
(•(ludilionsl  'i'he  following'  arc  anion;,'  the  measures  which  arc  believed  by 
uiauy  to  be  of  benetit: 

((/)  Jilci'linf/. — 'J'he  reproach  of  Van  llclmont,  that  ''a  bloody  ^loloch 
presides  in  the  chairs  of  medicine,''  can  not  be  brought  against  this  gen- 
eration of  physicians.  Ueforc  Louis'  iconoclastic  pa])er  on  bleeding  in 
pneumonia  it  would  have  been  regarded  as  almost  criminal  to  treat  a  case 
without  venesection.  We  employ  it  nowadays  much  more  than  we  did 
a  few  years  ago,  but  more  often  late  in  the  disease  than  early.  To  bleed 
at  tlu;  very  onset  in  robust,  healthy  individuals  in  whom  the  disease  sets 
in  with  great  intensity  and  high  fever  is,  1  l)elievc,  a  good  practice.  1  have 
seen  instances  in  which  it  was  very  beneficial  in  relieving  the  ])ain  and  the 
dyspncea,  reducing  the  temperature,  and  allayiiig  the  cereijial  symj)toms. 

{!))  Driii/s. — Certain  drugs  are  credited  Avith  the  power  of  reducing  the 
intensity  and  shortening  the  dui'ation  of  the  attack.  Among  them  vera- 
truni  viridc  still  holds  a  place,  doses  of  tii  ii-v  of  the  tincture  given  every 
two  hours.  Tartar  emetic — a  remedy  which  had  great  vogue  some  years 
ago — is  now  very  rarely  cmitloyed.  To  a  third  drug,  digitalis,  has  been 
attril)uted  of  late  great  power  in  controlling  the  course  of  the  disease. 
iVtresco  gives  at  one  time  as  much  as  from  4  to  1:3  grammes  of  the  pow- 
dered leaves,  aiul  claims  that  these  colossal  doses  are  specially  ellicacious 
in  shortening  the  course  of  the  disease  and  diminishing  the  mortality. 

{(•)  A)i(ipiiei(in()iiic  i^cntni. — This  is  still  in  the  trial  stage.  The  Klemn- 
■jix'Y  brothers,  Auld,  "Washbourn,  and  others  have  re])orted  favoral)lc  re- 
sults. The  seruni  is  injected  into  the  subcutaneous  tissues.  Washhourn 
recommends  as  a  dose  20  cc,  and  thinks  it  is  well  to  make  an  injection 
twice  a  day  until  the  ])atient  is  convalescent.  Fortunately,  the  serum  ap- 
pears to  be  harmless.    T  have  no  personal  ex])i'rience  with  it. 

4.  Sijmptoiiialic  Trc<ilment. — {a)  Tu  relieve  Ike  rain. — The  stitch  in 
the  side  at  onset,  Avhich  is  sometimes  so  agonizing,  is  best  relieved  by  a 
liypodermic  injection  of  a  quarter  of  a  grain  of  mor])hia.  When  the  ])ain 
is  less  intense  and  diffuse  over  one  side,  the  Paipudin  cautery  a|)plied  lightly 
is  very  ellicacious,  or  hot  or  cold  applic-ations  may  b(>  tri(>d.  When  tlie  dis- 
ease is  fairly  established  the  ])ain  is  not,  as  a  rule,  distressing,  except  ■when 
the  patient  coughs,  and  for  this  the  Dover's  powder  may  be  used  in  5-grain 
'loses,  according  to  the  ])atient's  needs.  Hot  poidtices,  formerly  so  much 
in  use,  relieve  the  pain,  though  not  more  than  the  cold  applications.  For 
children  they  are  often  preferable. 

{h)  To  rnmhat  the  To.va'mia. — Tferein  lies  our  chief  weakness  in  dealing 
uitli  pneumonia.  We  have  as  yet  no  specific,  either  drug  or  the  product  of 
tlie  bacteriological  laboratory,  -which  safely  and  surely  neutralizes  the  ]wison 
of  the  disease.  "We  may  reasonably  hope  that  such  a  remedy  ere  long  will 
be  forthcoming,  but  meantime  we  must  be  content  Avith  measures  which 
nim  at  keeping  up  the  strength  of  the  patient  in  his  fight  against  the  pro- 
gressive toxamda. 

(r)  The  third  and  all-important  indication  in  the  treatment  of  pneii- 


■5' 


130 


SI'l'X'IKIC   INFKCTIOL'S   DISEASES. 


J.  I 


inoiiiii  is  lo  Kupjmrt  llir  heart.  'V\w  praftitioniT  imist  ever  ho  nil  tlio  nlcrt 
to  i)ruvc'iit  the  onset  oi'  cardiac  weakness,  and  to  treat  it  shouhl  that  coiuli- 
tioii  arise. 

To  prevent  the  Onset  of  Cardiac  Weakness. — We  can  not  at  present  sepa- 
rate the  ell'ects  of  the  fever  from  those  of  the  jjoisons  circiihiting  in  tho 
hlood.  It  is  ])ossiljle,  indeed,  as  some  sii|)i)ose,  that  the  fever  itself  may 
be  benedciah  rn(h)uhte(lly,  however,  higli  and  i>roh)nged  ])yrexia  is  dan- 
gerous to  the  heart,  and  should  be  combated.  For  this  our  most  trusty 
weapon  is  hi/drdlhenipi/,  wliieh  in  imeiimonia  is  used  in  several  dill'erent 
ways.  The  ice-ljag  to  the  allVeted  side  is  one  of  tiie  most  convenient  and 
serviceable.  Its  good  elfects  have  been  strongly  insisted  upon  by  ^lays.  I 
have  used  ice  systematically  in  my  wards  for  the  past  six  or  seven  years.  It 
allays  the  pain,  reduces  the  fever  slightly,  and,  as  a  rule,  the  patient  says 
he  feels  very  much  more  comfortable.  JJroad,  Hat  ice-bags  are  now  easily 
obtained  for  the  purpose,  and  if  these  are  not  available  an  ice  poultice  can 
be  readily  made,  and  by  the  use  of  oil-silk  tho  clothing  and  bedding  of 
tho  i)atient  can  bo  protected  from  tho  water.  Cold  si)onging  should,  I 
think,  bo  e]n|)loy('il  as  a  routine  nu'asnro  in  cases  of  ])neumonia.  When 
done  liml)  by  limb  the  j)ationt  is  but  little  disturbed,  and  it  is  refreshing 
and  bonollcial.  AVith  very  pronounced  nervous  sym])toms  and  ])ersistent 
high  tom[)eraturo,  or  with  hyperpyrexia,  a  cold  bath  of  ten  minutes'  dura- 
tion may  bo  given.  Von  Jiirgensen,  one  of  the  best  of  living  students  of 
the  disease,  strongly  advises  it  under  these  conditions.  Personally,  my 
exi)erience  with  the  full  cold  bath  is  not  large  enough  to  enable  me  to 
express  a  positive  opinion.  In  this  country  we  have  not,  I  think,  used  it 
sulliciently  in  the  toxic  cases,  in  which  in  typhoid  fever  we  see  such  good 
results. 

Of  medicinal  antipyretics,  quinine  has  been  much  vaunted  in  doses  of 
from  30  to  60  grains  daily.  Unfortunately,  it  is  apt  to  disturb  the  stomach 
and  cause  unpleasant  ringing  in  the  ears;  according  to  some,  also,  it  is  very 
de])ressing,  but  I  must  say  I  have  never  soon  any  injurious  effects  from  it, 
though  I  have  not  used  it  for  some  years.  Antipi/rin,  antifehrin,  and 
phenacelin  have  been  thoroughly  tried  in  pneumonia,  and  the  general  opin- 
ion at  present  is  decidedly  against  their  systematic  employment. 

Alcohol  may  be  used  with  benefit  in  a  majority  of  cases  of  pneumonia. 
In  modernto  doses  it  diminishes  slightly  the  temperature,  increases  the  appe- 
tite, obviates  the  tendency  to  heart  weakness,  and  is  a  conservator  of  energy, 
being  itself  consumed  in  supplying  heat  in  place  of  the  body  tissues.  Two 
or  three  ounces  of  good  whisky  in  tho  twenty-four  hours  may  be  used  in 
ordinary  cases. 

To  treat  Heart  ]Yeal-ness  vhen  Present. — Xow  the  resources  and  judg- 
ment of  the  physician  are  taxed  to  tho  utmost.  Is  the  heart  weakness  duo 
to  progressive  distention  and  overfilling  of  the  right  heart?  This  is 
usually  indicated  by  increasing  cyanosis,  increasing  shortness  of  breath, 
signs  of  oodomatous  infiltration  in  the  uninvolved  parts  of  the  lung,  and  a 
small  and  feeble  radial  pulse.  lender  these  circumstances  a  free  venesection 
is  sometimes  helpful,  though  I  must  say  that  my  personal  experience  has 
not  been  very  satisfactory.     I  have,  however,  within  the  past  three  years 


/ 


LOBAR  PNEUMONIA. 


13i 


p  nlort 
fuiuU- 

t  sepfi- 
in  tho 
li'  may 
is  (lau- 

trusty 
ilTciviit 
■lit  and 
ays.  1 
ars.  It 
int  says 
V  easily 
[ice  can 
(linj^  of 
lould,  I 

When 
[reshinji 
.n'sistent 
s'  dura- 
lents  of 
illy,  my 
e  mo  to 

used  it 
1  good 

OSes  of 
tomach 
is  very 
'rom  it, 
in,  and 
111  opin- 

imonia. 
le  appe- 
energv, 
T\vo 
used  in 


seen  2  cases  in  which  it  seemed  to  he  timely,  even  life-saving.  Too  ol'teii 
the  progressive  cardiac  asthenia  is  due  to  tho  action  ol'  the  lever  and  of  the 
poisons,  partly  upon  the  heart  muscle  itseli',  partly  upon  the  lu'rve  centres, 
cardiac  and  respiratory.  An  increase  in  the  amount  of  aknltul  is  advisalile 
when  the  juilse  hecomes  small,  frecjuciit,  and  feehle  or  very  compressihle, 
and  when  the  heart-sounds,  particularly  the  second  jiulmonic,  begin  to  lose 
their  force.  The  amount  will  vary  with  the  age  of  the  jiatient  and  with 
his  habits.  It  may  be  increased,  if  necessary,  to  1'-*  or  l(i  ounces  in  the 
twenty-four  hours,  l^lrijchina  is  a  most  valuaijle  cardiac  tonic  in  pneu- 
monia, it  may  be  given  in  doses  of  from  one  sixtieth  to  one  thirtieth  of  a 
grain  hypodermically,  or,  if  the  heart's  action  becomes  more  feeble,  in  still 
larger  doses,  uj)  to  one  twentieth  or  even  one  twelfth  of  a  grain  every  three 
or  four  hours.  The  jirecise  indications  for  the  use  of  diijildlis  in  piU'U- 
monia  are  not  easy  to  estimate.  J  rarely  use  it  unless  the  heart's  action 
becomes  very  ra))id,  or  if,  as  above  stated,  there  is  a  sudden  onset  of  cardiac 
weakness,  indicated  by  a  very  (piick  and  irregular  ])iilse.  '^riien  it  may  lie 
given  freely,  either  in  the  form  of  the  tincture,  lo  or  'ii)  minims  every 
two  hours  until  VJ  drachms  are  given,  or  a  good  digitalin  hypodermically 
in  doses  of  from  a  thirtieth  to  a  twentieth  of  a  grain.  Other  remedies  still 
much  in  use  are  the  aromatic  spirits  of  ammonia,  camphor,  musk,  and  the 
hy])odermic  injections  of  ether.  Two  other  measures  may  be  referred  to 
under  this  section. 

O.ri/f/on  Gas. — It  is  doubtful  whether  the  inhalation  of  oxygen  in  pneu- 
monia is  really  beneficial.  Personally,  when  called  in  consultation  to  a  case, 
if  I  see  tho  oxygen  cylinder  at  tho  bedside  I  feel  the  ])rognosis  to  be  ex- 
tremely grave.  It  does  sometimes  seem  to  give  transitory  relief  and  to 
diminish  the  cyanosis.  It  is  harmless,  its  exhibition  is  very  sim|)le,  and 
the  process  need  not  be  at  all  disturbing  to  the  patient.  The  gas  may  be 
allowed  to  flow  gently  from  the  nozzle  directly  under  the  nostrils  of  the 
patient,  or  it  may  be  administered  every  alternate  fifteen  minutes  through 
a  mask.  As  already  stated,  Bollinger  regards  the  heart  weakness  as  in  ])art 
due  to  an  oligannia  from  the  loss  of  a  large  amount  of  solid  exudate  in  the 
lung.  The  use  of  saline  injpclions  hypodermically  has  been  advocated.  I 
have  seen  it  do  good  in  hel])ing  to  tide  over  a  critical  ])eriod  of  cardiac 
depression.  As  much  as  a  cou])le  of  ])ints  may  be  allowed  to  run  beneath 
the  skin  by  gravity,  a  rubber  bag  and  either  a  large  liy])odermic  or  a  middle- 
sized  aspirator  needle  being  us  '  The  injection  may  be  made  in  the  Hanks 
or  in  the  thighs. 

Treatment  of  Complications. — If  the  fever  persists  it  is  important  to 
look  out  for  pleurisy,  particularly  for  the  meta-pneumonic  empyema.  The 
exploratory  needle  should  be  used  if  necessary.  A  sero-fibrinous  effusion 
should  be  aspirated,  a  purulent  opened  and  drained.  In  a  complicating  peri- 
carditis with  a  large  effusion  aspiration  may  be  necessary.  Delayed  reso- 
lution is  a  difficult  condition  to  treat.  Eiess  has  recommended  pilocarpine, 
which  I  have  tried  in  one  or  two  cases  without  much  benefit. 


■ 


138 


SPKCIFIC   IXFKC'TIOUS  DISKASEfl. 


XVI.    DIPHTHERIA. 

Definition. —A  riiocilio  infi'ftioiis  discaso,  flinrnotorizi'd  1)y  n  looal 
filiriiiniis  I'Midiitf,  iisimlly  ii|tnn  n  iiuicoiis  iiicmliriiiu',  and  l)y  constitutional 
syinptonis  due  to  toxins  proiliiccd  at  the  site  of  tlic  Icsittn.  Tlic  jirt'scnco 
of  tlic  Kk'hs-Loclllcr  bacillus  is  the  etiological  criterion  l)y  wliicli  trno 
di|i|itliorin  is  distiii<,Miislic(l    from  other   forms  of  meinhranoiis   irdlamma- 

tioM. 

'i'lie  clinical  and  liacleriojogical  conecplions  of  diplitherin  are  at  pvesent 
not  in  fidl  accord.  On  the  one  hand,  there  are  cases  of  sim|tle  soiv  throat 
which  the  liacteriolojfists,  finding  the  Klehs-Loetller  hacillns,  call  tnie 
di|ililheria.  On  the  other  lumd,  cases  of  niernbranons,  slongliing  angina, 
diagnosed  l>y  the  physician  as  diphtheria,  are  calle(l  hy  the  bacteriologists, 
in  the  absence  of  the  Klebs-Loelller  bacillus,  pseudo-diphtheria  or  diph- 
theroid angina. 

The  term  (liplilhcroid  may  l)o  used  for  the  present  to  designate  those 
forms  in  which  the  Klebs-Loefller  bacillus  is  nut  present.  Though  usually 
nnbU'r,  severe  constitutional  disturbance,  and  even  ])aralysis,  may  follow 
these  so-called  pseudo-diphtheritic  processes. 

Historical  Note. — The  disease  was  known  to  Areta-nis  and  to  Galen. 
Ei)ideniics  occurred  throughout  the  niichlle  ages.  It  appeared  early  among 
the  settlers  of  Xew  Mngland,  and  accounts  are  extant  of  epidenncs  in  this 
country  in  the  si'vcnteenth  and  eighteenth  centuries.  Ilnxham  ami  Fother- 
gill  gave  excellent  descriptions  of  the  disease.  An  admirable  account  was 
given  by  Samuel  JJard,*  of  Xew  York,  whose  essay  is  one  of  the  most  solid 
contributions  made  to  medicine  in  America.  It  was  reserved  for  Pierre 
liretonneau,  of  Tours,  to  grasp  the  fact  that  nnijiiia  suffordtini,  '"  ri/iianrhe 
HKiliijiKi."'  the  "  putrid,"  and  other  forms  of  malignant  sore  throat,  were 
one  and  the  same  disease,  to  which  lie  gave  the  name  "  diphlhvrite" 

Etiology.' — The  disease  is  endemic  in  the  hirger  centres  of  population, 
and  beconu's  epidemic  at  certain  seasons  of  the  year.  AVhile  other  con- 
tagious diseases  have  diminished  within  the  ])ast  decade,  diphtheria  has  in- 
creased, ])articxdai'ly  in  cities.  It  has  ])revailed  also  with  great  severity  in 
country  districts,  in  which  indeed  the  alfection  seems  to  he  specially  viru- 
lent. A  close  relation  between  imperfect  drainage  or  a  ])olluted  water- 
sn]iply  and  diphtheria  has  not  been  determined. 

Diphtlu'ria  is  a  highly  contagious  disease,  readily  communicated  from 
person  to  ptM'son.  Tlie  hacilli  may  he  received,  "  (1)  from  the  memhranons 
exudate  or  discliarges  from  diphtheria  ])atients;  (2)  from  the  secretions 
of  the  nose  and  throat  of  cojivalescent  cases  of  di]ihtheria  in  which  the 
virulent  bacilli  ])ersist;  (;'))  from  the  throats  of  healthy  individuals  mIio 
liave  acquired  the  hacilli  from  being  in  contact  with  others  having  virulent 
germs  on  their  person  or  clothing:  in  such  cases  the  hacilli  may  sometimes 
live  and  develop  for  days  or  weeks  in  the  throat  witliout  causing  any  lesion  " 
(Park  and  ])eel)e).  In  the  tenement  districts  of  Xew  York  these  authors 
recognized  two  varieties  of  local  ci)idemics.     In  one,  the  cases  were  evi- 

*  Transactions  of  tlic  American  Pliilosopliicnl  Society,  vol.  i,  Philadelphia,  1770. 


DTIMITIIKHIA. 


ino 


(Icntlv  from  iioi'Hilinrlinod  infection;   wliili'  in  tlir  nilicr.  Ilic  infection  wm 


\  locfti 
ntional 
rescnce 
li   truo 

hiMiniii- 

prcscnt 
'  throat 
11  true 
aii^'iiiii, 

)lo^M>tS, 

r  dipli- 

;e  tho^!c 

usually 

'  follow 

)  Galen. 
,•  anion^' 
i  in  tliiri 
Fother- 
lunt  was 
lost  solid 
r   I'icrro 

it,  were 

I) 

lulation, 
lor  con- 
has  in- 
ci'ity  in 
ly  viru- 
water- 

;m1  from 

hrauous 

leretions 


icli 


10 
lO 


ir 


tl 
ils  wl 

ulont 
Inetinies 
lesion  " 
thors 


lau 


}ro  cvi- 


(lerived  Mom  >(Ii(mi|s.  yinee  a  whole  district  would  suddcidy  heconie  the 
seat  of  scattered  cases.  "  At  times  in  a  certain  area  of  the  city,  from  which 
several  schools  drew  their  scholars,  all  the  cases  (d"  diphtheria  would  occur 
(art  investi;iation  showed)  in  families  whose  children  attende(l  one  school, 
the  children  of  the  ntlicr  schools  hein^'  for  tlie  time  exein|it." 

Mo  disease  ol'  tein|ii'rate  re;;ioiis  proves  more  fatal  to  physicians  and 
nurses.  Thd'e  seems  to  he  particular  dandier  in  the  examination  and  swalt- 
hin;;  of  the  throat,  for  in  the  ;,ai^';,dn^',  coii;;iiin;:,  and  splulterin;;  ell'orts 
the  patient  may  coujrh  mucus  and  flakes  of  membrane  into  the  physician's 
face.  The  virus  attaches  itself  to  the  clothing;,  the  heddin^^  and  the  room 
in  which  the  patient  has  live(l,  and  has  in  many  instances  displayed  ;;reat 
tenacity.  It  has  heeii  found  to  live  on  hlood  scrum  for  one  hundred  and 
tifty-tive  days,  in  <ielatin  for  ei;,diteen  months,  dried  on  silk  threads  for  one 
hundred  and  seventy-two  days,  on  a  child's  plaything:  which  had  heeii  kept 
in  a  dai'k  place  for  five  months,  and  in  hits  of  dried  niemltrane  I'm'  from 
i'ourteen  to  twenty  weeks.  An  instance  has  heen  reported  ((Jolay)  in  which 
the  hacilli  were  [iresent  in  the  throat  for  three  hundred  ami  sixty-two  days. 
During  this  period  tliei'e  were  three  acute  relapses.  They  have  heen  found, 
too,  in  the  dust  of  a  diphtheria  pavilion,  and  in  the  hair  and  clothing  of 
the  nurses  in  attendance  upon  diphtheria  hahies  (Wright  and  Mmerson). 
Forhes  isolati'd  diphtheria  hacilli  fi'om  a  vessel  which  was  reji'arded  as  the 
cause  of  the  disease  in  twenty-four  families.  The  hacilli  grow  readily  in 
milk  without  changing  its  appearance.  From  cheese  which  was  made  on 
a  farm  on  which  diphtheria  |irevailed,  pure  culturt's  of  diphtheria  hacilli 
were  obtained  (New  York  JJoard  of  Health  Ileport,  ISDl). 

The  disease  may  he  transmitted  by  inoculation. 

Calves,  cats,  and  fowls  are  subject  to  contagious  meiul)i'am)us  diseases, 
which  are,  howevi'i',  not  identical  w  ith  di[)htheria  in  nuni  and  are  not  com- 
municable to  him. 

As  in  other  infectious  disorders,  indivi<Uial  susceptibility  plays  an  im- 
portant rnh'.  Not  oidy  do  very  nuiny  of  those  exposed  escape,  hut  even  of 
those  in  whose  tiiroats  the  l)acilli  lodge  and  grow. 

Of  ])redisposing  causes  age  is  one  of  the  most  im])ortant.  Very  young 
children  are  rarely  attacked,  but  .lacobi  states  that  he  has  seen  three  in- 
stances of  the  disease  in  the  newly  born.  Uetween  the  second  and  the  llf- 
tcenth  year  a  large  majority  of  the  cases  occur.  Tn  this  ])ei'iod  the  greatest 
number  of  deaths  is  between  the  st'cond  and  the  fifth  years.  Girls  are 
attacked  in  larger  numbers  than  l)oys,  jtrobahly  because  tliey  are  brought 
into  closer  contact  with  the  sick.  Adults  are  frequently  affected .  The 
iliseasc  is  most  jirevalent  in  the  cold  autumn  weather.  The  secondary 
pseudo-mend)ranous  inflammations,  caused  usually  by  the  streptococcus, 
■ittack  dehilitated  ])ersons.  the  subjects  of  fevers,  particularly  of  scarlet 
lever.  ty|)lioid,  and  measles. 

C'aille  regards  as  sjiecial  predisposing  elements  in  children  enlarged 
tonsils,  chronic  naso-pharyngeal  catarrh,  carious  teeth,  and  an  unhealthy 
Condition  of  the  mucous  mend)rane  of  the  mouth  and  throat. 

Eiudemics  vary  in  intensity.     While  in  sf)me  the  affection  is  mild  and 

0 


140 


HrKClKIC   INFKCTIOUS   DISK  ASKS. 


rarely  I'litiil,  in  others  it   is  elmnieteri/.eil  liy  wide  extensi<»ii  (if  tlu'  iii'iii- 
bniiie,  ihmI  slinws  a  special  temleiu  y  to  attaek  tlu'  larynx. 

The  Kleba-Loefflfcr  bacillus  oei-nrs  in  a  lar^ic  pereeiitajie  nf  all 
HUHpeeled  eascH.  ll  in  I'oiiinl  eliii-liy  in  Ihu  false  nu-rnhrane,  ami  does  not 
extend  into  the  snhjaront  mucosa.  In  the  majority  of  instances  the  or^^an- 
isms  ari'  localized,  and  only  a  lew  penetrate  into  the  interior.  In  excep- 
tional instaneen  the  bucilii  nru  found  in  the  hlood  and  in  the  internal 
orpins.  It  may  he  the  predonunating  or  sole  orjiiinism  in  the  hroiicho- 
pneunionia  so  common  in  the  disease.  Outside  the  throat,  the  common  site 
of  its  morhid  action,  the  Klehs-Loelller  hacillus  has  hei'n  found  in  <liph- 
theritie  conjunctivitis,  in  otitis  media,  sometimcH  in  wouml  diphtheria,  in 
lihrinous  rhinitis,  and  in  an  attenuated  condition  hy  Howard  in  a  case  of 
ulcerative  endocarditis. 

Morphological  Characters. — The  bacillus  is  non-moiile,  varies  from  '^'.5 
to  ;!  fi  in  length,  and  from  (»..')  to  U.S  /*  in  thickness.  It  appears  as  a  straij^dit 
or  Hli^fhtly  bent  rod  with  rounded  ends;  ii'rej,Mdar,  bizarre  forms,  i  \'\\  as 
rods  with  one  or  both  I'tids  swollen  and  simple  branchin;^  forms,  are  more 
or  less  common.  Tlu'  bacillus  stains  in  sections  or  on  tlu-  cover-gla.ss  by 
the  (iram  method. 

It  grows  best  upon  a  mixture  of  glucose  bouillon  and  blood  serum 
(Loelller),  forming  large,  elevated,  grayish-white  colonies  with  opacjue  cen- 
tres. It  grows  also  upon  all  the  ordinary  culture  media.  The  growth 
usually  ceases  at  temperatures  below  ^0°  ('. 

'I'he  bacillrs  is  very  resistant,  and  cultures  have  been  made  from  n  bit 
of  membrane  ])reserved  for  five  months  in  a  dry  cloth.  Incorporated  with 
dust  and  kept  moist,  the  bacilli  were  still  cnllivatable  at  the  end  of  eight 
week^ :  kept  in  a  dried  state  they  no  longer  grew  at  the  end  of  this  ])eriod 
(Hitter). 

Variation  in  Virulence. — For  testing  the  virulence  the  guinea-pig  is 
used,  beiug  most  susceptible  to  the  poison.  An  amount  of  a  forty-eight 
hour  bouillon  culture  e(pialling  one  half  ])er  cent  of  the  weight  of  the  ani- 
mal is  injected  subcutaneously.  "  A  fully  virulent  culture  is  one  which 
causes  the  death  of  a  guinea-pig  within  three  days  or  less;  a  culture  of 
medium  vindence  one  wliich  causes  the  death  of  the  animal  in  from  three  to 
live  days.  Cultures  which  only  produce  local  necrosis  and  ulceration  or  death 
after  a  greater  number  of  (hiys  may  he  consich'red  as:  of  slight  virulence'' 
(J.  II.  Wright).  At  the  seat  of  the  inoculation  there  is  local  necrosis  with 
fibrinous  exudate  which  contains  tlie  bacilli,  and  there  is  also  a  more  or 
less  extensive  (edema  of  the  subcutaneous  tissue.  The  Klos-Loefller 
])acillu8  evidently  has  very  varying  grades  of  virulence  down  even  to  com- 
])lete  absence  of  ])athogcnic  effects.  The  name  pseudo-bacillus  of  diph- 
theria should  not  lie  given  to  this  avirulent  organism. 

The  Presence  of  the  Klebs-Locffler  Bacillus  in  Non-membranous  Angina 
and  in  Healthy  Throats. — The  liacillus  has  been  isolated  from  cases  winch 
show  nothing  more  than  a  simjde  catarrhal  angina,  of  a  mild  ty]io  without 
any  membrane,  with  diffuse  redness,  and  ])erha]is  huskincss  and  signs  of 
catarrhal  laryngitis.  In  other  cases  the  anatomical  picture  may  be  that  of 
a  lacunar  tonsillitis. 


DirilTMKKIA. 


Ill 


ni'-'iu- 
(.f  all 

il'S   iu»t 

I'xce'p- 
iitt'i'iml 
■one'lio- 
lon  sito 
I  diitli- 
uria,  in 
t'ttHu  oi 

I'oin  '■.'.•') 
stnii^dil 
t'.'h  art 
re  more 
glass  by 

:1  Boruiu 

jf  row  til 

oiu  a  l»it 
ti'd  with 
()[■  iM;^lit 
IS  poriod 

'a-pifj  is 

|rty-o'i«ilit 

the  iini- 

11"  \\l\ich 

IlltlUT    of 

tlirc'O  to 

lor  dL'ath 

ulence  " ' 

|)sis  with 

inoi'o  or 

Loelllor 

to  foin- 

)f  diidi- 

Angina 

s  which 

without 

Ipigns  of 

that  of 


During'  the  prcvak'nco  of  an  ('|»idciiiif  tin'  orpuumiis  may  i»c  nu'l  with 
in  pi'i'lVctly  lu'althy  throats,  [lartiiularly  in  persons  in  tin;  same  house,  or 
Ihe  ward  attendants  and  nurses  in  IV-ver  hospitals. 

Kolldw  iiif,'  an  attack  of  di|>lithi'ria  the  hacilli  may  jtersist  in  the  thrujit 
after  all  the  mendtrane  has  disap|ieari'd  for  wci-ks  or  months.  Schiifcr 
notes  a  ease  in  which  they  were  present  six  months  after  the  uttai'k,  and 
in  a  nurse  in  my  ward  the  hacilli  persisted  for  ci^dity-four  days. 

Toxiiie  of  the  Klebs-Loeffler  Bacillus. — Woux  and  Yersin  showed  that 
a  fatal  result  following'  the  inocidiition  with  the  bacillus  was  not  caused 
hy  any  extension  of  the  micro-oru;anisms  within  the  body;  iind  they  were 
enabled  in  l)oudlon  cultures  to  separate  the  bacilli  from  the  |)oison.  The 
toxine  so  separated  killed  with  very  much  the  Bame  elFeets  as  those  caused 
hy  the  iuoeuhitioii  of  the  bacilli;  the  pseudo-mend)rane,  however,  is  not 
I'drmed.  These  results  were  contirmed  by  numy  observers,  particularly 
hy  Sidney  Martin,  wlut  separated  a  toxic  albumose.  The  precise  composi- 
tion of  the  body  and  whether  it  is  a  jtroteid  at  all  is  still  doubtfid. 

Production  of  Immunity. — Susce|)tible  nnimals  nuiy  be  reiuh'red  im- 
mune from  diphtheritic  infection  by  injectin;,'  weaki'iu'd  c\dtures  of  the 
liacillus  or,  what  is  better,  suitable  doses  of  the  diphtlu-ria  toxine.  'I'he 
result  of  the  injections  is  a  lebrile  reaction  which  soon  ])asses  away  and 
leaves  the  aninud  less  susceptible  to  the  poison  or  the  livin;,'  bacilli.  Uy 
ii'peatin^  and  ^n-adually  iucreasinii  the  (piantity  of  ]»oison  injected  a  lii;^h 
(K'^rce  of  immunity  can  be  jiroduced  i;i  lar<ie  aninuds  («!:oat,  horsi'^.  Dur- 
ing the  reaction  followiii};  the  injections  the  immunity  temporarily  falls 
oidy  to  exceed  the  previous  degree  at  its  end.  This  form  of  immunity,  de- 
iiitminated  antitoxic,  is  associati'd  with  the  development  of  a  curative  sul)- 
stancc,  which  is  containe(l  within  the  humors  and  cells  of  the  body,  and 
in  the  form  of  the  preserved  serum  of  the  blood  (horse)  is  known  com- 
mercially as  diphtheria  antitoxinc.  It  has  the  power  to  neutralize  the  ell'ects 
ef  th(>  toxine. 

The  Bacteria  associated  with  the  Diphtheria  Bacillus. — The  most  com- 

nmn  is  the  stre[)tococcus  ])yogenes.  Others,  in  addition  to  the  organ- 
isms constantly  found  in  the  mouth,  are  the  micrococcus  lanceolatus,  the 
liaeiUus  coli  communis,  and  the  staphylococcus  aureus  and  albns.  Of  these, 
]ir()l)al»ly  the  streptococcus  ])yogencs  is  the  most  important,  as  cases  of 
{reueral  infection  with  this  organism  have  been  found  in  diphtheria.  The 
suppuration  in  the  lymph-glands  and  the  l)roncho-j)neunu)nia  are  usually 
(though  not  always)  caused  by  this  organism. 

Pseudo-Diphtheria  Bacillus. — As  mentioned  above,  the  Klebs-LoefTler 
Imeillns  varies  very  much  in  its  virulence,  and  it  exists  in  a  form  entii'ely 
devoid  of  ])atbogenic  ]iroperties.  This  organism  should  not  be  designated 
the  ]iseudo-diphtheria  bacillus.  The  name  "should  be  confined  to  bacilli 
which,  though  resembling  the  di])hthcria  bacillus,  ditfer  from  it  not  only 
hy  absence  of  virulence,  but  also  by  cultural  peculiarities,  the  most  impor- 
tiiut  of  the  latter  being  greater  luxuriance  of  growth  on  agar,  and  the  ])res- 
orvation  of  the  alkaline  reaction  of  the  bouillon  cultures  "  (Welch).  Xeisser 
hiis  just  proposed  a  dilTerential  method  of  staining  to  discriminate  between 
these  organisms  that  gives  useful  results. 


U2 


SPECIFIC   INFECTIOUS   DISEASES. 


Diphtheroid  Inflammations. — Uiidcf  tlio  term  diphiJtero'ul  may 
1)1'  <;r()ii|ic'(l  tlidSL'  iiu'iiiliraiious  iiitliimiiiatioiis  which  arc  not  associatctl  witli 
lilt'  Klehs-Loi'lllcr  hacilhis.  It  is  pcrliaps  a  more  suitable  designation  than 
pseudo-iliphtheria  or  seeonchiry  diphtheria.  As  in  a  great  maj(jrity  of  caso8 
the  streptoeoceus  ])yogenes  is  the  active  organism,  the  term  "  streptococcus 
diphthcrilis  *'  is  oi'ten  employed.  The  name  "  diphtheritis  "  is  best  used  in 
an  aiiatoiiiical  sense  to  designate  an  inllammation  of  a  mucous  membrane 
or  integumentary  surface  characterized  l)y  necrosis  and  a  fibrinous  exudate, 
whereas  the  term  "  di|)htheria  "  should  be  limited  to  the  disease  caused  by 
the  Klebs-Loelller  bacillus.  The  ])roportion  of  cases  of  diphtheroid  in- 
llammation varies  greatly  in  the  diU'ercnt  statistics.  Of  the  large  number 
of  observations  made  by  I'ark  and  lieebe  (."),G11)  in  Xew  York,  -lO  per  cent 
were  dii)htheroid.  Figures  from  other  sources  do  not  show  l>o  high  a  })er- 
centage. 

It  is  not  to  bo  inferred  from  these  statistics  that  any  considerable  num- 
bi'r  of  the  cases  which  [)resent  the  ai)i)earances  of  typical  and  characteristic 
])rimary  diphtheria  are  due  to  other  micro-organisms  than  the  Klebs- 
Loelller  bacillus.  Xearly  all  such  cases,  when  carefully  examined  by  a  com- 
]ietent  bacteriologist,  are  found  to  be  due  to  the  dif)htheria  bacillus.  It 
is  the  less  characteristic  cases,  Avith  more  or  less  susi)icion  of  diphtheria, 
which  are  most  likely  to  be  caused  l^y  other  bacteria  than  the  Klcbs- 
Loefller  bacillus.  It  is  also  to  be  remembered  that  in  the  routine  exam- 
ination of  a  large  number  of  cases  for  boards  of  health  and  dii)htheria 
Avards  of  hospitals,  some  cases  of  genuine  diphtheria  may  escape  recog- 
nition from  lack  of  such  repeated  and  tliorough  bacteriological  tests  as  are 
sonietinies  reipiired  for  the  detection  of  cases  presenting  unusual  dilli- 
culties. 

('()H(Jilii)iisi  viidcr  irhirli  the  Di/)]ilheri)id  Affection  occurs. — Of  4.j0  cases 
(Park  and  lieebe),  3UU  occurred  in  the  autumn  months  and  150  in  the 
spring;  11)8  occurred  in  children  from  the  first  to  the  seventh  year.  In  a 
large  ])roportion  of  all  the  cases  the  disease  develops  in  children,  and  can 
only  lie  differentiated  from  di])htheria  pro])er  by  the  Imctcriological  ex- 
amination. In  many  of  the  cases  it  is  simply  an  acute  catarrhal  angina 
with  lacunar  tonsillitis. 

The  diphtheroid  inflammations  are  particularly  prone  to  develop  in 
connection  with  the  acute  fcA'ers. 

{ti)  Scartct  Freer. — In  a  large  proportion  of  the  cases  of  angina  in  scar- 
let fever  the  Klebs-Loelller  bacillus  is  not  present.  Booker  has  reported 
11  cases  conii>lieating  scarlet  fe^-er,  in  all  of  which  the  streptococci  were 
the  pi-i'doininant  organisms.  Of  the  450  cases  of  Park  and  Beebe,  4:3  com- 
plicated scarlet  fever.  The  angina  of  this  disease  is  not  always,  however, 
(]no  to  the  streptococcus.  AVhere  diphtheria  is  ])revalent  and  op])ortunities 
are  favorable  for  exposure,  a  large  proportion  of  the  cases  of  membranous 
Mii'oats  in  scarlet  fever  may  be  genuine  diphtheria,  as  is  shown  by  the  sta- 
tistics of  AVilliams  and  ^lorse  in  the  Boston  City  Hospital.  Here,  of  97 
cases  of  scarlet  fever,  mend)ranous  angina  was  present  in  35;  in  12  Avith 
the  Klebs-Loeftler  bacillus,  and  in  33  with  other  organisms.  Morse  reports 
99  cases  of  angina  in  scarlet  fever  in  which  TG  Avere  diphtheritic.     This 


iniiy 
wiUi 
than 
cases 

!()CCU9 

rcd  in 
ihvane 
udato, 
=od  1)y 
lid  in- 
uiiibor 
T  cent 
a  por- 

3  num- 
teristic 
Klebs- 
a  com- 
ius.    It 
btheria, 
Ivlebs- 
3  exam- 
)litlievia 
i  recog- 
s  as  arc 
111  dilVi- 

50  cases 

in  tlic 

In  a 

land  can 

ical  cx- 

angina 

I'elop  in 

lin  scar- 
peported 
tci  ^verc 

•>  com- 

licnvcver, 

knnitics 

Ibranons 

Itlie  sta- 

^  of  97 

|l2  with 

reports 

Tliis 


DIPIITIIERL^ 


[•let  ft 


143 

associated  with  true 


large  proportion  of  cases  in  Avliich  scarlet  lei 

diplitheria  is  attributed  to  local  conditions  in  the  hospital. 

(b)  Measles. — ^leiubranous  angina  is  nuicli  li'ss  conniion  in  this  disease. 
It  occurred  in  G  of  the  -loO  {li[»htlieroid  cases  in  A'ew  York.  Of  4  eases 
with  severe  niembranoiis  angina  at  the  j)oston  City  llosi)ital,  1  oidy  pre- 
sented the  Klelis-LoclUcr  bacillus. 

{(■)  \Vli()()]niif/-cuu(jli  may  also  be  complicated  with  membranous  angina. 
The  bacteriological  examinations  have  not  been  very  numerous.  Kscherich 
gives  4  cases,  in  all  of  which  the  Klcbs-liOelllcr  bacillus  was  found. 

{(I)  Typhoid  Fever. — Mcnd)ranous  inllammations  in  this  disease  are  not 
very  infrecpient;  they  may  occur  m  the  throat,  the  pelvis  of  tlie  kidney, 
the  bladder,  or  the  intestines.  The  complication  may  be  caused  by  the 
Klebs-Loelller  bacillus,  which  was  present  in  4  cases  described  by  ■Morse. 
It  is  frequen^i",  however,  a  strejjtococcus  infection. 

Ernst  Warner  has  remarked  upon  the  greater  fi-ei^uency  of  these  mem- 
branous inflammations  in  typhoid  fever  when  dii)htheria  is  prevailing. 

Clinical  Fcafi'.res  of  the  Diphlherui.l  Affeciion. — The  cases,  as  a  rule, 
arc  milder,  and  tnc  mortality  is  low,  only  '^.5  ])cr  cent  in  the  450  cases  of 
Park  and  lieebe.  The  diphtheroid  inllammations  complicating  the  specitic 
fevers  are,  however,  often  very  fatal,  and  a  general  strejjtococcus  infection 
is  by  no  means  infrequent.  As  in  the  Klcl)S-Lociller  angina,  there  may 
be  only  a  simi)le  catarrhal  process.  In  other  instances  the  tonsils  are  cov- 
ered with  a  creamy,  pidtaceous  exudate,  without  an_y  actual  mcud)rane. 
An  important  group  may  begin  as  a  simple  lacunar  tonsillitis,  while  in 
others  the  entire  fauces  and  tonsils  are  covered  by  a  continuous  membrane, 
and  there  is  a  foul  sloughing  angina  with  intense  constitutional  disturb- 
ance. 

Are  the  diphtheroid  cases  infectious?  General  clinical  experience  war- 
rants the  statement  that  the  membranous  angina  associated  with  the  fevers 
is  rarely  connnunicated  to  other  patients.  The  health  department  of  Xew 
York  does  not  keep  the  dii)htheroid  cases  under  supervision.  Their  inves- 
tigation of  the  450  diphtheroid  cases  seems  to  justify  this  conclusion.  Park 
and  Bcebe  say  that  "  it  did  not  seem  that  the  secondary  cases  were  any  less 
liable  to  occur  where  the  primary  case  was  isolated  than  when  it  was  not." 

Sequela'  of  the  Diphtheroid  Angina. — The  usual  mildness  of  the  disease 
is  in  part,  no  doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of 
the  worst  forms  of  general  stre]itococcus  infection  are,  however,  seen  in  this 
disease.  There  are  no  peculiarities,  local  or  general,  which  can  be  in  any 
way  regarded  as  distinctive;  and  if  the  observation  of  Bourges  should  be 
(■orroborated,  even  the  most  extensive  paralysis  may  follow  an  angina  caiiSL'(l 
by  it. 

Morbid.  Anatomy. — A  majority  of  the  cases  die  of  the  faucial  or 
of  the  laryngeal  disease.  The  exudation  may  occur  in  the  mouth  and 
cover  the  inner  surfaces  of  the  clieeks;  it  may  even  extend  beyond  the 
lips  on  to  the  skin.  This  was  met  once  in  30  autopsies  at  the  ^lontreal 
(ieiiera  ospital.  The  amount  of  exudation  varies  in  diifercnt  cases. 
I'sually  the  tonsils  and  the  pillars  of  the  fauces  are  swollen  and  covered 
with  the  false  membrane.     More  commonly,  in  the  fatal  cases,  the  exuda- 


lU 


SPECIFIC   INFECTIOUS  DISEASES. 


tion  is  very  extensive,  involving  tlie  iivula,  the  soft  palate,  the  ])osterior 
nares,  and  the  lateral  and  posterior  walls  ot  the  pharynx.  These  parts  are 
covered  with  a  dense  pseudo-membrane,  in  places  firndy  adherent,  in  others 
beginning  to  sei)arate.  In  extreme  cases  the  necrosis  is  advanced  and 
there  is  a  gangrenous  condition  of  the  i)arts.  The  inendu'ane  is  of  a  dirty 
greenish  or  gray  color,  and  the  tonsils  and  ])alate  may  be  in  a  state  of 
necrotic  sloughing.  The  erosion  may  be  deej)  enough  in  the  tonsils  to 
open  the  carotid  artery,  or  a  false  aneurism  may  be  produced  in  the  deep 
tissues  of  the  neck.  Tlie  nose  nuiy  be  comi)letely  blocked  Ijy  the  false  mem- 
brane, which  may  also  extend  into  the  conjunctiva}  and  through  the 
Eustachian  tubes  into  the  middle  ear.  In  cases  of  laryngeal  diphtheria 
the  exudate  in  the  pharynx  may  be  extensive.  In  many  cases,  however,  it 
is  slight  ujjon  the  tonsils  and  fauces  and  abundant  upon  the  ejjiglottis  and 
the  larynx,  which  may  be  completely  occluded  l)y  false  membrane.  In 
severe  cases  the  exudate  extends  into  the  trachea  and  to  the  bronchi  of 
the  third  or  fourth  dimension.  This  occurred  in  nearly  half  of  my  30 
Montreal  autopsies. 

In  all  these  situations  the  membrane  varies  very  much  in  consistence, 
dejjending  greatly  upon  the  stage  at  which  death  has  taken  place.  If  death 
has  occurred  early,  it  is  firm  and  closely  adherent;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  firmly  adherent  it  is  torn  olf  with  difficulty 
and  leaves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there 
is  extensive  necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lym- 
phatic glands  of  the  neck  are  enlarged,  and  there  is  a  general  infiltration 
of  the  tissues  with  serum;  the  salivary  glands,  too,  may  be  swollen.  In 
rare  instances  the  membrane  extends  to  the  gullet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  membranous  croup,  the 
rlina  is  seen  filled  with  mucus  or  with  a  shreddy  material  which,  when 
washed  off  carefully,  leaves  the  mucosa  covered  by  a  thin  grayish-yellow 
membrane,  which  may  be  uniform  or  in  patches.  It  covers  the  ary-epi- 
glottic  folds  and  the  true  cords,  and  may  be  continued  into  the  ventricles 
or  even  into  the  trachea.  Above,  it  may  involve  the  epiglottis.  It  varies 
much  in  consistency.  I  have  seen  fatal  cases  in  which  the  exudation  was 
not  actually  K^m])ranous,  but  rather  friable  and  granular.  It  may  form 
a  thick,  even  stratified  numbrane,  which  fills  the  entire  glottis.  The  ex- 
udation may  extend  down  the  trachea  and  into  the  bronchi,  and  may  pass 
beyond  the  epiglottis  to  the  fauces.  Usually  it  is  readily  stripped  off  from 
the  mucous  membrane  of  the  larynx  and  leaves  exposed  the  swollen  and 
injected  mucosa.  On  examination  it  is  seen  that  the  fibrinous  material 
has  involved  chiefly  the  epithelial  lining  and  ha^  not  greatly  infiltrated  the 
subjacent  tissues. 

Histological  Clianges. — "We  owe  largely  to  the  labors  of  Wagner,  Wei- 
gert,  and  more  particularly  to  the  splendid  work  of  Oertel,  our  knowledge 
of  the  minute  changes  which  take  jilace  in  dijihthcria.  The  following  is 
a  brief  abstract  of  the  views  of  the  last-named  author: 

The  diphtheritic  poison  induces  first  a  necrosis  or  death  of  cells  with 
which  it  comes  in  contact,  particularly  the  superficial  epithelium  and  the 
leucocytes.    The  deeper  cells  of  the  mucosa  and  of  the  other  parts  reached 


DIPHTHERIA. 


145 


sterior 
its  are 
others 
d  and 
1  dirty 
tate  of 
isils  to 
le  deep 
3  meiu- 
irli   the 
htheria 
ever,  it 
;tis  and 
ae.     In 
nchi  of 
my  30 

sistence, 
It  death 
shreddy, 
lifficulty 
ch  there 
he  lym- 
iltration 
lien.     In 


oup, 


the 


11,  when 

h-yellow 
ary-epi- 

L'ntricles 
t  varies 
ion  was 

lav  form 
The  ex- 
lay  pass 
IT  from 
len  and 
material 
ted  the 


F. 


Wei- 


lowledge 
twing  is 


Ills  with 

md  the 

Ireached 


hy  tlio  poison  may  also  he  all'ected.     The  second  change  is  hyaline  trans- 
formation of  the  (K'lul  cells,  or,  as  Weigert  terms  it,  the  production  of 


coaguiation-necrosii- 


The  bacilli  excite  inflammation  with  the  migration 


of  leucocytes,  whicli  arc  destroyed  Ijy  the  })oison  and  undergo  tiie  iiyaline 


chan 


rn 


Th 


lie  suifcrlicial  epithelial  layers  undergo  a  similar  alteration,  and 
what  we  know  as  tlie  false  memhrane  represents  in  large  part  an  aggrega- 
tion of  dead  cells,  most  of  which  have  undergone  the  transformation  into 
hyaline  material,  and  have  become  much  distorted  in  sha[)e.  Genuine 
iibrinous  exuchite  is,  however,  associated  with  this  coagulation-necrosis  of 
cells.  This  is  in  all  })rohability  a  conservative  process  by  which,  in  a  meas- 
ure, the  poison  is  localized  and  prevented  from  reaching  the  deeper  struc- 
tures. The  laminated  condition  of  the  exudate  is  probably  produced  by 
the  inflammation  of  dillerent  layers.  The  formation  of  these  foci  of 
necrobiosis,  starting  from  the  epithelium  and  proceeding  inward,  is,  ac- 
cording to  Oertel,  the  distinguishing  characteristic  of  cliphtheria.  The 
action  of  the  ])oison  is  by  no  means  confined  to  the  superficial  mucosa  on 
which  the  bacilli  grow.  Although  they  do  not  themselves  penetrate  deeply, 
the  contiguous  bronchial  glands  show  extensive  foci  of  necrosis.  In  severe 
cases  these  necrotic  areas  are  found  in  the  internal  organs,  in  the  solitary 
glands  of  the  intestines,  and  in  the  mesenteric  glands. 

The  blood-vessels  may  themselves  be  much  altered  and  the  capillaries 
may  show  extensive  hyaline  degeneration.  Every  one  of  the  histological 
changes  described  by  Oertel  in  human  diphtheria  may  be  paralleled  in  the 
experimental  disease  induced  by  the  Ivlebs-Loeffler  bacillus.  Welch  and 
Flexner  have  shown  that  similar  foci  of  necrosis  with  nuclear  fragmenta- 
tion in  lymphatic  glands,  the  liver,  spleen,  intestinal  mucosa,  and  other 
parts,  occur  in  the  experimental  diphtheria  of  guinea-])igs,  and  they  have 
demonstrated  that  these  necroses  are  due  to  the  so-called  tox-albumin  of 
the  diphtheria  bacillus.  The  local  exudate  is  caused  by  the  bacilli  them- 
selves and  cannot  be  produced  by  the  tox-albumin  alone. 

The  changes  in  the  otltcr  organs  are  variable.  "When  death  has  oc- 
curred from  asphyxia  there  is  general  congestion  of  the  viscera. 

Capillary  bronchitis,  areas  of  collapse,  and  patches  of  broncho- pneu- 
monia are  almost  constantly  found  in  fatal  cases.  Tlie  l)roncho-pneumonia 
complicating  diphtheria  often  contains  the  Klebs-Loeftler  l)acillus,  but 
usually  in  coml)ination  with  the  streptococcus  ])yogenes  or  tlie  diplococcus 
])neumonifB.  These  latter  organisms,  particularly  the  streptococcus,  are 
the  most  frequent  cause  of  the  i)ulmonary  complications  of  diphtheria. 
In  very  malignant  cases  the  blood  may  be  fluid.  Fibrinous  coagula  may 
be  found  in  the  heart,  but  the  wi(lesi)read  idea  that  they  may  cause  sud- 
den death  is  erroneous.  Myocardial  changes  are  not  infrequent,  and  in 
certain  cases  sudden  death  is  due  to  heart-failure  in  consequence  of  degen- 
eration of  the  muscle-fibres.  Endocarditis  is  extremely  rare.  It  was  not 
present  in  one  of  my  thirty  autopsies.  The  serous  membranes  often  show 
ecchymoses.  The  kidneys  present  parcncliymatous  changes,  such  as  are 
associated  with  acute  febrile  affections.  There  may,  however,  be  acute 
nephritis.  The  spleen  and  liver  show  tlie  usual  febrile  changer  The 
spleen  is  not  always  enlarged.    CTcneral  streptococcus  septicaemia  or  lesions 


I: 


146 


SPECIFIC  INFECTIOUS  DISEASES. 


of  internal  or^nnp  dnc  io  lofnlizatinns  of  the  stro]itnroconR  pyofjcnop  nro 
coninioii  Jiiid  most  (l.-iniici'oiis  coniplirntions  of  diplitlicria.  'Vlw  Klchs- 
.Ldclllcr  haciJliis  may  be  rouiul  at  autopsy  in  the  blood  and  internal  organs, 
but  usnally  only  in  small  number. 

Symptoms. — 'Die  j)eriod  of  incubation  is  "  from  two  to  seven  day^ 
oftencst   two." 

The  initial  symptoms  arc  those  of  an  ordinary  felirilo  attack — sli<rht 
(iiiliiness,  i'ever,  and  acjiiiif;  j)ain8  in  the  ])ack  and  limbs.  In  mild  cases 
tiiese  symptoms  are  trilUn^^,  and  tlie  child  may  not  feel  ill  enoiijrh  to  <;() 
to  l)ed.  I'sualJy  the  temperature  rises  witiiin  the  first  twenty-four  hours 
to  10^.5°  or  103°;  in  severe  cases  to  101°.  In  young  children  there  may 
be  convulsio'is  at  the  outset. 

Pharyngeal  Diphtheria. — In  a  typical  case  there  is  at  first  redness  of 
the  fauces,  and  the  child  compuMus  of  slight  dilHculty  in  swallowing. 
'^IMie  niend)rane  first  appears  upon  tiie  tonsils,  and  it  may  he  a  little  diffi- 
cult to  distinguish  a  patcliy  dipluiieritic  i)ellicle  from  the  exudate  of  the 
tonsillar  crypts.  The  i)haryngeal  mucous  membrane  is  reddened,  and  the 
tonsils  tlu'mselves  are  swollen.  By  Lac  third  day  the  mendjrane  has  covered 
the  tonsils,  the  i)illars  of  the  fauces,  and  perhaps  the  uvula,  -which  is  thick- 
ened and  (edematous,  ami  may  fill  comi)letely  the  space  1)etween  tlie  swollen 
tonsils.  The  mend)rane  may  extend  to  the  posterior  wall  of  the  ])harynx. 
At  first  grayish-white  in  color,  it  changes  to  a  dirty  gray,  often  to  a  yellow- 
white.  It  is  firndy  adherent,  and  when  removed  leaves  a  hleeding,  slightly 
eroded  surface,  which  is  soon  covered  hy  fresh  exudate.  The  glands  in 
the  neck  are  swollen,  ami  may  be  tender.  The  general  condition  of  a 
patient  in  a  case  of  moderate  severity  is  usually  good;  the  temjierature  not 
very  high,  in  the  absence  of  com])lications  ranging  from  10"^°  to  103°. 
The  pulse  range  is  from  100  to  I'^O.  The  local  condition  of  the  throat 
is  not  of  great  severity,  and  the  constitutional  depression  is  slight.  The 
symptoms  gradually  abate,  the  swelling  of  the  neck  diminishes,  the  mem- 
branes separate,  and  from  the  seventh  to  the  tenth  day  the  throat  becomes 
clear  and  convalescence  sets  in. 

-  Clinically  atypical  forms  are  extremely   common,  and   I   follow  here 
Ivoidik's  division: 

((/)  There  may  be  no  local  manifestation  of  membrane,  but  a  simple 
catarrhal  angina  associated  sometimes  with  a  croupy  cough.  The  detec- 
tion in  these  cases  of  the  Klebs-Loeffler  bacillus  can  alone  determine  the 
diagnosis.  Such  cases  are  of  great  moment,  inasmuch  as  they  may  com- 
municate the  severer  disease  to  other  children. 

(h)  There  are  cases  in  which  the  tonsils  are  covered  by  a  pultaceous 
exudate,  not  a  consistent  membrane. 

(r)  Cases  presenting  a  punctate  form  of  membrane,  isolated,  and  usually 
on  the  surface  of  the  tonsils. 

((I)  Cases  which  begin  and  often  run  their  entire  course  with  the  local 
picture  of  a  ty])ical  lacunar  amygdalitis.  They  may  be  mild,  and  the  local 
exudate  may  not  extend,  but  in  other  cases  there  are  rapid  development 
of  mendn-ane,  and  extension  of  the  disease  to  the  pharynx  and  the  nose, 
with  severe  septic  and  constitutional  symptoms. 


DIIMITHKRIA. 


U< 


lOP  arc 
Klobs- 

n  (lay^ 

id  cases 
li  to  fi<> 
ir  hours 
ere  may 

ilncis?  of 

illowin^'. 

tie  dilli- 

c  of  the 
and  the 

3  covered 

is  thick- 

e  swollen 

pharynx. 

a  yellow- 

r,  slightly 

glands  in 

tion  of  a 
ture  not 
0  103°. 

he  throat 
ht.     The 
le  meni- 
hecomes 

ow  here 

a  simple 

le  detec- 

mine  the 

may  com- 

mltaceous 

id  nsnally 

the  local 

the  local 

k-elopment 

the  nose, 


{(')  Under  the  term  "latent  diplitheria  "  Ilciihiicr  has  descriljed  cases, 
usually  secondary,  occurrini;  chielly  in  hospital  practice,  in  young  jiersons 
iiii'  sul)ject  of  wasting  alTiH'tions,  such  as  rickets  and  tulti'rculosis.  Tlu-re 
arc  i'cver,  naso-piiai'vngcal  catarrh,  and  gastro-intcstinal  disturhances. 
i)ipiitheria  may  not  he  sus[iecled  until  severe  laryngeal  coni[)lications  de- 
velop, or  the  condition  may  not  be  determined  until  autoi)sy. 

Systemic  Infection. — The  constitutional  disturbance  in  mild  diphtheria 
is  vei-y  sliglit.  'J'liere  arc  instances,  too,  of  extensive  local  disease  witliout 
grave  systenuc  symptoms.  As  a  rule,  the  general  features  ol'  a  case  bear 
a  definite  relation  to  the  severity  of  the  local  disease.  There  ai'e  I'are  in- 
stances in  whicii  from  the  outset  the  constitutional  prostration  is  extreme, 
the  i)ulse  frc(pH'nt  and  snuill,  the  fever  high,  and  the  nervous  phenomena 
are  i)ronounced;  the  ])atient  may  sink  in  two  or  tliree  days  overwhelmed  by 
the  intensity  of  the  toxsemia.  There  are  cases  of  this  sort  in  which  tlie 
exudate  in  the  throat  may  be  slight,  but  usually  the  nasal  symjjtoms  are 
])r()nounccd.  The  tem])eratnre  may  be  very  slightly  raised  or  even  sub- 
normal. ]\lore  commonly  the  severe  systemic  symptoms  appear  at  a  later 
(late  when  the  pharyngeal  lesion  is  at  its  height.  They  are  constantly  pres- 
ent in  extensive  disease,  and  when  there  is  a  sloughing,  fietid  condition. 
The  lymphatic  glands  become  greatly  enlarged;  the  jjallor  is  extreme;  the 
face  has  an  ashen-gray  hue;  the  ])\dse  is  va\)\(\  and  feel)le,  and  the  tempera- 
ture sinks  below  normal.  In  the  most  aggravated  forms  there  are  gan- 
grenous jn'ocesses  in  the  throat,  and  in  rare  instances,  when  life  is  i)ro- 
longed,  extensive  sloughing  of  the  tissues  of  the  neck. 

Escherich  accounts  for  the  discre])ancy  sometimes  observed  between 
the  severity  of  the  constitutional  disturbance  and  the  intensity  of  the  local 
])rocess,  by  assunung  varying  degrees  of  susce|)tibility  to  the  diphtheria 
l)acillus  on  the  one  hand,  and  to  its  ])oison  on  the  other  hand.  With  high 
local  susce])tibility  of  a  part  to  the  action  of  the  bacillus,  with  little  gen- 
eral susceptibility  to  the  toxine,  there  is  extensive  local  exudate  with  mild 
constitutional  syni])toms,  or  vice  versa,  severe  systemic  disturbance  with 
hmited  local  inflammation. 

A  leiicocytosis  is  present  in  diphtheria.  ^Forse  does  not  think  it  of  any 
jirognostic  value,  since  it  is  ])rcsent  and  may  be  jironounced  in  mild  cases. 

Nasal  Diphtheria. — In  cases  of  ])haryngcal  diphtheria  the  Kleljs-Loef- 
iler  bacillus  is  found  on  the  mucous  n\embrane  of  the  nose  and  in  the  secre- 
tions, even  when  no  membrane  is  present,  but  it  may  api)arently  produce 
two  affections  similar  enough  locally  but  widely  differing  in  their  general 
features. 

In  membranous  or  fd)rinous  rhinitis,  a  very  remarkable  affection  seen 
usually  in  children,  the  nares  are  occupied  by  thick  membranes,  but  there 
is  an  entire  absence  of  any  constitutional  disturbance.  The  condition 
has  been  studied  very  carefully  by  Park,  Abbott,  fJerbcr  and  Podack,  and 
others.  Kavenel  has  collected  77  cases  (]\Iedical  Xews,  ISiK"),  I),  in  41  of 
which  a  bacteriological  examination  was  made,  in  33  the  Klebs-Loefller  ba- 
cillus being  present.  All  the  cases  ran  a  benign  course,  and  in  all  but  a 
few  the  mend)rane  was  limited  to  the  nose,  and  the  constitutional  syni])- 
toms  were  either  absent  or  very  slight.     Remarkable  and  puzzling  features 


148 


SPECIFIC   INPEC^TIOUS   DISEASES. 


nro  that  the  disoaso  runs  a  hcni^ni  coiirsf,  and  that  iiifcH'tion  ol'  otl.^'r  chil- 
dren ill  tliu  family  i«  I'xtrciiie'ly  raic. 

On  the  otluT  liand,  m\m\  di]>htlit'ria  is  apt  to  present  a  most  malignant 
tyjie  of  the  disease.  The  inl'eetion  may  be  itriiiiary  in  the  nose,  and  in  a 
case  recently  in  my  wards  there  was  otitis  media,  and  the  Klehs-Loedler 
hacilliis  was  separated  from  tiie  discharge  before  the  condition  of  nasal 
diphtheria  was  siisj)ected.  While  some  cases  are  of  mild  character,  others 
are  very  intense,  and  the  constitntional  symj)tonis  most  profound.  The 
glandular  inflammation  is  usually  very  intense,  owing,  as  Jacobi  jioints  out, 
to  the  great  richness  of  the  nasal  mucosa  in  lymphatics.  From  the  nose 
the  inllammation  may  extend  through  the  tear-ducts  to  the  conjuctivie 
and  into  the  antra. 

Larjnigeal  Diphtheria. — Mfmhranous  Croup. — "With  a  very  large  pro- 
portion of  all  the  cases  of  membranous  hiryngitis  tlie  Klebs-IiOelller  l)acil- 
lus  is  associated;  in  a  much  smaller  number  other  organisms,  ])articularly 
the  streptococcus,  are  found.  Membranous  crou]),  then,  may  be  said  to  be 
either  genuine  diplitheria  or  dijditheroid  in  character.  Of  28G  cases  in 
which  the  disease  was  confined  to  tlie  larynx  or  bronchi,  in  229  the  Klebs- 
Loefller  bacilli  were  found.  In  57  they  were  not  jircsent,  but  17  of  these 
cultures  were  unsatisfactory  (Park  and  Beebe).  The  streptococcus  cases 
are  more  likely  to  be  secondary  to  other  acute  diseases. 

Symptoms. — Naturally,  the  clinical  symptoms  are  almost  identical  in 
the  non-specific  and  8[)ecific  forms  of  membranous  laryngitis. 

The  afi'ection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  has  been  apiilied.  After  these 
symptoms  have  lasted  for  a  day  or  two  with  varying  intensity,  the  child 
suddenly  becomes  worse,  usually  at  night,  and  there  are  signs  of  impeded 
respiration.  At  first  the  difficulty  in  breathing  is  paroxysmal,  due  prob- 
ably to  more  or  less  spasm  of  tlie  muscles  of  the  glottis.  Soon  the  dyspnoea 
becomes  continuous,  inspiration  and  expiration  become  difficult,  particu- 
larly the  latter,  and  with  the  insjiiratory  movements  the  epigastrium  and 
lower  intercostal  spaces  are  retracted.  The  voice  is  husky  and  may  be  re- 
duced to  a  whisper.  The  color  gradually  changes  and  the  imperfect  aera- 
tion of  the  blood  is  shown  in  the  lividity  of  the  lips  and  finger-tips.  Rest- 
lessness conies  on  and  the  child  tosses  from  side  to  side,  vainly  trying  to 
get  breath.  Occasionally,  in  a  severer  paroxysm,  portions  of  membrane  arc 
coughed  out.  The  fever  in  membranous  laryngitis  is  rarely  very  high  and 
the  condition  of  the  child  is  usually  very  good  at  the  time  of  the  onset. 
The  pulse  is  always  increased  in  frequency  and  if  cyanosis  be  present  is 
small.  In  favoral)le  cases  the  dyspnoea  is  not  very  urgent,  the  color  of  the 
face  remains  good,  and  after  one  or  U\o  paroxysms  the  child  goes  to  sleep 
and  wakes  in  the  morning,  perhaps  without  fever  and  feeling  comfortable. 
The  attack  may  recur  the  following  night  with  greater  severity.  In  un- 
favorable cases  the  dyspnrea  becomes  more  and  more  urgent,  the  cyanosis 
deepens,  the  child,  after  a  period  of  intense  restlessness,  sinks  into  a  semi- 
comatose state,  and  death  finally  occurs  from  poisoning  of  the  nerve  cen- 
tres by  carbon  dioxide.  In  other  cases  the  onset  is  less  sudden  and  is  pre- 
ceded by  a  longer  period  of  indisposition.    As  a  rule,  there  are  pharyngeal 


4 


DIPIITIIEIIIA. 


149 


hil- 


•r  c 


ilij^nnnt 
ml  in  a 
Loetllor 
)t'  nasal 
',  othorrf 
I.  The 
ints  out, 
:he  nose 
iijuctiviu 

i-ge  pro- 
er  bacil- 
•ticularly 
lid  to  1)0 

cases  in 
10  Klebs- 

of  these 
cus  cases 

sntical  in 

eness  and 
'tor  these 
the  child 
impeded 
ue  prob- 
dyspnoea 
particu- 
■ium  and 
lay  be  re- 
'oct  aera- 
bs.    Kest- 
trying  to 
brane  are 
Ihigh  and 
e  onset, 
present  is 
lor  of  the 
to  sleep 
ifortable. 
In  nn- 
cyanosis 
lo  a  semi- 
Icrve  cen- 
id  is  pre- 
laryngeal 


Mmptonis.  Tlio  constitutional  disturbance  may  bo  more  severe,  the  fever 
higher,  and  there  may  he  swelling  of  the  glands  of  the  neek.  Inspection 
of  the  fauces  may  show  the  presence  of  false  mi'mltranes  on  the  pillars  or 
on  the  tonsils.  JJactcriological  examination  can  alone  determine  wliether 
tiiese  are  due  to  the  Klebs-Loelller  bacillus  or  to  the  streptococcus.  Faggo 
held  that  non-contagious  memi)ranous  croup  nuiy  spread  upward  from  the 
larynx  just  as  diphtlicritic  inllainmatioii  is  in  tiie  habit  of  spreading  down- 
ward from  the  fauces.  Ware,  of  Jjostou,  wiiose  essay  on  croup  is  perluii)S 
the  most  solid  contribution  to  the  subject  made  in  this  country,  reported 
the  i)resence  of  exudate  in  the  fauces  in  74  out  of  75  cases  of  croup.  These 
observations  were  made  jjrior  to  ISlO,  during  jteriods  in  which  diphtlieria 
was  not  epidemic  to  any  extent  in  Uoston.  Jn  jjrotracted  cases  jjulmonary 
symptoms  may  develoj),  which  are  sometimes  due  to  the  dilHculty  in  ex})el- 
ling  the  muco-pus  from  the  tubes;  in  others,  the  false  mend)rane  extends 
into  the  trachea  and  even  into  the  bronchial  tul)es.  During  the  i)aroxysm 
t!ie  vesicular  murmur  is  scarcely  audil)le,  l)ut  the  laryngeal  stridor  may  be 
loudly  commuidcated  along  the  bronchial  tubes. 

Diphtheria  of  Other  Parts. — Primary  di[ththcria  occurs  occasionally 
in  the  cunjundiva.  It  follows  in  some  instances  the  alt'ection  of  the  nasal 
mucous  membrane.  Some  of  the  cases  are  severe  and  serious,  but  it  has 
been  shown  by  C.  Friinkel  and  others  that  the  diphtheria  bacilli  may  be 
present  in  a  conjunctivitis  catarrhal  in  character,  or  associated  with  only 
slight  crou})ous  deposits. 

Diphtheria  of  the  external  audilory  meatus  is  seen  in  rare  instances  in 
which  there  are  diphtheritic  otitis  media  and  extension  through  the  tym- 
l)anic  mendjrane. 

Diphtheria  of  the  sl'in  is  most  frequently  seen  in  the  severer  forms  of 
])haryngcal  di])hthcria,  in  which  the  membrane  extends  to  the  mouth  and 
lips,  and  invades  the  adjacent  portions  of  the  skin  of  the  face.  The  skin 
about  the  anus  and  genitals  may  also  be  attacked.  Psevulo-membranous 
inflammation  is  not  uncommon  on  xdcerated  surfaces  and  wounds.  In 
very  many  of  these  cases  it  is  a  stre])tococcus  infection,  but  in  a  majority, 
perha])S,  in  which  the  ])atient  is  sulfering  with  diphtheria,  the  Klebs-Loef- 
ller  bacillus  wiU'lje  found  in  the  fibrinous  exudate.  As  proposed  by  Welch, 
the  term  "wound  diphtheria"'  should  be  limited  to  infection  of  a  wound 
l)y  the  Klebs-Loefller  bacillus.  This  "  may  manifest  itself  as  a  simple 
inflammation,  or  inflammation  Avith  superficial  necrosis,  or  inflammation 
M'ith  more  or  less  adherent  ])scudo-mend)rane.  The  conditions  as  regards 
varying  intensity  and  character  of  the  infection,  association  with  other 
bacteria,  particularly  streptococci,  and  the  necessity  of  a  bacteriological 
examination  to  establish  the  diagnosis,  are  in  no  way  different  in  the  diph- 
tlieria of  wounds  from  those  in  di])htheria  of  mucous  membranes.  "Wound 
diphtheria  may  occur  without  demonstrable  connection  with  cases  of  diph- 
theria and  without  affection  of  the  throat  in  the  individual  attacked,  but 
such  occurrences  are  rare"  (Welch).  Paralysis  may  follow  w^ound  diph- 
theria. Pseudo-membranous  inflammations  of  wounds  are  caused  more  fre- 
quently by  other  micro-organisms,  particularly  the  streptococcus  pyogenes, 
than  Ijv  the  Klebs-LoefHer  bacillus.     The  fibrinous  membrane  so  common 


150 


SPRf'IFIf  INFEOTIOrs  DISEASES, 


ill  llic  ii('i;f|il»()rlio()(l  of  the  Irnchcotniiiy  woiiiid  in  (liplitlifria  is  niivly 
nnsociatt'd  with  Hik  Kii'lis-JiOt'lllcr  IhumIIus.  J)i[)litiit'riii  of  tiio  goniliils  is 
occiisioiiiilly  seen. 

Complications  and  Sequelae. — Of  local  coinijlicatioiis,  liu-inor- 
rliii<j:L'  from  liio  nose  or  throat  may  occur  in  llic  scvci'o  niccrativc  cases. 
Skin  rashoK  arc  not  iiil'ro(jnent,  iiarticnlariy  the  diirusc  erythema.  Occa- 
sionally there  is  urticaria  and  in  the  Povcre  cases  ])ur|)ura.  The  pidnionniy 
complications  are  extremely  important.  I-'atal  cases  almost  invarial)ly  show 
ca|)iliary  hronchitis  with  hroneho-pnennionia  and  lar^ie  ])atches  oi'  collapse. 
Jn  M'vy  had  cases,  with  extensive  slon^liiii;^',  tlie  septic  partich's  may  reach 
liic  hronchi  and  e.xcite  gangrenous  processes  which  may  lead  to  severe  and 
i'atal  ha-morrhage. 

lienal  complications  arc  common.  Alhiiiiiiiiiirid  is  present  in  all  severe 
cases.  It  may  cause  Avith  tiie  usual  tests  ojily  a  slight  tui'hidity  of  tiie  urine, 
the  ordinary  fei)rile  alhuminuria.  Jn  others  there  is  a  hirge  amount  of 
albumin,  curdy  in  character.  Jt  is  only  when  the  albumin  is  in  consider- 
able ([UJintity  and  associated  with  e|)ithelial  or  blood  casts  that  the  con- 
dition indicates  ])arenchymatous  nci)hritis  and  is  alarming.  The  nephritis 
may  ai)pear  cpiite  early  in  the  disease.  It  sets  in  occasionally  with  com- 
plete suppression  of  the  urine.  Jn  com])arison  with  scarlet  fever  the  renal 
changes  lead  less  frc(iuently  to  general  dro])sy.  Mention  lias  already  been 
made  of  the  freciuency  and  gravity  of  se])tica'mia  and  local  infection  of 
internal  parts  due  to  invasion  of  the  streptococcus  pyogenes,  which  is  nearly 
a  constant  attendant  of  the  Ivlebs-LoetUer  bacillus  in  the  human  body. 

Of  the  se(]uela'  of  di])htheria,  pnrali/sis  is  by  far  the  most  important. 
This  can  be  experiinentally  produced  in  animals,  as  already  noted,  by  the 
inoculation  of  the  toxic  material  ])roduced  by  the  bacilli.  The  paralysis 
occurs  in  a  variable  pro])ortion  of  the.  cases,  ranging  from  10  to  15  and 
even  to  20  per  cent.  Jt  is  strictly  a  sc(iuel  of  the  disease,  coming  on  usu- 
ally in  the  second  or  third  week  of  convalescence.  Occasionally  it  occurs 
as  early  as  the  seventh  or  eighth  day  of  the  disease.  It  may  follow  very 
mild  cases;  indeed,  the  local  lesion  may  be  so  trifling  that  the  onset  of 
the  paralysis  alone  calls  attention  to  the  true  nature  of  the  trouble.  It  is 
])ro])ortionately  less  frequent  in  children  than  in  adults.  " 

The  disease  is  a  toxic  neuritis,  duo  to  the  absorption  of  the  poison, 
and,  like  other  forms  of  multi])lc  neuritis,  has  an  extremely  complex  symp- 
tomatology, according  to  the  nerves  Avhich  are  affected.  The  paralysis  may 
be  local  or  general. 

Of  the  local  paralyses  the  most  common  is  that  which  affects  the  pal- 
ate. This  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return  of 
li(|uids  through  the  nose,  causes  a  difficulty  in  sAvallowing.  These  may  be 
the  only  symptoms.  The  palate  is  seen  to  be  relaxed  and  motionless,  and 
the  sensation  in  it  is  also  much  impaired.  The  affection  may  extend  to 
the  constrictors  of  the  pharynx,  and  deglutition  become  embarrassed. 
Within  two  or  three  weeks  or  even  a  shorter  time  the  paralysis  disa])])cars. 
In  many  cases  the  affection  of  the  ]ialate  is  only  part  of  a  general  neuritis. 
Of  other  local  forms  ]ierha]is  the  most  common  arc  paralysis  of  the  eye- 
muscles,  intrinsic  and  extrinsic.    There  may  be  strabismus,  ptosis,  and  loss 


DIPiITFIKUIA. 


151 


rnroly 
tain  is 

a'liior- 

t'uscs. 

Occii- 

n()i\!iry 

V  show 

tllllpSC. 

:  n'ut'h 
ire  and 


severe 
•  urine,  . 
junt  of 
)iisi(l('r- 
he  cou- 
I'pliritis 
[li  com- 
ic re  nil  I 
(ly  Iji'L'U 
C'tion  of 
is  nearly 
body. 
))ortant. 
,  l>y  the 
)aralysis 
15  and 
on  ns\i- 
t  occurs 
ow  very 
louset  of 
,e.     It  is 

poison, 
[X  symp- 
I'sis  may 

jtlie  pal- 
'turn  of 

may  be 
less,  and 
dend  t(^ 
|\rrassed. 
[ap])ears. 
Ineuritis. 

the  eye- 
land  loss 


of  power  of  iiccoiiimodntioii.  I'iicia!  paralysis  may  develop,  and  in  one 
case,  two  and  a  lialf  years  later,  it  still  persisted  with  contrnetures.  The 
neuritis  may  he  conlined  to  the  nerves  of  one  liml),  thonirh  more  commonly 
the  le^s  or  the  arms  ari' aifecled  toji'ether.  \'eryol'ten  with  tlu'  palatal  paraly- 
sis is  asstx'iated  a  weakness  of  the  leys  without  delinite  palsy  hut  with  loss 
of  the  knee-jerk. 

Jleart  symptoms  are  not  uncommon.  There  may  he  ^M'eal  retardation, 
even  to  thirty  heats  in  the  minute,  ih-adycardia  and  tachycardia  may 
alternate  in  the  same  patii'ut.  Ileart-railure  and  fatal  synco[ie  may  occur 
at  the  lieifiht  of  the  disease  or  durin<j:  convalescence.  If  they  occur  durin-,' 
the  fever,  the  child,  perhaps  after  an  e.\a«:^a'ration  of  symptoms,  ])resents  an 
unusual  |)allor.  The  pulse  heconu'S  weak  and  rapid,  hut  nuiy  fall  to  fifty, 
forty,  or  even  lower.  The  extremities  are  cold,  the  temperature  sinks,  and 
death  takes  place,  with  all  the  features  of  ccdlapse,  within  a  few  hours. 
More  frequently  the  fatal  collapse  comes  during  convalescence,  even  as 
late  as  the  sixth  or  seventh  week  after  appai'cnt  recovery.  The  attack 
may  set  in  ahruptly,  perhaps  following  a  sudden  exertion.  More  com- 
monly there  have  been  symptoms  jxtinting  to  disturbed  cardiac  rhythm, 
or  even  fainting-si)ells.  In  some  instances  vonuting  has  preceded  the 
serious  cardiac  attack.  There  nuiy  be  no  jthysical  signs  otiier  than  slight 
increase  in  the  cardiac  dulness  and  a  gallop-rhythm  indicating  dilatation. 
These  symptoms  were  formerly  ascribed  to  cardiac  thromhosis  or  to  endo- 
carditis. I'ossibly  in  some  of  the  cases  the  result  is  due,  as  jwinted  out 
hy  Mosler  and  Leydeu,  to  an  infectious  myocarditis,  but  in  a  nuvjority  of 
the  cases  the  symptoms  are  probably  due  to  a  neuritis  of  the  cardiac  nerves. 

The  multiple  form  of  diphtheritic  neuritis  is  not  unconnnon.  It  may 
begin  with  the  palatal  affection,  or  with  loss  of  power  of  accommodation 
and  loss  of  the  tendon  rellexes.  This  last  is  an  important  sign,  which,  as 
T>ernhardt,  Uuzzard,  and  1\.  L.  ^MacDonnell  have  shown,  may  occur  early, 
but  is  not  necessarily  followed  by  other  symptoms  of  neuritis.  There  is 
|iara[)lcgia,  which  may  be  complete  or  involve  only  the  extensors  of  the 
feet.  The  paralysis  may  extend  and  involve  the  arms  and  face  and  render 
the  patient  entirely  helpless.  The  muscles  of  respiration  may  be  s])ared. 
Tlie  chief  dansrer  in  these  severer  forms  comes  from  the  involvement  of 
the  heart  and  of  the  muscles  of  respiration;  but  the  outlook  is  in  many 
eases  not  so  bad  as  the  patient'.s  condition  would  indicate.  Of  13  cases 
collected  by  Cadet  de  Gassicourt  G  died.  The  sphincters  may  be  involved, 
Ihough  they  are  often  sy)ared. 

Diagnosis. — The  presence  of  the  Klebs-LoefTler  bacillus  is  regarded 
bv  bacteriologists  as  the  sole  criterion  of  true  di|)htheria,  and  as  this  organ- 
ism may  be  associated  with  all  grades  of  throat  affections,  from  a  simple 
catarrh  to  a  slousi-hinir,  gangrenous  process,  it  is  evident  that  in  manv 
instances  there  will  be  a  striking  discrepancy  between  the  clinical  and  tlie 
liacteriological  diagnosis.  One  inestimable  value  of  the  recent  studies  has 
heen  the  determination  of  '  ne  dii)hthcritic  character  of  many  of  the  milder 
forms  of  tonsillitis  and  pharyngitis. 

The  bacteriological  diagnosis  is  sinn)l(\  The  plan  adopted  by  the 
Xew  York  Health  Department  is  a  model  which  may  he  followed  with 


152 


SPKCIKIC   IN'l-'KCTIOUH   DISKASKS. 


Hilvaiitii;,'i'  in  other  cities.  Outfits  I'ur  iimkiiij;  cultiifes,  consist iii;;  of  a 
box  coiitaiiiiiij^  ii  liihi'  of  hjood-seriiin  and  u  slerili/.etl  bwal)  in  a  test-luiic, 
aro  distrihuti'd  to  al)out  forty  wtations  at  convt'nit'nt  pointH  in  the  city. 
A  list  of  these  pjaee.s  is  |»ui)lished,  and  a  physician  can  ol)tain  tiic  ontllt 
free  of  cost.  The  (hi'ections  are  as  fidiows:  "  The  patient  siiouhl  he  placed 
in  a  good  light,  and,  if  a  child,  properly  held.  In  cases  where  it  is  possihli' 
to  get  a  good  view  of  the  throat,  depress  the  tongiu'  and  rub  the  cotton 
swal)  gently  hut  freely  against  any  visiblu  exudate.  In  other  cases,  inclnd- 
ing  those  in  which  the  exudate  is  con(ine<l  to  the  laryn.v,  avoiding  the 
tongue,  pass  the  swab  far  back  and  rub  it  freely  against  the  mucous  nieni- 
l»riine  of  the  pharynx  and  tonsils.  Without  laying  the  swaij  down,  with- 
draw the  cotton  plug  from  the  culture-tube,  In.sert  the  swab,  and  rub  that 
portion  of  it  which  has  touched  the  exudate  gently  but  thoroughly  all  over 
the.snrface  of  the  blood-serum.  Do  not  |>ush  the  swab  into  the  blood- 
serum,  nor  break  the  surface  in  any  way.  Then  re|)lace  the  swab  in  its  own 
tnbe,  ping  both  tubes,  put  them  in  the  box,  and  return  the  cnlturo  outfit 
at  once  to  the  station  from  which  it  was  obtaine(l."  The  culture-tubes 
which  have  been  inoculatecl  ari'  kejtt  in  an  incubator  at  ;5T°  C  for  twelve 
iiours  and  are  then  ready  for  examination.  Some  prefer  a  method  by  which 
the  material  from  the  throat  collected  on  n  sterile  swab,  or,  as  recom- 
mended by  von  Esmarcli.  (ui  small  pieces  of  sterilized  sponge,  is  sent  to 
the  laboratory  where  the  cultures  and  microscopical  exandnation  are  nuule 
by  a  bacteriologist. 

An  immediate  diagnosis  without  the  use  of  cultures  is  often  ])ossible 
by  making  a  smear  preparation  of  the  exudate  from  the  throat.  The  Klebs- 
Loelller  bacilli  nuiy  be  ]iresent  in  sullicient  nund)ers,  and  may  be  (juite 
charai'teristic  to  an  expert.  In  this  connection  may  be  given  tlir  following 
statement  by  I'ark,  who  has  had  such  an  exceptional  experience:  "  'Vhv  ex- 
amination by  a  comi)etent  bacteriologist  of  the  bacterial  growth  in  a  blood- 
serum  tube  which  has  been  properly  inoculated  and  ke])t  for  fourteen  hours 
at  the  body  tem|)erature  can  be  thoroughly  relied  upon  in  cases  where  there 
is  visible  niembraiu'  in  the  throat,  if  the  culture  is  nuide  during  the  i)eriod 
in  M'hich  the  mend)rane  is  forming,  and  no  antiseptic,  especially  no  mer- 
curial solution,  has  lately  been  a])])lied.  In  cases  in  which  the  disease  is 
confined  to  the  larynx  or  l)ronchi,  surprisingly  accurate  results  can  he 
obtained  from  cultures,  but  in  a  certain  projiortiou  of  cases  no  diphtheria 
bacilli  will  be  found  in  the  first  culture,  and  yet  will  be  abundantly  ]iresent 
in  later  cultures.  We  believe,  therefore,  that  absolute  reliance  for  a  diag- 
nosis cannot  be  ])laced  upon  k  single  culture  from  the  pharynx  in  ])urely 
laryngeal  cases." 

Where  a  hacteriohn/irol  cxaminatinn  rniinnf  he  made,  the  prarfifioner  must 
regard  as  svspin'ons  all  forms  of  fhroat^afferltons  in  children,  and  rarr;/  out 
measures  of  isolation  and  disinfection.  In  this  way  alone  can  serious  errors 
be  avoided.  It  is  not,  of  course,  in  the  severer  forms  of  memhranous  an- 
gina that  mistake  is  likely  to  occur,  hut  in  the  various  lighter  forms,  manv 
of  which  are  in  reality  due  to  the  Xlebs-IiOefTler  bacillus. 

A  large  proportion  of  the  cases  of  diphtheroid  inflammation  of  the 
throat  are  due  to  the  streptococcus  pyogenes.     Tlioy  are  usually  milder. 


I 


I 


DIIMITIIKIUA. 


15:j 


ol'  a 

L-tul)l', 

J  city.             , 

outlit             i 

pllUl'tl 

orisihli' 

cotton           i 

iiiclutl-           j| 

11^'   tlio              ■ 

i  iiiL-ai- 

,  with-           1 

il»  tliat             ' 

ill  over             j 

|)1(M)(1-                      ' 

its  own 

0  outlit              j 

ri'-tul)cs             i 

•  twelve 

y  wliich 

recom- 

sent  to 

re  nuulo 

l)()ssi1)le 

e  Klebs- 

be   quite 

Dllowinfj: 

'IMu'  ex- 

it hlood- 

•u  hours 

Ire  tlu^re 

le  period 

luo  mer- 

lisease  is 

1  can  ho 

Iplitheria           ' 

1  ]iresent 

m  a  diag- 

li  jiurely 

Mier  viiist 

Ud-rji  ont 

lis  errors 

Bious  an- 

Hs,  many 

1  of  the 

H  milder, 

and  the  linhilily  to  jreiwrnl  iiirection  is  less  intense;  still,  in  scarlet  fever 
and  other  speeilie  fevers  some  of  the  most  virulent  cases  of  throat  disease 
which  we  see,  with  intense  systemic  infection,  are  caused  hy  this  niicro- 
or^'anism.  These  htrcptoi-occus  cases  ari'  proliahly  much  less  nunu'nuis 
than  the  (ij^ures  which  1  have  j,Mvcn  would  indicate.  The  more  careful 
examimitioiis  in  the  diphtheria  pavilions  of  hospitals,  particularly  in  Eu- 
rope, have  shown  that  in  the  laru'c  nuijority  of  cases  adnutted  the  Klehs- 
Loelller  Itacillus  is  present.  1  have  already  referred,  under  the  section  on 
scarlet  fever,  t(»  the  (|uestiou  of  the  dia^niosis  hetween  Hcarlet  lover  with 
severe  anjiiiui  and  diphtheria. 

Prognosis. —  in  hospital  practice  the  disease  is  very  fatal,  the  jier- 
(■eiitii;;t'  of  deaths  ran^in«;  from  thirty  to  fifty.  This  is  diw  in  jircat  part 
to  the  admission  only  (d'  the  severer  forms.  In  couidry  places  the  disease 
nuiy  display  an  appalling  virulence.  In  cases  of  ordinary  severity  the  out- 
look is  usually  good.  |)eath  results  fr(uu  involvement  of  the  larynx,  septic 
infection,  sudden  heart-failure,  diphtheritic  paralysis,  occasioiuiliy  from 
unenua,  and  sometimes  from  broncho-pneumonia  devi'loping  during  con- 
valescence. 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  the  clothing 
and  of  everything  that  has  come  in  contact  with  the  patient,  careful 
scrutiny  of  the  uulder  cases  of  throat  disorder,  and  more  stringent  surveil- 
lance in  the  period  of  convalescence  are  the  essential  measures  to  prevent 
the  s])read  of  the  disease.  Sus|)ected  cases  in  families  or  .schools  should  lie 
at  oiH-e  isolated  or  removed  to  a  hospital  for  infectious  disorders.  When  a 
death  has  occurred  from  diphtheria,  the  body  should  be  wrapped  in  a  sheet 
which  has  been  soaked  in  a  corrosive-sublimate  solution  (1  to  15, ()(>(>),  and 
]daced  in  a  closely  sealed  cothn.     The  funeral  should  always  be  jjrivate. 

In  cases  of  well-niarki'd  diphtheria  these  precaidions  are  usually  car- 
rii'il  out,  but  the  chief  (huiger  is  from  the  inilder  cases,  ])articularly  the 
ambulatory  form,  in  which  the  disease  has  perhaps  not  been  suspected. 
l?ut  from  such  patients  nungling  with  susceptible  children  the  disease  is 
often  conveyed.  The  healthy  children  in  a  fandly  in  which  diphtheria 
exists  may  carry  the  disease  to  their  sfhool-fcUows.  A  striking  illustration 
of  the  way  in  which  diphtheria  is  sjjread  is  given  by  Park  and  l')eel)e:  "  IMie 
child  of  a  nuin  who  ke])t  a  candy  store  develojied  diphtheria;  there  were 
four  other  children  in  the  fandly,  and  these  were  in  no  way  isolated  fi'om 
the  patient,  yet  none  of  them  develo])ed  diphtheria;  but  children  who 
bought  candy  at  the  store,  and  other  children  conung  in  contact  with  these 
in  school,  developed  di])htheria.  '^Phe  secondary  cases  ceased  to  develo])  so 
soon  as  the  candy  store  had  been  closed." 

A  very  important  matter  in  the  prophylaxis  relates  to  the  period  of 
convalescence.  It  has  been  shown  l)y  numerous  observations  that,  after  all 
the  membrane  has  cleared  away,  virulent  bacilli  nuiy  persist  in  the  throat 
from  periods  ranging  from  six  weeks  to  six  months,  or  even  longer.  There 
is  evidence  to  show  that  the  disease  may  be  commnnicated  by  such  patients, 
so  that  isolation  should  be  continued  in  any  given  case  until  the  bacteri- 
ological examination  shows  that  the  throat  is  free. 

It  cannot  be  too  strongly  emphasized  that  the  important  elements  in 


154 


SI'KCIFIC   INI'HCTlors   DISKASKS. 


f 


till'  |irn|»liylii\is  of  (li|ilitlit'ria  arc  tlic  ri^'id  scrutiny  dI'  tlic  iiiiltlcr  tyitts  of 
tlimiil  iillVclioii,  ami  llio  llioiougli  isolulioii  ami  tlisinffction  of  tlic  imli- 
viilual  patifiitM. 

C'art'fiil  atti'iitinn  sln)iilil  lie  driven  to  tlm  throats  niid  iiioiitlis  of  cliil- 
tlrcii,  partii'iiiarly  to  the  tcftli  and  tonsils,  is  I'ailli'-  lias  iir;r<''l.  Swollen 
iiml  ciilari^i'd  tonsils  should  he  rcinovcd.  In  ihtsous  cxiioscd,  the  anti- 
>it'|tlic  luoulli  washes,  hucIi  as  corroHlvt!  wuhliniatc  (1  to  in.ooo),  chlorino 
water  (I  to  1,1(1(1),  or  swahhin;;-  the  thcfiat  with  a  diluted  Loi-lUer's  solu- 
tion, slioidd  lie  elii|ilo_Ved. 

Treatment. — 'The  ini|ioiiant  points  are  liy;.nenie  measures  to  pre- 
vent the  spieiid  of  the  malady,  local  treatment  of  the  tlintat  to  destroy 
the  hacilli,  medication,  ^reneral  or  speeille,  to  counteract  the  ell'eets  of  the 
toxines.  and,  lastlv,  to  meet  the  complications  and  se<piela'. 

{(t)  Hygienic  Measures. — The  patient  should  he  in  a  room  from  which 
the  carpets,  curtains,  and  superlliious  furniture  have  heeii  removed.  The 
teinperaturo  Hliould  \n'  ahout  (IS",  and  thorough  ventilation  should  he 
secured.  The  air  may  ho  kept  moist  hy  a  kettle  m-  a  steam-atomizer,  if 
])ossihle,  only  the  nurse,  the  child's  mother,  ami  the  doctor  should  come 
in  contact  with  the  patient.  i)uriiig  the  visit  the  physician  should  wear 
a  linen  overall,  and  on  leaving  the  room  he  should  thoroughly  wash  his 
liands  and  face  in  n  corrosivo-suhlimate  solution.  The  strictest  (juaiiiiitine 
should  he  employi'd  against  other  memhers  in  the  liousi-. 

(/')  Local  Treatment. — in  mild  cases  the  throat  symptoms  are  ahme 
liromincul.  \'ig(U'ous  local  treatment  from  the  outset  should  be  carrieil 
out,  taking  especial  care  in  all  instances  to  avoid  mechaiiical  injui'y  to 
the  tissues.  A  very  large  nundier  of  solutions  have  been  recommended. 
They  are  l)(>st  employed  with  a  swab  of  cotton-wool  or  a  soft  sponge,  or 
irrigation  with  hot  antiseptic  solutions  jiiay  be  used.  The  direct  applica- 
tion with  a  swab  of  cotton-wo(d  or  sponge  is,  as  a  rule,  elfective.  in  many 
young  children  it  is  really  a  most  trying  procednre  to  cany  out  the  trcat- 
nient,  and  someiimes  one  is  compelled  to  desist.  The  ni  rse  should  hold 
the  child  (in  her  kni'es,  well  wrappe(l  in  a  shawl,  with  its  liead  resting  on 
lier  shouldci'.  The  nose  is  then  hehJ,  and  so  soon  as  the  child  opens  its 
mouth  a  cork  should  be  placed  ))etwcen  the  molar  teeth.  The  local  appli- 
Ciition  can  then  be  nuule,  or  thorough  irrigation  carried  out.  In  infants 
the  disinfecting  fluids  are  sometimes  better  applied  throngh  the  no;  trils. 
Tlie  following  solutions  may  be  employed: 

Loetller's  solution:  ^ienthol,  10  grammes  dissolved  in  toluol  to  30  cc. 
Liq.  L'erri  sesqnichlorati,  -\  cc;  alcohol  absol.,  GO  cc. 

Corrosive  sublimate,  1  to  ],()()(),  citiier  alone  or  with  tartaric  acid,  •" 
grammes  to  the  litre. 

Carbolic  acid.  3  per  cent  in  .'50  per  cent  alcohol  solution,  is  much  em- 
ployed; some  prefer  to  touch  the  small  spots  of  exudate  witli  pure  carbolic 
acid. 

Another  solution  is:  The  tincture  of  the  perchloride  of  iron,  a  draclim 
and  a  half,  in  glycerine,  one  ounce,  water,  one  ounce,  with  from  1')  to  2^) 
minims  of  carbolic  acid.  Chlorim'  water,  l)ovic  acid,  peroxide  of  hydrogen, 
iodoform,  lactic  acid,  tryjisin,  and  papain  are  also  recommended. 


DIIMITIIKUIA. 


155 


•pi't4    of 

•  incli- 

^i  fhil- 
^wollt'n 
0  luiii- 
■hlnrino 
•'ri  solu- 

to    itn- 
(U'stn»y 

s   Ol"    tilt! 

Ill  whicli 
..I.     TlH- 

lOUlll     l'»- 

lizcr.  It' 
iild  coinc 
)uKl  vvcuv 
wiisli  1»'h 
uamntin*' 

an'  al'tuf 

bo  cavrii'tl 

injury   t" 

inn'iuU'il- 

)()n,L'»\  '"■ 
iipplifa- 
In  many 

tin'  tn'at- 
)iil(l  liolA 

x^iuv^  on 
()])t'n>4  it^ 

)cal  appli- 


ic  acul,  •' 


tinuch  rni- 
•e  carljol'n' 


a  araehni 

15  to  '2^^ 

llivdrog-en, 


TiOclUcr'M  sollltinn.  wlliill  luif"   bt-i'll   ;^'i\('Il   a   \rry   tlininii;;ll    trial,   is   [UT- 

lia|is  tlic  most  satisractory. 

Nasal  (li|ilitli('ria  rcniiircH  prompt  and  thorou^rh  (lisinfcctioii  of  tin? 
]iassa^'('S.  .lat'olii  rcconiiiiciKis  j'liloridc  of  soiliuin,  sutiiratfil  lioric  acid, 
or  I  part  ol'  hichloridc  of  incrciiry,  :i."»  of  chloride  of  sodium,  and  l.oiM) 
nf  water,  or  the  1-per-ceiit  solution  of  eiirl)olie  aeid.  LoelUer's  solution 
may  he  diluted  and  applieil  with  n  syrin;,^'  or  a  spray.  To  he  elVectual 
diL'  inJL'i'lion  must  ho  properly  ;;iven.  The  nurse  bhould  l)c  inslruelcd  to 
pass  the  no/./le  of  the  ,-yi'in;;i'  hori/onlally,  not  vei'tieally;  otherwise  the 
lluiil  will  I'cturn  thron^di  the  same  in)stril. 

When  ihe  larynx  heeoines  in\ol\e(|,  n  steam  tent  may  he  arran;,'e(l 
upon  the  hi'd,  so  thai  the  child  nuiy  hrealhe  an  atniosplieri'  satui'ated 
with  nn)istui'('.  If  the  dyspinea  hi'tonies  ur;^('nt,  an  emetic  of  sulphate  (d" 
/ine  or  ipei'acuanha  may  he  ;,dven.  When  the  si;,nis  of  ohstrnetion  are 
luarkcil  there  should  he  no  delay  in  the  perfornuinee  of  inlui)ation  or 
1  lacht'otomy. 

ilot  applications  to  the  neck  are  nsnally  very  irrateful.  ]»articulai'ly  to 
'n)unj;  chiUlreii,  tlioii<:h  in  the  ease  of  older  ehildrea  and  a<lults  the  iee 
poultices  are  to  he  preferreil. 

{'•)  General  Measures. — The  food  should  le  licpiid — milk,  heef  juices, 
liarley  water,  alhumen  water,  and  soups.  The  child  should  he  encouraf^ed 
lo  driidv  water  fi'cely.  W'hi'n  the  pharyn^^eal  involvement  i.s  very  ^'reat 
and  swallowiiifi:  [lainful,  nutritive  enennita  should  he  used.  In  cases  with 
severe  constitutional  symptoms  stimulants  should  he  ^dven  early. 

Medicines  ^iiven  internally  are  of  veiT  little  avail  in  the  disease.  There 
is  still  a  widespi'ead  hclief  in  the  ])rof('ssion  that  forms  of  mercury  are  l)ene- 
licial.  The  tiiu-ture  (d'  the  percldoride  of  iron  is  also  very  warndy  recom- 
iiien(h'd.  W'v  are  still,  however,  without  dru^^s  which  can  dii'cctly  coun- 
tiTMcl  tlu'  to\-alhumins  of  this  dist'ase,  and  we  must  rely  on  ^■eiieral 
iiieasnrt'S  of  l'ee<lin<i  and  stimulants  to  suppoi't   the  stren<ith. 

'J'hc  convalescence  of  the  disease  is  not  without  its  dangers,  and  patient.s 
dn)nld  hi'  very  carefully  watched,  particularly  if  there  are  siyns  of  heart 
weakness. 

The  diphtheritic  i)aralysis  re(pnres  I'est  in  lud,  and  in  those  cases  in 
vhich  the  heart  I'hyihm  is  disturiied  the  avoidance  of  suddi'U  exertion. 
In  the  chronic  foinis  with  wasting-,  massa^'e,  electricity,  and  strychnine 
u'c  invaluahle  aids.  If  swallowiii":  heconu'S  veiw  dillicult.  the  patient  must 
'('  fed  with  the  stomach-tuhc,  ■which  is  very  much  preferahle  to  feeding 
'"'/•  rcrluw. 

('/)  Antitoxine  Treatment. — As  ahove  mentioned,  animals  ]nay  he  ren- 
Vred  immune  a^-'ainst  diphthei'ia,  and  the  hlood  of  an  aiumal  so  treated 
hen  introduced  into  another  animal  protects  it  from  infection  with  the 
iicilli  of  the  di.^ense.  The  f)hservations  of  I'.ehrinu',  Woux,  and  others 
ave  shown  that  the  use  of  ihe  hlood-sernm  of  animals  rendered  arti- 
iiially  immune  a^^ainst  di])Iitheria  has  an  important  healin^f  influence 
|ion  diphtheria  ?])ontaneonsly  ac(|uired  in  man.  In  ])re]iarin<jf  the  blood- 
l-rum  it  is  very  desirable,  of  cour.«e,  to  have  a  uniform  .standard  of  stren<rth. 
I'lie  tenth  of  one  cubic  centimetre  of  what  liehrintr  calls  his  normal  serum 
10 


I 


!.■)() 


SPECIFIC  INFECTIOUS  DISEASES. 


will  fonntornct  ten  timos  tlic  iiiininniiii  of  (li[)litli('ria  poison  fatal  for  a 
giiinea-|)i;^f  wi'iyliiiig  3U()  grajunR'S.  One  cubic  centimetre  of  this  normal 
eerum  he  calls  an  antitoxine  nnit.  Holt  gives  the  following  tlirections  for 
the  use  of  the  antitoxine:  "  The  general  exi)erience  of  the  profession  thus 
far  is,  that  for  children  over  two  years  okl  the  initial  close  slionld  be  from 
LoOU  to  ^,000  units  in  all  severe  cases,  including  those  of  laryngeal  steno- 
sis; this  dose  to  be  repeated  in  from  eighteen  to  twenty-four  hours  if  no 
improvement  is  seen,  and  again  in  twenty-four  hours  if  the  course  of  the 
disease  is  unfavorable.  The  third  dose  is  rarely  necessary.  Exceptional 
cases  of  great  severity,  especially  when  seen  late,  should  receive  somewhat 
larger  doses  than  those  mentioned — i.  e.,  3,000  units.  Mild  cases  should 
receive  1,000  units  for  the  first  injection,  a  second  being  rarely  required. 
For  children  under  two  years  old,  the  initial  dose  in  a  severe  case  or  one 
of  laryngeal  stenosis  shoidd  be  1,000  units,  to  be  repeated  as  above  indi- 
cated; in  a  mild  case,  (!U0  units.  The  most  concentrated  serum  is  to  be 
l)referred,  and  only  that  obtained  from  a  reliable  source  should  be  used." 

A  large  number  of  preparations  are  now  on  the  niarkut,  and  some 
caution  has  to  be  exercised  by  the  practitioner  as  to  the  serum  which  he 
emi)loys. 

In  favorable  cases  the  effects  of  the  serum  are  seen  in  a  marked  amel- 
ioration of  both  the  local  and  general  symptoms.  Within  twenty-four 
hours  the  swelling  of  the  fauces  subsides  and  the  membrane  begins  to  dis- 
appear. At  the  same  time  the  temperature  falls,  the  pulse  becomes  slower, 
and  the  general  condition  of  the  patient  improves  in  every  way.  In  cases 
of  moderate  severity,  when  the  injections  are  employed  early,  the  improve- 
ment in  both  the  throat  and  constitutional  symptoms  is  certainly  very 
striking.  The  earlier  the  cases  come  under  treatment  the  better  are  the 
results.  There  are  cases,  however,  of  great  severity  in  which  the  anti- 
toxine has  been  employed  early  and  yet  has  not  saved  life. 

Among  the  untoward  effects  of  the  treatment  may  be  the  developr  ent 
of  a  local  abscess,  which,  however,  is  rare,  diffuse  erythema  and  urticaria, 
joint  pains,  and  albuminuria.  None  of  these  are  serious,  and  the  evidence 
is  not  conclusive  that  the  incidence  of  albuminuria  is  greater  in  the  cases 
treated  with  antitoxine. 

During  the  past  three  years  evidence  has  been  accumulating  from  all 
parts  of  the  world  as  to  the  beneficial  effects  of  the  antitoxine  treatment 
in  di])htheria,  but  figures  need  no  longer  be  quoted  in  illustration.  The 
following  statement  from  Holt's  Avork  expresses  the  opinion  of  those  best 
able  to  judge  of  the  matter:  "  The  serum  is  much  loss  efficacious  in  the 
cases  of  so-called  mixed  infection  or  se])tic  diphtheria,  and  is  valueless  in 
the  membranous  inflammations  which  are  due  to  streptococci.  In  a  child 
the  serum  should  be  injected  upon  a  clinical  diagnosis  of  diphtheria  with- 
ovt  A  aiting  for  the  bacterial  examination.  In  a  mild  case  in  an  older  child 
this  perha]is  may  be  waited  for,  but  not  in  a  severe  one,  and  particularly 
not  in  a  laryngeal  case.  The  most  concentrated  preparation  of  antitoxine 
which  can  be  obtained  should  be  employed.  In  cases  injected  during  thi' 
first  two  days  the  mortality  is  less  than  5  per  cent.  The  evidence  is  con-, 
elusive  that  in  laryngeal  diphtheria  the  serum  in  sufficient  doses  largely 


ERYSIPELAS. 


157 


for  a 
onual 
118  for 
11  thus 
L'  from 

steno- 
s  if  no 

of  the 
•ptioiiul 
nvt'wbiit 

should 
equired. 
3  or  one 
,ve  indi- 

is  to  ))e 
;  used." 
nd  some 
^vhich  he 

ved  amel- 
enty-fonr 
ns  to  dis- 
les  slower, 

In  cases 

improve- 

[linly  very 

■r  are  the 

the  anti- 

ivelopr  ent 
urticaria, 

|e  evidence 
the  cases 

from  all 
treatment 

(ion.    The 
Ithose  best 
nis  in  tilt' 
lalueless  in 
Vln  a  chihl 
leria  with- 
)lder  child 
larticidarly 
lantitoxino 
Turing  the 
lice  is  con-, 
Ises  largely 


prevents  the  extension  of  nieinbraiio  into  tlie  trachea  and  bronchi,  and 
tliLis  prevents  broncho-pneumonia.  W'liile  much  still  remains  to  be  learned 
regarding  immunizatit)n,  present  knowledge  justities  the  statement  that 
for  a  period — a})proximately  a  niontli — the  protection  conferred  is  prac- 
tically complete.  Imnuinizing  doses  should  therefore  be  given  to  every 
child  in  an  infected  honseiiold  or  institution." 

The  (jucstion  of  immunizing  those  exposed  to  the  disease  is  a  very 
jiractical  one.  It  has  been  carried  out  on  a  large  scale  in  some  institu- 
tions with  satisfactory  results.  An  injection  of  the  Xo.  1  Behring  is  given, 
and  if  thought  ])roper  re])eated  in  a  few  days.  The  immunity  appears  to 
be  transient,  only  persisting  for  a  few  weeks. 


XVII.    ERYSIPELAS. 

Definition. — An  acute,  contagious  disease,  characterized  by  a  special 
inllammation  of  the  skin  caused  by  the  streptococcus  erysipelatos  (strei)to- 
coccus  pathogenes  longus). 

Etiology. — Krysi]ielas  is  a  wides])rcad  affection,  endemic  in  most  com- 
munities, and  at  certain  seasons  epidemic.  "We  are  as  yet  ignorant  of  the 
atmospheric  or  telluric  intluences  which  favor  the  diffusion  of  the  poison. 

It  is  particularly  jirevalent  in  the  s])ring  of  the  year.  Of  2,012  cases 
collected  by  Anders,  1,214  occurred  during  the  first  five  months  of  the 
year.  April  had  the  largest  number  of  cases.  The  affection  prevails  ex- 
tensively in  old,  ill-ventilated  hospitals  and  institutions  in  which  the  sani- 
tary conditions  are  defective.  With  the  ini])roved  sanitation  of  late  years 
the  number  of  cases  has  materially  diminished.  It  has  been  observed, 
however,  to  break  out  in  new  institutions  under  the  most  favorable  hygienic 
circumstances.  Erysipelas  is  both  contagious  and  inoc'ulable;  but,  except 
under  special  conditions,  the  poison  is  not  very  virulent  and  does  not 
seem  to  act  at  any  great  distance.  It  can  be  conveyed  by  a  third  person. 
The  poison  certainly  attaches  itself  to  the  furniture,  bedding,  and  walls 
of  rooms  in  which  patients  have  been  confined. 

The  disposition  to  the  disease  is  widespread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of 
any  sort.  Recently  delivered  women  and  persons  who  have  been  the  sub- 
jects of  surgical  operations  are  particularly  prone  to  it.  A  wound,  how- 
|ever,  is  not  necessary,  and  in  the  so-called  idiopathic  form,  although  it  may 
be  difficult  to  say  that  there  was  not  a  slight  abrasion  about  the  nose  or 
jlips,  in  very  many  cases  there  certainly  is  no  observable  external  lesion. 

Chronic  alcoholism,  debility,  a^'"!  Bright's  disease  are  predisposinfr 
[agents  Certain  persons  show  as  ^1  susceptibility  to  erysipelas,  and 
lit  may  recur  in  them  repeatedly.  uere  are  instances,  too,  of  a  family 
Ipredisposition. 

The  specific  agent  of  the  disease  is  a  streptococcus  growing  in  long 
Ithains,  vhich  is  included  under  the  group  name  Streptococcus  pyogenes, 
|t'  ..  which  the  Streptococcus  erysipelatos  ajipears  to  lie  identical.  The  fever 
»nd  constitutional  symptoms  are  due  in  great  part  to  the  toxins;;  the  more 


158 


SPECIFIC   INFECTIOCS    KISKASKS. 


.Miiriiinick   li:.> 
iloiikt'V.  Imrsi  . 


serious  visceral  comijlicntions  are  the  result    <>r  -ecoiidarv   iiietii>tatie   in 
J'eetioii. 

J iiiniiniili/. — Siisceptihle  animals  laii   lie  I'eiidiTed   iiiiiiiuiie   to  xiiiilcii 

streptocncei    hy    re|i(ateil    lioll-lethal    illjeclinii-;    of   eiiluiro 

atteiiipted  to  itrepare  a  ciii'ative  serum  \)\  iiijectini:  aiiima 
sliecp)  uitii  eultui'es  iiiteusilied  liy  lieiii::-  lii'owii  on  human  serum-houilloh. 
tSutdi  a  serum  is  said  to  iiave  hoth  immuiii/.iii;i  ami  curative  properties. 
The  tots  thus  lai'  made  are  not  [larticuhirly  prond^in^'. 

Morbid  Anatomy.— i-JTsipelas  is  a  simple  inlhimmatiou.  In  il- 
nncomplicated  Jorms  iliere  is  seen,  post  mortem,  little  else  than  inllamu:;,- 
tory  (edema.  lnvestij;ati(jns  have  shown  that  the  c<jcci  are  i'ound  chieliy 
in  tile  lym|ih-spa('es  and  most  ahnnchmtly  in  tlie  zone  of  spreadiuL:'  inllam- 
matioii.  in  the  iiiiinvolved  tissue  heyond  The  iiillameil  margin  they  are 
to  he  h)un(l  in  the  lymph-vessels,  and  it  is  here,  according;'  to  .Metsehiii- 
k(dT  and  others,  that  an  active  warfare  j^oes  ou  hetween  tlu'  leucocytes 
and  the  cocci  (phagocyto.sis).  In  more  extensive  and  virulent  l'orni> 
of  the  disease  there  is  usually  sup])urati(Mi.  it  is  stated  that  the  iiiilam- 
matiou  may  pa.ss  inward  from  the  scalp  throu,uh  the  skull  to  the  meninges. 
This  1  have  never  seen,  hut  in  one  case  I  traced  the  extension  from  the 
iace  along  the  llftli  nerve  to  the  meninges,  wliere  an  acute  meningitis  and 
tlir()nd)osis  of  the  lateral  sinus  were  excited. 

The  visceral  complications  of  erysipelas  art'  numerous  and  importanl. 
The  majority  of  them  are  of  a  septic  nature,  luhircts  occur  in  the  lungs, 
spleen,  and  kidneys,  and  there  may  he  the  gcnei-al  evidences  of  pyiemie 
infection. 

Some  of  the  worst  cases  of  malignant  enduciirditis  are  secon.iary  to 
erysi[)elas;  thus,  of  '^3  ca.ses,  3  occurred  in  eoimeetio]!  with  this  disease. 
Septic  ])ericarditis  and  jileuritis  also  occur. 

As  just  ment''»ned,  the  disease  may  in  rare  eases  extend  and  involve 
the  meninges,     rneumonia  is  not  a  v-i'ry  comuKUi  complication. 

Acute  ne])hritis  is  also  met  with;  it  is  (d'ten  ingrafted  upon  an  old 
chronic  trouhle. 

■  Symptoms. — 'Vlw  following  descri)>tion  a]i|ilies  specially  to  el•ysi])ell.^ 
of  the  face  and  head,  the  form  of  the  disease  which  the  physician  is  most 
commonly  called  upon  to  treat. 

''.I'lie  iiicuhaliiiii  is  variahle,  jU'ohahly  from  three  to  seven  days. 

The  stage  of  liirasinn  is  often  marked  hy  ji  'igor,  and  followed  hy  ; 
raidd  rise  in  the  temperature  and  other  characteristics  of  an  acute  fevei 
^\  nen  there  is  a  hjcal  ahrasion,  the  sjiot  is  slightly  i-eddened;  hitt  if  th' 
disease  is  idiopathic,  there  is  seen  witliin  a  few  hours  slight  redness  ovc 
the  hridge  of  the  nose  and  on  the  cluH'ks.  The  swidling  and  tension  of  tie 
skin  increase  and  within  twenty-four  hours  the  external  sym])toms  are  well 
marked.  The  skin  is  smooth,  tense,  and  oedematous.  It  looks  red.  feel- 
hot,  and  the  superficial  layers  of  the  epidermis  may  he  lifted  as  small  hleh-. 
The  patient  comjilains  of  an  un]deasant  feeling  of  tension  in  the  skin: 
the  swelling  raiiidly  increases;  and  during  the  ,<econd  day  the  eyes  a'-' 
usually  closed.  The  first-affected  parts  gradually  become  pale  and  le- 
swollen  as  the  disease  extends  at  the  jieriphery.     Wlien  it  reaches  the  fof- 


KRYSIPELAS. 


15lf 


Hie    HI- 

• 

ivk  !>;>■ 
;.  hurst  . 
iiuiilltii.. 

In    it- 
illanin;..- 
1   (liicl'ly 
••  inlliini- 
tlu'V  ari' 
Ictschni- 
..iK-ocyU'H 
:it     I'tivin- 
i'  inlliUii- 
iu'niti,tr<'>- 
I'roiii  tin 
igiti^;  and 

lupoi'tam. 
tiu!  hmgs. 
)\  iiyo-'inii- 

oiiMary   1<' 
is  dij^t'asc. 

1(1  invi>1v(. 

Lm  an   ol<l 

(>l•y^:ipc'lai^ 
lui  i^  inii-* 


|)\\c(l  l>y  ■ 
lute  fovcM 
mit  if  tlM 
llnrss  ov<  ' 
lion  of  ill' 
|i«  arc  \vi'i" 

red.  fec'- 
Imall  IjU'1'^ 

the  skin: 
li^  eyes  a''' 
and  It'-' 
the  fov(  - 


li.'inl  it  |)i'n;:'rr>s('>  ii>  an  iiil\  uminL;'  ridgt.'.  [lei'Tcct  ly  well  (Idini'il  and  rai.-cd; 
and  (ilicn,  (in  palpalinn.  Iiai'dcncd  exteiiJiions  can  lie  I'clt  licncatli  the  skin 
which  is  not  yet  re(l(h.'ne(L  Mveu  iu  a  case  ol'  moderate  severity,  the  taee 
i>  enei'niously  s\V(dlen,  the  eyes  are  e](j,sed.  the  lips  greiitly  uMh^niatuus.  the 
•  ■ars  thickened,  the  scalp  is  .-wonen,  and  the  patient's  IVatures  are  (pnte 
iiiirecognizahle.  'I'he  I'diniai  ion  ol'  hlehs  is  coininon  on  the  eyelids,  cai's, 
and  Ini'ehead.  The  cervical  lymph-glands  ai'e  swollen,  Init  ai'e  u.-nally 
ina.-ked  in  the  (edema  of  the  neck.  The  temperatni'e  keeps  high  without 
marked  rennssions  for  Jour  oj-  li\t'  day.-  and  then  ilefervescence  takes  jthice 
risis.     Leucoeytosis  is   present.      Kirkbritie  has  noted  the  ])resence  in 


i.y  ( 

•  uie  case  id'  leuein  and  tvrosin  in  the  ui'inc 


T 


le  general  ccnidition  ol'  th 


nl    \aries  much  with    his   previous  state  of  liealtli.      In   old   and   de 


iii!itate(l   persons,  ])artieul 


ariv   1 


n   those  addicted  to  ah.'ohol,  the   const itu- 


mal  dejiression  I'j'om  the  oiii.-ct  may  be  very  great.     Delii'ium  is  jiroent. 


III 


the  tongue 


bee 


omes  dry,  t  he  pulse  fe 


and  there  is  marked  tendency  to 


death  from  toxa'mia.  In  the  majority  of  cases,  lH)wever,  even  with  ex- 
tensive lesions,  the  const  itutional  disturliance,  considering  tlie  height  of 
h'ver  ranue,  is  slight.     The  mucous  mcudjrane  of  the  mouth  and  throat 


!ie 


may  iie  swollen  and  reddened.  The  erysipelat(nis  inllammation  may  extend 
e>  the  larynx,  but  the  severe  ledema  of  this  ]iai1  occasionally  met  with  is 
commonly  due  to  the  extension  of  the  inflammation  from  without  in- 
ward. 

There  are  eases  in  which  the  inllammation  extends  from  the  face  to  the 
and  oviT  till'  chest,  and   mav  eraduallv  miiirate  or  wander  ovei'  the 


llecK, 


ii'eater  pai't  of  the  boi 


iv  (/•; 


III  ill  rails). 


The  close  relation  between  the  erysi])elas  coccus  and  the  ])U^  organisms 
;>  shown  by  the  Ireqneiuy  with  which  suppnratitni  occurs  in  facial  ery- 
sipelas. Small  cntaneous  aliscesses  are  common  about  the  cheeks  and 
I'liclieail   and  neck,  and    lieiieatli  the  scalp  large  c(dlections  of   pus   may 


;iecumulate. 


S 


uppnration    seems  to  occur  more  fi'eiiuently   in   s(nne 


eni- 


lemics  than  in  others,  and  at   the  Philadelphia  lIosi)ital  (nie  year  nearly 
all  the  cases  in  the  erysipelas  wards  presented  local  ahscesses. 

Complications.  —  Meningitis    is    rare.      The    cases    in    \\hich    death 
icem's  with  marked  brain   -ymi)toms  do  not  usually  show,   post  mortem, 
meningeal  alfection.     The  delirium  and  coma  are  due  to  the  fever,  or  to 
luxa'uiia. 

I'neunionia  is  an  occa>ional  complication.     I'lcei'ative  endocarditis  ami 


•  liea'inia   are  moi'e  common. 


.Mbnminuria  is  almost  constant,   iiarticii 


:i:-.y  ni  ]iersons  ov 


■r  Hft 


!■ 


ihrit 


ue  ne)iiiritis  is  occasionally  seen. 


lb 


l»a  Cost; 


•  h 


•IS  called  attentioii  to  curious  irregular  returns  of  the  fever  which  occur 
rinu'  convalescence  uiiliout  anv  airsTavation  of  the  local  condition.     Ma- 


a  ni 


av  coexist  witl 


1   ervsipela^ 


r..   F.  llarker  has  reiiorted  such  a  cas( 


■viii'i'ing  in  my  wards. 

The  diagnosis  rarely  pi'csents  any  dillicnlty.  The  mode  of  onset,  th 
■'')i(l  vise  in  fever,  and  the  characters  of  the  local  disease  are  (juite  di> 
:i  ctive.  Acnte  necrosis  of  bone  may  sometimes  be  regarded  as  erysipel,-.; 
'  tiiistake  which  T  once  saw  made  in  connection  with  the  lower  end  of  th 
' ur. 


It, 


160 


SPECIFIC  INFECTIOUS  DISEASES. 


Prognosis.— ITt'iiltliy  adults  raroly  die.  The  general  mortality  in 
hosj)ita]s  is  about  7  per  eent,  in  i)rivate  jjraetice  about  4  per  cent  (Anders), 
In  the  new-born,  \\\wn  the  disease  attacks  the  navel,  it  is  almost  always 
fatal.  In  drnnkards  and  in  the  aged  erysipelas  is  a  serious  alfoction,  and 
death  may  result  either  from  the  intensity  of  the  fever  or,  more  commonly, 
■from  toxa'mia.  The  wandering  or  ambulatory  erysipelas,  which  has  a  more 
protracted  course,  may  cause  death  from  exhaustion. 

Treatment. — Isolation  should  be  strictly  carried  out,  particularly  in 
hospitals.  A  j)ractitioner  in  attendance  upon  a  case  of  erysipelas  should 
not  attend  cases  of  confinement. 

The  disease  is  self-limited  and  a  large  majority  of  the  cases  get  well 
without  any  internal  medication.  I  can  speak  definitely  on  this  point, 
having,  at  the  Philadelphia  Hospital,  ';reated  many  cases  in  this  way. 
The  diet  should  be  nutritious  and  light.  Stimulants  are  not  required 
except  in  the  old  and  feeble.  For  the  restlessness,  delirium,  and  ir  jomnia, 
chloral  or  the  bromides  may  be  given;  or,  if  these  fail,  opium.  ^^  nen  the 
fever  is  high  the  patient  may  be  bathed  or  sponged,  or,  in  private  practice, 
if  tliere  is  an  objection  to  this,  antipyrin  or  antifebrin  may  be  given. 

Of  internal  remedies  believed  to  influence  the  disease,  the  tincture  of 
the  ])erchloride  of  iron  has  been  highly  recommended.  At  the  Montreal 
General  Hospital  this  was  the  routine  treatment,  and  doses  of  half  a  drachm 
to  a  drachm  were  given  every  three  or  four  hours.  I  am  by  no  means 
convinced  that  it  has  any  special  action;  nor,  so  far  as  I  know,  has  any 
medicine,  given  internall}',  a  definite  control  over  the  course  of  the 
disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin 
of  the  spreading  areas  has  been  much  practised.  Two-per-cent  solutions 
of  carbolic  acid,  the  corrosive  sublimate  and  the  biniodide  of  mercury  have 
bet'U  much  used.  The  injection  sliould  be  made  not  into  but  just  a  little 
beyond  the  border  of  the  inflamed  patch.  F.  P.  Henry  has  treated  n  large 
number  of  cases  at  the  Philadel])hia  Hospital  with  the  bst-mentioned  drug, 
and  this  mode  of  practice  is  certainly  most  rational. 

Of  local  applications,  ichthyol  is  at  present  much  used.  The  inflamed 
region  may  be  covered  with  salicylate  of  starch.  Perhaps  as  good  an  ap- 
plication as  any  is  cold  water,  which  was  highly  recommended  by  Hip- 
pocrates. 


■ 


XVIII.    SEPTICi^MIA  AND   PY>EIVIIA. 


In  these  days  of  asepsis  physicians  see  many  more  cases  of  septici^mia 
and  ])yn?mia  than  do  the  surgeons.  For  one  case  in  the  post-mortem  room 
with  the  anatomical  diagnosis  of  sepficccmia  which  comes  from  the  surgical 
or  gynaecological  departments  of  the  Johns  Hopkins  Hospital,  at  least 
fifteen  or  twenty  come  from  my  medical  wards.  Certain  terms  must  first 
be  defined. 

An  infecfinn  is  the  morbid  process  induced  by  the  invasion  and  growth 
in  the  body  of  pathocrenic  micro-organisms.  An  infection  may  be  local, 
as  in  a  boil,  or  general,  as  in  some  cases  of  anthrax. 


SEPTICEMIA  AND   PY.EMIA. 


161 


ality  in 
\mlors). 
t  always 
ion,  and 
lumonly, 
s  a  more 

iilarly  in 
s  should 

get  well 
lis  point, 
:his  way. 

required 
ir  ;o)nnia, 
\\  nen  the 
;  practice, 
^-en. 
ncture  of 

]\Iontreal 

1  drachm 
no  means 
',  has  any 
56   of   the 

(le  margin 

solutions 

cury  have 

st  a  little 

d  ii  large 

ned  drug, 

inflamed 

|od  an  ap- 

by  Hip- 


Icpticoemia 
Item  room 
[e  surgical 
at  least 
Imust  first 

\d  growth 
he  local. 


An  intoxication  is  the  morbid  condition  caused  l)y  the  absorption  ol' 
toxJnes,  in  large  part  derived  from  patliogenic  organisms.  The  term 
mpnvmia  is  tlie  equivak'iit  of  sejitic  intoxication. 

A  liard-and-f'ist  line  cann(jt  l)e  drawn  hetwoen  an  infection  and  an 
intoxication,  but  agents  of  infection  alone  are  capable  of  re[)roduction, 
whereas  those  of  intoxication  are  chemical  poisons,  some  of  which  are  pro- 
duced by  the  agency  of  bacteria,  or  by  vegetable  and  animal  cells.  Infec- 
tious diseases  which  are  communicated  directly  from  one  person  to  another 
are  termed  contagious,  and  the  infecting  agent  is  sometimes  si)oken  of  as 
a  contagium.  "  Whether  or  not  an  infectious  disease  is  contagious  in  the 
ordinary  sense  depends  upon  the  nature  of  the  infectious  agent,  and  espe- 
cially upon  the  manner  of  its  elimination  from  and  reception  by  the  body. 
Most  but  not  all  contagious  diseases  are  infectious.  Scabies  is  a  contagious 
disease,  but  it  is  not  infectious  "  (Welch). 

There  are  three  chief  clinical  types  of  infection. 

1.  LOCAL  INFECTIONS  WITH  THE  DEVELOPMENT  OP  TOXINES. 

This  is  the  common  mode  of  invasion  of  many  of  tlie  diseases  which 
Ave  have  already  considered.  Tetanus,  diphtheria,  erysi])elas,  and  pneu- 
monia are  diseases  which  have  sites  of  local  infection  in  which  the  patho- 
genic organisms  develop;  but  the  constitutional  eifects  are  caused  by  the 
absorption  of  the  ])oisonous  products.  The  diphtheria  toxine  produces  all 
the  general  symjjtoms,  the  tetanus  toxine  every  feature,  of  the  disease  with- 
out the  presence  of  their  respective  bacilli.  Certain  of  the  symptoms  fol- 
lowing the  absor})tion  of  the  toxines  are  general  to  all;  others  are  special 
and  peculiar,  according  to  the  organism  which  produces  them.  A  chill, 
fever,  general  malaise,  prostration,  rapid  pulse,  restlessness,  and  headache 
jire  the  most  freciucnt.  With  but  few  excc])tions  the  febrile  disturbance  is 
the  most  connnon  feature.  The  most  serious  effects  are  seen  upon  the 
nervous  system  and  upon  the  heart,  and  the  gravity  of  the  symptoms  on 
the  part  of  these  organs  is  to  some  extent  a  measure  of  the  intensity  of 
the  intoxication.  The  organisms  of  certain  local  infections  produce  poisons 
which  have  special  actions;  thus  the  di])htheria  toxine,  besides  having  the 
cll'oets  already  referred  to,  is  especially  ])rone  to  attack  the  nervous  system 
and  to  cause  peripheral  neuritis.  The  tetanus  toxine  has  a  specific  action 
on  the  motor  neurones. 

2.   SEPTICEMIA. 

Formerly,  and  in  a  surgical  sense,  the  term  '"'  sejitica^mia  "  was  used  to 
designate  the  invasion  of  the  blood  and  tissues  of  the  body  by  the  organ- 
i.-^nis  of  suppuration,  but  in  the  medical  sense  the  term  may  be  ap])lied 
to  any  condition  in  whicli.  with  or  without  a  local  site  of  infection,  there 
i-^  ruicrol)ic  invasion  of  the  blood  and  tissues,  but  in  which  there  are  no 
foci  of  suppuration.  Owing  to  the  great  development  of  bacteria  in  the 
I'lood.  and  in  order  to  separate  it  sharply  from  local  infectious  processes 
witli  toxic  invasion  of  the  body,  it  is  proposed  to  call  this  condition  bac- 
tenemia;  toxaemia  denotes  the  latter  stat 


i; 


102 


!SI'1<:C1F1C   INFKCTIOL'S    DISHASKS. 


(ii)  Progressive  Septicaemia  from  Local  Infection.— 'I'hc  coinindn  strep- 
tufocxiLs  and  t«tii|ili\ioc()ccii!5  inrcctioii  is  as  a  rule  lirst  lot-al,  and  the  tox- 
incs  alone  pass  into  tlic  blood.  In  otiicr  iiislani'i-s  tlu'  cocfi  appear  in  the 
blood  and  tliroiiiiiioiit  tlie  tissues,  causing  a  septica'uua  wliicli  inteiisilies 
greatly  tlie  severity  of  tlie  case.  Other  inl'eetioiis  in  wliieli  tlie  bacterial 
invasion,  local  at  lii'st,  may  become  jfeiu'i'al  ai'c  |Mieunionia,  ty|ilioid  lever, 
anthrax,  /^dnori'ho'a,  and  puer|ieral  fever. 

The  clinical  features  of  this  form  are  well  seen  in  the  eases  of  j)uer- 
jiei'al  septica'niia  or  in  dissection  wound.s,  in  which  tlie  course  of  the  infec- 
tion may  be  traced  alon^''  the  lymphatics.  IMie  symptoms  usually  set  in 
within  twi'iity-foiir  hours,  and  rari'ly  later  than  the  third  or  fourth  day. 
'I'ln're  is  a  chill  or  chilliness,  with  nuxlerate  fever  at  iirst,  which  <:;radually 
rises  and  is  niiirked  l)y  daily  remissions  and  even  intermissions.  ^Fhe  judse 
is  small  and  comiu'cssible,  and  may  rt'ach  T.'o  or  higher.  (Jastro-intestinal 
disturbances  are  common,  the  tongue  is  red  at  the  mai'gin,  and  the  dorsum 
is  dry  and  (hirk.  '^riiei'c  may  be  early  delirium  or  marki'd  mental  prostra- 
tion and  apathy.  As  the  disease  ])ro<iresses  there  may  be  j)allor  of  the  face 
or  a  yellowish  tint.     ('a|)illary  luvmorrhages  are  not  uncommon. 

'J'he  outlook  is  si'rious  in  stre|)toco{cus  cases.  Death  may  occur  within 
twenty-four  hours,  and  in  fatal  cases  life  is  rarely  prolonged  for  more  than 
seven  or  eight  days.  On  post-mortem  examination  there  may  be  no  gross 
focal  lesions  in  the  viscera,  and  the  seat  of  infection  may  present  only  slight 
changes.  The  spleen  is  enlarged  and  soft,  the  blood  may  be  exti'cmely 
dark  in  color,  and  luemorrhages  arc  common,  ])articnlarly  on  the  serous 
surfaces.     Xeither  thrond)i  nor  endjoli  are  found. 

Many  instance.?  of  se])tica'mia  are  cond)ined  infections;  thus  in  diph- 
theria streiitococcus  se]it ica'inia  is  a  common,  and  the  most  serious,  event. 
Tlie  local  disease  and  tlu'  symptoms  produced  by  absorption  of  the  tox- 
ines  donunate  the  clinical  ])ictnre;  but  the  features  are  usually  much 
aggravated  by  the  systemic  invasion.  A  sindlar  infection  may  devt'lop  in 
typhoid  fever  and  in  tuberculosis,  and  nuiy  ol)scure  the  typical  picture, 
leading  to  serious  errors  in  diagnosis.  The  septicaemia  is  luit  always  due 
to  the  stre]itococcus. 

(b)  General  Septicajmia  without  Recognizable  Local  Infection.— rV//;;- 
iof/cnclir  i^i'iilicd'iiiias. — This  is  a  group  of  very  great  interest  to  the  physi- 
cian, the  full  impoi'tance  of  which  we  are  only  now  beginning  to  recognize. 

The  sidvjects  when  attacked  may  be  in  ])erfect  health;  more  commonly 
they  are  already  weakened  by  acute  or  chronic  illness.  The  i)athogenic 
organisms  ai'c  vai'ied.  The  streptococcus  ])yogenes  is  the  most  common; 
the  forms  of  staphylococcus  more  rare.  Other  occasional  causal  agents  are 
the  nncrococcus  lanceolatns  (|)neumococcus),  the  bacillus  proteus,  and  the 
bacillus  pyocyanens.  r)etween  ]\lay  1,  ISO?,  and  June  1,  189.5,  tluM-e  were 
sent  to  the  ]iost-mort(>m  room  from  my  wards  21  cases  of  general  infection, 
of  which  1.1  were  due  to  the  streptococcus  pyogenes,  2  to  the  staiihylococcus 
]iyogenes,  tv  '^  to  the  pneumococcus.  In  19  of  these  cases  the  ])atient^^ 
were  already  ,  c  sul)jects  of  some  other  malady,  which  was  aggravated,  or 
in  most  instances  terndnated.  by  the  general  septicamiia.  The  symptoms 
vary  somewhat  with  the  character  of  the  micro-organisms.     In  the  strep- 


. 


SEPTICEMIA   AND   PYAEMIA. 


103 


1  strep-        ! 
lu."  tox- 
•  in  the 
tc'iisilk'S 
ii\ct<  rial 

(1    ll'VLT, 

)1'  pueT- 

10  iiil't'i'- 

y  >^c't  in 

I'tli  (lay. 

;ra(lually 

ln'  pulse 

nU'stinal 

i  dorsum 
])rost  ra- 
the I'aeo 

ir  within 
lore  than 
no  gross 
nly  slight 
'xtreniely 
lie  ijorourf 

in  (li pil- 
ls, evi'iit. 
the  tox- 
ly    nuich 
level  op  in 
picture, 
iways  due 

• — ^'^IIP' 
ne  physi- 
I'ceognize. 
[onunonly 
lithogonic 
Icomnion: 
I  events  are 
and  the 
hero  wore 
Infection. 
IyIococcus 
])ationts 
Ivated.  or 
[yniptoms 
\\\Q  strep- 


I 


tococcus  cases  tiiere  may  he  cliills  with  high,  irregular  lever,  and  a  more 
characteristic  Kvjitic  ytatc  than  in  tlu'  pnenmococcus  infection. 

Most  of  these  ca^cs  come  correctly  under  the  term  "  iryptogcnetie  septi- 
ca'inia  "  as  employed  hy  Leuhi',  inasmuch  as  the  local  focus  of  infection  is 
not  evident  during  life,  and  may  not  he  i!ound  after  death.  Although  most 
(if  these  cases  are  tcrnnnal  infections,  yet  it  is  well  to  hear  in  mind  that 
there  are  instances  of  this  tyjie  of  all'ection  coming  on  in  a|ipai'ently 
healthy  i)ers()ns.  The  I'ever  may  he  extremely  irregular,  characteristic- 
ally septic,  and  j)ersist  for  many  weeks.  Foci  of  suppuration  may  not  de- 
velop, and  may  not  he  found  even  at  autopsy.  1  have  on  several  occa- 
sions met  with  cases  of  an  iidermitteut  pyrexia  persisting  for  weeks,  in 
which  it  seemed  impossihle  to  give  any  explanation  of  the  phenomena,  and 
some  which  ultimately  recovert'd.  and  in  which  tuhcrculosis  an<I  malai'ia 
could  he  almost  positively  excluded.  These  cases  recjuire  to  he  cai'idully 
studied  hacteriologically.  Dri'schfeld  has  descrihed  them  as  idiopathic.'  in- 
lernnttent  fever  of  pyivmic  character,  l^ocal  sym]itoms  nuiy  he  ahsent, 
though  in  three  of  his  cases  there  was  enlargement  of  the  liver,  and  in  two 
the  condition  was  a  dilfuse  suppurative  hepatitis.  '^Phe  jiyocyanic  disease, 
or  cyano-pviemia,  is  an  extremely  intcri'sting  form  of  infection  with  the 
bacillus  ])yocyaneus,  of  which  a  large  nuniher  of  cases  have  hoen  reported 
of  late  years.  (See  WoUstein's  paper.  Archives  of  Pediatrics,  Oetoher,  18!.>7, 
and  15arker,  Jour.  Am.  :\Ied.  Assoc,  ISii;.) 

3.  si:ptico-py.e:mia. 

The  pathogenic  nucro-organisms  which  invade  the  Idood  and  iissues 
may  settle  in  certain  foci  and  there  cause  suppuration.  When  multiple 
ahscesses  are  thus  ]iroduced  in  connection  -with  a  general  infection,  the 
condition  is  known  as  jn'a^mia  or,  ])erha]is  hotter,  soptico-pya'mia.  There  are 
iio  specific  organisms  of  suppuration,  and  the  condition  of  pyiemia  nuiy  he 
])ro(luced  hy  organisms  other  than  the  streptococci  and  stajdiylococci, 
though  these  are  the  most  common.  Other  forms  which  may  invade  the 
system  and  cause  foci  of  s\i])]iuration  are  the  micrococcus  lanceolatus,  the 
gonococcus,  the  hacillus  coli  communis,  the  bacillus  ty])hi  abdominalis,  the 
hacnius  ])rote'us,  the  liacillus  p.yocyancus,  the  l)acillus  influenza',  and  very 
]irol)ably  the  bacillus  a'rogeiies  ("i|isulatus.  In  a  large  proportion  of  all 
cases  of  pyfpnda  there  is  a  focus  of  infection,  cither  a  suppurating  external 
wound,  an  osteo-myelitis,  a  gonorrhnoa,  an  otitis  media,  an  oni])vaMna,  or  an 
area  of  suppuration  in  a  lymph-gland  or  about  the  appendix.  ]n  a  large 
iiinjority  of  all  these  cases  the  common  ]nis  cocci  are  ]irosent. 

Tn  a  suppurating  wound,  for  exam]do,  the  pns  organisms  induce  hyaline 
necrosis  in  the  smaller  vessels  with  the  ])roduction  of  thrombi  and  purulent 
I'lilebitis.  Tho  entrance  of  ])ns  organisms  in  small  numbers  into  the 
blood  does  not  necessarily  produce  ])ya^mia.  Commonly  the  transmission 
111  various  parts  from  the  local  focus  takes  place  hy  the  fragments  of 
llirondii  which  pass  as  emboli  to  different  parts,  whore,  if  the  conditions  are 
hivdi'able.  the  pns  organisms  excite  snppnration.  A  thrombus  which  is 
not  septic  or  contaminated,  when  dislodged  and  imi)acted  in  a  distant 
vc-sel.  produces  at  most  only  a  simple  infarction;  but,  coming  from  an 


1C4 


SPECIFIC  INFECTIOUS   TJISKASKS. 


iiil'<'i-t('<l  soiiroo  and  ('()i)tiiiiiiii<,'  piH  inicrnl)i'S,  an  iiidcpi'iKk'nt  centre  of 
inft'ction  is  I'stahlislu'd  wlu'rovcr  tlio  cinholns  may  lodffo.  Tlicst'  indu- 
IK'Mdt'Mt  Hiippiirativu  contrcH  in  pya-niia,  known  as  cinbutic  or  inelastatic 
ubsccssen,  liavu  tlio  I'ollowing  distribution: 

{(i)  In  cxtcrind  wonnds,  in  ostt'o-inyclitis,  and  in  acntc  ])liloj,Mnon  of 
tlie  skin,  the  cinljolic  particles  very  frccpicntly  excite  suppuration  in  tlie 
lungs,  proilucing  the  well-known  wedge-shaped  pya'niic  infarcts;  but  in 
some  eases  the  infeeted  particles  pass  through  the  lungs,  and  there  are  foci 
of  inflamnuition  in  the  heart  and  kidneys. 

(h)  Suppurative  foci  in  the  territory  of  the  portal  system,  i)artieularly 
in  the  intestines,  ])roduce  metastatic  abscesses  in  tlie  liver  with  or  without 
su])purative  pylephlebitis. 

Endocarditis  is  an  event  which  is  very  liable  to  occur  in  all  forms  of 
septicaemia,  and  modifies  materially  the  character  of  the  clinical  features. 
Streptococci  and  staphylococci  are  the  most  common  organisms  present 
in  the  vegetations,  hut  the  ])neumococci,  gonococci,  tubercle  hacilli,  ty- 
phoid bacilli,  anthrax  bacilli,  and  other  forms  have  been  isolated.  The 
vegetations  which  develoj)  at  the  site  of  the  valve  lesion  become  cov- 
ered with  thrombi,  jiarticles  of  which  may  be  dislodged  and  carried  as 
emboli  to  ditferent  })arts  of  the  body,  causing  multiple  abscesses  or  in- 
farcts. 

Symptoms  of  Septico-pysemia. — In  a  case  of  wound  infection, 
prior  to  the  onset  of  the  characteristic  symptoms,  there  may  be  signs  of  local 
troul)le,  and  in  the  case  of  a  discharging  wound  the  pus  may  change  in  char- 
acter. The  onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which 
the  teni])erature  rises  to  103°  or  104°  and  is  followed  by  a  profuse  sweat. 
These  chills  are  repeated  at  intervals,  either  daily  or  every  other  day.  In 
the  intervals  there  may  be  slight  pyrexia.  The  constitutional  disturliance 
is  marked  and  there  are  loss  of  appetite,  nausea,  and  vomiting,  and,  as 
the  disease  progresses,  rapid  emaciation.  Transient  erythema  is  not  un- 
common. Local  symptoms  usually  develop.  If  the  lungs  become  involved 
there  arc  dyspnoea  and  cough.  The  physical  signs  may  be  slight.  Involve- 
ment of  the  pleura  and  ])ericardium  is  common.  The  tint  of  the  skin  is 
changed;  at  first  pale  and  white,  it  subsequently  becomes  bile-tinged.  The 
spleen  is  enlarged,  and  there  may  be  intense  pain  in  the  side,  pointing  to 
perisplenitis  from  embolism.  Usually  in  the  rai)id  cases  a  typhoid  state 
develops,  and  the  patient  dies  comatose. 

In  the  chronic  cases  the  disease  may  be  prolonged  for  months;  tV.e 
chills  recur  at  long  interA'als,  the  temperature  is  irregular,  and  the  cordi- 
tion  of  the  patient  varies  fror^.  month  to  month.  The  course  is  usually 
slow  and  progressively  downward. 

Diagnosis. — Pva^mia  is  a  disease  frequently  overlooked  and  often  mis- 
taken for  other  affections. 

Cases  following  a  wound,  an  operation,  or  parturition  are  readily  recog- 
nized.    On  the  other  hand,  the  following  conditions  may  be  overlooked: 

Osfen-)ni/clifis. — Here  the  lesion  may  be  limited,  the  constitutional 
symptoms  severe,  and  the  course  of  the  disease  very  rapid.  The  cause  of 
the  trouble  may  be  discovered  only  post  mortem. 


SKPTILVKMIA  AND  PYAEMIA. 


105 


trc  of 

inilc- 

astalic 

\()\\   of 

in  tho 
l)ut  in 
.re  foci 

cularly 
vitliout 

)rms  of 
L'atures. 
present 
illi,  ty- 
1.  The 
no  cov- 
rried  as 
3  or  in- 

ifection, 
s  of  local 
in  char- 
cr  which 
sweat, 
ay.    In 
urbancc 
and,  as 
not  nn- 
mvolvcd 
nvolve- 
skin  is 
1.    The 
ting  to 
id  state 


n 


ths;  tV;e 

e  cordi- 

usually 

Iten  mis- 

Iv  recog- 
inked : 
Itntional 
2ause  of 


So,  too,  ncuto  soiitico-pya'niin  may  fullnw  (jonnrrhtva  or  n  prodalic 
ahsci'ss. 

Canes  are  soinetinics  confounded  with  li/plioid  feirr,  juirticularly  the 
more  chronic  instances,  in  uhicii  tiicrc  arc  diarrhdui,  great  jirostratinn, 
dcliriuni,  and  irrcgidar  IVvcr.  'I'hc  spK-cii,  too,  may  he  cidarg('(l.  'J'ho 
marked  knicocytosis  is  an  important  diircrcntial  point. 

In  some  of  the  instances  of  ulrcnilirc  cnildcdnlilis  tiie  diagnosis  is  very 
ditlicnlt,  particularly  in  what  is  known  as  the  typhoid,  in  contradistinction 
to  the  septic,  type  of  this  disease.  In  antic  niiliiirt/  titlirirKlosis  the  syni])- 
toiiis  occasionally  resend)le  those  of  sei)tica'nua,  more  commoidy  those  of 
typhoid   fever. 

The  j)()sl-f('1n-ilc  ortJirilidcs,  such  as  occur  after  scarlet  fever  and  gon- 
orrlnea,  are  really  instances  of  mild  septic  infection.  The  joints  may 
>ometimes  suppurate  and  jiya-mia  develop.  So,  also,  in  (iilinritlosis  of 
the  kithu'ijs  and  calculous  pi/clilis  recurring  rigors  and  sweats  due  to  septic 
inl'ection  are  conunon.  in  this  latitude  septic  and  ])ya'mic  jjrocesses 
are  too  often  confounded  with  malaria.  Jn  early  tuberculosis,  or  even 
when  signs  of  excavation  are  present  in  the  lungs,  and  in  cases  of  supt- 
tion  in  various  ])arts,  ])articularly  ein])yema  and  al)scess  of  the  livei,  i...; 
diagnosis  of  malaria  is  nuule.  The  ])ractitioner  nuiy  take  it  as  a  safe  rule, 
to  which  he  will  find  very  few  eAception.s,  that  an  intermittent  fever  which 
resists  quinine  is  not  malaria. 

Other  conditions  associated  witli  chills  which  may  he  ndstaken  for  pye- 
mia are  profound  ana'Uiia,  certain  cases  of  llodgkin's  disease,  the  hepatic 
intermittent  fever  associated  with  the  lodgment  of  gall-stones  at  the  orifice 
of  the  common  duct,  rare  eases  of  essential  fever  in  nervous  women,  and 
the  intermittent  fever  sometimes  seen  in  rapidly  developing  cancer. 

Treatment. — The  treatment  of  se])ticaMuia  and  pyannia  is  largely  a 
surgical  ])r()l)lem.  The  cases  which  come  under  the  notice  of  the  i)hysi- 
cian  usually  have  visceral  abscesses  or  idcerative  endocarditis,  conditions 
whicli  are  irremediable.  We  have  no  remedy  which  controls  the  fever. 
Quinine  and  the  new  antijiyretics  may  be  tried,  but  they  are  of  little  serv- 
ice. Quinine  is  probal)ly  better  than  anti])yrin  and  antifebrin,  which  lower 
the  temperature  for  a  time,  but  when  a  careful  two-hourly  twenty-four- 
hour  chart  is  taken,  it  is  often  found  that  the  dcju-cssion  under  the  influ- 
ence of  the  drug  is  nuule  up  at  some  other  period  of  the  day;  a  morning 
may  be  substituted  for  an  afternoon  fever. 

The  lirilliant  and  remarkable  results  whicli  follow  comjdete  evacuation 
of  the  pus  with  thorough  drainage  give  the  indication  for  the  only  success- 
ful treatment  of  this  condition. 

Unfortunately,  in  too  many  cases  which  the  physician  is  called  upon 
to  treat,  the  region  of  sup])uration  is  not  accessi])le,  and  we  have  to  ])e 
content  with  the  employment  of  general  measures  for  the  suppoit  of  the 


patient's  strength. 


TERMINAL   INFECTIONS. 


It  may  seem  paradoxical,  but  there  is  truth  in  the  statement  that  per- 
sons rarely  die  of  the  disease  with  which  they  suffer.     Secondary  infec- 


lOG 


Sl'ECIKIf   INKKCTK^l'S   DISKASKS. 


ti(»iis.  or,  as*  wc  arc  iipt  to  cull  tlicm  in  liospitiil  work,  terminal  infcction^t. 
carry  oil'  many  ol'  llif  incunililc  ciix's  in  the  wards.  {■'IfXMcr "'  has  aMaly/<'(| 
'ri't')  cases  of  elii'fiiiic  icnni  and  cui'diac  disca>e  in  which  com|ilete  hactcrio- 
lo;,dcal  examinations  were  made  nt  iini(i|isy.  i'!.\cludin;,'  tuhcrculous  inrec- 
tion,  '.'l.'l  pive  |»ositive  iiml    I".'  ni';:iiti\c  re>ults. 

'i'hc  inl'cclions  may  he  local  or  general.  The  former  are  extremely 
common,  and  are  found  in  a  lar^'e  proporlion  of  ;dl  cases  of  liri^ht's  di>eii>e, 
artei'io-,sclerosis,  hearl-disease,  cirrhosis  of  the  li\ei',  nnd  other  chronic  dis- 
ordert*.  All'ections  (d'  the  serous  mendniinc.-  (iiciile  pleurisy,  acute  peri- 
cardilis,  or  peritonitis),  nu'ninjiitis,  and  endocarditis  ari'  the  most  frcipicnt 
lesions.  It  is  perhaps  safe  to  say  that  the  nuijoiity  (d"  cases  of  advanced 
arterio-s(derosis  and  of  l>i'iLrht"s  disease  sncciimh  to  the>e  interenrrent  infee- 
tions.  The  infecti\i'  a^'ents  nre  very  varied.  The  >treptococciis  pyo<;ciK'S 
is  perhaps  the  most  common,  hut  the  pneiimoeoccus,  staphylococcus  aureus, 
the  hacillus  proleiis,  the  ^duococcus.  the  pis  hacillus.  and  the  hacilliis  pyo- 
cyaneus  iire  also  luet   wit  h. 

I'articidar  mention  may  he  here  made  of  the  tei'nunal  form  of  acuti' 
miliary  tuhercidosis.  It  is  surprisin;^'  in  how  many  instance,^  of  arterio- 
sclerosis, of  chronic  lu'art-oisease,  of  l>ri;:ht's  disease,  and  more  particu- 
larly of  cirrhosis  of  the  hver,  the  fatal  event  is  detcrmineil  hy  an  acute 
tuhercidosis  of  the  peritona'um  or  pleura. 

The  p'lieral  terminal  inlV'ctions  are  somewhat  less  common.  Of  S.")  cases 
of  chronic  renal  disease  in  which  l'"le.\ner  found  micro-orpmisms  at  au- 
topsy, ;)S  exhihited  ^^Mieral  infections;  of  -l(S  cases  of  chronic  cardiac  disease. 
in  11  the  dist  rihulioii  of  liacteria  was  <icneral.  The  hlood-serum  of  persons 
sulTerin^''  from  advanced  clii'onic  disease  was  found  hy  him  to  he  less  de- 
structive to  the  staphylococcus  aureus  than  normal  human  serum.  Other 
diseases  in  which  ^icneral  terminal  infection  may  occur  are  llodtikiirs  dis- 
ea.se,  leuka'una,  and  chronic  tuherculosis. 

And,  lastly,  i>rohal»ly  of  the  same  nature  is  the  terminal  ontero-colitis 
so  frequently  met  with  in  chronic  disorders. 


XIX.   RHEUMATIC    FEVER. 

Definition. — An  acute,  non-conta<:ious  fever,  dependent  upon  an  un- 
known infective  a-icnt,  and  characterized  hy  multiple  arthritis  and  a  marked 
tendency  to  inflammation  of  the  fihrous  tissues. 

Etiology. — Dlslrlhiitltiii  and  Prrralnin'. — It  ])revails  in  temjierate  and 
humid  climates.  Church  has  collected  interestin^r  statistics  on  this  ])oint. 
Oddly  enoujjh,  the  two  countries  with  the  hi'ihest  a(hnissiou  in  the  army  per 
thousand  of  stren^ffth — Eoypt,  T. (!-.',  and  Canada,  n.'it; — have  clim.ites  the 
most  diverse.  The  returns,  however,  from  Canada  for  the  six  years  from 
18S(]  to  IS!)"?  are  ])erhaps  more  correct,  2.83  jier  thousand  of  stnMitith.  The 
death-rate  for  the  five  years  ISSl-'So  in  Clreat  P>ritain  was  i)T  i)er  million. 
In  the  Tnited  States  there  are  no  satisfactory  statistics;  the  disease  is  not 


*  Jour,  Exp.  ^[ed..  i.  1896. 


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11).     'V\n> 
Imillion. 
is  not 


(Iciilt  willi  It)  the  lust  ('t'i)siis  l{('|i<»rt  iis  n  cihim'  nl"  dciiili.  So  t'nr  as  my 
Ittrsoiiiil  nliM'i'vat ioii  ^'iics,  it  ccrtiiiiilv  scciiicil  \i>  lie  nioic  |irt'valt'iit  in  Mt»ii- 
tiTiil  than  ii>  i'liilail('l|iliia  or  I'lalliiiiiirc.  'I'lic  ^riicriil  iiii|ii'*>ssi()ii  is  tiiat 
lilt' (iiscasf  |in'\ails  inure  in  tlic  r>i'ili>li  lslc<  tliiin  clscw  lici'c;  Itiit,  as  Chnrch 
remarks,  the  retnrns  are  very  ini|ierre(i  (this  hiiM<  i^oml  e\erv\\  here),  and 
prdlialdy  the  (h'ath-rati'  Troin  rheiinmtie  fever  itst'll'  is  very  niiieh  hiwer 
tliiin  the  li^iires  wdidil  inilieiite,  as  very  many  ditl'erent  disea>es  are  Mrdnped 
iiiKh'r  this  heading'.  In  Ndrway,  where  easi's  ol'  rheumatic  I'ever  are 
liotilied,  there  were  I'ul'  the  I'nur  years  lSSS-"!>'^  i:l,(I.")l  casL'H,  with  '*'.")<> 
(hMths. 

Season.  —  In  I.dndun  the  cases  reach  the  maximum  in  the  n)()nths  of 
Si'|iteml)er  and  Oetolier.  In  tl)e  Montreal  (leneral  ilnspital  I'.ell's  statis- 
tics of  4*)(!  cases  show  that  the  lar;,'est  nnmher  was  adniitle(|  iti  I'ehrnary, 
March,  and  April.  .Newshdlnie  has  lir(iii;:iit  I'oi'ward  statistics  to  show  that 
tilt'  disease  prevails  most  in  tlii'  dry  years  or  n  succession  of  such,  and  is 
specially  prevalent  when  the  snhsoil  water  is  ahnormally  low  and  the  tem- 
perature of  the  t-ai'th   lii;:li. 

Age.  —  Vi»un<j[  adults  are  most  fretpieiitly  all'eeted.  hut  the  disonso  is  by 
Mil  means  uue(in)mi>i)  in  children  lietwcen  the  a^ci  of  ten  aiul  lifteen  years. 
Sucklinifs  ai'e  rarely  attacl\e(l.  and  prohahly  many  u['  the  cases  which  have 
heeii  (Icscrihed  hidoui;'  to  a  totally  dill'erent  alVeetion,  the  arthritis  of  in- 
fants. Jn  exceptional  cases,  however,  true  rheumatism  does  occur.  TIk; 
following  afH'  table  is  based  upon  !."»(!  cases  admitted  to  the  Montreal  (ien- 
eral  Hospital:  I'nder  fifteen  years,  l.;5S  |)er  cent;  from  fifteen  to  twenty- 
five  years,  -IS. OS  per  cent:  from  twenty-five  to  thirty-five  years,  :i'>.H7  per 
cent;  from  thirty-five  to  forty-five  years,  IH.C!  per  cent;  al)ove  forty-five 
years,  7.1  per  cent.  Of  the  f!.").")  cases  analyzed  iiy  Wliipham  for  the  Col- 
lective Investi^ati<m  Committee  of  the  J?ritish  Medical  Association,  only 
.■)•.'  cases  occui'rcd  nnder  tlio  tenth  year  and  SO  per  cent  between  the  twen- 
tieth and  fortieth  year,  'i'heso  figures  scarcely  give  the  ratio  of  ca.><os  in 
cliilflren. 

Sex. —  If  all  ages  are  taken,  mak's  are  all'eeted  oftener  than  females. 
In  the  C()lk'ctive  Investigation  I{i']iort  there  were  ;5T.")  males  and  'iT!) 
fi'inales.  I'p  to  the  age  of  twenty,  however,  females  predominate.  J>e- 
tweei)  the  ages  of  ten  and  fifteen  girls  are  n)oro  prone  to  tiie  disease. 

llcirdili/. —  It  is  a  deeply  gronndcd  belief  with  the  public  and  the  pro- 
fession that  rheumatism  is  a  family  disease,  but  Church  thinks  the  evideneo 
is  still  imperfect.  Its  not  rare  occnrrenee  in  scvei'al  meml)ers  of  the  same 
family  is  used  by  those  who  believe  in  the  infectious  origin  as  an  argument 
in  favor  of  its  being  n  bouse  disease. 

The  iirniptilifins  which  necessitate  exi)o.«nre  to  cold  and  great  changes 
of  ten)i)eratiire  i)redispose  sti'ongly  to  rheumatic  fever.  The  disease  is  met 
with  oftenest  in  drivers,  servants,  bakers,  sailors,  and  Ial)orers. 

Chill. — Ex]>osnre  to  cold,  a  wetting,  or  a  sudden  change  of  teTn])crature 
ai'c  mnong  the  most  ini]iortant  factors  in  determining  the  onset  of  an 
attack. 

I  ni  mull  ill/  is  not  afforded  by  an  attack;  on  the  contrary,  as  in  piieu- 
iiiunia,  one  attack  predispo.ses  the  subject  to  the  disease. 


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108 


SPECIFIC  INFECTIOUS  DISEASES. 


Rheumatic  Fever  as  an  Acute  Infectious  Disease. — (a)  Geneml  EviJenre. 

— Klic'imiutic  fever,  as  Newsholmc  has  shown,  occurs  in  ei)i(k'niics  without 
regular  ])erio(lieity,  recurring  at  intervals  of  three,  four,  or  six  years,  and 
varying  much  in  intensity.  A  severe  epidemic  is  apt  to  he  followed  hy 
two  or  three  mild  outbreaks.  "  The  curves  of  the  mortality  statistics  .  .  . 
approximate  very  closely  to  those  of  ])yjvmia,  ])uerperal  fever,  ;md  erysij)e- 
las,  diseases  which  are  certainly  associated  with  specific  niicro-orifanisms  "' 
(Church).  The  constancy  also  of  the  seasonal  variations  is  an  a^iditional 
support  to  this  view. 

(/;)  CUniral  Fcahnrs. — Physicians  have  long  boon  impressed  with  the 
striking  similarity  of  the  symptoms  of  rheunuitic  fever  to  those  of  septic 
infection.  In  the  character  of  the  fever,  the  mode  of  involvement  of  the 
joints,  the  tendency  to  relapse,  the  sweats,  the  amvmia,  the  leucocytosis,  and, 
above  all,  the  great  liability  to  endocarditis  and  involvement  of  the  serous 
mend)ranes,  acute  rheumatic  fever  resembles  i)ya'mia  very  closely,  and 
may,  indeed,  l)e  taken  as  the  very  type  of  an  acute  infection.  But,  as 
Stephen  Mackenzie  remarks,  acute  rheumatism  should  be  considered  not 
simply  from  the  point  of  view  of  the  rheumatic  polyarthritis  of  the  adult, 
but  as  a  whole  in  its  manifestations  at  different  jK'riods  of  life;  yet  even 
from  this  standi)oint  the  multiform  manifestations  of  the  rheumatic  poison 
in  childhood  and  young  adults  may  very  reasonably  be  referred  to  the  effect 
of  the  toxines  of  micro-organisms. 

(c)  Special  Evidence. — The  l)acteriology  of  acute  rheumatism  has  lately 
attracted  a  great  deal  of  attention.  Mantle,  Sahli,  Leyden,  C'hvostek, 
Singer,  Achalme,  and  others  have  contributed  important  studies.  A  re- 
view of  their  work,  however,  justifies  the  conclusion  that  no  positive  proof 
has  as  yet  been  offered  of  the  constant  association  of  any  special  micro- 
organism with  the  disease.  Singer  in  an  extensive  monograjdi  attempts 
to  show  that  in  rheumatic  fever  the  organisms,  consisting  chiefly  of  sta- 
phylococci and  streptococci,  are  discharged  in  numbers  in  the  urine.  Spe- 
cial stress  has  been  laid  upon  the  tonsils  as  the  point  of  entrance  of  the 
infection.  It  has  long  been  known  that  tonsillitis  is  a  very  frequent  initial 
symptom  in  the  disease — 28  out  of  66  cases  in  Singer's  series.  Indeed, 
some  have  gone  so  far  as  to  say  that  there  is  always  a  primary  infective 
trouble  in  the  lacuna?  of  the  tonsils,  to  which  the  rheumatic  fever  is  second- 
ary, arising  from  the  absorption  of  microl)es  or  their  products. 

Other  views  as  to  the  nature  of  rheumatism  are  the  metaholic  or  cliemical: 
that  it  depends  iipon  a  morbid  material  produced  within  the  system  in 
defective  processes  of  assimilation.  It  has  been  suggested  that  this  mate- 
rial is  lactic  acid  (Prout)  or  certain  combinations  with  lactic  acid  (Latham). 
Our  knowledge  of  the  chemical  relations  of  the  various  products  produced 
in  the  regressive  nutritive  changes  is  too  limited  to  warrant  much  reliance 
upon  these  views.  Richardson  claims  to  have  produced  rheumatism  by  in- 
jecting lactic  acid  and  l)y  its  internal  administration. 

Nervous  Theory  of  Acvte  Rheinnatism. — This  Avas  specially  advocated 
by  the  late  Pr.  J.  K.  Mitchell,  of  Philadelphia.  According  to  this  view, 
cither  the  nerve  centres  are  primarily  affected  by  cold  and  the  local  lesions 
are  really  trophic  in  characier,  or  the  primary  nervous  disturbance  leads 


I 


RHEUMATIC  FEVER. 


169 


viJence. 
without 
irs,  and 
I  wed  1)}' 
ics  .  .  . 
orysii)o- 
misms " 
iditional 

vith  the 
)f  septic 
t  of  the 
)sis,  and, 
le  serous 
ely,  and 
But,  as 
cred  not 
lie  adult, 
yet  even 
ic  poison 
the  ctfect 

;ias  hitely 
L'hvostck, 
;.     A  re- 
ive proof 
micro- 
attempts 
of  sta- 
Spe- 
e  of  the 
nt  initial 
Indeed, 
infective 
second- 

iliemical: 
^rstem  in 
lis  mate- 
jatham). 
produced 
reliance 
n  by  in- 

Idvocated 
[lis  view, 
ll  lesions 
Ice  leads 


le. 


to  errors  in  metabolism  and  the  accumulation  of  lactic  acid  in  the  system. 
Tlio  advocates  of  this  view  regard  as  analogous  the  arthroi)athies  of  myelitis, 
locomotor  ataxia,  and  chorea. 

Morbid  Anatomy. — There  are  no  changes  characteristic  of  the  dis- 
ease. The  all'ected  joints  show  hy[»era'mia  and  swelling  of  the  synovial 
membranes  and  of  the  ligamentous  tissues.  There  may  be  slight  erosion 
of  the  cartilage.  The  tluid  in  the  joint  is  turbid,  albuminous  in  character, 
and  contains  leucocytes  and  a  few  lil)rin  Hakes.  I'us  is  very  rare  in  uncoiu- 
})licated  cases.  Eheumatism  ^arely  ])roves  fatal,  except  when  there  are 
serious  complications,  such  as  j) 'ricarditis,  endocarditis,  myocarditis,  i)leu- 
risy,  or  pneumonia.  The  conditions  found  show  nothing  pecxdiar,  nothing 
to  distinguish  them  from  other  forms  of  inflammation.  In  death  from 
liyperpy.  .'xia  no  s})ecial  changes  occur.  The  blood  usually  contains  an 
excessive  amount  of  librin.  In  the  secondary  rheumatic  inflammations, 
as  pleurisy  and  pericarditis,  various  pus  organisms  have  been  found,  pos- 
sibly the  result  of  a  mixed  infection. 

Symptoms. — As  a  rule,  the  disease  sets  in  abruptly,  but  it  may  be 
])rece(k'd  hy  iri'egular  i)ains  in  the  joints,  slight  malaise,  sore  throat,  and 
l)articularly  by  tonsillitis.  A  definite  rigor  is  uncommon;  njore  often 
there  is  slight  chilliness.  The  fever  rises  quickly,  and  with  it  one  or  more 
of  the  joints  become  ])ainful.  Within  twenty-four  hours  from  the  onset, 
the  disease  is  fully  developed.  The  tenqjerature  range  is  from  10'3°  to 
104°.  The  pulse  is  frequent,  soft,  and  usually  above  100.  The  tongue  is 
moist,  and  ra})idly  becomes  covered  with  a  white  fur.  There  are  the  ordi- 
nary symptoms  associated  with  an  acute  fever,  such  as  loss  of  appetite, 
thirst,  constipation,  and  a  scanty,  highly  acid,  highly  colored  urine.  In  a 
majority  of  the  cases  there  are  profuse,  very  acid  sweats,  of  a  peculiar  sour 
odor.  Sudaminal  and  miliary  vesicles  are  abundant,  the  latter  usually  sur- 
rounded by  a  minute  ring  of  hyijera^mia.  The  mind  is  clear,  except  in 
the  cases  with  hyperpyrexia.  The  affected  joints  are  painful  to  move, 
soon  become  swollen  and  hot,  and  present  a  reddish  flush.  The  knees, 
ankles,  elbows,  and  wrists  are  the  joints  usually  attacked,  not  together, 
but  successively.  For  example,  if  the  knee  is  first  affected,  the  redness 
may  (lisa])])ear  from  it  as  the  wrists  become  ])ainful  and  hot.  The  disease 
is  seldom  limited  to  a  single  articulation.  The  anu)unt  of  swelling  is  vari- 
able. Extensive  effusion  into  a  joint  is  rare,  and  much  of  the  enlargement 
is  due  to  the  infiltration  of  the  ])eriarticular  tissues  with  serum.  The 
swelling  may  be  limited  to  the  joint  ])roper,  but  in  the  wrists  and  ankles 
it  sometimes  involves  the  sheaths  of  the  tendons  and  produces  great  en- 
largement of  the  hands  and  feet.  Corresponding  joints  are  often  atfected. 
In  attacks  of  great  severity  every  one  of  the  larger  joints  may  be  involved. 
The  vertebral,  sterno-clavicular,  and  ])halangeal  articulations  are  less  often 
inflamed  in  acute  than  in  gonorrha-al  rheumatism.  Perha])s  no  disease  is 
more  painful  than  acute  polyarthritis.  The  inability  to  change  the  posture 
without  agonizing  pain,  the  drenching  sweats,  the  prostration  and  utter 
helplessness,  combine  to  make  it  one  of  the  most  distressing  of  febrile 
affections.  A  special  feature  of  the  disease  is  the  tendency  of  the  inflamma- 
tion to  subside  in  one  joint  while  developing  with  great  intensity  in  another. 


^sn 


170 


sPKCIPIC  INFECTIOUS  DISEASES. 


I 


The  tcnipei'iitiirc  v;\\\i::r  in  jiii  onl  iiary  attack  i.s  l)L't\vet'ii  10"2^  ami  104". 
It  is  j)(_'ciiliarly  iri'cf^iilar,  witli  marked  remissions  and  exacerbations,  de- 
|icii(iin,L:-  \crv  niiicli  ii|i(m  the  intensity  and  extent  of  tlie  ai'ticular  inllam- 
niation.  I  )erei'vcscence  is  nsnally  ^radnai.  The  proi'nse  sweats  materially 
inlhuiice  llie  tein|ieral uic  curve.  If  a  two-hourly  eJiart  is  made  and  oh- 
t^ervations  upon  tlie  sweats  are  noted,  tlie  remissions  will  usually  be  found 
eoincidenl  with  the  sweats.  The  pci'spiration  is  sour-smelling'  and  acid  at 
lirst;  hut.  when  persistent,  becomes  neutral  or  even  alkaline. 

The  Mood  is  profoundly  and  rapidly  altered  in  acute  rheumatism. 
There  is,  indi'cd,  no  acute  febrile  disease  in  which  the  anaemia  develops 
Avith  uri'ater  rapidity.     Tlu're  is  a  well-nuirked  leucoeytosis. 

With  the  Jii.uli  i'vwv  a  murmur  may  often  be  heard  at  the  apox  rc<rion. 
I"]ndocai'ditis  is  also  a  common  cause  of  an  apex  hniil.  The  lieart  should 
be  carefully  exanuned  at  the  lirst  visit  and  subseipientiy  each  day. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density  and  high 
color,  ll  is  very  acid,  and,  on  cooling,  deposits  urates.  The  chlorides 
may  be  gi'catly  diminished  or  I'ven  absent.  Fet)rile  albunnnuria  is  not 
uncommon. 

The  saliva  may  become  acid  in  reaction  and  is  said  to  contain  an  excess 
of  sulphocyanides. 

Subacute  Rheumatism. — This  represents  a  milder  form  of  the  dis- 
ease, in  which  all  the  synqitoms  are  less  i)ronounced.  The  fever  rarely  rises 
al)ove  101°;  fewer  joints  are  involved;  and  tliC  arthritis  is  less  intense. 
The  cases  may  drag  on  for  weeks  or  months,  and  the  disease  may  finally 
become  chronic.  It  should  not  be  forgotten  that  in  children  this  mild  or 
sid)acute  form  may  be  associated  with  endocarditis  or  pericarditis. 

Complications.— These  are  im|)ortant  and  serious. 

(1)  Hyperpyrexia. — The  a'mperature  may  rise  rajiidly  a  few  days  after 
the  onset,  and  be  a.'^sociated  with  delirium;  l)ut  not  necessarily,  for  the 
temperature  may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  with 
out  cerebral  symptoms.  Hyperpyrexia  is  mo.st  connnon  in  first  attacks, 
5T  of  KIT  case>i  (Church).  It  is  nu)st  apt  to  occur  during  the  second  week. 
The  dt'lirium  may  ]iri'C'.'de  or  follow  the  onset  of  tlie  hyperpyrexia.  As  a 
rule,  with  the  high  fever,  the  pulse  is  feeble  and  frequent,  the  prostration 
is  exti'enie,  and  finally  stu]ior  su]iervenes. 

{'i)  Cardiac  Affections. — (a)  Eiuhicardills,  the  most  frequent  and  sei'ious 
complication,  occurs  in  a  considerable  percentage  of  all  cases.  Of  889  cases, 
404  had  signs  of  old  or  recent  endocarditis  (Church).  The  liability  to 
endocarditis  diminishes  as  age  advances.  It  increases  directly  Avitli  the 
lunnber  of  attacks.  Of  11(!  cases  in  the  first  attack,  58. 1  i)cr  cent  had  endo- 
carditis. G3  per  cent  in  the  second  attack,  and  71  per  cent  in  the  third 
attack  (Ste])hen  ^Mackenzie).  The  nntral  segments  are  most  frequently  in- 
volved and  the  affection  is  usually  of  the  sim])le,  verrucose  A'ariety.  Ulcer- 
ative endocarditis  in  the  course  of  acute  rheumatism  is  very  rare.  Of  209 
cases  of  this  disease  which  I  analyzed,  in  only  24  did  the  symptoms  of  a 
severe  endocarditis  arise  during  the  progress  of  acute  or  subacute  rheuma- 
tism. This  coni]»]ication,  in  itself,  is  rarely  dangerous.  It  produces  few 
symptoms  and  is  usually  overlooked.     rnha])p;]y.  though  the  va^'e  at  the 


RHEUMATIC  FEVER. 


171 


illain- 
■rially 
1(1  ol)- 
i\)un(l 
.cid  at 

lilt  ism. 

rejiion. 
shoiild 

id  lii,i,'l^ 

lilorides 

is  not 

n  exct'ss 

the  dis- 
•oly  rises 

intense, 
y  iinally 
i  mild  or 
s. 

ays  after 
for  the 

10°,  wi 


th 


|:i( 


attacks, 
\  week. 
As  a 


bstration 


ll  serious 

Is;)  cases, 

)ihty  to 

Ivith  the 

d  endo- 


iie 


third 
'iitlv  in- 
licer- 
Of  '^09 
|nis  of  a 
Irheuma- 
ices  few 
at  the 


lime  may  not  be  seriously  danui.ucil,  the  iiillammation  starts  changes  which 
lead  to  sclerosis  and  retraction  of  the  segments,  and  so  to  chronic  valvular 
disease. 

(ll)  PcncardilU  may  occur  independently  of  or  together  with  endo- 
carditis. It  may  lie  simple  lilirinoiis,  sero-lihrinous,  or  in  children  puru- 
lent. Clinically  we  meet  it  moi'i'  fretiuently  in  connection  with  rheuma- 
ti>ni  than  nil  olliei'  all'ections  cniiihincd.  'V\\v  physical  signs  ai'c  very  char- 
aetcristic.  The  condition  will  he  fully  descrihed  under  its  appropriate  sec- 
tion. A  peculiar  form  of  dclii'ium  may  develop  during  the  progress  of 
rheumatic   pericarditis. 

(r)  M i/(icar(l[li!<  is  most  fre(pU'nt  in  coiiuectioii  with  eiido-pericardial 
changes.  As  Sturgcs  insisted,  the  term  ninlllls  is  a])plicahle  to  many  cases. 
'J"he  anatomical  condition  is  a  granular  or  fatty  degenei'at ion  of  the  heart- 
muscle,  which  leads  to  weakening  of  the  walls  and  to  dilatation.  It  is  not, 
1  think,  nearly  so  (ommon  as  the-other  cai'diac  all'ections.  S.  West  has  re- 
ported instances  of  acute  dilatation  of  the  lu'art  in  I'lu'umatic  fevei',  in  one 
cd'  which  marked  fatty  changes  were  found  in  the  heart-lihres. 

(3)  Pulmonary  Affections. — l^neumonia  and  pleurisy  fx-curred  in  D.D-t 
]ier  cent  of  3,4;53  caises  (Stephen  Mackenzie).  They  frecpu-ntly  accompany 
the  cases  of  endo-pericarditis.  According  to  Howard's  analysis  of  a  large 
nuinher  of  cases,  there  were  ])ulmonary  complications  in  only  10.,")  per 
cent  of  cases  of  rheumatic  endocarditis;  in  ."iS  per  cent  of  cases  of  ])eri- 
carditis;  and  in  Tl  ]»er  cent  of  cases  of  endo-pericarditis.  Congestion  of 
the  lung  is  occasionally  found,  and  in  several  cases  has  jjroved  rai)idly 
fatal. 

(4)  Cerebral  Complications. — These  are  due,  in  part,  to  the  hyper- 
]iyrexia  and  in  jiart  to  the  special  action  upon  the  brain  of  the  toxic  agent 
of  the  disease.  They  may  be  grou|)ed  as  follows:  (a)  Delirittnt.  This  is 
usually  associated  with  the  liyperpyrexia,  but  may  be  independent  of  it. 
It  may  be  active  and  noisy  in  character;  more  rarely  a  low  muttering 
delirium,  jiassing  into  stnpor  and  coma.  S])ecial  mention  must  be  made 
of  the  delirium  which  occurs  in  connection  with  rheumatic  pericarditis. 
Delirium,  too,  may  be  excited  by  the  salicylate  of  soda,  cither  shortly  after 
its  administraf'on,  or  more  commonly  a  week  or  ten  days  later,  (b)  Coma, 
which  is  more  serious,  may  develop  without  ]»reliniinary  delirium  or  con- 
vulsions, and  may  ])rove  ra])idly  fatal.  Certain  of  these  cases  are  associ- 
ated with  hyperpyrexia;  but  Southey  has  reported  the  case  of  a  girl  who, 
without  ])revious  delirium  or  high  fever,  became  comatose,  and  died  in  less 
than  an  hour.  A  certain  number  of  such  cases,  as  those  rei)orted  by  Da 
Costa,  have  been  associated  with  marked  n^nal  changes  and  were  evidently 
urivmic.  The  coma  may  develop  during  the  attack,  or  after  convalescence 
has  set  in.     (r)   ( '()i>ru]!^iims  are  less  cnniuKm,  though   they  may    i)recede 

Ithe  coma.  Of  1"?T  observations  cited  1)y  Besnier,  there  were  37  of  deliiium, 
only  7  of  convulsions.  17  of  coma  and  convulsions.  .54  of  delirium,  coma, 
and  convulsions,  and  3  of  other  varieties  (Howard),  (d)  Chorea.  The 
relations  of  this  disease  and  rheumatism  will  be  subsequently  discussed. 

lit  is  suflficient  here  to  say  that  in  only  88  oiit  of  554  cases  which  J  have 
analyzed  from  the  Infirmaiy  for  Diseases  of  the  Xervous  System,  I'liila- 
11 


f 


172 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


(Iflpliia,  uerc  clioroa  find  rlu'iiniiitisiu  ns.snciiitcd.  It  is  most  apt  to  develop 
ill  the  i^li^iitcr  attacks  in  ciiildliood.  {r)  Mrniinjitis  is  extremely  rare, 
tliougii  iimloiil»te(ll_y  it  does  oeeiir.  Jt  must  not  be  i'orgolten  tiial  iu  ideer- 
ative  endocarditis,  wliich  is  occasionally  associated  with  acute  rheumatism, 
meningitis  is  rre(pieiit. 

(5)  Cutaneous  Affections. — Sweat-vesicles  have  already  been  mentioned 
as  extrei.iely  common.  A  red  miliary  rash  may  also  develop.  iScarlalini- 
form  erujitions  are  occasionally  seen.  l'ur[)ura,  with  or  without  urticaria, 
may  occur,  and  various  forms  of  erythema.  It  is  doubtful  whether  the 
cases  of  extensive  pur|)ura  with  urticaria  and  arthritis — peliosis  rlieumatica 
— lielong  truly  to  acute  rheumatism. 

(G)  Rheumatic  Nodules.— These  curious  structures,  in  the  form  of  small 
subcutaneous  nodules  attached  to  the  tendons  and  fascia^  have  been  known 
for  some  years;  but  special  attention  has  been  paid  to  them  of  late,  since 
their  careful  study  by  Ikirlow  and  "Warner.  V'hile  not  so  common  in  this 
country  as  in  p]ngland,the  cases  are  by  no  means  infrequent  (Futcher.  J.  11. 
H.  Bulletin,  181)5).  They  vary  in  siza  from  a  small  shot  to  a  large  pea, 
and  are  most  numerous  on  the  fingers,  hands,  and  wrists.  They  also  occur 
about  the  elljows,  knees,  the  sjunes  of  the  vertebra^,  and  the  scapulte.  They 
are  not  often  tender.  They  do  not  necessarily  come  on  during  the  fever, 
but  may  be  found  on  its  decline,  or  even  independently  altogether  of  an 
acute  attack.  The  nodules  may  develop  Avith  great  rapidity  and  usually 
last  for  weeks  or  months.  They  are  more  common  in  children  than  in 
adults,  and  in  the  former  their  presence  may  be  regarded  as  a  positive  indi- 
cation of  rheumatism.  They  have  been  noted  ])articidarly  in  association 
with  severe  and  chronic  rheumatic  endocarditis.  Subcutaneous  nodules 
occur  also  in  migraine, gout, and  arthritis  deformans.  Histologically  they  are 
made  up  of  round  and  spindle-sha])ed  cells.  In  addition  to  these  firm,  hard 
nodules,  there  occur  in  rheumatism  and  in  chronic  vegetative  endocarditis 
remarkable  small  l)odies,  which  have  been  called  by  Fereol  "  nodosites  cu- 
tanees  ei)hemeres."  In  a  case  of  chronic  vegetative  endocarditis  (without 
arthritis),  which  I  saw  with  Dr.  J.  K.  ^litehell,  there  were,  in  addition  to 
occasional  elevated  spots  rescnd)ling  urticaria,  infiltrated  areas  of  soreness 
in  the  skin,  from  two  to  three  lines  in  diameter,  not  elevated,  but  pale  pink, 
and  exquisitely  tender  and  painful  even  without  being  touched. 

The  course  of  acute  rheumatism  is  extremely  variable.  It  is,  as  Austin 
Flint  first  showed,  a  self-limited  disease,  and  it  is  not  probable  that  medi- 
cines have  aiiy  s])ecial  influence  u])on  its  duration  or  covrse.  Gull  and 
Sutton,  who  likewise  studied  a  series  of  G2  cases  without  special  treatment, 
arrived  at  the  same  conclusion. 

Sudden  death  in  rheumatic  fever  is  due  most  frequently  to  myocarditis. 
Herringham  has  reported  a  case  in  which  on  the  fourteenth  day  there  wa- 
fatty  degeneration  and  acute  inflammation  of  the  myocardium.  In  a  few 
rare  cases  it  results  from  embolism.  I  saw  one  ease  at  the  Montreal  Gen- 
eral Hospital  in  which  we  thought  possibly  the  sudden  death  was  due  to 
Fuller's  alkaline  treatment,  which  had  been  kept  up  by  mistake.  There  w:i- 
slight  endocarditis  but  no  myocardial  changes.  Alarming  symptoms  of 
depression  sometimes  follow  excessive  doses  of  the  salicylate  of  soda. 


RHEUMATIC  FEVER. 


173 


(k'volop 

u  uk'i'V- 
imatisiu, 

eutioncd 

•iirlatiiii- 
LU'ticaria, 
.tliLT  the 
Loumatica 

\  of  small 

L'u  known 

lato,  since 

on  in  this 

her.  J.H. 

large  pea, 

also  occur 

ilffi.    They 
the  fever, 

ither  of  an 

md  usually 

en  than  in 

Dsitive  indi- 
association 

,i\s  nodules 

Uy  they  are 
iirm,  hard 
ndocarditis 

[odosites  cu- 

is  (without 

addition  to 

of  soreness 

it  pale  pink, 

,  as  Austin 
that  naedi- 
GuU  and 
h  treatment, 

jmyocarditis- 
ly  there  wa- 
in a  few 
pntreal  Gen- 
was  due  t'^ 
There  wa- 
lymptoms  of 
If  soda. 


Diagnosis. — rractieally,  the  recognition  of  acute  rliL'unia.isui  is  very 
easy;  luit  there  are  several  all'eetions  whicli,  in  some  particulars,  eh»stly 
resenil)le  it. 

(1)  Multiple  Secondary  Arthritis. — I'nder  this  temi  may  he  emhraciMl 
tiio  various  forms  of  arthritis  whieli  come  on  or  folhtw  in  the  course  of  the 
infective  diseases,  such  as  gonorrho'a,  scarlet  fever,  dysentery,  and  eerehro- 
spinal  meningitis.  Of  these  the  gonorrho'al  form  will  receive  s[)eeial  cou- 
sidei'ation  and  is  tlie  type  of  tiie  entire  grouj). 

{'Z)  Septic  Arthritis,  wliieh  develops  in  the  course  of  jjyaMiiia  from  any 
cause,  and  j)arlicularly  in  jiuerperal  fever.  No  hard  and  fast  line  can  he 
(li'awn  hetween  these  and  tlie  cases  in  the  first  groui);  hut  the  iidlanmuition 
raridly  passes  on  to  sup])uration  and  there  is  more  or  less  destruction  of 
tlie  joints.  The  conditions  under  which  the  artliritis  develops  give  a  clew 
at  once  to  the  nature  of  the  ease.  L'nder  this  section  may  also  he  men- 
tioned: 

{(i)  Acute  necrosis  or  acute  osteo-mi/elitis,  occurring  in  the  lower  end 
of  the  femur,  or  in  the  tihia,  ami  which  may  he  nnstaken  for  acute  rheu- 
matism. Sometimes,  too,  it  is  multii)le.  The  greater  intensity  of  the  local 
symjjtoms,  the  involvement  of  the  epii)hyses  rather  than  the  joints,  and 
tlie  more  serious  constitutional  disturhances  are  points  to  he  considered. 
The  condition  is  unfortunately  often  mistaken  for  acute  arthritis,  and,  as 
the  treatment  is  essentially  surgical,  the  error  is  one  which  nuxy  cost  the  life 
of  the  i)atient. 

{h)  The  acute  arthritis  of  infants  must  he  distinguished  from  rheuma- 
tism. It  is  a  disease  which  is  usually  confined  to  one  joint  (the  hip  or 
knee),  the  elfusion  in  which  rapidly  hecomes  purulent.  The  alfection  is 
most  common  in  sucklings  and  is  undouhtedly  jmrmic  in  character.  It 
may  also  develop  in  the  gnnorrho'al  ophthalmia  or  vaginitis  of  the  new- 
])orn,  as  pointed  out  hy  Clement  Lucas. 

(3)  Gout. — While  the  localization  in  a  single,  usually  a  small,  joint,  the 
age,  the  history,  and  the  mode  of  onset  are  features  which  enal)le  us  to  recog- 
nize acute  gout,  there  are  in  this  country  many  cases  of  acute  arthritis, 
called  rheumatic  fever,  wliich  are  in  reality  gout.  The  involvement  of  sev- 
eral of  the  larger  joints  is  not  so  infrequent  in  gout,  and  unless  tophi  are 
]>resent,  or  unless  a  very  accurate  analysis  of  the  urine  is  made,  the  diagnosis 
may  he  difficult. 

Treatment, — The  hed  should  have  a  smooth,  soft,  yet  clastic  mattress. 
The  patient  should  Avear  a  flannel  night-gown,  which  may  he  opened  all  the 
way  down  the  front  and  slit  along  the  outer  margin  of  the  sleeves.  Three 
or  four  of  these  should  he  made,  so  as  to  facilitate  the  frequent  changes 
required  after  the  sweats.  lie  may  wear  also  a  light  flannel  cape  a])out  the 
shonlders.  lie  should  sleep  in  hiaukets.  not  in  "heets,  so  as  to  reduce  the 
liahility  to  catch  cold  and  ohviate  the  unpleasant  clamminess  consecpuMit 
upon  heavy  sweating.  Chamhers  insisted  that  the  liahility  to  endocarditis 
and  pericarditis  was  much  reduced  when  the  ]iaticnts  were  in  hlankets. 

Milk  is  the  luost  suitahle  diet.  It  may  he  diluted  with  alkaline  min- 
ornl  waters.  Lemonade  and  oatmeal  or  harley  water  shonld  l)e  freclv  given. 
The  thirst  is  usually  great  and  may  he  fully  satisfied.     There  is  no  ol)jce- 


174 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


tioii  to  l)rf)ths  (111(1  sDiips  if  the  milk  is  not  well  borne.  Tho  food  slioiild 
lie  <:iv('ii  iit  siiort  iind  stilted  intervals.  As  conviilcsccncc  is  l•st;d)li^ll(•d  ii 
fidliT  did  niiiy  be  iillowcd,  hut  iiieat  siiould  ho  used  sparinj,dy. 

'J'lit'  local  trcatiiK'iit  is  of  the  ^M'tatcst  iinportanco.  Jt  often  suilices  to 
MTap  the  atrcctcd  joints  in  cotton,  if  the  jiain  is  severe,  liot  cloths  may 
be  a|i|ilied,  saturated  with  Fuller's  lotion  (cai'i)onate  of  soda,  G  drachms; 
laudanum,  1  oz.;  j.dycerine,  'I  oz.;  and  water,  !»  oz.).  ^'inctun;  <d'  aconite 
or  chloral  nuiy  be  employed  in  an  aJKaline  solution,  ('hloroform  liniment 
is  also  a  ^txtd  a])|)lication.  Fixation  of  the  joints  is  of  great  service  in  allay- 
ing the  ])ain.  1  have  seen,  in  a  (ierman  hos|)ital,  the  joints  enclosed  in 
])laster  of  I'aris,  apjiareiitly  with  gi'eat  ridief.  Splints,  ])adde(l  and  bandaged 
with  nio(lerate  firmness,  will  often  be  found  to  relieve  pain.  Friction  is 
rarely  well  borne  in  an  acutely  inilamed  joint.  Cold  eoni|)resscs  are  much 
used  in  (Jerniany.  The  ap]ilicatioii  of  blisters  above  rnd  below  the  joint 
often  relieves  the  ])ain.  This  method,  which  was  used  so  much  a  irw  years 
ago,  is  not  to  be  compared  with  the  light  ap[)lication  of  the  I'acpielin 
thermo-cautery. 

Medicines  have  little  or  no  control  over  the  duration  or  course  of  the 
disease,  which,  like  other  self-limited  alfections,  ])ractically  takes  its  own 
time  to  disa])])ear.  Salicyl  compounds,  which  were  regarded  so  long  as 
specific,  are  now  known  to  act  chielly  by  relieving  ])ain.  li.  P.  Howard's 
elaborate  analysis  shows  that  they  do  not  influence  the  duration  of  tho 
disease.  Xor  do  they  prevent  the  occurrence  of  cardiac  complications, 
■wliile  under  tlieir  use  relapses  are  considerably  more  i're(|uent  than  in 
any  other  method  of  treatment.  In  acute  cases  with  severe  pain  the  salicyl 
com])ounds  give  ])ron)])t  relief  and  rarely  disap])oint  ns  in  their  action. 
Sodium  salicylate,  in  fifteen-grain  doses  for  eight  or  ten  doses,  may  be 
given.  The  bicarl)onate  of  ])otassiiini  in  twenty-grain  doses  may  be  used 
with  it.  ]\lany  ])rel'er  salicin  (gr.  20)  in  wafers;  others  the  salicylic  acid 
(gr.  20)  or  salol.  I  have  for  the  ]»ast  five  or  six  years  used  the  oil  of 
Avintergreen,  recommended  by  Kinnicutt,  and  have  found  it  quite  as  effi- 
cacious. Twenty  minims  may  be  given  every  two  hours  in  milk.  The 
salicyl  com])f)Uuds  are  best  given  in  full  doses  at  the  outset  of  the  disease, 
to  relieve  the  ])ain.  Then  the  dose  should  be  reduced  in  frequency,  or,  if 
the  symjjfoms  have  abated,  stopjjcd  altogether,  as  relapses  are  certainly 
more  frequent  Under  their  use. 

Alkalies  may  be  combined  with  the  salicylates,  or  may  be  used  alone. 
The  ])otassium  bicarbonate  in  half-dracliui  doses  may  be  given  every  three 
or  four  hours  until  the  urine  is  rendered  alkaline,  p^iller,  who  so  warmly 
supported  this  method  of  treatment,  was  in  the  habit  of  ordering  a  drachm 
and  a  half  of  the  sodium  bicarbonate  ^■itli  half  a  drachm  of  potassium 
acetate  in  three  ounces  of  water,  rendered  effervescent  at  the  time  of  ad- 
mnistration  ])y  half  a  drachm  of  citric  acid  or  an  ounce  of  leuKm-juice. 
This  is  given  every  three  or  four  liours,  and  usually  by  the  end  of  twenty- 
four  hours  the  urine  is  alkaline  in  reaction.  The  alkali  is  then  reduced, 
and  the  amount  subsequently  regulated  by  the  degree  of  acidity  of  the 
urine,  only  enough  being  given  to  keep  the  secretion  alkaline.  Opinion 
is  almost  unanimous  that,  under  the  alkaline  treatment,  cardiac  complica- 


( 


-:■' 


CHOLERA  ASIATICA. 


to 


shod  a 

lU'CS  to 
lis  iniiy 
•iii'luiis; 
aconite 
iiiimont 
11  alliiy- 
losi'd  in 
iin«la,i:*'<l 

ictinll    is' 

re  iinu'h 
Uv  joint 
cw  years 
L'a(iiH'lin 

;e  of  the 

,  its  oAvn 

1  long  as 

Howard's 

in  of  tho 

ilications, 
than   in 

he  salicyl 

ir  action. 

1,  may  l)e 
be  used 
ylic  acid 
he  oil  of 
\\v  as  eih- 
II  IK.     Tlie 
e  disease, 
hey,  or,  if 
certainly 

ted  alone. 
I'cry  three 
[o  warmly 
I  a  drachm 
potassium 
ine  of  ad- 
lion-juice. 
If  twenty- 
reducefl, 
ty  of  the 
Opinion 
Icomplica- 


tions  are  le.sss  common.  The  comhiiialiini  of  the  saHcylates  witli  tlie  alkali 
is  prohahly  the  most  satisfactory.  Care  must  ho  taken  to  watch  the  heart 
(luring  the  adniinislrat  ion  of  tlif.-c  icmcdies,  since,  if  given  freely,  they  are 
Vel'V  <le|ircssing. 

To  allay  the  pain  o|iiiini  may  he  given  in  the  form  of  Dover's  powder, 
or  morphia  hy|)odennically.  Antipyrin,  antifeitrin,  and  ])lienacetin  are 
useful  sonu'limi's  for  the  pui'po.-e.  During  convalescence  iron  is  indicated 
in  full  (lo.ses,  and  (piinine  is  a  useful  tonic.  Of  the  coin|)lications,  hyper- 
pyrexia should  ho  treated  hy  tho  cold  hath  or  the  c()ld  |)ack.  The  treat- 
ment of  endocarditis  aiul  pericarditis  and  the  puluHjnary  complications 
will  he  considered  undei'  theii'  rcs[)cctive  sections. 

To  ]trevcid  and  arrest  endocarditis  Caton  urges  the  use  of  a  series  of 
small  hiisters  along  the  course  of  the  third,  fourth,  fifth,  and  sixth  inter- 
costal nerves  of  tho  left  side,  applied  one  at  a  tinu'  and  repeated  at  ditfer- 
cut  points.  I'otassium  or  sodium  iodide  is  given  in  addition  to  the  salicyl- 
ates.   Tho  i)ationts  are  kept  in  hed  i'or  al)out  six  weeks. 


XX.    CHOLERA    ASIATICA. 

Definition. — A  speciiic,  infectious  disease,  caused  by  the  comma  l)a- 

oillus  of  Xoch,  and  charae-teri/.ed  clinically  hy  violent  ])urging  and  rapid 
Collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  fioiu  a 
remote  period,  hut  (»nly  within  tho  present  century  has  it  made  inroads  into 
Kurojie  and  Anu'rica.  Aii  extensive  epidemic  oc-curred  in  l(S3"i,  in  whicli 
year  it  was  bnnight  in  immigrant  ships  from  (ireat  Uritain  to  (^uel)ec.  It 
travelled  along  tho  lines  of  traltic  up  the  Cireat  Lakes,  and  finally  reached 
as  far  west  as  the  military  ])osts  of  tho  u]t]jer  ^Mississippi.  In  the  same 
year  it  entered  the  rnited  States  by  way  of  Xew  York,  '^riiere  were  re- 
curi'ences  of  the  disease  in  IS.'),")-":}!;.  In  IS  IS  it  entered  the  country  through 
Xew  Orleans,  and  S])rea(l  widely  up  the  ^rississip])i  "S'alley  and  across  the 
continent  to  California.  In  ISP.)  it  again  appeared.  Ju  IS.")  I  it  was  intro- 
duced l)y  immigrant  shijjs  into  Xev.'  York  and  ])rovailed  widely  through- 
out the  country.  In  ISGCt  and  in  ISiiT  there  were  less  si  .lous  epi<lemies. 
In  ]ST3  it  again  ap])eared  in  the  Tnited  States,  hut  did  not  ])revail  widely. 
In  18S-i  there  was  an  oiit])reak  in  lMiro])c,  and  again  in  1S!)3  and  1S!);1 
Althougli  occasional  cases  have  been  brought  hy  shi]i  to  the  (piarantine 
shitions  in  this  countrj'',  tho  disease  has  not  gaitu'd  a  foothold  here  since 
isr:^. 

Etiology. — In  ISS-f  Koch  announc(Ml  the  discovery  of  the  specific 
organism  of  this  disease.  Subsequent  ol)servations  have  confirmed  his 
statement  that  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in 
the  true  cholera,  and  in  no  other  disease.  It  has  the  form  of  a  slightly 
hcnt  rod,  which  is  thicker,  bnt  not  more  than  al)ont  half  the  length  of  the 
tubercle  bacillus,  and  sometiim^s  occurs  in  corkscrew-like  or  S  foi'ms.  Tt  is 
not  a  true  liacillus,  but  really  a  s])irocha^te.  The  organisms  grow  upon  a 
gi'cat  variety  of  media  and  display  distinctive  and  characteristic  a])pear- 


170 


SIM'XIFIC   INFECTIOUS  DISKASKS. 


/ 


lUK'cs.  Kocli  I'oiiiiil  tliciii  ill  tlio  Wiitcr-tiinks  in  Indiii,  iind  tlicy  wcro  isnlattil 
froiii  tliL'  I'illtc  wiittr  (luriiij:  tlu'  lliiiiibiir;,'  e'|ti(l('iiiic  ol'  1S1)»\  Duriiij"'  cpi- 
tlciiiics  virulent  liiicilli  iiiiiy  !»(•  I'oiiiid  in  tlic  t'lvci's  dl'  lii'iiltiiy  persons.  'I'ho 
liiieilli  Jife  luiind  in  the  intestine,  in  the  stoids  rmni  the  curliest  period  of 
the  disease,  iind  very  ahnndiintly  in  the  charaeteristie  I'ice-water  I'vaena- 
tions,  in  whieli  they  may  he  seen  as  an  almost  inire  enlture.  They  very 
rarely  oeenr  in  the  vomit.  IVst  mortem,  they  are  i'onnd  in  enormous  num- 
hers  in  the  intestine,  in  nciitely  fatal  eases  they  do  not  seem  to  invade  the 
intestinal  wall,  hut  in  those  with  a  more  protracted  course  they  are  found 
in  the  depths  of  the  glands  and  in  the  still  deeper  tissues,  jvxperimental 
aiumals  are  not  susee|)tihle  to  cholera  <;erms  administered  per  os.  IWit 
if  introduced  after  neutralization  of  the  gastric  contents,  and  if  kept  in 
contact  with  tlu'  intestinal  mucosa  by  controlling  peristalsis  with  opium, 
guinea-pigs  sueeund)  after  showing  cholera-like  symptoms.  The  intt-stines 
are  lilk'd  with  thin,  watery  contents,  containing  comma  bacilli  in  almost 
l)ure  cidture. 

Cholera  Tuxinc. — Koch  in  his  studies  of  cholera  failed  to  find  the 
spirilla  in  the  internal  organs,  lie  concluded  that  the  constitutional  symp- 
toms of  the  disease  resulted  from  the  absorption  of  toxic  bodies  from  the 
intestine.  In  old  cholera  cidturi'S  ]»tomaines  are  contained;  these  ])rol)ably 
have  nothing  to  do  with  the  into.xication  of  human  cholera.  K.  I'feill'er 
has  shown  that  the  cholera  to.xine  is  intimately  associated  with  the  proteid 
of  the  l)aeterial  cells,  and,  being  of  a  very  labile  nature,  cannot  be  separated. 
J)cad  cultures  are  toxic;  and  the  symptoms  ])roduced  by  the  introduction  of 
even  minimal  amounts  are  often  comparable  with  those  of  the  algid  stage 
of  cholera  asiatica.  The  .symptoms  develoj)  very  rajiidly,  and  death  often 
results  in  eight  to  twelve  hours;  in  non-fatal  cases  recovery  is  often  e((ually 
as  rapid.  The  intracellular  cholera  toxine  is  ]»oisonous  to  animals  if  intro- 
duced into  the  blood,  jicritoneal  cavity,  or  subcutaneous  tissues.  Xo  ab- 
sorption takes  place  from  the  intestine  unless  the  epithelial  layer  has  been 
injured. 

hnmiinitji. — Lazarus  found  that  the  blood-serum  of  human  beings  who 
had  recovered  from  cholera  contained  an  antidotal  substance  which  would 
prevent  the  fatal  result  of  intraperitoneal  injecti(nis  of  cholera  vibrios  in 
guinea-]>igs.  R.  Pfeiffer  showed,  contrary  to  Lazarui?,  that  this  substance 
was  not  of  the  nature  of  an  antitoxine,  but  was  actively  bactericidal,  and 
caused  rapid  disintegration  of  the  introduced  bacilli.  The  blood-serum 
of  animals  rendered  innnuue  to  the  bacillus  contains  this  body.  Ujxm  its 
presence  depends  the  success  of  the  "Pfeiffer  serum  reaction"  for  the 
identification  of  the  true  cholera  vibrio  and  its  differentiation  from  all  other 
forms  which  resemble  it.  ITalTkine  has  carried  out  immunizing  injections 
of  cholera  culturis  in  India  on  a  large  scale  with  very  ]U'omising  results. 

Modes  of  Infection. — As  in  oher  diseases,  individual  oeculiarities  count 
for  much,  and  diiring  epidemics  virulent  cholera  bacilli  jiave  been  isolated 
from  the  normal  stools  of  healthy  men.  Cholera  cultures  have  also  been 
swallowed  with  impunity. 

The  disease  is  not  highly  contagious;  physicians,  nurses,  and  others  in 
close  contact  with  patients  are  not  often  affected.     On  the  other  hand. 


CHOLERA  ASIATIC  A. 


177 


riod  of 
L'vac'Uii- 
.y  very 
IS  num- 
lulo  the 
J  I'oiintl 
imentivl 
s.     I'.ut 
kept   ill 
opium, 
lU'stino!* 

I  iiliuost 

liud  the 
ill  syinp- 
from  the 
pr()l)al)ly 
.  Pfcilfor 
c  proteiil 
c'pavatftl. 
uction  of 
und  stage 
ith  often 

II  LMiiially 
if  intro- 

Xo  ab- 
lias  been 

lings  wlio 
^h  would 
■il)rio;i  in 
nibstanco 
idal,  and 
od-seruni 
|T'pon  its 
for  the 
all  otbor 
njections 
fsults. 
ies  count 
,olatod 
\ho  been 

others  in 
ler  band, 


;va.-licnvoin('n  and  ihoso  who  arc  Iiroiiohl  into  vitv  close  couhK't  with  the 
liiieii  of  the  choli'm  patients,  or  witii  their  stools,  are  particularly  p"Mm'  to 
ciitch  the  disease.  'I'heri'  have  heeii  several  instances  of  so-calh'd  **  hdioni- 
tory  cholera,"  in  which  students,  havinj;  heeii  accidentally  infected  while 
workinj;  with  tlu>  cultures,  have  developed  the  disease,  and  at  least  one 
death  has  resulte<l  from  this  cause.* 

Ve<jetabh's  which  liave  heeu  washed  in  11h>  infi'cted  water,  particularly 
lettuces  and  cresses,  may  convey  the  disease.  Milk  may  also  be  contami- 
nated. 'I'he  bacilli  live  on  fresh  bread,  butter,  and  meat,  for  from 
six  to  eight  days.  In  regions  in  which  the  disease  prevails  tin;  possihil- 
iiy  of  the  infection  of  food  hy  Hies  should  he  home  in  mind,  since  it  has 
been  shown  thai  the  bacilli  may  live  for  at  least  three  days  in  their  intes- 
tines. 

Infection  througli  the  air  is  not  to  ])o  nnu'h  dreaded,  since  the  germs 
when  tlried  die  rapidly. 

The  disease  is  propagated  chiefly  by  contaminated  water  used  for  drink- 
ing, cooking,  and  washing.  The  virulence  of  an  epidemic;  in  any  region 
is  in  direct  proportion  to  the  imperfection  of  its  water-supply.  In  India 
the  demonstration  of  the  connection  hetwi'cn  drinking-water  and  cholera 
infection  is  complete.  The  Hamburg  e])ideniic  is  a  most  remarkable  illus- 
tration. The  unflltered  water  of  the  KIhe  was  the  chief  sup])ly,  although 
taken  from  the  river  in  such  a  situation  that  it  was  of  necessity  directly 
contami^iated  hy  sewage.  It  is  not  known  accurately  from  what  source  the 
contagion  came,  whether  from  IJussia  or  frr)in  France,  but  in  August,  1892, 
there  was  a  sudden  explosive  c])ideinic,  and  within  three  mo;  ihs  nearly 
18,000  ])ersons  were  attacked,  with  a  mortality  of  4'^. 3  \wr  cent.  The  neigh- 
boring city  of  Altona,  which  also  took  its  water  from  the  Kibe,  but  which 
luid  a  thoroughly  well-e([uipj)ed  modern  liltration  system,  had  in  the  same 
])eriod  only  olG  cases. 

Two  main  ty])es  of  epidemics  of  cholera  are  recognized:  the  first,  in 
which  many  individuals  are  attacked  simultaneously,  as  in  the  Ilamhurg 
outhreak,  and  in  which  no  direct  co'.inection  can  be  traced  between  the 
individual  cases.  Tn  tliis  ty])e  theie  is  wides])read  contamination  of  the 
drinking-water.  In  the  other  the  cases  occur  in  groups,  so-called  cholera 
nests;  individuals  are  not  attacked  simultaneously  but  successively.  A 
direct  connection  between  the  cases  may  be  very  dillicult  to  trace.  Again, 
both  these  types  may  be  combined,  and  in  an  epidemic  which  has  started 
in  a  wides])read  infection  through  water,  there  may  be  other  outbreaks, 
which  are  examples  of  the  second  or  chain-like  type. 

Tettenkofer,  on  the  other  hand,  denies  the  trutli  of  this  drinking- 
water  theory,  and  maintains  that  the  conditions  of  the  soil  are  of  the  great- 
est importance;  particularly  a  certain  porosity,  combined  with  moisture 
and  contamination  with  organic  matter,  such  as  sewage.  He  holds  that 
germs  develop  in  the  subsoil  moisture  during  the  warm  months,  and  that 
they  rise  into  the  atmosphere  as  a  miasm. 

The  disease  always  follows  the  lines  of  human  travel.    In  India  it  has, 

*  Reincke,  Deut.  meJ.  Wochenschr.,  189-L 


178 


Sl'KCIKlC!   IN'KKCTlorS    DISHaSKS. 


in  ninny  notnlilo  fiscs,  hccn  widely  HpHMid  liy  iHl.LM'inis.  It  is  curried  nUn 
\iy  cnravunfj  and  in  sliips,     Jt  is  not  eniiveyed  tlii'nii;:li  tiu'  lUniospliere. 

I'Inees  situated  at  the  sea-level  are  nmre  |iriine  to  llie  diseiiso  than  inland 
towns.  In  lii,L;li  altitudes  the  disease  does  not  prevail  so  extensively.  A 
lii^h  teinperatMre  favors  the  develo|iinent  of  elndera,  hut  in  Murope  and 
Anieriea  the  e|iidenii{s  have  heen  ehielly  in  tlii'  late  summer  and  in  the 
autumn. 

The  ilisease  afreets  persons  of  all  aj^cs.  It  is  partieulurly  ])rone  to  attack 
the  intemperato  and  those  dehilitated  hy  want  of  food  and  hy  had  sui'round- 
imrs.  |)epressin;j  ettiotions,  such  as  fear,  nndouiitedly  havi'  a  niarkecl  inllu- 
ence.  It  is  douhtful  whether  an  al'ack  furnishes  immunity  against  a 
second  one. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  changes 
in  cholera;  hut  a  |iost-moi'teni  diagno.-is  of  the  nature  of  the  disease."  couhl 
he  made  hy  any  competent  hacteriidogist,  as  the  micro-organisms  are  spe- 
cific and  distinctive.  The  hody  has  the  appearances  associated  with  ]M'o- 
foimd  collapse.  There  is  often  marked  post-mortem  elevation  of  tem))era- 
tiire.  The  rii/iir  niorlis  sets  in  I'arly  and  nuiy  produce  disidacement  of  the 
linihs.  The  lower  jaw  has  hi'cn  seen  to  move  and  the  eyes  to  rotate,  \avi- 
ous  movements  of  the  arms  and  legs  have  also  heen  noted.  The  l)lood  is 
thick  and  dark,  and  there  is  a  remarkahle  diminution  in  the  aiiioiiiil  of  its 
water  and  salts.  The  peritona'iim  is  sticky,  and  the  coils  of  intestines  are 
congested  and  look  thin  and  shrunken.  There  is  nothing  siiecial  in  the 
ap[tearance  of  the  stomach.  The  small  intestine  usually  contains  a  turhid 
serum,  similar  in  appearance  to  that  which  was  passed  in  the  stools.  The 
mucosa  is,  as  a  rule,  swollen,  and  in  very  acute  cases  slightly  hyjievivniic; 
later  the  congestion,  which  is  not  nniform,  is  more  marked,  especially 
ahont  tlie  I'eyer's  patches.  Post  mortem  the  epithelial  lining  is  sometimes 
denuded,  hut  this  is  ])rohal)ly  not  a  change  which  takes  ])l!n'e  freely  during 
life.  In  the  stools,  however,  large  nnnihevs  of  eohininar  epithelial  cells  have 
heen  descrihed  hy  many  ohservers.  The  hacilli  are  found  in  the  contents  of 
the  intestineand  in  th(>  nuicous  nicnihrane.  The  si)leen  is  iisnallysmall.  The 
liver  and  kidneys  show  cloudy  swelling,  and  the  latter  extensive  coagulation- 
necrosis  and  deslrn(>tion  of  the  epithelial  cells.  The  heart  is  ilahhy;  the 
right  chamhers  are  distended  with  hlond  anil  the  left  chamhers  are  usually 
em])ty.     The  lungs  are  collapsed,  and  congested  at  the  hascs. 

The  ahove  ajipi'aranccs  are  those  met  with  in  cases  which  prove  rajiidly 
fatal.  When  the  patient  survives  and  death  occurs  during  reaction,  there 
may  he  more  definite  inflammatory  a])]iearances  in  the  intestines  leading 
to  extensive  necrosis  and  fibrinous  exudation,  and  more  ])ronounced  changes 
in  the  kidneys  and  liver. 

Tn  the  acute  cases  the  rice-water  discharges  contain  the  vihrios  in  jirac- 
tically  ]iure  cultures;  at  a  somewhat  later  stag(>  other  hacteria  make  their 
appearance,  while  in  the  stage  of  cholera-typhoid  the  comma  hacilli  are 
denionsfrateti  wiih  dilhculty. 

Symptoms. — A  period  (^f  incul)ation  of  uncertain  length.  ]irohahly 
not  more  than  from  two  to  five  days,  precedes  the  development  of  the 
synii»toniS. 


CIIOLKHA   ASIATICA. 


170 


ero. 
inlanil 
L-lv.     A 
»pe  and 

ill  tilt' 

1  utiack 
rroiiml- 
m1  inllu- 
riiinft  a 

L-liiin;j;es 
se  c()ul<l 
arc  spc- 
ith  i>rii- 
ti-'iuiu'ra- 
it  ol'  the 
L\    Vari- 
blood  is 
ml  of  its 
tines  are 
il  in  the 
a  tnrliiil 
[lis.    The 
)L'ra'niic; 
l»fi'ially 
metinit'S 
(lurin<r 
Is  have 
tents  of 
all.   The 
inlation- 
(hy.  the 
usually 

rai)i(ily 
>n,  tliere 
leading 
changes 

in  prac- 
ike  tlioir 
iR'illi  are 

]irol)al)ly 
>t  of  the 


Throo  Htnges  may  lie  recognized  in  the  jittaek:  the  iircliiuinary  diar- 
rha-a,  the  c()lla|ise  htage,  ami  the  peiind  df  reiution. 

('/)  The  pirlinilniiri/  ilidrrlnm  imiy  set  in  ahniptly  withont  any  |»revioiis 
iiidieiitions,  .M((re  c-onniionly  there  are,  fi)r  one  or  two  days,  culieky  pains 
ill  the  iilidonien,  with  looseness  of  the  bowels,  perhaps  vomiting,  willi  head- 
ache and  depression  of  spirits,     'i'here  may  he  no  fever. 

{h)  Cdlhi/ifti'  Shhft'. — The  ilianhu'ii  increases,  or,  withont  any  of  the 
preliminary  syMi|itoiMS,  sets  in  with  the  greatest  intensity,  and  profuse 
li(piid  evacuations  succeed  t-ach  other  rapidly.  There  are  in  some  instances 
griping  jiains  ami  lenesmiis.  More  coinimuily  there  is  a  sense  of  exhauslinu 
iind  collapse.  The  thirst  hecoiiu'S  extreme,  the  tongue  is  white;  cramps  of 
great  severity  occur  in  the  legs  and  feet.  Within  a  few  hours  vomiting 
sets  in  ami  heconies  incessant.  The  patieid  ra|iidly  sinks  into  a  condition 
of  collapse,  the  featiii'es  are  shrunken,  the  skin  has  an  ashy  :ray  'lue.  the 
cyehalls  sink  in  the  sockets,  the  imsc  is  piiieheil.  the  cheeks  are  hollow, 
llie  voice  hecomes  husky,  the  extremities  an  cyanosed,  and  the  skin  is  shriv- 
elled, wrinkled,  and  covered  with  a  clammy  perspiration.  The  temperature 
sinks.  Ill  the  axilla  or  in  the  month  it  may  he  from  live  to  ten  degrees 
lielow  iioriiial,  hut  ill  the  rectum  ami  in  the  inleriial  parts  it  may  lie  loir 
er  lor.  The  pulse  heconies  extremely  feehle  and  llickering,  and  the  patient 
gradually  jiasscs  into  a  condition  of  cimia.  though  consciousness  is  often 
retained  until  near  the  end. 

'i'lie  J'a'ces  are  at  first  yellowish  in  color,  from  the  iiile  |igmcnt.  hut 
soon  they  hccoiiie  grayish  white  and  look  like  turhid  whey  or  rice-water; 
wlieiice  the  ti'rm  "rice-water  stools."'  'J'here  are  found  in  thi-m  numerous 
t-iiiall  Hakes  (d'  nnicus  and  granular  nuitter,  and  at  times  Mood.  The  re- 
action is  usually  alkalim".  'I'he  iluid  contains  alhumin  and  the  chief  min- 
eral ingredient  is  chloride  of  sodium.  ^Microscopically,  mucus  and  epithelial 
cells  and  innumcrahle  hacteria  are  seen,  the  majoi'ity  of  the  latter  heiug 
the  conuna  liacilli. 

The  condition  of  the  ]iatient  is  largely  the  result:  of  the  concentration 
of  the  hlood  consequent  ujion  the  loss  of  serum  in  the  stools.  There  is 
iihnost  complete  arrest  of  secretion,  particularly  of  the  saliva  and  the  urine. 
On  the  other  hand,  the  sweat-glands  increase  in  activity,  and  in  nursing 
women  it  has  been  stated  that  the  lacteal  How  is  uiialVi'ctcd.  'i'liis  stage 
sniiKifiines  lasts  not  more  than  two  oi- three  hours,  "it  more  commonly  froni 
twelve  to  twenty-four,  'i'here  are  instances  in  which  the  patient  dies 
hefore  ])urging  bcii'ins — the  so-called  cliuhrii  siccn. 

(c)  f!('(irlinii  ^huje. — ^VIlen  the  patient  sui'vi\-es  the  collapse,  the  cyano- 
sis gradually  disajipears.  the  warmth  returns  to  the  ^kiii,  which  may  have 
for  a  time  a  nudtled  color  or  present  a  definite  erythematous  rash,  'i'ho 
Iieart's  action  becomes  stronger,  the  ui'ine  increases  in  <|uantity,  the  irrita- 
bility of  the  stomach  disappears,  the  stools  are  at  longer  intervals,  and  there 
is  no  al)dominal  ]»ain.  In  the  reaction  the  temperature  may  not  rise  above 
normal.  Xot  infretpiently  this  favorable  condition  is  interrupted  by  a  recur- 
rence of  severe  diarrhcra  and  the  patient  is  carried  off  in  a  rela])se.  Other 
cases  ])ass  into  the  condition  of  what  has  been  called  rhnJi-m-h/pliniil.  a 
state  in  which  the  patient  is  delirious,  the  pulse  rapid  and  feeble,  and  tlie 


180 


SPECIFIC  INFECTIOUS   DISEASES. 


/ 


1()n<riu'  dry.  Doath  finally  occurs  with  cnma.  '^Plicsc  syiiiptoiiis  liavc  boon 
iiUrilnitcd  to  unviiiia. 

During  c'j)idt'inic.s  attacks  are  found  of  nil  grades  of  severity.  There 
are  ea.ses  of  diarrliu-a  with  griping  ])ains,  liquid,  copious  stools,  vomiting, 
and  crani|»s,  '.vith  .'flight  collapse.  To  these  the  teviu  cholerine  has  hecn 
applied.  'JMiey  resenible  tli«  milder  cases  of  chutera  nostrat\  At  the  o]))")- 
site  eud  of  the  series  there  are  the  instances  of  cholera  sicca,  h\  which 
death  may  occur  in  a  few  hours  after  the  onset,  without  diarrluea.  ^J'hcre 
are  also  cases  in  which  the  patients  are  overwhelmed  with  the  poison  and 
die  comatose,  without  the  preliminary  stage  of  -Mllapse. 

Complication:-:  and  Sequelaa. — The  typhoid  condition  has  al- 
ready been  referred  to.  The  consecutive  nephritis  rarely  induces  dropsy. 
Diphtheritic  colitis  has  been  uescribed.  There  is  a  special  tendency  to 
di|»htheritic  inflammation  of  the  mucous  membranes,  particularly  of  the 
throat  and  genitals.  I'neumonia  and  jileurisy  may  develo]),  and  destruc- 
tive abscesses  may  occur  in  different  ])arts.  Su[)purative  parotitis  is  not 
very  uncommon.  In  rare  instances  local  gangrene  may  deveh)]).  A  trouble- 
some symptom  of  convalescence  is  cramps  in  the  muscles  of  the  arms  and 
legs. 

Diagnosis. — The  only  affection  with  which  Asiatic  cholera  could  bo 
confounded  is  the  cholera  nostras,  the  severe  choleraic  diarrluea  which 
occurs  during  the  summer  months  in  temperate  climates.  The  clinical 
jiicture  of  the  two  affections  is  identical.  The  extreme  collapse,  vomiting, 
and  rioe-water  stools,  the  cramps,  the  cyanosed  ap])earance,  are  all  seen  in 
the  worst  forms  of  cholera  nostras.  In  enfeebled  persons  death  may  occur 
within  twelve  hours.  It  is  of  course  extremely  im]iortant  to  be  able  to  diag- 
nose between  the  two  affections.  This  can  only  l)e  done  by  one  thoroughly 
versed  in  bacteriological  methods,  and  conversant  with  the  diversined  flora 
of  the  intestines.  The  comma  bacillus  is  lu'cscnt  in  the  dejections  of  a 
great  majority  of  the  cases  and  can  be  seen  on  cover-glass  preparations. 
Though  the  eye  of  the  expert  may  be  able  to  differentiate  between  the 
bacillus  of  true  cholera  and  that  which  occurs  in  cholera  nostras,  cultures 
should  be  made,  from  which  alone  positive  results  can  be  obtained. 

Attacks  very  similar  to  Asiatic  cholera  are  produced  in  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  in  diagnosis 
could  scarcely  arise. 

The  prognosis  is  always  uncertain,  as  the  mortality  ranges  in  different 
e]iidemics  from  30  to  80  per  cent.  Intem])erance,  debility,  and  old  age 
are  unfavorable  conditions.  The  more  rajiidly  the  colla])se  sets  in,  the 
greater  is  the  danger,  and  as  Andral  truly  says  of  the  malignant  form,  "It 
begins  where  other  diseases  end — in  death."  Cases  with  marked  cyanosis 
and  very  low  temperature  rarely  recover. 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation 
of  the  sick  and  thorough  disinfection  have  effectually  prevented  the  dis- 
ease entering  England  or  the  Fnited  States  since  1873.  On  several  occa- 
sions since  that  date  cholera  has  been  brought  to  various  ports  in  America, 
but  has  been  checked  at  quarantine.  During  eiiidemics  the  greatest  care 
should  be  exercised  in  the  disinfection  of  the  stools  and  linen  of  the  pa- 


CHOLERA  ASIATICA. 


IS  I 


;  boon 

There 
iiitin?, 
s  boon 

o])po- 

vhich 

There 
DU  and 

las  al- 
dropsy. 
Mic'V  to 
of"  the 
lostrnc- 
i  is  not 
troublo- 
'lus  and 

•onld  be 
a  Nvhich 
clinioal 
omitin<,s 
I  seen  in 
ay  occur 
to  diag- 
iroughly 
lod  llora 
)ns  of  a 
^rations, 
con  the 
cultures 

[uing  by 
liagnosis 

hifferont 

old  age 

in,  the 

|rni,  "It 

[cyanosis 

lisolation 

Itbe  dii<- 

rnl  occa- 

Linorica, 

tost  care 

the  pa- 


tients. Wlion  an  cpuleniic  prevails,  persons  should  1)0  warned  not  to  drink 
water  unless  previously  boiled.  Errors  in  diet  should  he  avoided.  As  the 
disease  is  not  more  eoiitjigious  than  typhoid  fever,  the  chanee  of  a  ])erson 
passing  safely  through  an  epidemic  depends  very  niueh  \\])o\.  how  far  ho 
is  able  to  carry  out  thoroughly  i)rophylactie  nu-asures.  Digestive  disturh- 
iiuees  are  to  be  trented  i»i'omi)lly,  and  particularly  the  diarrhcea,  wiiieh  so 
often  is  a  preliminary  symi>tom.  For  this,  opium  and  acotato  of  load  and 
large  doses  of  bismuth  should  hi'  given. 

Medicinal  Treatment. — During  the  initial  stage,  when  the  diar- 
rluea  is  not  excessive  but  the  abdominal  ])ain  is  nuirkod,  opium  is  the  most 
elliciont  remedy,  and  it  should  be  given  hy{)odermically  as  morphia.  It  is 
iidvisablc  to  give  at  once  a  full  dose,  which  may  bo  rope  tod  on  the  return 
of  the  ])ain.  It  is  best  not  to  attempt  to  give  remedies  by  the  mouth,  as 
they  disturb  the  stonuich.  Ice  sliould  be  given,  and  brandy  or  hot  coll'ee. 
la  the  eolla])se  stage,  writers  speak  strongly  against  the  use  of  opium.  Un- 
doubtedly it  must  be  given  with  caution,  but,  judging  from  its  effects  in 
cholera  nostras,  I  should  say  that  colla])so  per  sc  was  not  a  contra-indica- 
tion.  The  patient  may  be  allowed  to  drink  freely.  For  the  vomiting,  which 
is  very  difficult  to  check,  cocaine  may  be  tried,  and  lavage  with  hot  water. 
C'rcasote,  hydrocyanic  acid,  and  creolin  have  been  found  useless.  Kumpf 
advises  calomel  (gr.  -J)  every  two  hours. 

External  applications  of  heat  should  be  made  and  a  hot  bath  may  be 
tried.  "Warm  aiijdications  to  the  abdomen  are  very  grateful,  llypodormic 
injections  of  other  will  be  found  serviceable. 

Irrigation  of  the  bowel — ontoroclysis — with  warm  water  and  soa]),  or 
tannic  acid  (2  per  cent),  should  be  used.  AVith  a  long,  soft-rubber  tube, 
as  much  as  3  or  4  litres  may  be  slowly  injected.  Not  only  is  ihe  colon 
cleansed,  but  the  small  bowel  may  also  be  reached,  as  shown  by  the  fact 
that  the  tannic-acid  solutions  have  boon  vomited. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concentrated, 
and  absorption  takes  place  rapidly  from  the  lymph-spaces.  To  moot  this, 
intravenous  injections  were  introduced  by  Latta,  of  Lcith,  in  the  epidemic 
of  1833.  jMy  preceptor,  Bovoll,  first  ])ractisod  the  intravenous  injections 
of  milk  in  Toronto,  in  the  epidemic  of  1854.  A  litre  of  salt  solution  at  107° 
may  be  injected,  and  repeated  in  a  few  hours  if  no  reaction  follows.  Less 
risky  and  eipially  elUcacious  is  the  subcutaneous  injection  of  a  saline  solu- 
tion. For  this,  common  salt  should  be  used  in  the  jiroportion  of  about  four 
grammes  to  the  liter.  "With  rubber  tubing,  a  cannula  from  an  aspirator,  or 
oven  with  a  hypodermic  noodle,  the  warm  solution  may  ho  allowed  to  run 
hy  pressure  beneath  the  skin.  It  is  rapidly  absorbed,  and  the  process  may 
lie  continued  until  the  pulse  shows  some  sign  of  improvement.  This  is 
really  a  valuable  method,  thoroughly  i)hysiological,  ami  should  ])e  tried 
in  all  severe  cases. 

In  the  stage  of  reaction  special  ]iains  should  l)e  taken  to  regulate  the 
diet  and  to  guard  against  recurrences  of  the  severe  diarrhoea. 


182 


SPECIFIC  INFECTIOUS  DISEASES. 


y 


XXI.    YELLOW    FEVER.  » 

Definition. — A  fever  of  tropical  and  subtropical  countries,  chnracter- 
i."";l  by  a  toxieniia  of  varvin<;  intensity,  with  jaundice,  alljununuria,  and  a 
r  nrkcd  tenflency  to  hii'niorrliaLTc,  especially  from  tiie  stomach,  causinu:  the 
''  black  vomit."  A  sj)eci(ic  bacillus  has  been  desci'ibed  by  Sanarelli,  out 
its  causal  relationshij)  with  the  disease  caniujt  be  said  to  have  been  delinitely 
established. 

Etiology, — Tho  disease  prevails  endcmically  in  the  AVest  Indies  and 
in  eiTtain  .sections  of  the  Spaidsh  .Main.  From  these  re^trions  it  occasionally 
extends  and,  under  suitable  conditions,  prevails  e|)idemically  in  the  South- 
ern States.  Now  and  then  it  is  brou^dit  to  the  lar<,fe  seaports  of  the  Atlantic 
coast.  Formerly  it  occurred  extensively  in  the  l.'nited  tStates.  In  the 
latter  ])art  of  the  last  century  and  the  beginning  of  this,  frightful  e|)i- 
demics  ]  'evaded  in  I'liiladclphia  and  other  Northern  cities.  The  ei»idemic 
of  171)."'),  in  I'liiladclphia,  so  jM-^phically  described  by  Matthew  Carey,  was 
the  nu)st  serious  that  has  ever  visited  any  city  of  the  ^Middle  States.  The 
mortality,  as  given  by  Carey,  dui'ing  tlu;  months  of  August,  SeptendxT. 
October,  and  Xovend)er,  was  4,011,  of  whom  3,-i;).j  died  in  the  months  of 
Septcnd)cr  and  October.  The  population  of  the  city  at  the  time  was  only 
40,000.  J'lpidcmics  occurred  in  the  United  States  in  1797,  17<J8,  170U.  and 
in  1.S02,  when  tlie  disease  prevailed  slightly  in  Boston  and  extensively  in 
Baltimore.  Jn  1S0.3  and  1S0,5  it  again  aj)peared:  then  for  many  years  the 
outbreaks  were  slight  and  localized.  In  li<oo  the  disease  raged  throughout 
the  Southern  States.  In  Xew  Orleans  alone  there  was  a  mortality  of  nearly 
8,000.  Ill  LS(;7  and  lS7-'5  there  were  moderately  severe  e])idemics.  In  1S7S 
the  last  extensive  ei)idemic  occurred,  chielly  in  Louisiana,  Alaljama,  and 
Mississipjii.  The  total  mortality  was  nearly  1(),000.  There  have  since 
been  local  outbreaks,  the  last  in  181)7,  in  which  in  Xew  Orleans  from  Sep- 
tember 8th  to  December  11th  there  were,  according  to  the  Marine  nos])ital 
Eeports,  1.902  cases,  with  288  deaths.  In  Europe  it  has  occasionally  gained 
a  foothold,  but  there  have  been  no  Avides])read  epidemics  exce])t  in  the 
S))anish  ports.  The  disease  exists  on  the  west  coast  of  Africa.  It  is  some- 
times carried  to  ports  in  Oreat  P>ritain  and  France,  but  it  has  never  ex- 
tended into  those  countries.  The  history  of  the  disease  and  its  general 
symptomatology  are  exhaustively  treated' of  in  the  classical  works  of  Bene 
La  Boche  and  Berenger-Feraud. 

(Juiteras  recognizes  three  areas  of  infection:  (1)  The  focal  ;^one  in  which 
the  disease  is  never  absent,  including  TFavana,  Vera  Cruz,  Bio,  and  other 
S])anisli-Am(M-ican  ports.  (2)  The  perifocal  zone  or  regions  of  ])eriodic  epi- 
demics, including  the  ports  of  the  tro])ical  Atlantic  in  America  and  Africa. 
(3)  The  zone  of  accidental  e])idemics,  between  the  parallels  of  4-5°  north 
and  ;)r»°  soTith  latitude. 

The  e])idemics  are  invariably  due  to  the  introduction  of  the  ])oisoii 
either  by  ]»atients  an'ect(^d  with  the  diseas(^  or  throngli  infected  articles. 
Lntpu'stionably  the  poison  may  be  conveyed  by  fomites.  The  channels  of 
infection  are  believed  to  be  the  digestive  canal  and  the  lungs.  Individuals 
of  all  ages  and  racet-  are  attacked.    The  negro  is  much  less  susceptible  than 


YELLOW  FEVER. 


183 


racter- 
and  IX 
nsr  tlu' 
li,  i>iit 
UuiU'ly 

ics  iuhI 
^ipnally 

South- 
\tliintie 

ill  tho 
I'ul  epi- 
pidoinie 
rev,  ^vas 
}s.^  Tho 
[)toml»('i'. 

was  only 
79!J,  an«l 
,>;ively  in 
years  tlu' 
roughout 
lof  nearly 
In  1^1.^ 
ua,  and 
:e   sine*-' 
m  Sep- 
[osi)ital 
V  uained 
i   in  the 
is  sonie- 
lever  ex- 
o-cneral 
ol:  liene 

111  wliicli 
nd  iitlu'V 
i(»dic  cpi- 
d  Africa, 
north 

lie   poison 

articU's. 

lannels  of 

dividuals 

lilile  than 


roi 


tlie  ■\vhitc,  hilt  lie  doejj  imt  enjoy  an  iiiiiiiimity.  Uesidents  in  soutlieiii 
countries,  in  \\hi(li  the  disease  is  prevalent,  are  not  so  susceptible  as 
strangers  and  temporary  residents.  Males  are  more  l"re(pientl\  all'ected  and 
the  mortality  is  greater  among  them,  owing  prohahly  to  greater  e.\])()siire. 

N'ery  young  ehildi'eii  ii>iially  escape;  hut  in  the  epidemics  ol'  large 
cities  the  niimlM'i'  under  live  attacked  is  large,  since  they  coiistitnte  a  con- 
siderahle  proportion  ol'  the  population  iin|»r()tected  hy  pri'vioiis  attack, 
(itiiteras  states  that  the  *'  loci  of  eiideniicity  of  yellow  fever  are  essentially 
maintained  hy  the  ci'cole  ini'ant  popiilatinn.  Mhieli  is  siihjecl  to  the  disease; 
in  a  verv  mild  form."'  Immunity  is  ac(piired  hy  ])assing  through  an  attack 
(ij-  hy  ]n'((liingei|  I'esidence  in  a  locality  in  which  the  disease  is  endemie.  The 
>tatenK'nt  so  often  made  that  the  Creoles  are  exem[)t  from  yellow  fever  has 
heen  ahiindantly  disproved.  They  certainly  are  not  so  susce|)tihle,  hut  in 
-evere  epidemics  they  die  ,11  niiinhers.  The  evidence  in  favor  of  inherited 
imniimity  is  not  conclusive. 

('tiiiililidiis  fartiriiKj  ihc  Drrrhipmriit  of  EiiiiJcmirs. — Yellc  fever  is  a 
disease  of  the  sea-coast,  ami  rarely  ])reva'  in  regions  Avith  an  elevation 
ahove  l.ddO  feet.  Its  ravages  are  most  serious  in  cities,  ])articularly  when 
ihe  sanitary  conditions  ai'c  unfavorahle.  It  is  always  most  .'-evere  in  the 
hadly  draineil.  unhealthy  port  ions  of  a  city,  vhere  the  population  is  crow(h'd 
tog  'ther  in  ill-ventilated,  hadly  drained  hou<es.  '^Fhe  disease  ])revails  dur- 
ing the  hot  season.  Humidity,  heat,  darkness,  and  want  of  air  seem  to  he 
the  ])ro])er  coetlicients  for  the  preservation  of  the  ])oison  (Sanarelli).  In 
Havana  the  death-rate  is  greatest  during  the  months  of  June,  July,  md 
.Vugust.  The  cpid(  mics  in  the  United  States  have  always  heen  in  the  sum- 
mer and  autumn  months,  disa])])earing  ra])idly  with  the  onset  of  cold 
weather. 

Bacteriology  of  Yellow  Fever. — Sanarelli,*  the  director  of  the 
Institute  of  Experimental  ]\Iedicinc  at  ^lontevideo,  has  descrihed  an  organ- 
ism, -whicli  he  calls  tlic  hariJhis  iricroldcf^,  with  the  following  characters: 
It  is  a  slender  rod  from  2  to  4  mikrons  in  length,  a  facnlt  .ivo  anjrrohe, 
ciliated  and  motile.  It  decolorizes  hy  (iramV  method,  grows  well  on  ordi- 
nary media,  does  not  coagulate  milk,  ferments  saccharine  fluids,  and  is 
patliogenie  to  lowei  animals.  Tn  man.  dogs,  and  monkeys  it  is  stated  to 
produce  a  clinical  ])icture  similar  to  that  of  the  natural  disease.  The 
hacillus  is  founil  only  in  the  Mood  and  tissues,  never  in  the  stomach  or 
howels.  Tt  occurs  in  very  small  niimhers.  hut  produces  a  toxine  of  extram-- 
dinary  intensity.     It  has  only  heen  found  in  rather  more  than  half  of  the 

*  Tho  werk  of  SniiMVolli  luis  licrn  mfirrcd  Iiy  m  scries  f>f  niijiistifiiiblc  cxperiiiieiits  upon 
men,  which  should  rceoive  tlio  unqualifit'il  coiiilomniitiini  of  tlio  profession.  In  one  scn.'io 
every  dose  of  medieinc  given  is  nn  experiment,  sinee  who  ran  tell  the  nature  of  the  reac- 
tion ?  But  tlie  liinitntif>n  of  (Iclilierrite  experiinent.itioji  (in  liuinan  licintjs  should  tie  clearly 
defined.  Voluntarily,  if  with  fidl  knowledi^e,  a  fellow-creature  may  submit  to  certain 
tests  and  trials,  just  as  a  physician  may  experiment  on  himself.  Druirs.  the  value  of 
which  has  l^oen  carefully  tested  on  animals  (if  found  harmless),  may  be  tried  on  jiatients, 
since  in  this  way  alone  can  projrress  be  made.  But  deliiierate  experiments  such  as  .Sana- 
relli carried  out  with  cultures  of  known  and  tested  virulence,  and  which  were  followed  by 
serious,  nearly  fatal  illness,  arc  simply  criminal. 


184 


SPECIFIC  INFECTIOUS  DISEASES. 


cnses.  This,  Sanarolli  claims,  is  owin^'  to  tlic  almost  constant  intervention 
oi'  secondai^y  infections,  in  which  streptococci,  staphylocijcci,  or  the  colon 
bacilli  overspread  the  body,  l)et'ore  the  death  of  the  })atient,  with  snch  a 
qnantity  of  toxic  prodncts  that  they  kill  or  attenuate  the  bacillus  icteroides. 
This  is  a  very  weak  ])()int  in  his  statement.  The  bacillus  possesses  a  remark- 
able resistance  to  dryin*,'  and  to  the  action  of  sea-water.  'IMie  presence  of 
moulds  favors  its  vitality  and  growth.  The  amaril  ])()is()n,  as  Sanarelli  calls 
the  product  of  the  bacillus  icteroides,  is  said  to  ])ossess  three  s])ecial  prop- 
erties— emetic,  hacmorrliagic,  and  steatogenie.  Tlie  injection  of  the  liltiTc  1 
cultures  into  man  produced  "the  fever,  congestions,  ha-morrhages,  vomit- 
ing, steatosis  of  the  liver,  cephalalgia,  nephritis,  anuria,  ura>mia,  icterus, 
delirium,  and  colla])se''!  The  results  of  inoculation  into  dogs  are  equally 
remarkable,  lioth  the  bacilli  by  tliemsclvcs  and  the  toxines  produce  fever, 
diarrluea,  vomiting,  and  an  early  hiomatemesis.  The  most  characteristic 
changes  are  in  the  liver,  which  presents  large  patches  of  yellow  color,  made 
np  of  liei)atic  cells,  whicli  have  undergone  complete  fatty  degeneration. 
The  kidneys  show  an  acute  parenchymatous  nei)hritis. 

An  interesting  ])oint,  one  which  favors  the  specificity  of  the  bacillus 
icteroides,  and  sujjplements  in  an  important  way  Sanareili's  work,  is  the 
existence  of  an  agglutinative  reaction  in  the  blood  of  yellow  fever  patients. 
The  Archinards  of  New  Orleans  and  Woodson  of  the  United  States  army 
state  that  in  50  cases  of  yellow  fever  studied  during  the  recent  epidemic  the 
agglutination  with  cessation  of  motion  was  obtained  in  over  70  per  cent. 
The  work  was  done  with  cultures  of  the  bacillus  icteroides  of  Sanarelli 
obtained  from  the  Pasteur  Institute,  and  a\  ith  cultures  made  from  the  local 
cases.  Shauld  this  fact  be  confirmed  in  subsequent  epidemics,  it  will  solve 
the  all-important  question  of  the  early  (''agnosis  of  the  disease.  Blood 
taken  as  early  as  the  second  day  gave  a  proi,  |)t  and  characteristic  reaction. 
Surgeon-General  Sternberg,  whose  researches  on  yf  <  j\y  fever  have  been  so 
important,  described  an  organism  Avhich  he  called  ii.  j  bacillus  X,  and  which 
he  claims  to  be  the  same  as  Sanareili's  bacillus.  It  has  much  the  same 
characters,  but  presents  minor  peculiarities.  The  question  of  the  identity 
of  the  two  has  not  yet  been  settled. 

Morbid  Anatomy. — The  skin  is  more  or  less  Jaundiced.  Cutane- 
ous ha}morrhages  may  be  present.  No  specific  or  distinctive  internal  lesions 
have  been  found.  The  blood-serum  cc  lins  haemoglobin,  owing  to  de- 
struction of  the  red  cells.  Just  as  in  pernicious  malaria.  The  heart  some- 
times, not  invariably,  shows  fatty  change;  the  stomach  presents  more  or 
less  hypera:>mia  of  the  mucosa  with  catarrhal  swelling.  It  contains  the 
material  which,  ejected  during  life,  is  known  as  the  black  vomit.  The  esscMi- 
tial  ingredient  in  this  is  transformed  blood-pigment.  In  the  two  specimens 
which  I  have  had  an  opportunity  of  examining  it  differed  in  no  respect 
from  the  material  found  in  other  affections  associated  with  ha^matemesis. 
There  is  no  proof  that  this  l)lack  material  depends  upon  the  growth  of  a 
micro-organism.  The  liver  is  usually  of  a  pale  yellow  or  ■/rownish-yciiow 
color,  and  the  cells  are  in  various  stages  of  fatty  deofcneration.  From  the 
date  of  Louis'  observations  at  Gibraltar  in  1828,  the  ap]iearances  of  this 
organ  have  been  very  carefully  studied,  and  some  have  thought  the  change;;- 


YELLOW  P^EVER. 


1S5 


entinn 
J  colon 
swch  a 
^.'voiclos. 
■(Miiiirk- 
cncc  of 
■Hi  call.^ 
\\  i)roi>- 

,  Yoinit- 
ictoriis, 
equally 
ce  l'ov(>r, 
ictoristio 
or,  mado 
novation. 

.  hacillns 
•k,  is  the 
patients, 
ites  army 
clemic  the 
per  cent. 
Sanarelli 
the  local 
will  solve 
Blood 
reaction, 
e  been  so 
md  which 
the  same 
e  identity 


in  it  to  he  charnctcristic.  Coinicihnan  lias  described  remarkable  appear- 
ances in  the  liver-cells  which  he  believes  arc  distincti^;-  and  peeidiar.  I'iitly 
d(';,a'neration  and  rt';^'ions  of  necrosis  are  ])resent  in  all  cases.  The  kidneys 
often  show  traces  of  dill'nse  nephritis.  The  epitheliiiin  of  the  comohited 
tnhules  is  swollen  and  very  ^M'anular;  there  may  also  l)c  necrotic  changes. 
In  l)oth  liver  and  kidneys  l)acteria  of  various  sorts  have  hccn  described. 

Symptoms. — The  incuhation  is  usually  three  or  four  days,  hut  it 
may  be  less  than  twenty-four  hours  or  )irolon<:ed  to  seven  days.  The  onset 
is  sudden,  as  a  rule,  without  j)i'enionilory  symittoms,  and  in  the  early  hours 
of  the  morning.  Chilly  feelings  are  common,  and  are  nsnally  as.sociated  with 
headache  and  very  severe  i)ains  in  the  back  and  limits.  The  fever  ri.ses 
rapidly  and  the  skin  feels  very  hot  and  dry.  The  tongue  is  furred,  but 
moist;  the  throat  sore.  Xansea  and  vomiting  are  jjresent,  and  bei'oine  more 
intense  on  tlie  second  or  third  day.  The  bowels  are  usually  constipated. 
The  following,  in  detail,  are  the  more  important  characteristics: 

Fades. — Kven  as  early  as  the  first  morning  the  i)atient  nn\y  present  a 
very  characteristic  facies,  according  to  Cuiteras,  one  of  the  three  distin- 
guishing features  of  the  disease,  'i'lie  following  description  is  taken  from 
him:  The  face  is  decidedly  Hushed,  more  so  than  in  any  other  acute  infec- 
tious disease  at  such  an  early  period.  The  eyes  arc  injected,  the  color  is 
a  bright  red,  and  there  may  be  a  slight  tumefaction  of  the  eyelids  and  of 
the  li})s.  Even  at  this  early  date  there  is  to  be  noticed  in  connection  with 
the  injection  of  the  superficial  capillaries  of  the  face  and  conjunctiviu  an 
element  of  icterus,  and  "  the  early  manifestation  of  jaundice  is  undoubtedly 
the  most  characteristic  feature  of  the  facies  of  yellow  fever."  It  has  to  be 
looked  for  very  carefully. 

The  Fever. — On  the  morning  of  the  first  day  tha  temperature  may  vary 
between  100°  and  10()°,  nsnally  between  103°  and  lO.T.  During  the  even- 
ing of  the  first  day  and  the  morning  of  the  second  day  the  temperature 
keeps  about  the  same.  There  is  a  slight  diurnal  variation  on  tlie  second 
and  third  day.  In  very  mild  cases  the  fever  may  fall  on  the  evening  of  the 
second  or  on  the  morning  of  the  tliird  day,  or  in  abortive  cases  or  in  unde- 
veloped cases  in  children  even  at  the  end  of  twenty-four  hours.  In  cases 
tliat  are  to  terminate  favorably  the  defervescence  takes  ])lace  ])y  lysis  during 
a  ])eriod  of  two  or  three  days.  The  remission  or  stage  of  calm,  as  it  has  been 
called,  is  sncceeded  by  a  febrile  reaction  or  secondary  fever,  which  lasts  one, 
two,  or  three  days,  and  in  favorable  cases  falls  by  a  short  lysis.  On  the 
other  hand,  in  fatal  cases  the  teniiieraturc  rises  rapidly,  becomes  higher 
than  in  the  initial  fever,  and  deatli  follows  shortly. 

The  Pulse. — On  the  first  day  the  jndse  is  rarely  more  than  100  or  110. 
On  the  second  or  third  day,  while  the  fever  still  keeps  u]i,  the  pulse  begins 
to  fall,  and  may  have  become  slower  by  as  much  as  20  beats  while  the  tem- 
jtcraturo  has  risen  1.5°  or  2°.  On  the  evening  of  the  third  day  there  may  be 
a  temperature  range  of  103°  and  a  pulse  of  only  75,  or  ''a  temperature 
between  103°  and  104°  with  a  pulse  running  from  70  to  80."  This  imj^or- 
tant  diagnostic  feature  was  first  .  -cribed  by  Faget.  of  Xew  Orleans.  Dur- 
ing the  defervescence  the  pulse  may  become  still  slower,  down  to  50,  48,  or 
45,  or  even  as  low  as  30.     A  slow  pulse  with  the  defervescence  is  not  the 


186 


SIM-X'IFIC  INFECTIOUS  DISEASES. 


^ix'ciiil  firciiliitory  IVatiirc  ol"  the;  (H.-m.-i',  hut  //  ■  aluwiiKj  of  the  pidtn'  wUh 
a  flcuily  (ir  crni  riniiKj  Icniiwralnrt'. 

Albuminuria. — Thin,  rt'frnnh'd  hy  (iiiiteras  as  tlic  third  characteristic 
symptom  of  the  disease,  occurs  as  early  as  tlie  evening'  of  the  tliird  day.  lie 
says  very  tridy  tluit  it  is  very  rare  so  early  in  other  fevers  except  those  of  an 
unusually  severe  type.  "Kveii  in  the  mild  cn.ses  that  do  not  go  to  hed — 
cases  of  'walking  yellow  fever" — on  the  second,  third,  or  fourth  day  «d' 
the  disease  alhuminuria  will  show  itself.''  it  may  he  (luite  transient.  Jn 
the  .•severer  cases  the  amount  of  alhnnun  is  large,  and  there  may  be  numer- 
ous tuhe-casts  and  all  the  signs  ol'  an  intense  acute  nephritis;  or  complete 
su|ipression  of  the  urine  may  sui)ervene,  and  death  may  occur  in  uraMuic 
convulsions  or  coma  within  twenty-four  or  thirty-six  hours.  Guiteras  in- 
sists that  the  evening  urine  should  be  si)ecially  examined,  lie  states  that 
the  presence  of  albuuun  on  the  first  day  and  its  jjersistence  on  the  second 
indicate  a  severe  case.  With  the  sec(mdary  rise  in  temperature  the  jaundice 
becoujcs  more  intense. 

(Jaslrir  Features. — "Black  Vamil."' — Irritability  of  the  stomach  is 
present  from  the  very  outset,  and  the  vomited  matter  consists  of  the  con- 
tents of  the  stomach,  and  subsequently  of  mucus  and  a  grayish  fluid.  In 
the  second  stage  of  tl:e  disease  the  vomiting  becomes  more  ])ronoimced  and 
in  the  severe  cases  is  characterized  by  the  ])rescnce  of  blood.  It  may  he 
co])i()Us  and  forcible,  ])roducing  much  ])ain  in  the  abdomen  and  along  the 
gullet.  There  is  nothing  s])ecific  in  the  •"■  Idack  vonut "'  of  yellow  fever. 
It  consists  of  altered  blood.  "  Ulack  vomit  "  is  not  necessarily  a  fatal  symp- 
tom, though  it  occurs  only  in  the  severer  forms  of  the  di.sease.  Other  htvm- 
orrhagic  features  may  he  present — i)etechitv'  on  the  skin  and  bleeding  from 
the  gums  or  from  other  mucous  meuiorani's.  The  bowels  arc  usually  con- 
stipated, the  stools  not  clay-colored,  as  in  jaundice  from  obstruction.  They 
are  sometimes  tarry  from  the  presence  of  altered  blood. 

2[eu(al  Features. — In  very  severe  cases  the  onset  may  be  with  active 
delirium.  "As  a  rule,  in  a  majority  of  cases,  even  when  there  is  black 
vomit,  there  is  a  ]ieculiar  alertness;  the  patient  watches  everything  going 
on  about  him  with  a  pccidiar  intensity  and  liveliness.  This  may  be  due 
in  part  to  the  terror  the  disease  inspires"  (Guiteras).  The  first  signs  of 
mental  cloudiness  may  he  due  to  the  unrmic  coma. 

Rela]ises  occasionally  occur.  Among  the  varieties  of  the  disease  it  is 
important  to  recognize  the  mild  cases.  These  are  characterized  by  slight 
fever,  continuing  for  one  or  two  days,  arid  succeeded  by  a  rapid  convales- 
cence. Such  cases  would  riot  be  recognized  as  yellow  fever  in  the  'absence 
of  a  prevailing  ei)idemic.  Cases  of  greater  severity  have  high  fever  and 
the  features  of  the  disease  are  M-ell  marked — vomitiug.  prostration,  and 
hamiorrhages.  .\nd  lastly,  there  are  malignant  cases  in  which  the  ])atient 
is  overwhelmed  by  the  intensity  of  the  fever,  and  death  takes  place  in  two 
or  three  davs.* 


*  For  a  full  rliscnssinn  of  the  morbid  anatomy  and  symptomatolotry  of  the  disease  the 
student  is  referred  to  the  works  of  .Joseph  Jones,  of  \ew  Orleans,  and  to  his  papers  in  the 
Journal  of  the  American  'Medical  Association,  1895,  I. 


VKLLOW  FFA'KH. 


is; 


('  in 


th 


toristic 
y.    lie 

I'  of  an 
,  bod- 
day  of 
111.     U\ 
muncr- 
oiiqik'te 
iini'inic 
eras*  in- 
ites  tliat 
0  second 
janndice 

niach    is 
tlie  con- 
luid.     In 
need  and 
t  may  1)0 
alontr  'i'^^^ 
low  fever, 
ital  synip- 
hcr  hivm- 
lin.t:  from 
uallv  con- 
Mi.  '  They 

litli  active 
is  Idack 
i,L'  jioin^ 
IV  1)0  due 
signs  of 

k'ase  it  is 
by  slight 
eonvalos- 
le  nV)sence 
fover  and 
tion,  and 
le  patient 
Ice  in  two 


I  (lisoaso  the 
iipcrs  in  the 


In  «ovorc  cases  convah'sceiuo  may  Ijo  complicated  I)V  tlio  occurrence  of 
])arotiris,  ahsccsises  in  various  parts  of  the  body,  and  dlarrhd'a.  An  attat  k 
confers  an  inimiuiity  wliich  persists,  as  a  rule,  through  life. 

Diagnosis. — (a)  From  Dvikjuc — The  ditliculty  in  the  diil'orential 
diagao>is  of  these  two  diseases  lies  in  their  fre(|iient  coexistence,  as  during 
the  epidemic  of  1S!>T  in  ])arts  of  the  Southern  States.  For  example,  whether 
yellow  fover  existed  last  year  in  (ialveston  is  still  unsettled,  some  observers 
clainung  that  dengue  alone  pri'vailed,  others,  im-luding  (luiteras  and  West, 
atlirming  that  there  wore  a  cort.iin  number  of  cases  of  true  yollow  fever.  Uu 
the  oiu'  hand,  if  the  suspicious  cases  were  dengue,  we  nnist  acknowledge  that 
l)reak-bone  fover  may  lie  a  much  more  serious  disease  than  writers  state, 
and  that  certain  of  the  symjitoms,  particularly  the  luomorrhages,  occur  in  a 
larger  ]»roportiou  of  cases  than  has  been  heretofore  acknowledged.  Of  the 
other  sym])toms,  too,  one  writer  states  that  jaundice  of  mihl  grade  was  the 
rule  from  first  to  last.  Albunun  was  not  infrequently  present  in  tlie  urine, 
and  the  lack  of  correlation  between  the  pulse  and  the  temperature  was  so 
frequent  as  to  l)e  almost  the  rule.  There  was  no  ease  of  black  vomit. 
Dengue,  as  I  have  stated  in  tlie  article  f)n  that  dii-ease,  ])revailed  to  a  remark- 
able extent  in  the  city  of  (ialveston.  On  the  other  hand,  if  the  cases  ex- 
amined by  Guitoras  and  declared  by  him  to  be  yellow  fever  were  truly 
examples  of  that  disease,  there  is  the  anomalous — indeed,  unicpie — fact  of 
an  outbreak  of  yellow  fover  in  a  city  which  had  not  had  the  disease  in  epi- 
demic form  since  1SG7,  and  in  which  it  did  not  assume  epidemic  propor- 
tions and  did  not  increase  the  death-rate,  which  for  the  months  of  August, 
September,  and  October  of  1897  was  lower  than  for  the  corresponding 
three  months  in  189G  and  IS'Jo.  After  a  review  of  the  local  literature  on 
the  question,  I  confess  myself  to  be  quite  unable  to  decide  upon  the  i)oints 
at  issue.  I  have  dwelt  upon  this  matter  in  order  that  practitioners  may 
realize  how  dilTicult  the  diagnosis  may  be  mder  certain  circumstances.  It 
is  quite  useless  to  emphasize  in  parallel  columns  the  ditfereatial  points 
between  the  two  disea.'^es.  Doubtless  in  a  majority  of  all  the  cases  the  three 
diagnostic  points  ni)on  which  Guitoras  lays  stress — the  facies,  the  albu- 
minuria, and  the  slowing  of  the  pidse  with  maintenance  or  elevation  of 
the  fever — are  sufficient  for  the  diagnosis.  He  states,  too,  that  jaundice, 
which  does  sometimes  occur  in  dengue,  rarely  appears  as  early  as  the  second 
or  third  day  of  the  disease,  and  on  this  much  stress  should  be  laid.  Ilaim- 
orrhages  are  much  less  common  in  dengue,  but  that  they  do  occur  has  been 
recognized  by  authorities  ever  since  the  time  of  Ensh.  It  is  most  sincerely 
to  be  hoped  that  the  work  of  the  Archinards  and  Woodson  on  the  serum 
diagnosis  may  prove  final,  in  which  case  wc  shall  have  a  positive  diagnostic 
criterion,  such  as  we  now  have  for  malarial  fever. 

(b)  From  Malarial  Fever. — In  the  early  stages  of  an  epidemic  cases  are 
very  apt  to  be  mistaken  for  forms  of  malarial  fever.  In  the  Southern  States 
the  outbreaks  have  nsnally  been  in  the  late  summer  months,  the  very  season 
in  which  the  restivo-autumnal  irregular  malarial  ferer  prevails.  Among 
rhe  points  to  be  specially  noted  are  the  absence  of  early  jaundice  in  ma- 
larial fever.  Even  in  the  most  intense  types  of  infection  the  color  of  the 
skin  is  rarely  changed  within  four  or  five  days.  To  the  experienced  eye 
12 


i^^ 


ill: 


188 


SPECIFIC  INFECTIOUS  DISEASES. 


the  facica  wcnild  \)v  oi  coiisidcrahlr  ii('l|).  Alhiiniin  is  rnroly  present  in  the 
urine  so  curly  us  tiic  si-cund  day  in  u  malarial  inlVetion.  Other  important 
points  are  the  marked  sweliint,'  of  the  sjjleen  in  nuiluria,  while  in  yellow 
fever  it  is  not  ol'len  eidarged.  lla'inorrluijres,  und  particularly  the  hlack 
vomit,  are  very  rare  in  the  ucute  forms  of  ie.^tivo-uutumnal  malarial  infee- 
tion.  In  the  so-called  lui'inorrhaj^nc  malarial  I'ever  the  patient  has  nsually 
had  previous  attucks  of  malaria,  lla'maturiu  is  a  prominent  feature,  while 
in  yellow  fever  it  is  l)y  no  means  frecpient.  '^^I'wo  s[)eeial  jxnnts  of  more 
importance,  ])erhaps,  than  any  of  tiiese  general  symptomatic!  features  are 
(1)  the  examination  of  the  blood  for  nudarial  purusites.  The  forms  to  be 
looked  for  are  the  small,  ring-shuped  organisms  of  the  a'stivo-uutumnal 
infections.  As  a  rule,  their  presence  is  readily  determined  by  any  one 
familiar  wil'i  their  general  characters.  They  are,  however,  of  all  forms  the 
most  dillicult  to  recognize,  and,  while  they  may  be  very  abundant,  there  arc 
cases  in  which  the  organisms  are  extremely  scanty  in  the  jjeripheral  cir- 
culation. Under  such  circumstances  in  u  case  of  doubt  it  might  be  justi- 
fiable to  ta])  the  s])leen.  (2)  If  Sanarelli's  researches  are  confirmed,  the 
agglutination  test  will  be  a  very  inqjortant  aid  in  the  diagnosis  of  doubtful 
cases. 

Prognosis. — In  its  graver  forms,  yellow  fever  is  one  of  the  most 
fatal  of  epidemic  diseases.  The  mortality  has  ranged,  in  various  epidemics, 
from  15  to  85  per  cent.  In  heavy  driidcers  and  those  who  have  been  ex- 
posed to  hardships  the  death-rate  is  much  higher  than  among  the  better 
classes.  In  the  epidemic  of  1878,  in  New  Orleans,  while  the  mortality  in 
hospitals  was  over  50  per  cent  of  the  white  and  21  per  cent  of  the  colored 
patients,  in  private  practice  it  was  not  more  than  10  per  cent  among  the 
white  patients.  The  death-rate  was  very  low  in  the  epidemic  of  1897. 
Favorable  symptoms  are  a  low  grade  of  fever,  slight  jaundice,  absence  of 
ha'morrhages,  and  a  free  secretion  of  urine.  If  the  temperature  rise  a])Ovo 
103°  or  104°  during  the  first  two  days,  the  outlook  is  serious.  Black  vomit 
is  not  an  invariably  fatal  symptom.  Cases  with  suppression  of  urine,  de- 
lirium, coma,  and  convulsions  rarely  recover. 

Prophylaxis. — The  measures  to  be  taken  are — 

(a)  "  Exclusion  of  the  exotic  germ  of  the  disease  by  the  sanitary  super- 
vision, at  the  port  of  departure,  of  ships  sailing  from  infected  ports,  and 
thorough  disinfection  at  the  port  of  arrival,  when  there  Is  evidence  or  rea- 
sonable suspicion  that  they  are  infected;  (h)  isolation  of  the  sick  on  ship- 
board, at  quarantine  stations,  and,  so  far  as  practicable,  in  recently  infected 
places;  (c)  disinfection  of  excreta,  and  of  the  clothing  and  bedding  used 
by  the  sick,  and  of  localities  into  which  cases  have  been  introduced,  or 
Avhich  have  become  infected  in  any  way;  (d)  depopulation  of  infected  places 
— i.  e.,  the  removal  of  all  susce]itible  persons  whose  presence  is  not  neces- 
sary for  the  care  of  the  sick  "  (Sternberg).  During  an  epidemic,  individuals 
who  must  remain  in  the  locality  should  avoid  the  regions  in  which  the  dis- 
ease prevails  most;  they  should  live  temperately,  avoiding  all  excesses,  and 
should  bo  careful  not  to  get  overheated,  either  in  the  sun  or  by  exercise. 

Treatment. — Careful  nursing  and  a  symptomatic  plan  of  treatment 
probably  give  the  best  results.     Bleeding  has  long  since  been  abandoned. 


BUBONIC   PLAGUE. 


180 


w  the 
rtunt 

I'lloW 

))lni'k 
inl't'i- 
sually 

more 

OS   lU'O 

1  to  be 
■umnnl 
[\y  one 
■ins  the 
lore  ore 
ral  cir- 
le  j"**ti- 
,0(1,  the 

l()Ul)lIul 

l\c  nwst 
)idemvfs, 
been  cx- 
le  better 
L-tality  in 
le  colored 
iiong  the 
of  1897. 
)sence  of 
Ise  above 
Ick  vomit 
irine,  de- 


Iry  super- 
lorts,  and 
\e  or  rea- 
on  ship- 
infected 
ling  nsed 
luced,  or 
[ed  phices 
lot  neces- 
idividuals 
the  dis- 
3sses,  and 
jrcise. 
treatment 
iandoned. 


How  much  patients  will  stand  in  this  disease  is  illustrated  by  Rush's  prac- 
tice, which  was  of  the  most  heroic  character,  lie  says:  "  From  a  newly 
arrived  J-lnj^lisliman  1  took  1  I  I  (tunce^•.,  at  twelve  l)lcedings,  in  si.x  days; 
four  wore  in  tw<'uty-four  liuurs.  I  ^mvo  within  thi'  course  of  the  same  six 
days  nearly  !.")<)  j,M'ains  of  calouiol,  with  the  usual  [iroportions  of  jalap  and 
ganil)oge."  *  With  the  counifre  of  his  convictions  this  modern  Saugrado 
hiuiself  sid)niittcd  to  two  bleeding's  in  ouo  day,  and  had  his  iiifaut  of  six 
weeks  old  bled  twice!  Xoithor  emetics  nor  purf,'ativos  arc  now  oiu|»loyod. 
Of  s[iccial  remedies  ([uiniuo  is  warmly  ri'couinioudod,  and,  when  luouior- 
rhage  sets  in,  the  jiorchloride  of  iron.  Digitalis,  aconite,  and  jal)onindi 
have  been  employed.  Sternberg  ailvises  the  following  mixture:  Hicar- 
honate  of  soda,  l.")()  grains;  bichloride  of  mercury,  J  grain;  pure  water, 
1  (piart.  Throe  tal)lospoonl'uls  every  hour.  This  is  given  on  the  vii'W  that 
the  specific  agent  is  in  the  intestine,  and  that  its  growth  Jiuiy  possibly  bo 
restrained  by  this  antacid  and  antiseptic  mixture.  The  fever  is  best  treated 
by  hydrotherapy.  There  are  several  re])orts  of  the  good  cU'ects  of  cold 
baths,  sponging,  and  the  appliontion  of  ice-cold  water  to  th(>  head  and  the 
extremities  in  this  disease.  \'omiting  is  a  very  dilbcult  symptom  to  control. 
Morphia  hypodermically  and  ice  in  small  quantities  are  ])robably  the  best 
remedies.  Medicines  given  by  the  mouth  for  this  purpose  are  said  to  be 
rarely  olTicacious. 

We  have  no  drug  which  can  ])e  depended  upon  to  chock  the  luvm- 
orrhages.  Ergot  and  acetate  of  lead  and  opium  are  reconuuondod.  The 
uramiic  symptoms  are  best  treated  by  the  hot  bath.  Stimulants  should  be 
given  freely  during  the  second  stage,  when  the  heart's  action  becomes 
feeble  and  there  is  a  tendency  to  collapse.  The  ])atient  shoidd  he  carefully 
fed;  but  when  the  vomiting  is  incessant  it  is  host  Jiot  to  irritate  the  sto" 
ach,  bnt  to  give  nutritive  enemata  until  the  gastric  irritation  is  allayed. 

Serum  Trrafmrnf  in  YclJair  Fever. — Sanarelli's  most  recent  communica- 
tion, ]\rarch  8,  1808,  o-jves  an  account  of  the  use  of  the  blood-serum  from 
two  horses,  one  of  which  bad  Ixm'U  under  treatment  for  eighteen  months, 
the  other  for  twelve.  Altogether  of  the  22  cases  treated  with  the  scrum  !> 
died,  a  mortality  of  22. T  iier  cent.  lie  has  been  testing  the  ])rophylactic 
power  of  this  antiamarilic  serum,  bnt  so  far  on  too  small  a  scale  to  judge  of 
its  efficacy. 

XXM.    BUBONIC    PLAGUE. 

Definition. — A  specific,  infecticms  disease  of  extraordinary  virulence 
and  vorv  rai)id  course,  characterized  l)y  inflammation  of  the  lymphatic 
glands  (buboes),  carbuncles,  and  often  lurmorrhages. 

History  and  Geographical  Distribution. — The  disease  was 
probably  not  known  to  the  classical  Greek  writers.  The  earliest  positive 
account  dates  from  the  second  century  of  our  era.  The  plague  of  Athens 
and  the  pestilence  of  the  reign  of  !^^arcus  Anrelius  were  apparently  not  this 
disease  (Payne).     From  the  great  plague  in  the  days  of  Justinian  (sixth 

*  Manuscript  letter  to  Rerlman  Coxe. 


I'JO 


SIMX'IFIC  INFECTIOUS  DISKASHS. 


/ 


\ 


ccnturj')  to  the  iiiidfllc  of  the  BcvcntotMilli  crutmy  t'liidoniics  of  varying 
severity  itcciirrcfl  in  iMiroiic.  AiiKtii;,'  the  most  (lisaatnuis!  wiis  the  j'aiiiouri 
"  hliiciv  (h'lith  "  of  the  loiirteeiith  eeiitiiry,  which  overrnii  Kiiropc  iiikI  de- 
8tr(iye<l  a  htiirtii  of  the  i)()|)uhiti(tii.  In  the  seventeenth  century  it  rii^^'cd 
viruh'nily,  .nid  (hirin<,'  the  |,'reat  plagne  of  hoiidon,  in  l(i(I5,  al)()ut  70,(100 
pooi)k'  died,  inuring  the  present  century  the  jila^^ue  in  Kurope  Juis  hecn 
confined  ahnost  exchisively  to  'i'nrkey  and  soiitiiern  h'ussia.  'J'lu!  last  out- 
brealv  was  a  small  epidemic  in  iJSTS-'T'J.  There  are  now  live  indepen(h'nt 
endemic  centres  of  the  disease — (1)  the  province  of  Tripoli,  {'I)  southwest- 
ern Arabia,  (3)  a  large  section  of  Asia,  comprising  ]\lesopotaniia,  I'ersia, 
and  Kiirdeslan,  (I)  the  districts  of  Kuiiiaon  and  (iiuwhal  in  northwestern 
India,  and  ("))  southwestern  China  (I'ayne). 

Iicncwed  iniereet  Inis  recently  hecn  aroused  in  the  disease  by  the  e]>i- 
demic  at  Ilong-kojig  in  18!)t,  from  which  in  tlie  space  of  three  months 
2,r)00  peoi)le  died.  Far  more  serious  has  been  the  outbreak  in  India  in  the 
j)resi(h'n('y  of  I>ond»ay.  It  l)egan  in  the  city  of  IJombay  in  September, 
iNlHi,  during  three  months  develope<l  gradually,  ninintnined  a  great  in- 
tensity for  three  months,  and  then  slowly  declined.  In  the  nine  months 
at  least  20,000  people  died.  After  a  period  of  (piiescence  in  the  city  of 
Boml)ay  it  again  l>rokc  out  witli  great  virulence  during  the  early  ])art  of 
the  ])resent  yi'ar  (18*JS).  At  the  time  of  writing  it  has  sjjread  widely 
throughout  the  presidency,  and  is  in  many  respects  the  most  ominous  of 
recent  e])idemics. 

Etiology. — The  spccifie  organism  of  the  disease  is  a  bacillus  discov- 
ered by  Kitasato  and  carefully  studied  by  Yersin  and  others.  It  reseml)le3 
somewhat  the  bacillus  of  chicken  cholera,  and  grows  in  a  perfectly  char- 
acteristic manner.  The  bacillus  pestis  occurs  in  the  blood  and  in  the 
organs  of  the  body,  and  has  also  been  found  in  the  dust  and  in  the  soil  of 
houses  in  which  the  ]iatients  have  lived.  Flies  and  fleas  die  from  the  dis- 
ease, and  may  convey  the  infection.  Eats,  mice,  and  dogs  arc  readily  in- 
fected, aiul  diseased  animals  will  convoy  the  plague  to  healthy  ones. 

The  disease  i)revails  most  frecpicntly  in  hot  seasons,  though  an  out- 
break may  occur  during  the  coldest  weather  of  winter.  Persons  of  all  ages 
are  attacked.  It  S])reads  chiefly  among  the  poorer  classec,  in  the  slums  of 
the  great  cities,  and,  in  fact,  Mhercver  the  hygienic  conditions  are  most 
faulty.  There  is  much  in  favor  of  the  view  that  the  ])lague  is  a  soil  disease, 
the  virus  of  Avhich,  like  that  of  anthrax  and  tetanus,  resides  pennanently 
in  the  soil  of  the  affected  districts  (see  Payne  in  Allbutt's  System).  The 
method  of  spread  was  well  recognized  by  Pe  Foe:  "  Xo  one  in  this  whole 
nation  ever  received  the  sickness  or  infection  hut  M'ho  received  it  in  the 
ordinary  May  of  infection  from  somebody,  or  the  clothes,  or  touch,  or 
stench  of  someljody  that  was  infected  before." 

While  the  vims  of  the  plague  may  he  communicated  from  one  person 
to  another  throngh  the  air.  the  disease  has  not  the  extreme  contagiousncs? 
of  small-pox  or  of  scarlet  fever.  Tf  attaches  itself  particularlv  to  houses 
and  to  the  clothing  and  bedding.  In  the  Piomhay  epidemic  few  attendant- 
tipon  the  sick — nurses  and  physicians — have  heen  attacked,  and  a  writer 
states  that  among  the  hundreds  of  British  troops  daily  employed  on  cordon 


lU'nOXIC   PLAflUK. 


191 


1.1  <lo- 
;o,»ioO 

■i    1)0L'U 

st  out- 
(■nilent 

IVrsia, 
western 

the  ci)i- 
inonths 
111  in  the 
ptc'ialior, 
Tri'iit  in- 
j  months 
c  city  of 
y  part  of 
vd  widely 
n^iuourt  of 

us  discov- 
i-csomldt'S 
.ctly  cliar- 
nd  in  the 
the  soil  of 
m  the  dis- 
Irciidily  ii^- 
es. 

■\\  an  ont- 
of  all  agt'S 
le  slums  of 
Is  are  most 
;oil  disease, 
■nuancntly 
om).     Thr 
this  whole 
d  it  in  tho 
touch,  or 

lone  person 
ltapiousnc== 
to  honpo= 
attendant- 
id  a  wTitor 
on  cordon 


(hity  nnd  sonrdi  partii'S  and  in  the  disiiitVilinti  of  houses  not  a  single  cuso 
oeciirrfd. 

Clinical  Forms. — Most  wriltTs  rcco^inizo  three  varieties — pcslis 
siilrmns,  or  the  i'ulniiiiant  variety,  /irsfis  majtn;  and  pcslis  miiiur.  In  the 
pfslis  siiln-diis  dciitii  may  occur  within  twenty-four  hours.  It  is  an  intense! 
septieii'rnia,  with  or  willioul  the  (h'vchi|>nii'nt  of  hieniorrhaj^'es,  and  randy 
with  ghiiuhdar  eidiir^'einents.  'i'hc  prslis  major  is  tlu-  conimoii  severe 
huhonic  form — malifinanl  (uhnilis,  as  t'antiie  terms  it.  'Idu-  pcxtix  niiiior 
is  usually  met  with  Ixd'orc  the  outl)rcak  of  the  severe  e|»idcniie,  and  is  char- 
ucterize(i  hy  glandular  swellings  hut  very  slight  fever  and  eonslitutional 
(lislurl>aiu'i's,  and  is  rarely  fatal. 

A  very  interesting  form  has  hecn  recognized  during  the  ]?omhay  epi- 
demic; namely,  the  primary  plaguc'  pneumonia,  whieh  hegins  with  a  chill, 
pain  in  the  side,  and  cough,  with  rusty  expectoration.  There  are  randy 
swellings  of  the  lymph  glands.  The  ilomhay  J'lague  Committee  give  tho 
following  interesting  classification: 

Femoral. 


1.  With    cnliirgi'il    pluiids    (gravity  ueeonling    to  , 
syrnploins  and  severity  of  iitLauk). 


2.  Without  enlarged  glands  (iihnost  always  fatal). 


Iiigiiinnl. 
Axillary. 
( "ervieal. 
Tonsillar. 

'  SeptieaMnic. 
I'neiiinoiiit;. 
Mesenteric,  enteric,  ot 

gH.str<)-intestiual. 
Ne|iliritic. 
Cerebral. 


Symptoms. — The  following  is  a  brief  summary  of  the  symptoms  of 
the  ordinary  huhonic  form: 

The  stage  of  incubation  is  rarely  more  than  three  or  four  days. 

The  stage  of  invasion  is  characterized  by  headache,  backache,  stiifness 
in  the  limbs,  a  feeling  of  anxiety  and  restlessness,  and  great  (le|)rcssion  of 
spirits.  The  breathing  is  hurried,  and  luvmorrhages,  particularly  fn)m  the 
nose  or  from  the  lungs,  may  occur.  After  these  symptoms  have  persisted 
for  from  twelve  to  tliirty-six'  hours,  the  temperature  rises  and  the  pulse 
becomes  rapid.  The  fever  may  reach  104°  or  even  100°;  the  ttrngue  be- 
comes ;)rown,  collapse  synijitoms  are  a])t  to  supervene,  and  in  very  severe 
infections  the  patient  may  die  at  this  stage.  In  at  least  two  thirds  of  all 
cases,  however,  a  fourth  period  is  reached,  characterized  by  the  development 
of  glandular  swellings  or  l)uboos.  The  inguinal  glands  are  most  often  af- 
fected, then  in  order  the  axillary,  the  cervical,  and  the  popliteal.  The  first 
sign  of  the  swelling  a])pears  usually  from  the  third  to  the  fifth  day.  Reso- 
lution may  occur,  or  su])puration,  or  in  rare  cases  gangrene.  Carbuncles 
also  may  develop  in  dilTerent  parts  of  the  skin,  particularly  on  the  legs, 
buttocks,  or  back.  Suppuration  is  a  favorable  feature.  De  Foe  recognized 
this  in  his  graphic  account  of  the  London  plague,  stating  that  "  if  these 
swellings  could  be  brought  to  a  head  or  to  break  and  run,  or,  as  the  sur- 
geons call  it,  to  digest,  the  patient  generally  recovered." 


l'J2 


SPECIFIC  INFKCTIOUS  DISKASKS. 


At  this  stiip'  pi'tccliiii'  vi'i'y  coimiioiily  hIiow  tli(.'iiist'lv('s,  and  iiiiiy  In*  very 
rxtt'iisivi'.  Tlicsc  liavi!  hi'i-n  ciiIKmI  tlic  "  |iliigiii'  Himts,"  or  llif  *'  tokens  of 
tilt'  dist-asi',"  and  ^iavo  to  it  in  the  niiddlt'  a|,'t's  tlio  name  of  tlii'  lUark 
l>oatli.  ilu'Hiorrliagfs  from  tlic  mucous  nu'uilu'anes  may  also  oL-cur;  in 
some  I'pidcmifs  liii'mo[)tysiH  has  bci'ii  especially  frcipicnt. 

( 'nnvalcsccncc  nia\  proceed  rapidly,  or  may  he  much  prolonp'(l  hy  tho 
suppurating'  ludiocs, 

'I'hc  mortality  of  tho  disease  is  tlu'  hi<,'hcst  of  any  known  infection, 
reaching'  from  70  to  !)()  ])cr  cent  of  all  attacked.  In  tho  llonj^-konj(  lloa- 
])ital  during  the  recent  epidemic  it  is  statetl  that  tho  mortality  was  it.")  per 
cent. 

Prophylaxis. — The  Hdlowing  hricf  extract  is  taken  from  Kitasato's 
rei)ort:  "  'I'hc  disease  prevails  especially  under  faulty  hygienic  conditions; 
it  is  therefore  urged  that  general  hygienic  nu'asures  he  carried  out.  Prop.T 
receptacles  for  sewage  should  he  provided;  a  ]»ure  water-supply  alVordcd; 
houses  and  streams  are  to  he  cleansed'  all  persons  sick  of  the  disease  iso- 
lated; tho  furniture  of  the  sick-room  washed  with  a  !i-i)er-ccnt  carbolic 
solution  in  milk  of  lime;  old  clothes  and  hedding  are  to  he  st  'amcd  at 
100°  ('.  for  at  least  an  hour,  or  exposed  for  a  few  hours  to  sunlight.  If 
fcasil)lc,  all  infected  articles  should  he  burned.  The  evacuations  of  the 
sick  are  to  be  mixed  with  milk  of  lime,  and  those  who  die  of  the  disease 
are  to  be  buried  at  a  depth  of  three  metres,  or  jireferably  cremated.  After 
recovery  the  patient  is  to  be  kept  in  isolation  at  least  one  month.  All  con- 
tact with  tl  >  sick  is  to  be  avoided,  and  great  care  is  to  bo  exercised  with 
rcl'cri'nce  to  food  and  drink."  For  the  disinfection  of  buildings,  ilalfkine 
suggests  sulphuric  acid  of  tho  strength  of  1  to  200. 

Treatment. — Tn  a  disease  the  mortality  of  vhicli  may  reach  as  high 
as  80  or  UO  per  cent  the  (luestion  of  treatnu'ut  rt.  ..Ives  itself  into  nuiking 
the  patient  as  comfortable  as  possible,  and  followivig  out  certain  general 
principles  such  as  guide  us  in  the  care  of  fever  ])atients.  Cantlie  recom- 
mends purgation  and  stimulation  from  the  outset,  and  the  use  of  morphia 
for  the  pain.  The  local  treatment  of  the  hoboes  is  important,  and  good 
results  apparently  follow  the  injection  of  the  bichloride  of  mercury. 

Preventive  inoculation  has  been  introdv'ced  by  Ilalfkine.  Sterilized 
bouillon  cultures  of  the  i)lague  bacillus  are  used.  Injections  with  increas- 
ing (plant i ties  of  these  soluble  toxines  are  ])ractised,  which  arc  followed  by 
mild  reactionary  syini)toms.  Sonu^  thousands  of  ])orsons  have  been  inocu- 
lated by  him  in  India.  Ilalfkine  claims  for  the  nu^thod  very  ])ositive  suc- 
cess, and  (pi(  .es  the  following  in  support  of  his  contention:  "First,  as  re- 
gards animals  beirg  rendered  immune.  Twenty  rats  from  a  ship  newly 
arrived  from  Enrone  were  r-oized;  of  these,  10  wore  inocidated.  Subse- 
quently the  t.'0  rats  were  kcjjt  together  in  a  cage,  into  which  a  rat  sulfering 
from  plague  Mas  introduced.  Of  the  iminoculated.  0  Avcre  seized  with 
plague  and  died,  whereas  of  those  rendered  immune  only  1  contracted  the 
disease.  Secondly,  at  Uran,  a  village  ]iossessing  1,000  inha1)itants,  when 
])lague  hroke  out  420  persons  Avcro  inoculated  by  tho  serum  in  fpiestion. 
Of  these,  only  7  were  attacked  by  ])lague,  and  all  recovered,  whilst  of  the 
uninoculated  2G  were  seized  and  24  died.     Thirdly,  in  the  town  of  Lower 


DYSRNTKUY. 


11)3 


be  vory 
kfUri  of 
L.  lUack 
■ciir;  ill 

[  l)y  tho 

\  faction, 
u^i  llos- 
rf  St.")  per 

ritiisato'rt 
udititiiis; 

alV(»r(U'(l; 

H'aSO    180- 

carbolic 
'aint'd  lit 
iglit.  If 
18  of  the 
le  ilisoasc 
(1.    After 

All  c'on- 
'isccl  with 

llalTkine 

1  as  high 
jo  making 
111  gt'Ut'ral 
lie  .I'coin- 
morphia 

md  good 
jiiry. 

SU'vilizt'd 
|i  incroas- 
lUowt'd  by 
icn  inocii- 

Mtivc  sue- 
as  ve- 


il'; 


liip  newly 

Subse- 

putl'ering 

i/A'd  with 

•acted  the 

lits,  when 

question. 

list  of  the 

lof  Lower 


Paniaun  IMUT  perHons  were  inoculated,  (],i)',V,]  remaining  unproteetod.  Of 
ili(  latter,  l,lHv'  died,  whiTeart  only  'Mi  of  tlif  pcrsouH  inoeiilaled  nueeumbed 
to  the  dinmse.  l-'ourtldy,  at  liiiiKAvli,  a  village  with  TOO  iidiabitants,  Home 
two  luMirs'  distanci'  from  I'ximltay,  ;5".'M  persons  were  iiiiu  idatcd,  and  HT7 
were  content  to  remain  iinprolcilcd.  Among  the  former  there  were  It 
cases  and  7  deaths;  among  the  latter — that  is,  the  nninoculated — TH  per- 
sons contracted  the  disease,  of  whom  oH  died.  I'iftlily.  at  K.ikec,  out  of 
a  total  (d'  I,. '»;;(»  inhabitants,  (!T1  availed  themselves  ol"  the  treatment,  while 
,s.')!i  remained  unprotecti'd.  Of  the  latter,  I  i;{  had  ]ilague,  with  US  deaths; 
\vlier<'as  of  the  inoculated  'Mi  cases  occurred,  with  IT  deaths  only  "  (Uritish 
Med.  .lour.,  1S!>H,  J). 

A  serum  therapy  has  l)een  introduced  by  Yersin,  the  immuni/ing  serum 
being  obtained  from  the  horse,  in  Canton  good  results  a|»pear  to  have 
i'l'llowed,  the  wtui  o''  tiie  berum,  but  the  recent  report*  froju  Ijondniy  uro 
not  so  favorable. 

XXIII.    DYSENTERY. 

Definition. — I'nder  this  clinical  term  are  desc'ribed  sevi'ral  dilferi'nt 
I'nims  of  intestiiuil  llux,  cluiracterized  by  freipient  .stools,  and  in  the  acute 
'age  by  tormina  and  tenesmus.  Anatomically  there  is  inilammation  and 
..'Ually  ulceration  of  the  large  bowel. 

Etiology. —  Dysentery  is  one  of  tho  four  great  ei)idemie  diseases  of 
the  world.  Jn  the  tropics  it  destroys  more  lives  than  cholera,  and  it  has 
lieen  more  fatal  to  arnues  than  powder  and  .shot. 

While  especially  severe  in  tlie  trojjies,  sporadic  cases  constantly  occur 
in  more  temperate  climates,  and  uiuler  favoring  circumstances  epidemics 
jire  found  even  in  the  more  northern  countries,  such  as  ('ana<la  and  Nor- 
way. It  has  become  less  frecpient  of  late  years,  owing  to  improved  sani- 
tiiry  conditions.  The  statistics  of  the  Montreal  (ieneral  Hospital,  for  tho 
twenty  years  ending  ^lay  1,  1889,  show  a  remarkable  decrease  in  the  dis- 
eiise.  In  the  decade  ending  ^lay,  187i>,  1.50  cases  were  admitted;  whereas 
in  the  last  ten  years  there  have  been  only  ;{!  admissions.  There  has  been 
a  similar  decrease  at  the  Pennsylvania  Hospital. 

In  the  Southern  cities  of  tliis  country  dysentery  is  more  prevalent;  even 
when  not  e]>idemie,  sporadic  cases  are  common.  In  Baltimore  it  j)revails 
every  summer,  and  has  on  several  occasions  been  epidiMuic. 

Epidemics  of  dysentery  have  occurred  in  the  United  States  for  more 
tlian  a  century,  and  Woodward  has  collected  tho  data  which  show  the 
Yiirions  outbreaks.  Perha]»s  the  most  serious  was  that  which  ])revailed 
from  18-17  to  18.")^.  Puring  the  war  of  secession  the  disease  existed  to  an 
iilarming  extent  in  both  armies.  According  to  Woodward's  re));)rt,'*  there 
Were  in  the  Federal  service  in  all  259,071  cases  of  acute  and  28,451  cases 
of  chronic  dysentery.  Probably  a  considerable  proportion  of  the  182,586 
<iises  of  chronic  diarrhoea  should  also  come  in  this  category.     The  deccn- 

*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Medical,  vol.  ii ;  the  most 
exhaustive  treatise  extant  on  intestinal  fluxes — an  enduring  monument  to  the  industry 
and  ability  of  the  author. 


194 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


nial  census  reports  since  ISoO  show  a  profrressive  decrease  in  the  total  num- 
ber of  (leatlis  from  this  disease.  It  previuls  most  extensively  in  tiie  siimnier 
and  autumn.  Sudden  changes  of  temperature  ap|iear  more  harmful  than 
variations  in  moisture.  The  elUuvia  from  decom[)osin<j;  animal  matter  have 
heen  thought  h}'  some  to  predispose  to  or  even  to  cause  the  disease.  That 
d\'sent(!ric  all'ections  are  more  fre(incnt  in  malarial  localities  has  long  been 
known,  and  is  probaljly  connected  with  external  conditions  favoring  their 
development.  With  reference  to  the  inlluence  of  drinking-water.  Wood- 
ward is  doubtless  correct  in  stating  that  the  eifccts  of  dissolved  mineral 
matters  have  been  greatly  exaggerated.  0'''  the  other  hand,  from  the  days 
of  the  old  Oreek  physicians,  it  has  been  held  tiuit  the  impurities  in  the 
stagnant  water  of  marshy  districts  and  ponds  may  give  rise  to  diarrlnea 
and  dysentery.  Here,  however,  it  is  not  probable  that  the  vegetable  impuri- 
ties are  directly  causative,  but  that  the  organic  matter  renders  the  water 
a  more  favoral)le  medium  for  the  develojnnent  of  the  organisms  which 
cause  the  disease. 

Dyspeptic  conditions,  particularly  those  caused  by  the  ingestion  of  Ijad 
food  and  unri])e  fruit,  seem  to  predispose  to  the  disease.  Great  stress  has 
been  laid  by  German  authorities  on  the  importance  of  constipation  as  a 
causal  factor. 

Dysentery  occurs  at  all  ages.  There  is  no  race  immunity.  The  con- 
tagiousness of  the  disease  is  doubtful.  The  experience  of  the  civil  war  is 
decidedly  against  it,  but  the  possibility,  as  with  typhoid  fever,  must  be 
acknowledged. 

Clinical  Forms. — (a)  Acute  Catarrhal  Dysentery. — This  may  occur 
sporadically  or  endemically,  and  iS  the  variety  most  frequently  found  in 
temperate  climates. 

Morhid  Anatomy. — The  lesions  are  confined  to  the  large  bowel;  some- 
times the  ileum  also  is  involved.  The  mucous  membrane  is  injected, 
swollen,  and  often  covered  with  tenacious  blood-stained  mucus.  The  most 
striking  feature  is  the  enlargement  of  the  solitary  follicles,  which  stand 
out  prominently  from  the  mucous  membrane.  In  very  acute  forms,  as  in 
children,  the  picture  is  that  of  an  acute  follicular  colitis.  In  more  pro- 
tracted cases  the  follicles  su])purate  or  are  capped  with  an  area  of  necrotic 
tissue.  In  other  instances  the  sloughs  have  separated  and  the  entire  colon 
])resents  numerous  ulcers  most  of  which  have  developed  from  the  follicles, 
while  others  have  resulted  from  necrosis  and  sloughing  of  the  intervenin"- 
tissue. 

Sympioms. — There  may  bo  preliminary  dyspepsia  or  slight  pains  in  the 
al)domen.  Chills  are  rare.  Diarrha\a  is  the  most  constant  initial  symp- 
tom, and  at  first  is  not  painful.  Usually  within  thirty-six  hours  the  char- 
acteristic features  of  the  disease  develop — abdominal  pain  of  a  colicky, 
griping  character  and  frequent  stools,  which  are  passed  with  straining  and 
tenesmus;  the  constitutional  disturbance  is  variable,  and  in  mild  cases 
may  be  slight.  The  temperature  is  not  high;  at  the  o^  <-set  the  range  may 
be  103°  or  103°.  The  tongue  is  furred  and  moist,  and  as  the  disease  pro- 
gresses becomes  red  and  glazed.  Xausea  and  vomiting  may  be  present, 
but  as  a  rule  the  patient  retains  nourishment.    The  constant  desire  to  go- 


DYSENTEKY. 


195 


il  nuni- 
juminer 
111  than 
;er  havo 
.  That 
ng  btcu 
ig  llieir 
,  Woocl- 

minoral 
Iho  (lays 
9  in  the 
liarrhn'ii 

inipuri- 
[le  water 
IS  wliich 

n  of  l)a(l 
irc'ss  lia^ 
tion  as  a 

The  oon- 

;[l  war  is 

must  be 

lay  occur 
found  in 

el;  pomc- 
injected, 
ho  most 
ch  stand 
jms,  as  in 
lore  pro- 
necrotic 
ire  colon 
follicles, 
ervening 

Ins  in  the 
jal  symp- 
Ithe  char- 
colicky, 
Ining  and 
lild  cases 
m^e  mav 
fcase  pro- 
present, 
tire  to  go- 


to stool  and  the  straining  or  tenesmus  are  the  most  distressing  symi)toms. 
The  ahdonien  may  be  Hat  and  hard.  The  thirst  is  often  excessive.  The 
stools  ill  this  variety  of  dysentery  have  the  following  characters:  During 
Uie  iirst  twenty-four  or  forty-eight  hours  they  consist  of  m(jre  or  less  clear 
mucus  and  blood  mixed  with  small  fieeal  scyi)ala.  Alter  this  they  become 
])urely  gelatinous  and  bloody,  and  are  small  and  frequent,  from  lifteen  t(t 
two  hundred  in  twenty-four  hours,  according  to  the  severity  of  the  case. 
About  the  end  of  the  first  week  the  mucus  becomes  o|)a(|ue,  the  proportion 
of  blood  diminishes,  and  grayish  or  brownish  shreddy  material  appears  in 
the  stools,  which  become  gradually  reduced  in  frecpiency.  At  this  tiiiic 
they  may  be  wholly  coni]»osed  of  a  greenish  pultaceous  material  with  mucus. 
As  the  disease  subsides,  fa'cal  matter  again  appeal's  in  the  stools,  increasing 
in  amount  until  they  become  normal.  ^licroscopical  examination  of  the 
glairy  bloody  stools  shows  red  blood-corpuscles,  few  or  many  leucocytes, 
and  constantly  large,  sv>-ollen,  rouml  or  oval  epithelioid  cells,  containing 
fat-droi)S  and  vacuoles.  These  are  not  infreciuently  mistaken  for  anioibte. 
Occasionally  the  cercoiiionas  iiili'sliiKilis  is  seen  in  large  numbers.  The  ba- 
cillus pyocyaneus  has  been  found  by  F.  C  Curtis  in  a  recent  epidemic  at 
llartwick,  X.  Y.  Xot  only  was  it  ]>resent  in  the  stools  in  large  numbers, 
but  it  was  isolated  from  the  drinking-water  in  almost  ])ure  culture. 

Course  of  the  Disfusc. — The  milder  cases  run  a  coui\.-;e,  as  Flint  has 
shown,  of  about  eight  days;  severer  ones  rarely  terminate  within  four 
weeks.  The  affection  occasionally  becomes  chronic.  Peritonitis  and  liver 
abscess  are  extremely  rare.  Of  abscesses  of  the  liver  among  the  first  1,000 
autopsies  at  the  Johns  Hopkins  Hospital,  not  more  than  two  or  three  were 
associated  with  dysentery  other  than  amoebic. 

{h)  Tropical  Dysentery — Amoebic  Dysentery. — This  form  of  intestinal 
flux  is  characterized  by  irregular  diarrlnea  and  the  constant  j)resence  in  the 
stools  of  the  aina'ha  coll  (Losch),  ainn'ha  clj/senli'ria'  (Councilman  and  La- 
ileur).  It  is  this  variety  which  i)revails  extensively  in  the  tropical  and  sub- 
tropical regions,  and  which  proves  so  fatal  in  epidemic  form.  The  amwha 
is  a  uiiicellular,  i)rotoi)lasniic,  motile  organism,  from  15  to  30  /a  in  diameter, 
consisting  of  a  clear  outer  zone,  ectosarc,  and  a  granular  inner  zone,  endo- 
sarc,  containing  a  nucleus  and  one  or  more  vacuoles.  It  was  first  described 
by  Lambl  in  1859,  and  subse(iuently  by  Losch,  who  considered  it  the  cause 
of  the  disease.  In  the  endemic  dysentery  of  Egypt,  Kartulis,  in  1883, 
found  these  amoeba?  constantly  in  the  stools,  in  the  intestines,  and  in  the 
liver  abscesses.  He  was  afterward  enabled  to  cultivate  them  in  straw  in- 
fusion, and  reproduced  the  di.sease  experimentally  in  cats.  In  1890  I 
reported  a  case  of  dysentery  with  abscess  of  the  liver,  originating  in 
Panama,  in  which  the  amoeba}  were  found  in  the  stools  and  in  the  pus  from 
the  abscess;  and  Councilman  and  Lafieur  *  have  described  the  clinical 
features  and  anatomical  lesions  in  a  series  of  cases  of  this  form  of  dysen- 
tery in  my  wards.  Dock  has  demonstrated  tlu  ir  presence  in  a  number  of 
cases  in  Galveston,  and  Musser  has  found  them  in  Philadel])hia.  A  careful 
study  has  been  made  recently  of  35  cases  by  II.  F.  Harris.     Amoebae  are 

*  Johns  Hopkins  Hospital  Reports,  vol.  IL 


I 


190 


SPECIFIC  INFECTIOUS  DISEASES. 


occasionally  found  in  the  stools  of  healthy  men.  (Quincke  and  Rons  roc'o<?- 
nize  three  forms  of  parasitic  amo'ha',  two  of  wliicli  are  ])alliojf('iiic.  Tho 
disease  is  very  common  in  tropical  and  siil)tro|)ical  eoiiiitrics,  Jt  is,  how- 
ever, found  more  or  less  widely  (listril)uted  tlirou<,di()ut  I'hirope  and  North 
America.  The  sources  of  infection  are  not  known,  but  it  seems  i)robal)le 
that  one  of  them  is  drinkin^'-water. 

Morbid  Analonn/. — The  lesions  are  found  in  the  lar<:je  intestine,  some- 
times in  the  lower  ])ortion  of  the  ileum.  Abscess  of  the  liver  is  a  common 
sequence.     Perforation  into  the  ri<,dit  lung  is  not  infrequent. 

Infestincs. — IMie  lesions  consist  of  idceration,  ])roduccd  by  preceding 
infdtration,  general  or  local,  of  the  submucosa,  due  to  an  cedematous  con- 
dition ami  to  multi])lication  of  the  lixed  cells  of  the  tissue.  Jn  the  earliest 
stage  these  local  infiltrations  appear  as  hemispherical  elevations  above  the 
general  level  of  the  mucosa.  The  mucous  mend)rane  over  these  soon  be- 
comes necrotic  ami  is  cast  oil',  exposing  the  infiltrated  submucous  tissue  as 
a  grayish-yellow  gelatinous  mass,  which  at  lirst  forms  the  floor  of  the  ulcer, 
but  is  subse(iuently  cast  olf  as  a  slough. 

The  individual  idcors  arc  round,  oval,  or  irregular,  with  infdtrated, 
undermined  edges.  The  visible  aperture  is  often  small  compared  to  the 
loss  of  tissue  beneath  it,  the  ulcers  undermining  the  mucosa,  coalescing, 
and  forming  sinuous  tracts  bridged  over  by  ap[)arently  normal  mucous 
membrane.  According  to  the  stage  at  \vhich  the  lesions  arc  observed,  the 
floor  of  the  nicer  nuiy  be  formed  by  the  submucous,  the  mnscular,  or  the 
serous  coat  of  the  intestine.  ^Fhe  ulceration  may  affect  the  whole  or  some 
portion  only  of  the  large  intestine,  particularly  the  caecum,  the  hepatic 
and  sigmoid  flexures,  and  the  rectum.  ]n  severe  cases  the  whole  of  the 
intestine  is  much  thickened  and  riddled  with  nlcers,  with  only  here  and 
there  islands  of  in. act  mucous  membrane. 

The  disease  advances  by  progressive  infdtration  of  the  connective-tissue 
layers  of  the  intestine,  which  produces  necrosis  of  the  overlying  structures. 
Thiis,  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  slough- 
ing en  masse  of  the  mucosa  or  of  the  muscularis,  and  the  same  process  is 
observed,  but  not  so  cons])icuously,  in  the  less  severe  forms. 

In  some  cases  a  secondary  di})htheritic  inflammation  complicates  the 
original  lesions. 

Healing  takes  place  by  the  gradual  formation  of  fibrous  tissue  in  the 
floor  and  at  the  edges  of  the  ulcers,  which  may  ultimately  result  in  partial 
and  irregidar  strictures  of  the  bowel. 

^Iicrosco])ical  examination  shows  a  notable  absence  of  the  products  of 
purulent  inflammation.  In  the  infiltrated  tissues  polynuclear  leucocyte,.^ 
are  seldom  found,  and  never  constitute  purulent  collections.  On  the  other 
hand,  there  is  proliferation  of  the  fixed  connective-tissue  cells.  Amoebie 
are  found  more  or  less  abundantly  in  the  tissues  at  the  base  of  and  around 
the  ulcers,  in  the  lymphatic  spaces,  and  occasionally  in  the  blood-vessels. 

The  lesions  in  the  liver  are  of  two  kinds:  firstly,  local  necroses  of  the 
parenchyma,  scattered  throughout  the  organ  and  possibly  due  to  the  action 
of  chemical  ]"'oducts  of  the  amoobo?;  and,  secondly,  abscesses.  These  may 
be  single  or  multiple.    When  single  they  are  generally  in  the  right  lobe, 


DYSENTERY. 


107 


'.     Tlio 
,8,  how- 

0.  sonio- 
common 

U)us  c'on- 
^e  earliest 
il)Ove  the 
poon  1)0- 
;  tissue  as 
the  xilcev, 

infiltrated, 
red  to  the 
coalescing, 
al  nuicous 
served,  the 
ilar,  or  the 
lie  or  some 
le  hepatic 
lole  of  the 
y  here  and 

active-tissue 

structures. 

wel  slough- 

e  process  is 

ilicates  the 

Issue  in  the 
It  in  partial 

Iproducts  of 
leucocytfi 
In  the  other 
AmochiV 
land  around 
l-vessels. 
l-oses  of  the 
the  action 
These  may 
right  lobe, 


(illii^r  toward  the  convex  surface  near  lis  diapliraginatic  attacluncnt,  or  on 
llic  concave  surface  in  iiroxiinity  to  the  howc  1.  Mulliple  abscesses  an; 
siiiidl  and  generally  snpcrlicial.  In  an  early  stage  the  abscesses  are  grayish- 
vcllow,  with  sharply  <le(ined  contours,  and  contain  a  spongy  lu'crotic  iiia- 
Icrial,  with  more  or  less  lliiid  in  its  interstices.  'I'he  larger  abscesses  have 
niggeil  necrotic  walls,  and  contain  a  more  or  less  viscid,  greenish-yellow 
nr  reddish-yellow  purulent  material  nu.\e(l  with  blood  and  shreds  of  liver- 
lissiie.  Till'  older  abscesses  have  fihrous  walls  of  a  di'iise,  almost  carti- 
laginous toughness.  A  section  of  the  abscess  wall  shows  an  inner  necrotic 
zone,  a  middle  zone  in  which  there  is  great  jiroliferation  of  the  connective- 
tissue  cells  and  coiupression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  intense  liy])cra'niia.  '^Pliere  is  the  same  absence  of  purulent  inllam- 
iiiation  as  in  the  iiiti'stine,  except  in  those  cases  in  wliicli  a  secondary  in- 
fection with  ])yogenic  organisms  has  taken  ])lace.  ^Phe  material  from  the 
iihscess  cavity  shows  chiefly  fatty  and  granular  detritus,  few  cellular  ele- 
ments, and  amo'bi!  in  variable  numbers,  which  are  also  found  in  the  abscess 
walls,  chietly  in  the  inr""'  necrotic  zone.  .Mallory  has  devised  a  dilferential 
stain,  by  which  they  he  distinguished  in  tissues.     Cultures  are  usually 

sterile.  Lesions  in  tlic  .jngs  are  seen  when  an  abscess  of  the  liver — as  so 
frequently  ha])])ens — points  toward  the  dia|)liragm  and  extends  by  eon- 
timiity  through  it  into  the  lower  lobe  of  the  right  lung.  An  exhaustive 
study  of  the  anuebic  abscf'ss  of  the  liver  has  recently  been  made  by  W.  T. 
lb)ward,  Jr.,  and  C.  F.  Hoover,  of  Cleveland  (American  Journal  of  the 
.Aledieal  Sciences,  1897,  ii). 

Si/iiiplonix. — The  onset  may  be  sudden,  as  in  catarrhal  dysentery,  or 
gradual,  beginning  as  a  trifling  and  ])erha|)s  transient  diarrho'a.  In  severe 
gangrenous  cases  the  abrupt  onset  is  more  common.  The  suliseipicnt  course 
is  a  very  irregular  diarrhoea,  marked  by  exacerbations  and  intermissions, 
and  progressive  loss  of  strength  and  flesh.  There  is  moderate  fever  as  a 
rule,  but  niany  cases  are  afebrile  throughout  the  greater  jiart  of  their  course. 
Abdominal  i)ain  and  tenesmus,  usually  jirescnt  at  the  onset,  es|)ecially  in 
severe  cases,  may  be  entirely  absent,  and  vomiting  and  nausea  are  only 
occasionally  observed.  The  stools  vary  very  much  in  numlier  ami  a])pear- 
ancc  in  different  cases  and  at  dilferent  jieriods  in  the  same  cases.  They 
may  lie  very  frequent,  l)loody,  and  mucoid  at  the  outset,  as  in  catarrhal 
dysentery;  but  their  main  characteristic,  when  the  disease  is  well  estab- 
lished, is  fluidity.  From  six  to  twelve  yellowish-gray  liipiid  stools,  con- 
taining mucus  and  occasionally  blood  in  varying  ]n-oportions,  are  passed 
daily  for  weeks.  Actively  moving  amo?ba^  are  found  in  these  stools,  more 
abundantly  during  exacerl)ations  of  the  diarrluea,  and  disappear  gradually 
as  the  stools  become  formed. 

Abscess  of  the  liver,  and  especially  of  the  liver  and  lung,  is  a  frequent 
and  formidable  complication.  In  India  it  occurs  once  in  every  four  or  five 
cases. 

The  duration  of  the  disease  in  uncomplicated  cases  varies  from  six  to 
twelve  weeks.  Eecovery  is  tedious,  owing  to  ana-mia  and  muscular  weak- 
ness, often  delayed  by  relapses,  and  there  is  in  all  cases  a  constant  tend- 
ency to  chronicity.    The  mortality  is  much  higher  than  in  catarrhal  dysen- 


198 


SIVECIFIC   INFECTIOUS   DISEASES. 


tcry.  A  fatal  issue  is  due  citlicr  to  tlic  initial  j^ravity  of  the  intestinal 
lesions,  to  exliaustion  in  [)rolonged  cases,  or  to  involvement  of  the  liver. 

(c)  Diphtheritic  Dysentery. — A  form  of  colitis  or  entero-colitis  in 
which  arras  of  necrosis  occur  in  the  nnieous  membranes,  which  on  sei)a- 
ration  leave  ulcers.  This  occurs:  («)  As  a  prhnanj  disease  comiuf?  on 
acutely  and  sometimes  proving  fatal.  In  its  milder  grades  the  tops  of  the 
folds  of  the  colon  are  capped  with  a  thin,  yellow  cxiidate.  In  severer  forms 
the  colon  is  enormously  enlarged,  the  walls  are  thickened,  stitf,  and  infil- 
trated, and  the  mucosa,  from  the  ileo-c.Tcal  valve  to  the  rectum,  is  repre- 
sented by  a  tough,  yellowish  nuiterial,  in  which  on  section  no  trace  of  the 
glandular  elements  can  be  seen.  The  condition  is  one  of  extensive  necrosis 
of  the  mucosa.  There  are  cases  in  which  this  necrosis  is  superficial,  in- 
volving only  the  upper  layers  of  the  mucous  nieraljrane;  but  in  the  most 
advanced  forms  it  may  he,  as  in  the  descrii)tion  by  Rokitansky,  "  a  black, 
rotten,  friable,  charred  mass."  The  areas  of  necrosis  may  l)e  more  local- 
ized, and  large  sloughs  are  formed  which  may  be  a  half  to  three  fourths 
of  an  inch  in  thickness  and  extend  to  the  serosa.  There  are  instances  in 
which  this  condition  is  confined  to  the  lower  portion  of  the  large  bowel. 
A  sailor  from  the  Mediterranean  was  admitted  to  the  ilontreal  General 
nosi)ital  under  my  care  with  symptoms  resembling  typhoid  fever.  The 
autopsy  showed  enormous  sloughs  in  the  rectum  and  in.  the  sigmoid  flexure, 
but  scarcely  any  disease  in  the  transverse  or  ascending  colon.  In  cases 
which  last  for  many  weeks  the  sloughs  separate  and  may  be  thrown  off, 
sometimes  in  large  tubular  i)ieces. 

{h)  Secondary  Diphtheritic  Dysentcri/. — This  occurs  as  a  termina  event 
in  many  acute  and  chronic  diseases.  It  is  not  infrequent  in  chronic  heart 
affections,  in  Bright's  disease,  and  in  cachectic  states  generally.  In  acute 
diseases  it  is,  as  pointed  out  by  Bristowe,  most  frequently  associated  with 
pneumonia.  Anatomically  there  may  be  only  a  thin,  superficial  infiltra- 
tion of  the  upper  layer  of  the  mucosa  in  localized  regions,  particularly  along 
the  ridges  and  folds  of  the  colon,  often  extending  into  the  ileum.  In  severer 
forms  the  entire  mucosa  may  be  involved  and  necrotic,  sometimes  having 
a  rough,  granular  appearance.  In  the  secondary  colitis  of  pneumonia  the 
exudation  may  be  pseudo-membranous  and  form  a  firm,  thin,  white  pellicle 
which  seems  to  lie  upon,  not  wdthin,  the  mucous  membrane. 

Symptoms. — The  clinical  features  of  diphtheritic  dysentery  are  very 
varied.  In  the  acute  primary  cases  the  patient  from  the  outset  is  often 
extremely  ill,  with  high  fever,  great  prostration,  pain  in  the  abdomen,  and 
frequent  discharges.  Delirium  may  be  early  and  the  clinical  features  may 
closely  resemble  those  of  severe  typhoid.  I  have,  on  more  than  one  occa- 
sion, known  this  mistake  to  be  made.  Tlie  abdomen  is  distended  and  often 
tender.  The  discharges  are  frequent  and  diarrhoeal  in  character,  and  tenes- 
mus may  not  be  a  striking  symptom.  Blood  and  mucus  may  be  found  early, 
but  are  not  such  constant  features  as  in  the  follicular  disease.  This  primary 
form  is  very  fatal,  but  the  sloughs  may  separate  and  the  condition  become 
chronic.  In  the  secondary  form  there  may  have  been  no  symptoms  to 
attract  attention  to  the  large  bowel.  In  a  majority  of  the  cases  the  patient 
has  a  diarrhoea — three,  four,  or  more  movements  in  the  day,  which  are  often 


DYSENTERY. 


199 


cstinal 
iver. 
itis    in 

I  sojm- 
iujr  on 

of  the 
r  forms 
1(1  intil- 
j  re[)re- 
3  of  the 
ni'crosis 
cial,  in- 
hc  most 
a  black, 
re  local- 
■  fourths 
ances  in 
;e  bowel. 

General 
or.     The 

II  flexnre, 
In  cases 

rown  off, 

ina'  event 
nic  heart 

In  acute 
ited  with 
I  infiltra- 
irly  along 

n  severer 
cs  having 
kionia  the 
]te  pellicle 

are  very 
is  often 
Imen,  and 
lures  may 
lone  occa- 
land  often 
lind  tenes- 

md  early. 
Is  primary 
In  become 
Iptoms  to 

lie  patient 
are  often 


jirofiiso  and  weakening.    A  little  l)lood  and  mucus  may  be  jiassed  at  first, 
hut  they  are  not  si)eciully  characteristic  elements  in  the  stools. 

Jn  all  forms  of  dysentery  death  usually  results  from  asthenia.  The 
]»ulse  l)ecomes  weaker  and  more  rapid,  the  tongue  dry,  the  face  pinched, 
the  skin  cool  and  covered  with  sweat,  and  the  patient  falls  into  a  drowsy, 
tori)id  condition.  Consciousness  may  be  retained  until  the  last,  but  in 
the  ]trotractecl  cases  there  is  a  low  delirium  dee])ening  into  collapse. 

(d)  Chronic  Dysentery. — This  usually  succeeds  an  acute  attack,  thougli 
the  anuebic  form  may  he  sui)acute  from  the  outset  and  not  ])resent  an  acute 
period.  Anatomical  changes  in  the  large  intestine  in  chronic  dysentery 
are  variable.  There  may  be  no  ulceration,  and  the  entire  mucosa  presents 
a  rough,  irregular  ])uckered  apjiearance,  in  places  slate-gray  or  blackish  in 
color.  The  suhmucosa  is  thickened  and  the  muscular  coats  are  hyper- 
troi)hied.  There  may  be  cystic  degeneration  of  the  glandular  elements,  as 
is  beautifully  figured  in  Woodward's  volume. 

Ulcers  are  usually  present,  often  extensive  and  deeply  pignuMited,  in 
jdaces  ])erhaps  healing.  .The  submucous  and  muscular  coats  are  thick- 
ened and  the  calibre  of  the  bowel  may  be  reduced.  Stricture,  however,  is 
very  rare. 

The  sympioms  of  chronic  dysentery  are  by  no  means  definite,  and  it  is 
not  always  ])ossiblo  to  separate  the  cases  from  those  of  chronie  diarrhoea. 
Many  of  the  characteristic  symptoms  of  the  acuU'  il,sease  are  absent.  Tenes- 
mus and  severe  griping  pains  rarely  occur  except  in  acute  exacerbations. 
The  character  of  the  stools  varies  very  much.  ]^)lood  and  necrotic  slireddy 
tissue  are  not  often  found,  ^fuous  is  passed  in  variable  amounts.  On  a 
mixed  diet  the  fa}ces  are  thin,  often  frothy,  and  contain  particles  of  food. 
The  motions  vary  from  fcmr  or  five  to  twelve  or  more  in  the  twenty-four 
liQurs.  There  are  cases  in  which  marked  consti])ation  alternates  with  at- 
tacks of  diarrhoea,  and  scybala  may  be  passed  with  much  mucus.  In  many 
cases  the  fa}ces  have  a  scmi-lluid  consistency,  and  a  yellowish  or  brown  color 
depending  on  the  amount  of  bile.  Fragments  of  undigested  food  may  be 
found,  and  the  discharges  have  the  character  of  what  is  termed  a  lienteric 
diarrhcca.  Indeed,  variations  in  the  bile  and  in  the  food  give  at  once  cor- 
responding dilferenecs  in  the  character  of  the  stools.  In  the  amtcbic  form 
recurrences  are  common  in  which  blood  and  mucus  again  appear  in  the 
stools,  accompanied  perliaps  by  pus.  Flatulence  is  in  some  cases  distress- 
ing, and  there  is  always  more  or  less  tenderness  along  the  course  of  the 
colon.  The  appetite  is  ca]u-icious,  the  digestion  disordered,  and  unless  the 
]iatient  is  on  a  strictly  regulated  fliet  the  numljcr  of  stools  is  greatly  in- 
creased. The  tongue  is  not  often  furred;  it  is  more  commonly  red,  glazed, 
and  beefy,  and  becomes  dry  and  cracked  toward  the  end  in  protracted 
cases.  There  is  alwa}'s  ana^nia  and  the  emaciation  may  be  extreme;  with 
the  exception  of  gastric  cancer,  we  rarely  see  such  ghastly  faces  as  in 
patients  with  prolonged  dysentery.  The  com])lications  are  those  already 
referred  to  in  the  acute  form.  The  greater  debility  renders  the  patient 
more  liable  to  the  intercurrent  affections,  such  as  pneumonia  and  tuber- 
culosis. Ulceration  of  the  cornea  was  frequently  noted  during  the  civil 
war. 


200 


SPECIFIC  INFECTIOUS  DISEASES. 


^ 


Complications  and  Sequelae. — A  local  i)oritonitis  may  arise  by 
cxten^jioii,  or  a  dill'iitiL'  iiillaniiimlion  may  I'ollow  perroration,  wliich  is  usually 
fatal.  "When  this  occurs  about  the  ciucal  region,  ])erityplilitis  results;  wbeu 
low  down  in  the  rectum,  ])eriproctitis.  In  108  autopsies  collected  by  Wood- 
Avard  ])erf()ration  occurred  in  11.  J3y  far  tlie  most  serious  complication 
is  abscess  of  the  liver,  which  occurs  freciuently  in  the  tropics  and  is  n(jt 
very  Uncommon  in  this  country.  It  was  not,  however,  a  frequent  com- 
plication in  dys'  rv  during  the  civil  war.  In  this  latitude  it  is  certainly 
not  uuconimon.  isually  comes  on  insidiously.     The  symptoms  will  be 

discussed  in  conin    ,ion  with  hepatic  abscess. 

In  extensive  epidemics,  however.  Woodward  states  that  cases  of  ordinary 
dysentery  occur  associated  with  all  the  phenomena  of  malaria.  AVe  have 
had  a  number  of  instances  of  the  coexistence  of  the  two  diseases.  AVith 
reference  to  typhoid  fever,  as  a  com])lication,  this  author  mentions  that  the 
combination  was  exceedingly  freciuent  during  the  civil  war,  and  charac- 
teristic lesions  of  both  diseases  coexisted.  In  civil  practice  it  is  extremely 
rare. 

Sydenham  noted  that  dysentery  was  sometimes  associated  with  rhou- 
nuitic  pains,  and  in  certain  e})idemics  joint  swellings  have  been  especially 
prevalent.  They  are  probably  not  of  the  nature  of  true  rheumatism,  but 
rather  analogous  to  those  of  gonorrheal  arthritis.  In  severe,  protracted 
cases  there  niay  be  ])leurisy,  pericarditis,  endocarditis,  and  occasionally  pya?- 
mic  manifestations,  among  which  may  be  mentioned  pylephlebitis.  Chronic 
Bright's  disease  is  also  an  occasional  sequel.  In  protracted  cases  there  may 
be  an  anamiic  oedema.  An  interesting  sequel  of  dysentery  is  paral3'sis. 
AVoodward  reports  8  cases.  "Weir  Mitchell  mentions  it  as  not  uncommon, 
occurring  chiefly  in  the  form  of  para])legia.  As  in  other  acute  fevers,  this 
is  due  probably  to  a  neuritis.  Intestinal  stricture  is  a  rare  se(juence — so 
rare  that  no  case  was  reported  at  the  Surgeon-Gonerars  olfice  during  the 
war.  Among  the  sequela^  of  chronic  dysentery,  in  persons  who  have  recov- 
ered a  certain  measure  of  health,  may  bo  mentioned  persistent  dyspepsia 
and  irrital)ility  of  the  bowels. 

Diagnosis. — The  recognition  of  the  acute  follicular  form  is  easy;  the 
frequency  of  the  passages,  the  presence  of  blood  and  mucus,  and  the  tenes- 
mus forming  a  very  characteristic  picture.  Local  affections  of  the  rectum, 
particularly  syphilis  and  epithelioma,  may  ]iroducc  tenesmus  -with  the 
passage  of  mucoid  and  bloody  stools.  The  acute  diphtheritic  form,  coming 
on  with  great  intensity  and  with  severe  constitutional  disturbances,  is  not 
infrequently  mistaken  for  typhoid  fever,  to  Avhicli  indeed  in  many  cases 
the  resemblance  is  extremely  close.  The  higher  grade  of  fever,  the  more 
pronounced  intestinal  symptoms,  the  presence,  ]iarticularly  in  the  early 
stage,  of  a  small  amoimt  of  blood  in  the  stools,  the  a])sence  of  enlargement 
of  the  sjileen,  the  rose  rash,  and  the  Widal  reaction  should  lead  to  a  correct 
diagnosis.  In  the  ama>bic  form  the  diagnosis  can  readily  be  made  by  ex- 
amination of  the  stools.  A  characteristic  feature  of  these  cases  is  their 
irregular,  chronic  course.  A  patient  may  be  about  and  in  fairly  good  con- 
dition, with  well-formed  stools  and  very  slight  intestinal  disturbance,  in 
whose  fa?ces  the  amoeba  may  still  be  discovered,  and  in  whom  the  disease 


DVSENTKRY. 


201 


rise  by 
usually 
s;  when 

ilication 
1  is  not 
nt  com- 
'ortainly 
will  1)0 

ordinary 
^Ve  have 
i.  ^Vilh 
that  the 
L  charac- 
xtronicly 

til  rhcu- 
}spccially 
tisni,  but 
irotracted 

.ally  pytc- 
Chronic 

here  may 

paralysis. 

icommon, 
ers,  this 

icnce — so 
ring  the 
0  r(^cov- 
yspopsia 

easy;  the 
le  tenes- 
rectnm, 
with   the 
coming 
es,  is  not 
ny  cases 
the  more 
the  early 
argement 
a  correct 
le  by  ex- 
s  is  their 
ood  con- 
lance,  in 
e  disease 


is  at  any  time  likely  to  recur  with  intensity.  In  some  cases,  complicated 
by  abscess  of  the  liver  and  lung  discharging  through  a  bronehus,  the  diag- 
nosis may  rest  on  the  detection  of  aniiebic  in  the  s[»uta,  when  they  cannot 
be  found  in  the  stools  owing  to  tlie  latency  of  the  intestinal  disturbance. 
Leucocytosis  is  rare  except  wlicn  coni[>lications  arise.  Instances  have  oc- 
curred in  my  wards. 

Treatment. — Flint  iuis  sliown  tluit  sporadic  dysentery  is,  in  its 
slighter  grades  at  least,  a  sell'-limited  disease,  which  runs  its  course  in  eight 
or  nine  days,  heading  a  report  of  his  cases,  one  is  struck,  however,  with 
their  comparative  nuldness. 

The  enormous  surface  involved,  anu)unting  to  nuiny  scjuare  feet,  the 
constant  presence  of  irritating  i)articles  of  food,  and  tiie  impossibility  of 
getting  a1)solutc  rest,  are  comlitions  which  render  the  treatment  of  dysen- 
tery peculiarly  difTicult.  ]\roreover,  in  the  severer  cases,  when  necrosis  of 
the  nnicosa  has  occurred,  ulceration  necessarily  follows,  and  cannot  in  any 
way  be  obviated.  When  a  case  is  awn  early,  particularly  if  there  has  been 
constijjation,  a  saline  purge  should  be  given.  The  free  watery  evacuations 
])roduced  by  a  dose  of  salts  cleanse  the  large  bowel  with  the  least  jjossiblo 
irritation,  and  if  necessary,  in  the  cov  se  of  the  disease,  particularly  if 
scyhala  are  present,  the  dose  nuiy  be  n  peated.  I'urgatives  are,  as  a  rule, 
(il)jretiomdde,  and  the  ])rofession  has  largely  given  up  their  use.  Of  nu'di- 
cines  given  by  the  mouth  which  arc  supposed  to  have  a  direct  effect  upon 
the  disease,  ipecacuaidua  still  maintains  its  reputation  in  the  tro})ics.  It 
did  not,  however,  prove  satisfactory  during  the  civil  war;  nor  can  I  say 
that  in  cases  of  sporadic  dysentery  I  have  ever  seen  the  nuirked  elfect 
described  by  the  Anglo-Indian  surgeons.  The  usual  method  of  adminis- 
tration is  to  give  a  i)reliminary  dose  of  opium,  in  the  form  of  laudanum  or 
morphia,  and  half  an  hour  after  from  20  to  GO  grains  of  ipecacuanha.  If 
rejected  by  vomiting,  the  dose  is  repeated  in  a  few  hours. 

]\Iinute  doses  of  corrosive  sublimate,  one  hundredth  of  a  grain  excy 
two  hours,  are  warmly  recommended  by  Eingcr.  Large  doses  of  bismuth, 
lialf  a  draclim  to  a  drachm  every  two  hours,  so  that  the  patient  may  take 
fnun  12  to  1.5  drachms  in  a  day,  have  in  many  cases  had  a  l)eneficial  effect. 
To  do  good  it  must  be  given  in  large  doses,  as  recommended  by  ]\[onnerct, 
M'ho  gave  as  high  as  70  grammes  a  day.  It  certainly  is  more  useful  in  the 
chronic  than  the  acute  cases.  It  is  best  given  alone.  Opium  is  an  invalu- 
able remedy  for  the  relief  of  the  pain  and  to  quiet  the  peristalsis.  It  should 
be  given  as  morphia,  hypodermically,  according  to  the  needs  of  the  pa- 
tient. 

The  treatment  of  dysentery  by  topical  ap])lications  is  by  far  the  most 
rational  plan.  A  serious  obstacle,  however,  in  the  acute  cases,  is  the  ex- 
treme irritability  of  the  rectum  and  the  tenesmus  wdiich  follows  any  at- 
tempt to  irrigate  the  colon.  A  ])reliminary  cocaine  suppository  or  the  injec- 
tion of  a  small  quantity  of  the  4-per-cent  solution  will  sometimes  relieve 
ibis,  and  then  with  a  long  tube  the  solution  can  be  allowed  to  flow  in  slowly. 
The  patient  should  be  in  the  dorsal  position  with  a  pillow  under  the  hips, 
i^o  as  to  got  the  effect  of  gravitation.  Water  at  the  temperature  of  100° 
is  very  soothing,  but  the  irritability  of  the  bowel  is  such  that  large  quan- 


202 


SPECIFIC  INFECTIOUS  DISKASES. 


titles  can  rarely  he  rL'taiiiL'd  I'or  any  time.  When  the  acute  syuijttonis  sub- 
side, the  Injeetious  are  hetter  borne.  Various  astrin<rents  may  he  used — 
alum,  acetate  of  lead,  suli)hato  of  zinc  and  co|)|)er,  and  nitrate  of  silver. 
Of  these  remedies  the  nitrate  of  silver  is  the  best,  tboufih,  1  thiid'C,  not  in 
very  acute  eases.  In  the  chronic  form  it  is  ))erha|)S  the  most  satisfactory 
metiiod  of  treatment  which  we  have.  It  is  useless  to  f^ive  it  in  the  small 
injections  of  two  or  three  ounces  with  1  to  2  ^^rains  of  the  salt  to  the  ounce. 
It  must  he  a  larue  irripitin>r  injection,  which  will  reach  all  ])arts  of  the 
colon.  This  plan  was  introduced  by  Ilaro,  of  Kdinbur^di,  and  is  highly 
recommended  hy  Stephen  .MacKcJizie  and  11.  C  Wood.  The  solution  must 
be  fairly  strong,  20  to  30  grains  to  the  pint,  and  if  possible  from  3  to  0 
j)ints  of  fluid  must  be  injected.  To  begin  with  it  is  well  to  use  not  more 
than  a  drachm  to  the  2  ])ints  or  2h  ])ints,  and  to  let  the  warm  fluid  run 
in  slowly  through  a  tube  ])assed  far  into  the  bowel.  It  is  at  times  intensely 
])ainful  and  is  rejected  at  once.  Argyria,  so  far  as  1  know,  has  never  fol- 
lowed the  prolonged  use  of  nitrate  of  silver  injections  in  chronic  dysentery. 
In  the  cases  of  amcebic  dysentery  we  have  been  using  at  the  Johns  ilo]»kins 
llosjiital  with  great  benefit  warm  injections  of  ((uinine  in  strength  of  1  to 
5,000,  1  to  2,r)00,  and  1  to  1,000.  The  amceba^  are  rapidly  destroyed  by 
the  drug.  These  large  injections  arc  said  not  to  be  without  a  certain  degree 
of  danger.  I  have  never  seen  any  ill  effects,  even  with  the  very  large 
amounts.  A\'hen  there  is  not  much  tenesmus,  a  small  injection  of  thin 
starch  with  half  a  drachm  to  a  drachm  of  laudanum  gives  great  relief,  but 
for  the  tormina  and  tenesmus,  the  two  most  distressing  symi>toms,  a  hqio- 
dermic  of  morphia  is  the  only  satisfactory  remedy.  Local  applications  to 
the  abdomen,  in  the  form  of  light  poultices  or  turpentine  stupes,  are  A'ery 
grateful. 

The  diet  in  acute  cases  must  be  restricted  to  milk,  whey,  and  broths, 
and  during  convalescence  the  greatest  care  must  be  taken  to  provide  only 
the  most  digestible  articles  of  food.  In  chronic  dysentery,  diet  is  perhaps 
the  most  im])ortant  element  in  the  treatment.  The  number  of  stools  can 
freciuontly  be  reduced  from  ten  or  twelve  in  the  day  to  two  or  three,  bv 
placing  the  patient  in  bed  and  restricting  the  diet.  Many  cases  do  well 
on  milk  alone,  but  the  stools  should  be  carefully  watched  and  the  amount 
limited  to  that  which  can  be  digested.  If  curds  ap])ear,  or  if  much  oily 
matter  is  seen  on  microscopical  examination,  it  is  best  to  reduce  the 
amount  of  milk  and  to  supplement  it  with  beef-juice  or,  better  still,  egg- 
albumen.  The  large  doses  of  bismuth  seem  specially  suitable  in  the  chronic 
cases,  and  tlic  injections  of  nitrate  of  silver,  in  the  way  already  mentioned, 
should  ab.vays  be  given  a  trial. 


XXIV.    MALARIAL    FEVER. 


Deflnition. — An  infectious  disease  characterized  by:  (n)  paroxysms  of 
intermittent  fever  of  quotidian,  tertian,  or  cpiartan  type;  (b)  a  continued 
fever  with  marked  remissions;  (c)  certain  pernicious,  rapidly  fatal  forms; 
and  (d)  a  chronic  cachexia,  with  amemia  and  an  enlarged  spleen. 


MALARIAL   FKVEK. 


2u:j 


i  usetl — 
^i  silver. 
k,  not  in 
:isfact()ry 
the  small 
lie  oiinco. 
•is  of  the 
is  highly 
tion  must 
mi  3  to  ti 

not  n\ore 

11  aid  run 
}  intensely 

never  fol- 
(ly>*entery. 
IS  liopkins 
rth  of  1  to 
■stroyed  by  | 
tain  degree 

very  largo 
on  of  thin 
I  relief,  but 

ms,  a  hjTpo- 
ilications  to 
es,  are  very 

and  broths, 
rovide  ouly 
is  y)erhai)S 
[  stools  can 
ir  three,  by 
scs  do  well 
:he  amount 
niuch  oily 
reduce   the 
;r  still,  egg- 
the  chronic 
mentioned, 


laroxysms  of 
continued 

fatal  form^; 


"With  the  disease  arc  invariably  associated  \\w.  luvniatozoa  described  l»y 
La  vera n.* 

Etiology.— (1)  Geographical  Distribution.— in  iluroiK',  southern  Ilus- 

siu  and  certain  parts  oi'  Italy  arc  now  the  cliii'l'  seats  of  llie  ilisease.  It 
is  not  widely  prevalent  in  Germany,  France,  or  Kngland,  and  the  foci  of 
(■|)idemics  arc  hccoining  yearly  more  restricted. 

In  the  I'nited  States  malaria  has  progressively  diniinisiuMl  in  extent 
and  severity  during  the  i)ast  lifty  years.  'J'he  records  of  tlie  health  hoai'ds 
<pf  the  larger  cities  on  the  Atlantic  coast  which  give  a  high  mortality  from 
the  disease  are  (piite  untrustworthy.  J-'i'oni  New  Kngland,  where  it  once 
prevailed  extensively,  it  has  gra<lually  disappeared,  Imt  there  has  of  late 
years  been  a  slight  return  in  some  })laces.  in  the  city  of  New  ^'ork  the 
milder  forms  of  the  disease  are  not  uiu-omnion.  In  riiiladelpiiia  and  along 
thi;  valleys  of  the  Delaware  and  Sciiuylkill  ivivers,  formerly  iiot-beds  of 
malaria,  the  disease  has  become  much  restricted.  In  ilaltimorc  a  few  ea.>^es 
develop  in  tiu'  autumn,  but  a  majority  of  tiu'  ])atients  seeking  relief  are 
fnnu  the  outlying  <Iistricts  and  one  or  two  of  the  inlets  of  Chesapeake  IJay. 
Througliout  the  Southern  States  there  are  many  regions  in  which  malaria 
prevails;  but  here,  too,  tiie  disi-ase  has  diminished  in  ])revalence  and  in- 
tensity. In  the  Xorthwestern  Statt's  malaria  is  almost  unknown.  It  is  rare 
ou  the  I'acilic  coast.  In  the  region  of  the  (Ireat  Lakes  malaria  prevails 
only  in  the  Lake  Eric  and  Lake  St.  Clair  regions.  The  St.  Lawrence 
districts  remain  free  from  the  disease. 

In  India  malaria  is  very  ])revalent,  ])articularly  in  the  great  river  basins. 
In  iUirma  and  Assam  severe  types  are  met  with,  and  recently  the  anomalous 
form  of  fever  known  as  the  Kdla-azar  of  Assam  has  been  slujwn  to  be  ma- 
larial (Ivogers). 

In  Africa  the  malarial  fevers  form  the  great  obstacle  to  Euro])eifn  set- 
tlements on  the  coast  and  along  the  river  .basins.  The  hltid--irah'r  or  West 
African  fever  of  the  Cold  Coast  is  a  very  fatal  type  of  malarial  lurmo- 
glol)inuria. 

(2)  Telluric  Conditions. — The  importance  of  the  state  of  the  soil  in  the 
etiology  of  malaria  is  universally  recognized.  It  is  seen  particularly  in 
low,  marshy  regions  which  have  an  abuiKuUit  vegetable  growth.  Estu- 
aries, badly  drained,  low-lying  districts,  the  course  of  old  river-bed.^  tracts 
of  land  which  are  rich  in  vegetable  matter,  and  ])articularly  districts  such 
as  the  Roman  Cami)agna,  which  have  been  .illowed  to  fall  out  of  cultiva- 
tion, are  favorite  localities  for  the  developir.ent  of  the  malarial  ])(Uson. 
These  conditions  are  most  freiiuently  found,  of  course,  in  tropical  and 
siihtro])ical  regions,  but  nothing  can  be  truer  than  the  fact  iaat  reeking 
iiiiU'shcs  of  the  most  pestilent  a])pearance  may  be  entirely  devoid  of  the 
jioison,  and  the  disappearance  of  the  disease  fi'oni  a  locality  is  not  neces- 

*  For  a  full  onnsidorntion  of  tlie  malnria  prohlein  as  it  has  prosontod  itself  to  us  in 
Baltimore  dnrinc:  the  past  nine  years,  the  reader  is  referred  to  the  monograph  of  Thayer 
and  Ilewetson,  and  the  article  of  Barker  in  vol.  v  of  the  Johns  Hopkins  Hospital  Re- 
ports, to  the  exhaustive  article  by  Welch  and  Thayer  in  Loomis  and  Thompson's  System 
of  Medicine,  and  to  Thayer's  Lectures  on  the  Malarial  Fevers,  New  York,  1807. 
13 


•i 


204 


SPECIFIC   IXFKCTIOUS  DISKASES. 


pnrily  nssorintod  with  nny  nintcrinl  iiiiprovonicnt  In  the  condition  of  the 
luaisiics  or  of  thi'  soil.  Thus,  in  Svw  J'Jighiiid  and  iii  parts  of  wcsttTU 
C'anathi,  in  whicii  malaria  formerly  was  very  prevalent,  the  increased  salu- 
hrity  is  usually  attrihuted  to  tho  dearin/f  of  the  forests  and  the  bettor 
draina^rc  of  the  ground;  hut  these  improvements  aloue  can  scarcely  ex- 
j)lain  the  disappeanuice,  since  in  many  districts  there  are  marshy  tracts 
and  low-lyiii",'  lands  in  every  respect  like  those  in  which,  even  in  the  same 
hititude,  the  disease  still  prevails.  In  short,  it  is  impossihle  to  ascertain 
from  tlie  nature  of  the  soil  and  climate  in  any  {fiven  place  whether  it  is 
malarial  or  not.  In  the  ahsence  of  accurate  knowledge  as  to  the  habitat 
of  the  luvmatozoa,  the  only  means  of  deciding  this  point  is  by  noticing  the 
elTeet  of  residence  in  such  n  jdace  on  the  luunan  subject,  preferably  one  of 
the  Caucasian  race. 

(3)  Season. — In  the  tro])ics  there  are  minimal  nnd  maximal  period'*, 
the  former  corresponding  to  the  summer  and  winter,  the  latter  to  the 
spring  and  av^unin  months.  Tn  temperate  regions,  like  the  central  Atlan- 
tic States,  th.TO  are  only  a  few  cases  in  the  spring,  usnally  in  the  month  of 
^fay,  and  a  large  nnmber  of  cases  in  Scpteml)er  and  October,  and  some- 
times in  Xovend)er. 

(4)  Meteorological  Conditions. — (a)  Ileal. — A  tcderably  high  tempera- 
ture is  one  of  the  essential  conditions  for  the  development  of  the  virus. 
It  is  more  ])revalent  after  prolonged  hot  summers. 

{h)  ifoisturc. — In  the  tropics  the  malarial  fevers  are  most  prevalent  in 
the  rainy  seasons.  In  the  tem|)erate  climates  the  relation  between  the 
rainfall  and  nudaria  is  not  so  clear,  and  cases  are  more  numerous  after  a 
dry  summer;  but  if  either  heat  or  moisture  is  excessive,  the  develoi)ment 
of  the  virus  is  checked  for  a  time. 

(f)  Winds. — ]\rany  facts  are  on  record  which  seem  to  indicate  that  the 
poison  may  be  carried  to  some  distance  by  winds.  The  jjlanting  of  trees 
has  been  held  to  interfere  with  the  transmission  by  prevailing  winds. 
Possibly,  however,  the  quickly  growing  trees,  such  as  the  Eucalyptus  ghhti- 
lus,  have  acted  more  beneficially  by  drying  the  soil. 

<5)  Specific  Gravity.— That  the  distribution  of  the  poison  of  malariii 
is  influenced  by  gravity  has  long  been  conceded.  Persons  dwelling  in  th.- 
upper  stories,  or  in  buildings  elevated  some  distance  above  the  ground, 
are  exempt  in  a  marked  degree. 

The  Specific  Germ. — As  Ilirsch  correctly  remarks,  the  late  J.  K.  ]\Iitch- 
ell  "  was  the  first  to  a])proach  in  a  scientific  spirit  the  nature  of  infec- 
tive disease  and  particidjirly  in  malarial  fever."  ]\Iany  attempts  were 
made  to  discover  a  constant  and  characteristic  organism.  In  1880  Laveran. 
a  French  army  surgeon,  announced  the  discovery  of  a  parasite  in  the  blood 
of  patients  attackcd-»by  malarial  fever.  During  the  next  three  years  li<' 
])ublished  nine  additional  conmiunications,  but  for  a  time  these  observa- 
tions attracted  little  attention.  The  Italian  observers  Marchiafava,  Celli. 
and  Golgi  corroborated  Laveran's  statements.  In  this  country  Laveran'- 
work  was  confirmed  by  Councilman,  by  myself,  "Walter  James,  Dock,  and 
many  others.  In  India,  Vandyke  Carter's  good  work  on  the  subject  Itti- 
been  followed  up  by  a  number  of  observers.    So  far  as  I  know,  not  a  single 


MAT.AUIAL   FKVER. 


2(t5 


western 
„hI  salu- 
i  bettor 
L;ely   ex- 
y  tnietA 
he  HUine 
\si'ertiiiti 
l\i'r  it  is 
;  hiiliitat 
icinj,'  tlu) 
ly  one  ot* 

[  period'^, 
L^r  to  the 
ral  Atlan- 
month  of 
md  Bome- 

tempera- 
the  virus. 

rovnlent  in 

.'tween   the 

Dus  after  a 

veloi)ment 

tc  that  the 

11  or  of  trees 

in<^  winds. 

ptus  fjhJbn- 

lof  mahwiii 
lling  in  th^' 
}ie  ground, 

K.  Mitch- 
le  of  infcc- 
jnipts  wcro 
50  Lavcran. 
the  blood 
36  -"'ears  bi' 
|se  observa- 
Ifava,  Celli. 
Laveran'- 
Dock,  and 
|pubject  Iw- 
lot  a  single 


(ihflorver,  who  has  had  the  iicccssary  tniiiiiii;,'  and  the  nuiterial  ai  his  com- 
mand, has  I'aiU'd  to  dcmoiiHtrate  the  existein-e  of  these  parasites. 

'J'lie  l)odii's  which  have  been  foimd  invariably  associated  with  all  forms 
of  malarial  fevers  belonj^  to  the  proto/oa  and  to  a  j,M'oup  of  orpmisms 
known  as  the  iKnnori/fDzod,  usnally  placed  amon^  the  sporozoa.  Parasites 
of  the  red  blood-corpnscIes  have  lieen  met  with  alninilanlly  in  the  blodd 
(if  lisii,  turtles,  and  many  species  of  birds  (see  papers  by  \V.  (i.  Mai'alhim 
iind  Opie  in  Jonrmd  of  Ivxperimental  Medicine,  vol.  ii). 

'riie  jmrasites  are  true  ha'mocytozoa,  existing,'  and  pursninj,'  their  cycle 
(d'  existence  within  the  red  blood-corpuscles  of  the  infected  individual, 
'i'lie  yonn^^est  forms,  small,  hyaline,  amieiioid  bodies,  enter  the  reil  blood- 
(()rpns(dcs  and  develoj),  aecnmnlating,  as  they  increase  in  size,  line  gran- 
ules of  dark  pigment,  which  is  formed  at  tlie  ex]»ense  of  the  Inemoglobin 
of  the  in(du(ling  corpuscle.  When  the  organisms  have  reacdied  their  full 
(lev(dopment  and  destroyed  their  hosts,  tlu!  pigment  granules  gather  into 
a  central  clump  or  block,  and  the  parasites  break  up  into  a  nund)er  of  snudl 
round  or  ovoid  hyaline  bodies,  each  one  of  which  represents  a  fresh  young 
organism  ready  to  attack  a  new  corpuscle  and  begin  again  a  cycle  of 
existence. 

Several  varieties  of  the  ])arasite  have  been  se]mrated,  eacdi  of  which  is 
iissociated  with  a  characteristic  type  of  fever.  These  varieties  are:  (1) 
The  parasite  of  tertian  fever;  (2)  the  parasite  of  (piartan  fever;  {'.^)  the 
l)arasite  associated  with  the  more  irregular  fevers  occurring  in  temperate 
climates,  in  the  later  summer  and  autumn — the  "  a'stivo-autummd  fever" 
(if  the  Italians.  Golgi  first  jminted  out  the  remarkable  fact  that  the  para- 
sites of  the  regularly  intermittent  fevers — the  tertian  and  cpiartan  ])arasite.s 
— exist  in  the  blood  in  great  groups,  all  the  members  of  which  are  approxi- 
mately at  the  same  stage  of  develo])ment.  Thus  an  entire  group  of  myriads 
of  ])arasites  undergoes  sporulation  within  a  period  of  several  hours.  The 
sporvJdtion  of  such  a  group  of  pnrnsifes  is  always  followed  hj/  the  malarial 
pnroxysm,  which  very  possibly  de])ends  upon  some  toxic  snbstance  which  is 
developed  at  the  time  of  sporulation.  The  tertian  ])arasite  re(|uircs  about 
forty-eight  hours  to  accomjdish  its  cycle  of  develojunent  and  undergo 
8i)orulation.  Thus  with  infections  with  a  single  group  of  tertian  parasites, 
sporulation  occurs  every  other  day,  resulting,  as  might  be  expected,  in 
tertian  paroxysms.  IMore  often,  however,  infections  with  two  groups  of  ter- 
tian parasites  are  seen — gronps  reaching  maturity  on  alternate  days,  and 
causing  (piotidian  paroxysms.  Very  rarely  infections  with  multiple  groups 
of  the  parasite  are  met  with. 

The  cycle  of  existence  of  the  quartan  parasite  lasts  about  seventy-two 
honrs,  and  if  but  one  group  of  organisms  be  present,  typical  (piartan  fever 
results.  The  presence  of  two  gronps — double  quartan  infection — is  asso- 
ciated with  paroxysms  on  two  successive  days,  followed  by  a  day  of  inter- 
mission; the  presenc  of  three  groups  gives  rise  to  quotidian  paroxysms. 
Very  rarely  more  than  three  gronps  may  bo  present. 

The  parasite  of  the  autumnal  type  possesses  a  cycle  of  development  the 
exact  duration  of  which  is  still  a  siibject  of  dispute;  it  is  probably  vari- 
able, lasting  from  twenty-four  hours  or  less  to  forty-eight  hours  or  oven 


2oC 


SIMX'IFIC  INFECTIOUS  DISKASKS. 


iiioro,  tlic  vnrintions  (IcpctKlin;,'  ii|>oti  condifinim  hmI  wIkiIIv  known.  AVIiilo 
at  till'  I )('^M lining;  <i|'  the  inlVction  the  iirniii;.M'tiit'iit  ol'  tlic  imrnsito  in  ;;i'oii|m 
may  1ii>  iiiadc  out,  tliin  rc^'til.ir  iirniii^^i'tiiiiit  ortcn  (li>ii|),M-)irs,  tiiiil  orgnii- 
iHiiiH  nt  tliircrciit  ntiip-H  of  (li>vclo|itnciit  iiiiiy  Im>  I'ouixI  at  tlic  sanif  time. 

Sc;:iii('iilalion  imiy  thus  occur  tit  irrc^Milnr  intervals,  sometimes  almoHt 
('«Miliinioii>ly.  Tlic  result  in;:  lever  may  l»c  rc;:ularly  intermitteMt,  Imt  is 
ol'teti   irrc^iihir  ami  sometimes  eoiitiiiiioiis. 

Thr  /iiinisilr  nf  (vrliiut  fcrrr  ltc;.'iiiH  itw  cycle  of  (levclopmcnt  as  a  small, 
hyaline,  aiiKclioid  Ixuly.  'I'liis  rapidly  aceuuiulates  line  lirown  |>i^Muent 
j,'raniiles  wliicli  iirc  llirouii  into  active  motion;  the  iiK-lmlin^'  coi'|iiisclu 
lieconics  c.\piindc(l  and  decolorized  as  the  parasite  j,'ro\vs.  The  l'iill-;:ro\vii 
tertian  or^iiiiisni  is  ahout  the  size  of  a  normal  red  corpuscle.  In  sporulu- 
tion  the  se^rments  niimlicr  from  lil'tccii  to  twenty,  (tr  cvi'ii  more. 

'I'lie  jKirnsilc  of  ijiKirhiii  frrrr  is  very  similar  in  its  appearance  to  the 
tertian  or^fanism.  The  aiiuehoid  movements  .ire,  however,  slower,  and 
the  pi^Miicnt  ^'raiiiiles  are  cotirscr,  darker,  and  in  less  active  motion.  Tlu; 
I'lilly  developed  ]»arasile  is  smaller,  while  the  corpuscle  in  which  the  or- 
^'aiiisin  develops,  instead  of  heconiin^'  expanded  and  (h-eolorized,  as  in  the 
tertiiin  infections,  ratlici-  shrinks  nhoiit  the  parasiie  nnd  assumes  a  deeper, 
greenish,  somewhat  hrassy  color,  in  sporiilalion  the  se^Miients  are  fewer, 
from  live  to  ten  in  niimher.  'riiey  are  arran^'cd  with  ^M'l'at  rej,Milarity 
nhont  the  central  pi^Miicnt  clump  oi-  Mock,  forinin;,'  heautiful  ''rosettes." 

yiic  /Kinisilr  (if  the  (rslini-niil miiiKtl  frrrr  is  con^idcl•ahly  smaller  than 
the  other  varieties;  at  full  de\i'lo|iment  it  is  often  h'ss  than  one  half 
tlie  size  of  a  re<l  l)|ood-eorpuscle.  'I^ie  i)i^Mnent  is  much  scantier,  often 
consisting,'  of  a  few  minute  ^■ranules.  At  first  only  the  earlier  sta^^'cs  of  di- 
velopnii'iit,  small,  hyaline  hodies,  sometiini's  with  one  or  two  pigment  gran- 
ules, ai'e  to  he  found  in  the  peripheral  circulation;  ihe  later  stages  are  ordi- 
narily only  to  he  seen  in  the  hlood  of  certain  internal  organs,  the  spleen 
and  hone  marrow  jiavtieularly.  The  cor])Uscles  containing  the  parasites 
become  not  infre(,nently  .slirunken,  crcnated,  and  hrassy-eolored.  After 
the  process  has  existed  for  ahont  a  week,  larger,  refractive,  crescentic, 
ovoid,  and  round  hodies,  witli  central  clumps  of  ooars(>  pigment  granides, 
begin  to  a])i)ear.  These  bodies  are  eliaracteristic  of  lestivo-autumnal  I'ever. 
Their  significance  is  a  matter  of  dispute. 

From  the  full-grown  tertian  and  (piartan  ])arasites,  and  from  the  round 
bodies  witli  central  ])igment  elum]ts  in  a'stivo-autumnal  infections,  long, 
actively  moving  llagclla  may  develoj);  these  may  at  times  break  loose  and 
move  about  free  among  the  corpuscles.  The  ob.scrvations  of  W.  (!.  ^fae- 
allum  suggest  that  flagellation  is  a  sexnal  process,  the  flagella  representing 
the  male  elements.  ]\buison  tbinks  tliat  the  llagclla  represent  the  forms 
in  which  the  jjarasites  exist  outside  the  body.  ]»o.ss,  in  India,  observed 
the  flagellation  in  blood  taken  from  the  stomach  of  mosquitoes  which  bad 
l)een  alloMcd  to  feed  upon  malarial  subjects,  ^fanson  suggests  that  the 
mosipiito  is  the  intermediate  host  in  the  life  history  of  the  iiarasitc. 

The  general  sym])toms  and  morbid  anatomy  of  malaria  are  in  luir- 
mouy  Avith  the  changes  which  these  parasites  induce.  The  remarkable 
periodicity  of  the  manifestations  of  paludism  are  well  explained  Avhcn  we 


die 
;iiv 
tllll 


MALAUIAL   I'KVKU. 


2(>7 


Wliilo 

I  (truiiii- 
:iiiu'. 
s  iilin<)st 

[,  Imt   is 

11  Kiniill, 

Jli^llU'Ml 

•oriniHcl'J 

ill-jrrowii 

hporMlii- 

:•(•  to  Iho 
wtT,  aiitl 
on.  Tlu! 
\\  llic  or- 
as  in  the 

ire  IVwiT, 
rc^Milarity 

[•(tSt'ttl'S. 

alliT  tliiin 
oiu'  luill' 
icr,  (tl'tni 
•fcs  of  il*j- 
ifiit  jirnn- 
s  arc  ordi- 
hc  splci'n 

l>arasitrs 
.(1.  Aflor 
Icrcscentic, 

(^raiuik's, 
liiiiil  fever. 

iho  round 
Ions,  lon«r, 
loose  and 
.  (1.  Mae- 
|)resentin>i 
I  the   forms 
ol)serYed 
,hich  had 
h  that  the 
isite. 
ro  in 
rcmar 
when  ^ve 


har- 
kahlc 


consifler  the  roIntionH  wliich  these  nuniifestation.s  hear  to  the  life  history 
of  the  parasite.  The  dt>triietion  of  the  red  l)l(»od-eorptis(  les  hy  the  orgun- 
i.-iii  ean  he  traced  in  all  staj^es.  The  pn'snici'  of  i>iiiiiinil  iti  the  hlood  and 
siscera  so  eharaeterisiie  cd'  malaria  results  from  tiie  Iransformalion  of  the 
liiemo^dohin  hy  the  parasites.  The  aiuemia  is  a  direct  conse(|uenco  of  the 
\vides|)read  destruction  of  the  corpuscles  themselves.  The  severe  cerehrul 
symptoms  in  pernicious  cases,  as  well  as  the  occasional  cases  of  clnderi- 
t'orm  nuilaria,  have  heen  shown  to  he  associated  with  the  special  localizu- 
tion  of  the  parasites  in  capillaries  of  the  hrain,  ur  in  the  niiu.'ous  memhranu 
of  the  ^astro-intestinal  tract. 

Till'  Mosqiiiti)  (iiiil  Miiliiri'ii. — Since  tlie  (irst  printing;  of  (his  edition  tlm 
i.liservations  of  Woss,  of  the  Indian  Mt'dical  Service,  have  shown  thai  thu 
malarial  or<^'anisin  under;rocs  development  in  the  hody  of  the  mosipiito. 
Ill  liirds  he  has  proved  that  the  mosipdto  is  the  intermediate  host  of  tlu; 
|iroteosoma,  a  parasite  very  similar  to  the  malarial  orpinism  in  man.  (Irassi 
liclicvcs  that  there  ai'o  three  varieties  of  the  mosipiilo  associatccl  with  the 
iiialariid  fevers — the  Aiiuphi'lfs  rliirif/cr,  the  Culvx  i>ciiirilUiris,  and  the  Ciilrx 
niiiliiriir.  Ui;,Miami  has  produced  malaria  experimentally  hy  ohtaininj,'  adult 
iiios(|uit()eH  from  a  malarious  district  and  allowing'  them  to  hitc;  an  indi- 
\i(lual  who  had  lived  for  six  years  in  a  hospital  in  which  no  case  of  malaria 
had  ever  heen  known  to  develop. 

.Meantime,  awaiting'  further  kiu»wledf,'e,  advantaj^'c  nuiy  he  taken  of  the 
constant  ])resence  of  tin;  parasite  in  malaria.  This  alone,  without  refer- 
ence to  the  true  nature  of  the  orf^^anism,  is  a  fact  of  the  hi<:hest  impor- 
tance. To  he  aide,  everywhere  and  under  all  circumstances,  to  dill'erenti- 
ate  l»etween  malaria  and  other  forms  of  fever  is  one  of  the  most  important 
advances  which  has  heen  made  of  late  years  in  oractical  me(licine. 

Morbid  Anatomy. — The  changes  result  ironi  the  (lisintej.Mation  of 
tlic  red  blood-corpuscles,  acciimnlal ion  of  the  pi,i,nnent  tlierehy  l'orm<'d,  and 
possihly  the  iidluence  of  toxic  materials  produced  hy  the  parasite.  Cases 
iif  simple  malarial  infection,  the  a^ue,  are  rarely  fatal,  and  our  knowledji^c; 
(if  the  morhid  anatomy  of  the  disease  is  drawn  from  tlie  pernicious  malaria 
or  the  chronic  cachexia.  Unpture  of  the  enlar<,''ed  spleen  may  occur  s[ion- 
tiineously,  hut  more  commonly  from  trauma.  A  case  of  the  kind  was  ad- 
mit ted  under  my  colleague,  Jlalsted,  in  June,  ISSU,  and  Dock  has  re- 
cently re])orted  two  cases. 

( 1 )  Pernicious  Malaria. — The  Idood  is  hydnvmic  and  the  serum  may 
even  i)e  tinged  with  Inemoiilohin.  The  red  hlood-corpuscles  pr(>sent  the 
I'lidoglohular  forms  of  the  parasite  and  are  in  all  stages  of  destruction. 
The  spleen  is  enlarged,  often  only  moderately;  thus,  of  two  fatal  cases 
ill  my  wards  the  s])leens  measured  13  X  8  cni.  and  1-i  X  8  cm.  res])ect- 
ivcly.  In  a  fresh  infection,  the  spleen  is  usually  very  soft,  and  the  pulp 
liike-colored  and  turhid.  In  cases  of  intense  reinfection  the  spleen  may 
he  enlarged  and  firm.  The  amount  of  pigment  in  the  spleen  elements 
is  greatly  increased.  The  ]>ulp  contains  large  numhers  of  red  corpu.'jcles 
f'lulosing  parasites.  Enormous  numhers  of  ])hagocytes,  large  and  small, 
iiic  to  ho  seen,  some  of  the  larger  heing  necrotic.  The  lirrr  is  swollen  and 
turbid.     In  very  acute  casco  there  is  not  necessarily  any  macroscopic  pig- 


208 


SPECIFIC  INFECTIOUS  DISEASES. 


mentation,  tlmu^li  microscopically  the  ca))illaries  niny  he  packed  with 
phagocytes,  which  may  ahnost  occhide  tlie  vessels.  Parasites  may  l)e  i)res- 
ont  in  considerable  numbers,  usnaliy  witliin  the  red  eori»nscles.  Areas  of 
disseminated  necrosis  closely  similar  to  those  observed  in  tyi)hoid  fever, 
(lilththeria,  and  other  acnte  infectious  diseases,  have  been  described  by 
Guarnieri,  Jiigiiami,  and  Barker.  In  association  witli  these  areas,  Barker 
describes  capillary  thrombosis.  I'erivascular  (portal)  infiltration  has  been 
found  in  a  very  acute  case  in  a  young  man  (Dock).  The  kidneys  show  only 
moderate  pigmentation,  with  more  or  less  parenchymatous  degeneration. 
In  severe  cases  with  haunoglobinuria  there  may  be  extensive  necrosis  of 
the  epithelium  of  the  convoluted  tubes  with  lurmorrhages  into  the  glom- 
eruli and  interstitial  tissue.  The  hrain  usually  shows  interesting  changes. 
In  severe  cases  i .  some  duration  the  tissue  is  stained,  sometimes  chocolate- 
colored.  In  mild  cases  the  discoloration  is  present,  but  less  marked.  The 
blood-vessels,  especially  the  arterioles  and  capillaries,  contain  large  num- 
bers of  parasites,  with  partial  or  total  destruction  of  red  blood-corpuscles, 
and  phagocytes.  Occlusions  of  arterioles  by  parasites  are  often  seen,  to- 
gether with  perivascular  infection  and  punctate  hremorrhages.  In  some 
instances  changes  of  this  sort  occurring  in  special  areas  have  given  rise  to 
focal  symptoms. 

In  some  acute  pernicious  cases  with  choleraic  symptoms,  the  capillaries 
of  the  gastro-intestinal  mucosa  may  be  packed  with  parasites. 

(3)  Malarial  Cachexia. — In  fatal  cases  of  chronic  paludism  death  occurs 
usually  from  antemia  or  the  haemorrhage  associated  with  it. 

The  anaemia  is  profoimd,  particularly  if  the  patient  has  died  of  fever. 
The  spleen  is  greatly  enlarged,  and  may  weigh  from  seven  to  ten  pounds. 
If  the  disease  has  persisted  for  any  length  of  time,  it  is  firm  and  resists 
cutting.  The  capsule  is  thickened,  the  parenchyma  brownish  or  yellowish- 
brown,  with  areas  of  pigmentadon,  or  in  very  protracted  cases  it  is  ex- 
tremely melanosed,  particularly  in  the  trabeculae  and  about  the  vessels. 

The  liver  may  be  greatly  enlarged;  but,  as  a  rule,  the  increase  in  size 
is  moderate  in  ])roportion  to  that  of  the  spleen.  It  may  present  to  the 
naked  eye  a  grayish-brown  or  slate  color,  due  to  the  large  amount  of  pig- 
ment. In  the  ])ortal  canals  and  beneath  the  ca])sule  the  connective  tissue 
is  impregnated  with  melanin.  Varying  with  the  duration  of  the  disease, 
the  shade  of  color  of  the  liver  ranges  from  a  light  gray  to  a  uo^p  slate- 
gray  tint.  The  texture  k  firm,  but  there  is  not  necessarily  any  great  in- 
crease in  the  connective  tissue.  Histologically,  the  pigment  is  seen  in  the 
Ivupffer's  cells  and  the  perivascular  tissue. 

The  kidneys  may  be  enlarged  and  present  a  grayish-red  color,  or  areas 
of  pigmentation  may  be  seen.  The  pigment  may  be  diffusely  scattered 
and  particularly  marked  about  the  blood-vessels  and  the  Malpighian  bodies. 
The  peritonaeum  is  usually  of  a  deep  slate-color.  The  mucous  membrane 
of  the  stomach  and  intestines  may  have  the  same  hue,  due  to  the  pigment 
in  and  about  the  blood-vessels.  In  some  cases  this  is  confined  to  the  lymph 
nodules  of  Peyer's  patches,  causing  the  shaven-beard  appearance. 

(3)  The  Accidental  and  Late  Lesions  of  Malarial  Fever. 

(a)  The  Liver. — Paludal  hepatitis  plays  a  very  important  role  in  the 


MALARIAL  FEVER. 


209 


0(1   with 

1)L'  ])ri'S- 

Art'iis  of 

id  lever, 

ribecl  by 

i,  Barker 

has  been 

how  only 

sneration. 

xerosis  of 

;he  glom- 
changes. 

L'hocolate- 

vcd.    Tlie 

Tge  nura- 

;orpuseles, 
seen,  to- 
In  some 

ren  rise  to 

capillaries 

?ath  occurs 

\A  of  fever. 
2n  pounds, 
and  resists 
yellowish- 
it  is  ex- 
vessels, 
ase  in  si'-ce 
ent  to  the 
mt  of  pig- 
ive  tissue 
le  disease, 
uo^p  slate- 
y  great  in- 
een  in  the 


V 


r,  or  areas 
scattered 
ian  bodies. 

membrane 
le  pigment 

the  lymph 


irole  in  the 


history  of  malaria,  as  described  l)y  French  writers.  Kelsch  and  Kieiier 
devote  over  si.xty  jmges  to  a  description  of  the  various  forms,  parenchym- 
iitoiis  and  interstitial,  describing  iindi'r  the  latter  three  dill'erent  varieties. 
The  existence  of  a  cirrhosis  dependent  npon  tiie  irritation  of  large  (jiian- 
tities  of  pigment  in  the  liver  is  unqnestioned,  but  only  those  cases  in  which 
the  history  of  chronic  malaria  is  delinite,  and  in  which  the  melanosis  of 
l)()th  liver  and  sjjleen  coexist,  should  be  regarded  as  of  i)aludal  origin. 

{!))  Pneumonia  is  believed  by  many  authors  to  be  common  in  malaria, 
jind  even  to  depend  directly  ujuju  the  malarial  [)oison,  occurring  either  in 
the  acute  or  in  the  chronic  forms  of  the  disease.  I  have  no  [)ersonal 
knowledge  of  such  a  special  i)neumonia.  It  certainly  does  not  occur  in  the 
intermittent  or  remittent  fevers  which  prevail  in  Philadelphia  and  Balti- 
more. The  two  diseases  may  be  concurrent.  Inflammation  of  the  lungs 
may  develop  during  a  simple  intermittent,  and  the  quinine  may  check  the 
chills  without  influencing  in  any  way  the  pneumonia, 

{c)  Kephrilis. — Moderate  albuminuria  is  a  frecpient  occurrence,  having 
occurred  in  4G.4  per  cent  of  the  cases  in  my  wards.  It  is  much  more  fre- 
<pient  in  the  a^stivo-autumnal  infections. 

Acute  nephritis  is  a  not  unusual  complication  of  the  disease.  Eare  in 
tlio  milder  forms,  it  is  relatively  frequent  in  ivstivo-autumnal  infections, 
having  occurred  in  over  4.5  per  cent  of  my  cases.  Chronic  ne])hritis  occa- 
sionally follows  long-continued  or  fre(piontly  re])eated  infections. 

Clinical  Forms  of  Malarial  Fever.— (I)  The  Regularly  Inter- 
mittent Fevers. — (a)  Tertian  fever;  (h)  quartan  fever.  These  forms  are 
characterized  by  recurring  })aroxysms  of  what  are  known  as  ague,  in  which, 
iis  a  rule,  chill,  fever,  and  sweat  follow  each  other  in  orderly  sequence.  The 
stage  of  incubation  is  not  definitely  known;  it  probably  varies  much  ac- 
cording to  the  amount  of  the  infectious  material  absorbed.  Experimentally 
the  period  of  incubation  varies  from  thirty-six  hours  to  fifteen  days,  being 
a  trifle  longer  in  quartan  than  in  tertian  infections.  Attacks  have  been 
reported  within  a  very  short  time  after  the  apparent  exposure.  On  the 
otlier  hand,  the  ague  may  be,  as  is  said,  "  in  the  system,"  and  the  patient 
may  have  a  paroxysm  months  after  he  has  removed  fiom  a  malarial  region, 
though  I  doubt  if  this  can  bo  the  case  unless  he  has  had  the  disease  when 
living  there. 

Description  of  'the  Paroxysm. — The  patient  generally  knows  he  is  going 
to  have  a  chill  a  few  hours  before  its  advent  by  uni)leasant  feelings  and 
iiueasy  sensations,  sometimes  by  headache.  The  paro.xysm  is  divided  into 
three  stages — cold,  hot,  and  sweating. 

Cold  Sta(je. — The  onset  is  indicated  by  a  feeling  of  lassitude  and  a 
desire  to  yawn  and  stretch,  by  headache,  uneasy  sensations  in  the  epigas- 
trium, sometimes  by  nausea  and  vomiting.  P^vcn  before  the  chill  begins 
the  thermometer  indicates  some  rise  in  temperature.  Ciradually  the  pa- 
tient begins  to  shiver,  the  face  looks  cold,  and  in  the  fully  developed  rigor 
the  whole  body  shakes,  the  teeth  chatter,  and  the  movements  may  often 
he  violent  enough  to  shake  the  bed.  Xot  only  does  the  patient  look  cold 
;uiil  blue,  but  a  surface  thermometer  will  indicate  a  reduction  of  tlie  skin 
tciiii)erature.     On  the  other  hand,  the  axillary  or  rectal  temperature  may. 


i 


i 


i 


210 


SPECIFIC  INFECTIOUS   DISEASES. 


H 

o 


SSSS38S3S 


s;     $ 


MALARIAL  FEVER. 


211 


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S      5       S       3      3 


212 


SPECIFIC  INFECTIOUS  DISEASES. 


,' 


(luring  the  chill,  ho  greatly  increased,  and,  as  shown  in  the  chart,  the  fever 
may  rise  during  the  cliill  to  1U5°  or  10G°.  Of  symptoms  associated  witli 
tile  cliill,  nausea  and  vomiting  are  common.  There  may  be  intense  licail- 
«ehe.  The  ])ulse  is  quick,  small,  and  hard.  The  urine  is  increa.sed  in 
quantity.  The  chill  lasts  for  a  variable  time,  from  ten  or  twelve  minutes 
to  an  hour,  or  even  longer. 

The  hoi  slcuje  is  ushered  in  by  transient  flushes  of  heat;  gradually  the 
coldness  of  the  surface  disappears  and  the  skin  becomes  intensely  hot. 
The  contrast  in  the  patient's  appearance  is  striking:  the  face  is  Hushed, 
the  hands  are  congested,  the  skin  is  reddened,  the  pulse  is  full  and  bound- 
ing, the  heart's  action  is  forcible,  and  the  patient  may  conijjlain  of  a  throb- 
bing headache.  There  may  be  active  delirium.  A  i)atient  in  this  st.vo 
jumjied  through  the  ward  window  and  sustained  fatal  injuries.  The  rectal 
temperature  may  not  increase  much  during  this  stage;  in  fact,  by  the 
termination  of  the  chill  the  fever  may  have  reached  its  maximum.  The 
duration  of  the  hot  stage  varies  from  half  an  hour  to  three  or  four  hours. 
The  patient  is  intensely  thirsty  and  drinks  eagerly  of  cold  water. 

Sweating  Stage. — Beads  of  perspiration  appear  upon  the  face  and  grad- 
ually the  entire  body  is  bathed  in  a  copious  sweat.  The  uncomfortable 
feeling  assoc  .ited  with  the  fever  disappears,  the  headache  is  relieved,  and 
Avithin  an  hoir  or  two  the  paroxysm  is  over  and  the  i:)atient  usually  sinks 
into  a  refre.-~liing  sleep.  The  sweating  varies  much.  It  may  be  drenching 
in  character  or  it  may  be  slight. 

Chart  XI  is  a  fac-simile  of  a  ward  temperature  chart  in  a  case  of  tertian 
Ague.  The  duration  of  the  paroxysms  on  February  1st,  3d,  and  5th  was 
from  twelve  to  sixteen  hours.  Quinine  in  two-grain  doses  war  given  on 
the  oth  and  was  sufficient  to  prevent  the  on-coming  paroxysms  on  the  7th, 
"though  the  temperature  rose  to  100.5°,  The  small  doses,  however,  were 
not  effective,  and  on  the  Oth  he  had  a  severe  chill. 

The  total  duration  of  the  paroxysm  averages  from  ten  to  twelve  hours, 
hut  may  be  shorter.  A^ariations  in  the  paroxysm  are  common.  Thus  the 
patient  may,  instead  of  a  chill,  experience  only  a  slight  feeling  of  coldness. 
The  most  common  variation  is  tlie  occurrence  of  a  hot  stage  alone,  or  with 
very  slight  sweating.  During  the  paroxysm  the  spleen  is  enlarged  and 
the  edge  can  usually  be  felt  below  the  costal  margin.  In  the  interval  or 
intermission  of  the  paroxysm  the  patient  feels  very  well,  and,  unless  the 
disease  is  unusually  severe,  he  is  able  to  be  up.  Bronchitis  is  a  common 
symptom.  Herpes,  usually  labial,  is  perhaps  as  frequently  seen  in  ague  as 
in  pneumonia. 

Types  of  the  Begnlarhj  Intermittent  Fevers. — As  has  been  stated  in  the 
description  of  the  parasites,  two  distinct  types  of  the  regularly  intermit- 
tent fevers  have  been  separated.  These  are  (a)  tertian  fever  and  (I))  qiiartan 
fever. 

(a)  Tertian  Fever. — This  type  of  fever  depends  xipon  the  presence  in 
the  blood  of  the  tertian  parasite,  an  organism  M'hich,  as  stated  above,  is 
usually  present  in  sharply  defined  groups,  whose  cycle  of  development  lasts 
filiproximately  forty-eight  hours,  sporulation  occurring  every  third  day. 
In  infections  with  one  group  of  the  tertian  parasite  the  paroxysms  occur 


MALAIilAL  FEVER. 


213 


e  fovor 
d  with 
;  head- 
ised  in 
ninuted 

illy  the 
;ly  hot. 
flushed, 

bouud- 
a  throb- 
lis  stncrc 
le  reuial 

by  the 
n.  The 
ir  hours. 

nd  grad- 
nfortable 
ived,  and 
dly  sinks 
Lrenching 

of  tertian 
5th  was 

civen  on 
the  7th, 
er,  were 

e  hours. 

Thus  the 

coldness. 

or  with 
rged  and 
itcrval  or 
nless  the 

common 
11  agne  as 

ed  in  the 

intcrmit- 

[)  quartan 

[esenco  in 
above,  is 
icnt  lasts 

hiird  day. 

tins  occur 


,<ynehronou!«ly  with  si)orulation  at  remarkably  regular  intervals  of  al>out 
lorty-L'ight  hours,  every  third  day — lieiice  the  name  trrliaii.  Very  com- 
iiioiily,  however,  there  may  be  two  groups  oi'  ))arasites  which  reach  maturity 
on  alternate  days,  resulting  thus  in  daily  ((jualidittii)  i)ar()xysms — tlmibh 
Icrliun  iiifcclidii.  (^uoti(liaii  I'ever,  depending  \i\H)n  double  tertian  infec- 
tion, is  the  moL^t  frecjuent  ty])e  in  the  acute  intermittent  fevers  in  this 
latitude. 

(/>)  Qnarian  Fever. — This  type  of  fever  depends  upon  infection  with 
the  quartan  jjarasite,  an  organism  which  occurs  in  well-delined  groups, 
whose  cycle  of  existence  lasts  ahout  seventy-two  hours.  In  infection  with 
(iiie  group  of  parasites  the  paroxysm  occurs  every  fourth  day;  hence  the 
term  quarlan.  At  times,  however,  two  groujjs  of  the  })arasites  may  be 
|ii'esent;  under  these  circumstances  paroxysms  occur  on  two  successive 
•(hiys,  with  a  day  of  intermission  following.  In  infection  with  three  groups 
(if  ])arasites  there  are  daily  paroxysms. 

Thus  a  quotidian  intermittent  fever  may  be  due  to  infection  with 
cither  the  tertian  or  quartan  parasites. 

Coxirse  of  the  Disease. — After  a  few  paroxysms,  or  after  the  disease  has 
]K'rsisted  for  ten  days  or  two  weeks,  the  })atient  may  get  well  without  any 
special  medication.  I  have  repeatedly  known  the  chills  to  stop  spontane- 
ously. Such  cases,  however,  are  very  liable  to  recurrence.  Persistence  of 
the  fever  leads  to  ana.'niia  and  htvmatogenou.i  Jaundice,  owing  to  the  de- 
.st ruction  of  the  red  blood-disks  by  the  parasites.  Ultimately  the  condition 
may  become  chronic,  and  will  be  described  under  malarial  cachexia.  The 
regularly  intermittent  fevers  yield  promptly  and  immediately  to  treatment 
with  quinine. 

(2)  The  more  Irregular,  Remittent,  or  Continued  Fevers.  —  Jlstivo 
autumnal  Fever. — This  tyi)e  of  fever  occurs  in  temperate  climates,  chiefly 
ill  the  later  summer  and  fall;  hence  the  term  given  to  it  by  Marchiafava 
iiiid  Celli,  astivo-imtumnal  fever.  The  severer  forms  of  it  prevail  in  the 
Southern  States  and  in  tropical  countries,  where  it  is  known  cliiefly  as 
hUious  remittent  fever.  The  entire  group  of  cases  included  under  the  terms 
remittent  fever,  hilious  remittent,  and  ti/p]io-matarial  fevers  requires  to  be 
s^tudicd  anew. 

This  type  of  fever  is  associated  with  the  presence  in  the  blood  of  the 
fl^^tivo^autumnal  parasite,  an  organism  the  length  of  whose  cycle  of  de- 
velopment is  probably  subject  to  variations,  while  the  existence  of  multiple 
groups  of  the  parasite,  or  the  absence  of  arrangement  into  definite  groups, 
is  not  infrequent. 

The  symptoms  are  therefore,  as  might  be  expected,  often  irregular.  In 
some  instances  there  may  be  regular  intermittent  fever  occurring  at  uncer- 
tain intervals  of  from  twenty-four  to  forty-eight  hours,  or  even  more.  In 
the  cases  with  longer  remissions  the  paroxysms  are  longer.  Some  of  the 
(piotidian  intermittent  cases  may  closely  resemble  the  quotidian  fever  de- 
I'l'nding  upon  double  tertian  or  triple  quartan  infection.  Commonly,  how- 
oxer,  the  paroxysms  show  material  differences;  their  length  averages  over 
twenty  hours,  instead  of  from  ten  or  twelve;  the  onset  occurs  often  with- 
out chills  and  even  without  chilly  sensations.     The  rise  in  temperature  is 


214 


SPECIFIC  INFECTIOUS  DISEASES. 


^ 


fnupu'iitly  grndual  and  slow,  instead  of  sudden,  wliile  the  fall  may  occur 
liy  lysis  instead  of  hy  crisis.  There  is  a  marked  tendency  toward  anticipa- 
tion in  the  paro.vysnis,  while  fre([uently,  from  the  anticipation  of  one  parox- 
ysm or  the  retardation  of  another,  more  or  less  continuous  fever  may 
result.  Sometimes  tiiere  is  continuous  fever  withuut  sharp  paroxysms,  lii 
these  cases  of  continuous  and  remittent  fever  the  patient,  seen  fairly  early 
in  the  disease,  has  a  Hushed  face  and  looks  ill.  'J'he  ton<,aie  is  furred,  the 
l)ulse  is  full  and  hounding,  hut  rarely  dicrotic.  The  temperature  may  range 
from  10"^°  to  103°,  or  is  in  some  instances  higher.  The  general  apitear- 
ance  of  the  patient  is  strongly  suggestive  of  typhoid  fever — a  suggestion 
still  further  home  out  hy  the  existence  of  acute  splenic  enlargement  of 
moderate  grade.  As  in  intermittent  fever,  an  initial  hronchitis  may  he 
present.  The  course  of  these  cases  is  variahle.  The  fever  may  he  con- 
tinuous, with  remissions  more  or  less  marked;  definite  paroxysms  with  or 
witliout  chills  may  occur,  in  which  the  temperature  rises  "to  105°  or  10()°. 
Intestinal  symi)(oms  are  usually  ahsent.  A  slight  ha.'matogenous  jaundice 
may  develop  early.  Delirium  of  a  mild  type  may  occur.  The  cases  vary 
very  greatly  in  severity.  In  some  the  fever  suhsides  at  the  end  of  the  week, 
and  tlie  practitioner  is  in  douht  whether  he  has  had  to  do  with  a  mild 
ty]»hoid  or  a  simple  fehricula.  In  other  instances  the  fever  persists  for 
from  ten  days  to  two  weeks;  there  are  marked  remissions,  perhaps  chills, 
with  a  furred  tongue  and  low  delirium.  Jaundice  is  not  infrequent.  Tiiese 
are  the  cases  to  which  the  term  bilious  rpiuiltcnl  and  fi/pho-malarial  fevers 
are  ait]»lied.  In  other  instances  the  symptoms  hecome  grave  and  assume 
the  character  of  the  pernicious  type.  It  is  in  this  form  of  malarial  fever  that 
so  much  confusioiv  still  exists.  The  similarity  of  the  cases  to  typhoid  fever 
is  most  striking,  more  ])articularly  the  appearance  of  the  facies,  and  the 
patient  Inal-s  very  ill.  The  cases  develop,  too,  in  the  autumn,  at  the  very 
time  when  tyjihoid  fever  occurs.  The  fever  yields,  as  a  rule,  promptly 
to  quinine,  though  here  and  there  cases  are  met  with — rarely  indeed  in  my 
experience — which  are  refractory.  It  is  just  in  this  group  that  the  ohserva- 
tions  of  Laveran  will  he  found  of  the  greatest  value.  Several  of  the  charts 
in  Thayer  and  Ilewetson's  re])ort  show  how  closely,  in  some  instances, 
the  disease  may  simulate  typhoid  fever. 

The  (liaijnosis  of  malarial  remittent  fever  may  he  definitely  made  by 
the  examination  of  the  blood.  The  small,  actively  motile,  hyaline  forms^ 
of  the  a^stivo-autumnal  ])arasite  are  to  be  found,  while,  if  the  case  has 
lasted  over  a  week,  the  larger  crescentic  and  ovoid  bodies  are  usually  seen. 
In  many  cases  here  we  are  at  first  unable  to  distinguish  between  typhoid 
and  contin  cd  malarial  fever  without  a  blood  examination.  A  more  wide- 
spread use  of  this  means  of  diagnosis  will  enable  us  to  bring  some  order 
out  of  the  confusion  which  exists  in  the  classification  of  the  fevers  of  the 
South.  At  present  the  following  febrile  affections  are  recognized  by  vari- 
ous ])hysician3  as  occurring  in  the  subtropical  regions  of  this  continent: 
(a)  Ty])hoid  fever;  (h)  ty])ho-malarial  fever — a  typhoid  modified  by  ma- 
larial infection,  or  the  result  of  a  combined  infection;  (c)  the  malarial 
remittent  fever;  and  (d)  continued  thermic  fever  (Guiteras).  In  these 
various  forms,  all  of  which  may  be  characterized  by  a  continued  pyrexia 


MALARIAL  FKVKU. 


215 


occur 

ticipa- 

parox- 

r  may 

13.    In 

^  early 

jd,  the 

'  range 

H)l)C!ar- 

gostion 

lent  of 

nay  be 

je  con- 

A'itli  or 

ir  10(5°. 

lundice 

,es  vary 

e  week, 
a  mild 

lists  ioT 

s  chilli. 
These 

il  fevers 
assume 

ver  that 

id  fever 

and  the 
le  very 

romptly 
1  in  my 
obsorva- 
e  charts 
stances, 

lade  by 
e  forms 
ase  has 
ly  seen, 
typhoid 
e  wide- 
e  order 
K  of  the 
)y  vari- 
itinent: 
by  ma- 
alarial 
n  these 
pyrexia 


with  remissions  or  with  cliills  and  sweats  (for  we  must  remember  that  chills 
luid  sweats  in  typhoid  fever  are  Ijy  no  means  rare),  the  blood  examination 
will  enable  us  to  discover  those  which  depend  upon  the  malarial  poison. 
In  many  of  these  cases  of  continued  or  remittent  fever  careful  iiujuiry 
will  show  that  at  the  beginning  the  ])atient  had  several  intermittent  parox- 
ysms. In  this  latitude  we  have  not  the  opportunity  of  seeing  many  of 
the  i»rotntcted  and  severe  cnses,  iuit  1  am  inclined  to  think  that  future 
oijservations  will  show  tluit,  apart  from  the  thermic  fever,  there  are  only 
two  forms  of  these  continued  fevers  in  the  South — the  one  due  to  tiie 
hlfihdiil  and  the  other  to  the  intihiridl  infection.  The  typhoid  fever  of 
riiiladelphia  and  ISaltimore  presents  no  essential  diU'erence  from  the  dis- 
ease as  it  occurs  in  Montreal,  a  city  practically  free  from  malai'ia.  Dock 
has  shown  conclusively  that  cases  diagnosed  in  'J'exas  as  continued  malarial 
fever  were  really  true  typhoid.  The  Widal  reaction  is  now  an  ini))ortant 
aid  in  diagnosis. 

Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  teni])erate  cli- 
iiiatcs,  and  the  numher  of  cases  which  now  occur,  f(n'  examj)le,  in  I'hila- 
(lelphia  and  JJaltimore,  is  very  much  less  than  it  was  thirty  or  forty  years 
ago.  Among  the  cases  of  malaria  which  have  been  under  observation  during 
the  j>ast  eight  years  there  were  only  seven  of  the  ])ernicious  form.  IVr- 
iiicions  fever  is  always  associated  with  tlie  a>stivo-autuninal  j>arasite.  The 
lollowing  are  the  most  important  types: 

(a)  The  comatose  form,  in  which  a  patient  is  struck  down  with  symp- 
toms of  the  most  intense  cerebral  disturljance,  either  acute  delirium  or, 
more  frecpiently,  a  rapidly  developing  coma.  A  chill  may  or  may  not  ])re- 
cede  the  attack.  The  fever  is  usually  high,  and  the  skin  hot  and  dry. 
The  nnconscionsness  may  persist  for  from  twelve  to  twenty-four  hours,  or 
the  patient  may  sink  and  die.  After  regaining  consciousness  a  second 
attack  may  come  on  and  prove  fatal.  Tn  these  instances,  as  has  been  stated, 
the  special  localization  of  the  infection  is  in  the  brain,  where  actual  thrombi 
(if  jtarasites  with  marked  secondary  changes  in  the  surrounding  tissues  have 
lieen  found. 

(b)  Ah/id  Form. — Tn  this,  the  attack  sets  in  usually  with  gastric  symp- 
loms;  there  are  vomiting,  intense  ])rostration,  and  feel)leness  out  of  all 
|irnportion  to  the  local  disturbance.  I'hc  patient  c()m|)lains  of  feeling  cold, 
although  there  may  be  no  actual  chill.  The  temi)erature  may  be  normal, 
or  even  subnormal;  consciousness  nuiy  be  retained.  The  pulse  is  fee])le 
and  small,  and  the  re,«])irations  are  increased.  There  may  be  most  severe 
iliarrlm'a,  the  attack  assuming  a  cboleriform  nature.  The  urine  is  often 
(liuiinished,  or  even  sup])resse(l.  This  condition  nuiy  y^ersist  with  slight 
exacerbations  of  fever  for  several  days  and  the  ])atient  may  die  in  a  condi- 
tion of  profound  asthenia.  This  is  cs.'^entially  the  same  as  described  as 
llie  (intlu'ttir  or  ii(]i/)irniiir  form  of  the  disease.  Tn  the  cases  with  vomiting 
and  diarrluva,  ^larchiafava  has  shown  that  the  gastro-intestinal  mucosa  is 
(iften  the  seat  of  a  special  invasion  by  the  parasites,  actual  thrombosis  of 
the  small  vessels  with  superficial  ulceration  and  necrosis  occurring.  Simi- 
lar lesions  were  found  by  Barker  in  the  gastro-intestinal  tract  of  a  case 
fi'oni  my  wards. 


I 


216 


SPECIFIC   INFECTIOUS   DISEASES. 


(c)  Ihrworrhdi/ir  Fnriiis. — In  all  the  sovcro  types  of  malarial  infec- 
tion, especially  if  persistent,  lueniorrliage  may  occur  from  the  mucous 
membranes.  An  important  form  is  tiie  malarial  lui'Diuluria,  which  in  some 
instances  assumes  a  very  nuili^nuint  tyi)e.  J'aroxysms  of  a;,'ue  may  pre- 
cede the  attack,  hut  in  many  cases  calle(|  nuilarial  luematuria  there  is  no 
febrile  |)aro.\ysm.  The  condition  is  usually  an  luemoj,dobinuria,  though 
blood-corpuscles  are  j)resent  also.  In  severe  cases  there  is  ))leeding  from 
the  mucous  membranes.  Jaundice  is  i)resent,  but  to  a  variable  extent, 
and  is  luematogenous,  due  to  the  destruction  of  the  red  blood-corpuscles. 
^Malarial  luenuituria  occurs  in  epidemic  form  in  nuiny  regions  of  the  South- 
ern States,  and  in  some  seasons  jjroves  very  fatal. 

Many  different  forms  of  pernicious  malarial  fever — diai)horetic,  synco- 
pal, pneumonic,  ])leuritic,  choleraic,  cardiac,  gastric,  and  gangrenous — all 
of  which  de))end  upon  some  special  symptom,  have  been  described. 

Malarial  Cachexia. — The  symptoms  of  chronic  nuilarial  ])oisoning  are 
very  varied.  It  may  follow  the  frequent  recurrence  of  ordinary  inter- 
mittent fever,  a  common  sequence  in  this  country.  A  patient  has  chills 
for  several  weeks,  is  improperly  or  imperfectly  treated,  and  on  exposure 
the  chills  recur.  This  may  be  repeated  for  several  months  nntil  the  ])a- 
tient  presents  the  two  striking  featnres  of  malarial  cachexia — namely, 
anci'inia  and  an  enlanjed  spleen.  Cases  developing  without  chills  or  with- 
out fel)rile  paroxysms  are  almost  nnknown  in  this  region.  They  nnvy 
occur,  however,  in  intensely  malarial  districts,  l)ut  in  snch  cases  the  ])atients 
have  fever,  though  chills  may  not  su])ervene.  The  most  pronounced  types 
of  malarial  cachexia  which  we  meet  with  here  are  in  sailors  from  the  "West 
Indies  and  Central  America.  There  is  profound  auifmia;  the  blood  count 
may  be  as  low  as  one  million  per  cubic  millimetre;  the  skin  has  a  sall'ron- 
yellow  or  lemon  tint,  not  often  the  light  yellow  tint  of  pernicious  aniemia,. 
bnt  a  darker,  dirtier  yellow.  The  spleen  is  greatly  enlarged,  firm,  and. 
hard.  It  rarely  reaches  the  dimensions  of  the  large  leuka^mic  organ,  but 
comes  next  to  it  in  size. 

The  general  symptoms  are  those  of  ordinary  anaemia — breathlessness 
on  exertion,  oedema  of  the  ankles,  hemorrhages,  particularly  into  the  retina, 
as  noted  by  Stephen  Mackenzie.  Occasionally  the  bleeding  is  severe,  and 
I  have  twice  known  fatal  haMuatemesis  to  occur  in  association  with  the' 
enlarged  Pi)loen.  The  fever  is  variable.  The  temperature  may  he  low  for 
days,  not  going  above  99.5°.  In  other  instances  there  may  be  irregular 
fever,  and  the  temperature  rises  gradually  to  102.5°  or  103°.  The  cases 
in  fact  present  a  picture  of  splenic  anaemia. 

With  careful  trca^  ent  the  outlook  is  good,  and  a  majority  of  case& 
recover.  The  s])lcei  o  gradually  reduced  in  size,  but  it  may  take  several 
months  or,  indeed,  in  some  instances,  several  years  before  the  ague-cake 
entirely  disa])pears. 

Among  the  rarer  symptoms  which  may  develop  as  a  result  of  malarial 
intoxication  may  be  mentioned  parnplef/ia,  cases  of  which  have  been  de- 
scribed by  Gibney,  Suckling,  and  others.  Some  of  the  cases  are  doubtful, 
and  have  been  attributed  to  malaria  simply  because  the  paralysis  was  inter- 
mittent.    It  is  a  condition  of  extreme  rarity.     Xo  case  is  mentioned  by 


MALARIAL   FEVER. 


21: 


1  infec- 
inueous 
in  somi' 
my  prt'- 
rc  is  no 
th()U;.i;li 
iig  from 

CXtflll, 

rpuscU's. 
e  S(nith- 

c,  synco- 
lous — all 

ning  arc 
ry  inter- 
las  chills 
exposure 
1  the  i)a- 
-namoly, 
or  with- 
hcy  may 
3  patients 
ccd  types 
the  West 
od  count 
I  salt'ron- 
anffimia,. 
irm,  and 
;gan,  but 

[hlessness 
lie  retina, 
li'cre,  and 

•ith  the 
low  for 
lirregular 

'he  caseS' 

of  cases- 
le  several 
Igue-cake 

malarial 

Iheen  de- 

louhtful, 

ks  inter- 

koned  by 


Kelsch  and  Kiener.  Suckling's  case  had  had  several  attacks  of  n\alaria, 
the  last  of  wliich  preceded  by  about  two  weeks  the  onset  of  ti»e  nervous* 
syni|)toms,  wliieh  were  lu'adiube,  giddiness,  loss  of  speech,  and  paraplegia. 
The  attack  was  transient,  but  he  had  a  subseipient  attack  wiiirii  also 
followed  an  ague-fit.  The  ))atient  was  an  old  soldier  who  had  had  syph- 
ilis, a  jioint  which  somewhat  complicated  the  case.  Orchitis  has  l)eeii 
describeil  as  developing  in  malaria  by  Charvot  in  Algiers  and  Fedeli  in 
Jfome. 

Diagnosis. — The  blood,  as  one  might  expect,  shows  nuirked  changes 
in  nudarial  fever.  In  the  regularly  intermittent  fevers  there  is  a  loss  in  red 
corpuscles  after  each  ])aroxysm,  which  nuiy  be  considerable,  but  which  is 
rapidly  compensated  during  the  intermissions.  In  a'stivo-autumnal  fever 
the  losses  are  oftener  greater  and  more  periminent.  In  any  case  of  malaria 
which  has  existed  for  any  length  of  time  there  is  always  consideraljle 
aiuemia.  The  luemoglobin,  as  in  all  secondary  arnvmias,  is  dinunished, 
usually  in  greater  ])roportion  than  the  corpuscles.  The  leiu^ocytes  are 
almost  invariably  diminished  in  numljcr  in  nudarial  fever.  The  reduc- 
tion is  greatest  just  after  the  paroxysms,  the  nund)er  increasing  slightly 
at  the  beginning  of  the  febrile  paroxysm.  The  dilVerential  count  shows  a 
relative  diminution  in  polynuclear  leucocytes,  with  a  relative  iiu-riNise  in 
the  large  nu^nonuclear  forms,  exactly  the  same  condition  that  is  seen  in 
ty})hoid  fever.  Sometimes  in  fatal  ])ost-malarial  anaunia  the  blood  shows- 
all  the  characteristics  of  true  pernicious  anaunia;  in  other  instances  of 
fatal  ana-mia,  where  the  blood  during  life  has  shown  an  absence  of  leuco- 
cytosis,  or  of  nucleated  red  cor])uscles,  the  marrow  of  the  long  bones  ha;^ 
been  found  to  be  perfectly  yellow,  showing  no  evidence  of  regenerative 
activity. 

The  diagnosis  of  the  various  forms  of  malaria  is  usually  easy.  The 
continued  renuttcnt  and  certain  of  the  ])ernicious  cases  olfer  dilliculties, 
which,  however,  are  now  greatly  lessened  or  entirely  overcome  since  Lav- 
eran's  researches  have  given  us  a  positive  diagnostic  iiulication.  ^lany 
forms  of  intermittent  ])yrexia  are  mistaken  for  nmlarial  fever,  particu- 
larly the  initial  chills  of  tuberculosis  and  of  septic  infection.  In  these  in- 
stances the  blood  shows  leucocytosis,  which  is  rare  in  nudaria.  If  the  ])rac- 
titioner  will  take  to  heart  the  lesson  that  an  internuttcnt  fever  which  resists 
quinine  is  not  malarial,  he  Avill  avoid  many  errors  in  diagnosis.  In  the 
so-called  masked  intermittent  or  duml)  ague,  the  febrile  manifestations  are 
more  irregular  and  the  symptoms  less  pronounced;  but  occasionally  chills 
occur,  and  the  therapeutical  test  usually  removes  every  doubt  in  the  diag- 
nosis. 

The  malarial  poison  is  supposed  to  influence  many  afTections  in  a  re- 
markable way,  giving  to  them  a  paroxysmal  character.  A  whole  series  of 
minor  ailments  and  some  more  severe  ones,  such  as  neuralgia,  are  attrib- 
uted to  certain  occult  effects  of  paludism.  The  more  closely  such  cases 
are  investigated  the  less  definite  appears  the  connection  with  malaria. 
Practitioners  in  districts  entirely  exempt  from  the  disease  have  to  deal  with 
ailments  which  present  the  same  odd  periodicity,  and  which  the  physicians 
of  the  Atlantic  coast  attribute  to  a  "  touch  of  malaria." 


218 


SPKCIFIC  INFECTIOrS   DTSFASES. 


Treatment.—  W'v  •!<»  not  know  ns  yet  Imw  tlir  iMiixm  rcndu's  llu'  nys- 
ti'in.  liift'dion  Ht'ciiis  most  linMi'  t(»  otcur  at  iii^'lit.  In  ic^rionH  in  wliicli 
the  uifcasi'  prevails  oxtcnsivt-ly  nios<|uilo  ncttinj;  should  !»(•  used,  us  tliu 
rcscarclics  of  Hdss  render  it  iii^ddy  prohiiMe  (Iiat  the  disease  is  trans- 
nuttetj  in  this  way.  Persons  ^unna  to  a  niahirinl  re;;:i<»n  sh<tidd  laUo 
alioiit  10  nraiiis  of  i|iiiiiine  daily,  th(»ngli  Se/.ary  I'mind  that  '■i  |,'rains  three 
times  a  (hiy  was  a  sullieient  protection  H«;ainst  the  disease.  Diirinj,'  the! 
paroxysm  the  patient  slioidd,  in  the  cold  sta^'e,  he  wrajiped  in  hhinkets  and 
j:ivi'n  hot  drinks.  'I'he  reactionary  lever  is  rari  ly  danj^crons  even  if  it 
reaches  a  lii^^ii  ^M'ade.  'i'iie  hody  may,  however,  he  spon^icd.  in  (piinine 
we  jiossess  a  si>ecifie  remedy  apunst  malariid  infection.  Ivxperiment  has 
shown  that  the  i)arasite8  are  most  easily  destroyed  hy  (pnnine  at  the  sta^'e 
when  they  arc  free  in  the  circulation — that  is,  (hiriu;,''  ami  just  after  sporu- 
lation.  While  in  most  instances  the  par;'<ilcs  of  the  i'c;iuhirly  intermittent 
fevers  may  he  destroyed,  even  in  the  iiitra-eorpuseular  staj^e,  in  a-stivo-au- 
tumnal  fever  this  is  much  more  dillieult.  It  should,  then,  lie  our  ohjeet, 
if  we  wish  to  most  eirectually  eradicate  tlii'  infection,  to  have  as  much 
(piinine  in  circulation  at  the  time  of  the  paroxysm  and  shortly  hefore  as  is 
possihie,  i'or  this  is  the  period  at  which  sporulation  occurs.  In  the  re^^u- 
larly  intermittent  fevers  from  lo  to  'M)  ;^'raiiis  in  divided  doses  throu^ihout 
the  day  will  in  many  instances  prevent  any  I'resh  ))aroxysms.  Jf  the  ]>atient 
conies  under  ohservation  shortly  hefore  an  e\|)ecte(l  paroxysm,  the  admin- 
istration of  a  <,'ood  dose  of  (piinine  just  hefore  its  onset  may  lie  advisalile 
to  ohtain  a  maximum  ell'ect  upon  that  <:rou|)  of  parasites.  The  (piinine 
will  not  prevent  the  ))aroxysm,  hut  will  destroy  the  greater  part  of  the 
<;roup  of  orj^anisms  and  ])i'event  its  further  recurrence.  It  is  safer  to  ^ive 
at  least  "^(t  to  .'iO  <^rains  daily  for  the  first  three  days,  and  then  to  continue 
the  reine(ly  in  smaller  doses  for  the  next  two  or  three  weeks.  In  lestivo- 
autumnal  fever  larger  doses  may  lie  necessary,  though  in  relatively  few  in- 
stances is  it  necessary  to  give  more  than  30  to  10  grains  in  the  twenty-four 


nours. 

MM 


The  (piinine  should  he  ordered  in  solution  or  in  capsules.  The  jiills 
and  compressed  tnhlets  are  more  nncertain,  as  they  may  not  1)C  dissolved. 

A  question  of  interest  is  the  efficient  dose  of  quinine  necessary  to  cure 
the  disease.  T  have  a  nunil)er  of  charts  showing  that  grain  doses  thre(! 
times  a  day  will  in  many  cases  prevent  the  ])aroxysni,  hut  not  always  with 
the  certainty  of  the  larger  doses.  In  cases  of  a^stivo-autumnal  fever  with 
pernicious  sym])tomp  it  is  necessary  to  get  the  system  under  the  influence 
of  (piinine  as  rapidly  as  ])ossil)le.  In  these  instances  the  drug  should  he 
administered  hypoderniically  as  the  hisulphate  in  liO-grain  doses,  with  5 
grains  of  tartaric  acid,  every  two  or  three  hours.  The  muriate  of  (piinine 
and  urea  is  also  a  good  form  in  which  to  administer  the  drug  hy|>oder- 
mically;  10,  15,  or  20  grain  doses  may  he  necessary.  In  the  nuist  severe 
instances  some  ohservers  advise  the  intravenous  administration  of  (piinine, 
for  which  the  very  soluldc  himuriate  is  well  adapted.  Fifteen  grains  Avith 
a  grain  of  sodium  chloride  may  he  injected  in  ahout  2  drachms  of  distilled 
water.  For  extreme  restlessness  in  these  cases  opium  is  indicated,  and  car- 
diac stimulants,  such  as  alcohol  and  strychnine,  are  necessary.     If  in  the 


1 


MALTA    FKVKH. 


210 


romntoso  fnrm  tlm  iiitcriiiil  tiiii|M'ratun'  is  rniftcd.  Ilif  puticiit  slioultl  In- 
]iiit  ill  II  Itiitli  iiidI  iloiisnl  with  niM  wiitfi*.  I'm*  niiiluriiil  iuia>tiiiti,  iron  ami 
arst'iiic  at')'  iiKlit-atol. 

All  iiittTotiii;,'  (|ii('stioii  is  iiiiuli  (lisciisscd,  wliiilicr  (|iiiiiiiif  tlitcrf  not 
caiisi'  or  at  any  rate  a^r^'ravaft'  tlii'  lia'nio;;lol)imiria.  We  have  not  yet  ««'fii 
a  case  in  wliidi  this  comlilioii  has  otciin'cM  as  a  result  of  the  use  of  tlu! 
di'ii;.'.  It  sccins  joctilizcd  in  (•ci'tain  sections;  ami  I'mslianrlli  states  that  it 
is  not  seen  in  the  linnian  niMliiiial  levers.  He  reconiniemls  that  in  aiiv  ease 
of  lia'nio;.dohiniiria  if  the  hlnod  siiows  parasites  (|iiinine  should  l»e  admin- 
istered freely.  In  the  post-inilarial  forms  »|ninim' a;r>j;ravat(.'8  the  attack.  In 
;in  active  maliirial  infection  'he  piiticnt  runs  le.ss  risk  with  the  quinine. 


I 


piliri 
lived. 
()  cure 
s  throe 
•s  with 
■r  with 
Ihieiice 
luld  he 
with   5 
|uinine 
^•poder- 
severe 
uinine, 
IS  with 
listiUed 
nd  ear- 
in  the 


> 

I 


^  XXV.    MALTA    FEVER. 

( ('n(liil(tnt  Fever.) 

Definition. — An  emleniie  fever,  characterized  hy  an  irre^'iilar  course, 
midulatory  jiyrexini  relapses,  )>rofuso  swc^its,  rheumatic  pains,  arthritis, 
mid  an  enlar<j;ed  spleen.  An  orjiiinism,  the  micrococcus  Meliteiisis,  is  pres- 
ent in  all  cases. 

The  ^ri'ater  part  ui  our  kiiowled^ie  of  this  rciiiarkalde  di.-ease  we  owe 
to  the  work  of  the  army  siirjicoiis  statioiietl  at  (iiltraltar  ami  .Malta,  par- 
ticularly to  ]\rarston.  to  l^ruce,  and  recently  to  llii,i,dies,  whose  iniporlant 
work  on  the  suliject  1  have  used  freely  for  this  article. 

Distribution. — 'I'he  disease  prevails  extensively  at  Malta,  and  is  also 
met  with  ill  the  countries  horderin^  on  the  Mediterranean;  luiice  the  name 
^fediterranean  fever.  It  is  known  in  (Jihraltar  as  Uock  fever,  and  in  Sicily 
;ii)d  Italy  it  is  known  as  Neapolitan  fever.  It  proi)ai)ly  is  also  met  with 
ill  India  and  China.  Ihiiihes  siiizirests  that  some  of  the  indeliiiite  forms  of 
fever  in  America  conform  to  this  tyjie,  but  the  evidence  before  us  at  pres- 
ent is  certainly  a.uainst  this  view. 

Etiology. — The  disease  is  not  contaj^dous.  It  jirevails  in  suniiiier,  and 
in  infected  r'^ions  is  endemic,  occasionally  assuminj,'  epidemic  characters. 
In>anitary  condilions  favor  its  spread,  hut  we  cannot  as  yet  say  whether  the 
poison  is  air-l)oriie  or  water-horne.  Huddles  thinks  that  the  former  is  the 
more  proliahle  view,  IJruce  the  latter.  Yoiin/jf,  healthy  adults  are  chielly 
attacked. 

The  micrococcus  ^[elitensis,  discovered  hy  JJriice.  has  not  yet  heen  iso- 
lati'd  from  the  hlood,  hut  occurs  in  lar<i('  numhtu's  in  the  spleen.  Tt  is  con- 
stantly jiresent  in  fatal  cases.  The  morphological  and  cultural  characters 
have  heen  accurately  studied  hy  II.  Iv  Durham.  Inoculations  into  monkeys 
produce  a  disease  somewhat  similar  to  that  in  man.  riid  the  micrococcus 
can  he  isolated  from  the  infected  animnl. 

Symptoms.— There  is  no  specific  fever  which  presents  the  same  re- 
iiiarkahle  iiTou])  of  phenomena.  1''he  period  of  incubation  is  from  six  to 
ten  days.  "  ('linioally  the  fever  has  a  peculiarly  irrosinlar  temperature  curve, 
iniisistim;-  of  intermittent  waves  or  undidatioiH  of  jtyrexia,  of  a  distinctly 
remittent  character,  '^riiese  pyrexial  waves  or  undulations  last,  as  a  rule, 
14 


990 


SI'KCIKIC    INKKCTlors    IMSKASMS. 


fiiiiii  one  to  llinr  weeks,  wiili  nil  ii|»yi('\iiil  iiilfivnl,  or  piTicMl  of  Iciiipoinry 
iilnilfiiiciit  ol'  |tyrt'\iiil  iiitfii>ilv  lirlwirii,  liisliii;,'  lor  two  or  more  ilnvs. 
Ill  rare  ctihcH  tlie  reiiii>>ioii>  iiiii\  lieioiiie  so  imirkeil  as  lo  ^'ive  an  iiliiioht 
ilileriiiilteiil  elmineler  lo  ilie  lelirile  eiirvc,  clearly  (lisliii^niislialiU',  liow- 
('\er.  I'miii  llie  |iiiiii\y>iiis  o|'  |ialiiilie  iiirecliuii.  'This  pyrevinl  roiiditioii  is 
lu»Uiilly  iiiiuli  |ii'o|oii^e(|,  Iia\iii^'  ail  iiiieciliiiii  (liiialioii,  lasliii;;  I'or  eseii 
nix  iiiotillis  or  more.  I  iilike  |iiiliitlism,  its  eoiiive  is  not  marketlly  alVeeteil 
hy  tlic  atlmiiiistratioii  of  i|iiiiiiiie  or  ai'.>eiii<'.  Its  course  is  ol'tcii  irrc<i;iilar 
anil  even  ernilic  in  nature.  This  |iyrc\ia  is  usually  accoiii|iaiiici|  liy  olisti- 
natc  constipation,  progressive  ami'inia,  ami  deliility.  II  is  ol'ien  compli- 
catcil  with  and  followed  l»y  nciiral;;ic  syin|»lonis  referred  to  the  pcripheinl 
or  ceiitiiil  nervous  system,  arthritic  clViisions,  painful  inllammatory  condi- 
tions »d'  certain  lihrous  striU'lurcs,  id'  a  l(»cali/.e(l  miliirc,  or  swelling'  id'  the 
testicles"  (lliiL:hcs).  This  author  reco^ni/cs  a  mali^Mianf  type,  in  which 
the  (Mscase  may  prove  fatal  within  a  week  or  ten  days;  an  iindiilatory  type 
—the  common  variety — in  which  the  l'e\i'r  is  marked  hy  iiitermitfent  waves 
or  undulations  of  variahh'  lcn;;tli,  sc|iarati'd  hy  periods  of  apyrexia  and  free- 
dom from  symptoms.  In  thi.»*  really  lie  tin-  peculiar  features  (»f  the  dis- 
ease, and  till'  unfortunate  victim  may  siiU'er  a  series  of  rela|»ses  which  may 
extend  from  three  months,  the  avera^'c  time,  to  two  years.  Lastly,  there 
is  an  inti'i'iiiillciit  type,  in  which  the  patient  may  simjily  have  daily  jjyrexia 
toward  eveiiinjf,  without  any  special  complicatictns,  and  may  do  well  and 
he  aide  to  jro  ahont  his  work,  and  yet  at  any  time  the  other  serious  fealiircs 
of  the  disease  may  di-vclop. 

The  mortality  i**  fli^dit,  only  ahout  ",.'  per  cent.  There  are  no  charactcr- 
istie  niorhid  lesions.  The  seriousness  of  the  disea.se  is  in  its  protracted 
cour.se,  so  that  in  the  army  the  loss  of  time  is  a  very  {.'rave  ilein.  Malta 
fever  has  to  he  distinguished  carefully  from  ty|)hoid  fever  and  from  ma- 
laria. From  the  latter  it  can  he  now  readily  diU'erentialcd  hy  the  examina- 
tion of  the  blood.  A  characleristic  serum  reaction  is  present.  From  Dur- 
ham's ohservalions  on  animals  it  ia  prohahle  that  the  orpmism  may  he 
isolated  from  the  urine  even  after  ajipan'tit  recovery. 

Treatment. — (ieneral  measures  suitahle  lo  typhoid  fever  are  indi- 
cated. F'luid  food  should  he  jriven  durinj;  the  febrile  jieriod.  Jlydro- 
therapy,  either  the  hath  or  the  cold  j»ack,  should  be  used  every  third  hour 
when  the  temperature  is  above  103°  F.  Otherwise  the  treatment  is  symp- 
tomatic. No  druLTs  ap]'  'nr  to  have  any  sjn-cial  inlluouce  on  the  fever.  A 
chaniio  of  cliuuUo  soei  romote  eonvalesceucc. 


in 


XXVI.    BERIBERI. 


Definition. — An  endemic  and  epidemic  multi|>le  neuritis  of  unknown 
etiology,  occurring  in  tro])ical  and  subtropical  countries,  characterized  by 
motor  and  sensory  ]iaralysis  and  anasarca. 

History. — The  disease  is  believed  to  be  of  great  anti(iuity  in  China, 
and  is  ])ossibly  nienti(nied  in  the  oldest  known  nu^dieal  treatise.  In  the 
early  years  of  this  century  it  attracted  much  attention  among  the  Anglo- 


UKUI  HKHI. 


;•('    lliul- 

llv.lro- 
ird  hour 
Is  symi) 
Ivcr 


A 


Inknown 
:izcel  1)y 

China, 
Tn  tho 
Anglo- 


Iixliiiii  ,>*iir;.'('niis,  mill  uc  rmiy  <liili'  lln'  iihmIith  Hciciiliru'  hlmly  nf  Ihf  <li- 
I'iiHu  I'roiii  Miili'iiliiiMtirs  iiii)ii<i;;ra|ih,  |iiihli.-ht'<|  in  Mntliiis  in  IHII.*).  Thr 
oiKiiin;^'  of  .liipiin  ^'iivr  nil  M|i|iui-hiiiit y  tu  tlic  ( m>i-iiiiiii  iiliysicians  holiliii;^ 
uiiivt'isily  |itisili(ins,  |iiirlifiiliiily  lliiclz,  Si  lieiihr,  iiml  ninic  rtMnnlly  (iiitniii, 
to  invcsli^iilt'  Iht'  disi'iist'.  'I'lic  stih!i"s  of  Ihi-  iiiitivc  ilii|iiiiit'S('  physiriiiiis, 
|iiii-liciilarly  Miiiiii  iiihI  'l'iikii;ji,  nnil  n|'  the  hutch  physicians  in  liic  I'iast, 
hiivu  conlrihiitcil   inii<h   to  unr  know  h'(|Ht>.     An   achh'il   interest    has   hiiM 

jiivcll  to  the  sillijcci  hy  the  (hscn\ciy  nf  the  ih.-ease  aiiiniijf  the  Cape  ( 'o.l 
(ishcrnieii,  ami  hy  the  reciiirin^'  uiilhicaks  of  eiKieinie  iiciintis  at  the  Wic'i- 
iiiniiil  Asyliiiii  ill  hiihlin  ami  at  the  State  Insane  lluspital  ill  TiiscalDotiU, 
A  I.I. 

Distribution.  — Ueri-heri.  Kakke,  or  emlemie  neuritis  prevails  rnnsf 
extensively  in  llu'  Malay  Ai'eliiiiela;^'(i;  in  eeitiiiii  nf  the  Dutch  cnlui.ics  tlir 
niurtality  ainonj,'  the  coolies  is  simply  rii;;litriil.  It  is  widely  (lislrilnitcd 
throu^di  parts  of  China  and  .lapan.  In  India  it  has  hecninc  less  coinimiii, 
hut  is  still  prevalent  in  parts  of  Unrimi.  Locali/ed  oiithreaks  have  oecuried 
in  Australia.  It  prevails  c.vtensivcly  in  parts  (d'  South  America  and  in  the 
West  Indies,  and  from  the  ports  of  these  coiinlries  cases  oecasicnally  leai  h 
llie  I'liitetl  States.  Mirj,M',  of  I'roviiicetown,  and  .1.  .1.  I'ntnain  eiiconnteird 
hcri-heri  amon^'  the  lishennen  on  the  Xowfoundland   lianks.     I'drj,'(;  wrilis 

(.March    Id,   ISDS)  that  he  has  s i    IT  cases  of  hoth  the  wet  and  the  dry 

foriii.  The  disease  is  not  entirely  conliiied  to  the  (ishermen  on  the  (Iraiid 
r>aiiks,  hilt  develops  occasionally  iinion^'  those  livin;;  on  shore  or  niakin;; 
"shore  trips."  In  |S!l.')  "!)(!  a  remarkalile  oiillireiik  <d'  cndi'inic  neuritis 
occurred  at  the  State  In.sanc  Hospital  at  Tuscaloosa,  .\la.,  which  has  hecii 
descrihed  fully  hy  I).  I).  I'xiiidiii'ant.'"  Uetween  l''ehriiaiy,  JSilo.and  Octohcr. 
IMH!,  in  a  po|)ulalion  of  I,V(H)  there  were  11  cases  with  '.M  deaths.     .None 


(!(•( 


lined 


anion",'  the  "^dO  employees  ol 


the  h 


(isjiiial 


le  iiciM'ocs  were  rela- 


tively less  airocleil  than  the  whites.  The  chief  symptoms  were  "  muscular 
Weakness,  tenderness,  pain,  para'sthcsia',  loss  of  deep  rcllcxes,  followed  hy 
atrophy  of  muscles  and  the  electrical  reaction  of  de^'eiieration,  accom- 
panied hy  rise  of  temperature,  j^'astro-intestinal  disturhance,  iieiieral  aiia- 
siirca,  and  tachycardia."  At  the  Arkansas  State  Insane  A.syliim  at  Little 
h'ock,  in  ISll."),  there  was  an  oiithrcak  of  hetween  '.*()  and  ;!<»  cases  possiltly 
of  hcri-heri. 

In  (ireat  IJritain  the  disease  is  not  infreipieiif  at  the  seaports. 

At  the  Itichmond  Asylum,  l)iil»lii),  there  !iave  heen  extensive  outhreaks 
in  till'  years  1H!)4,  IHIH),  1S!»T,  under  conditions  of  shameful  overcrowdin<j:. 

Etiology. — Two  main  views  ])revail  as  to  the  nature  of  the  disease — 
that  it  is  an  infection,  and  that  it  is  a  toxa'inia  caiiseil  hy  food. 

1.  Bcri-hrri  as  an  Ariilc  fnferlion. —  I'aelz  and  Schenhe,  with  many  of 
the  Dutch  ]»hysicians,  hold  that  the  disease  is  due  to  a  livinj;  jjerm.  in 
favor  of  this  view,  Schenhe  refers  to  the  fact  that  stroii'',  wpll-noiirished 


younjr  ])eo] 


)le  are  attacked,  that  the  disease  has  definite  foci  in  which  it 


irevails,  definite  seasonal  relations,  and  has  of  late  years  spread  in  some 
countries  as  an  epidemic  without  any  special  change  in  the  diet  of  the 

*  New  York  Medical  Journal,  1897,  ii. 


I 


222 


SPECIFIC  INFECTIOUS  DISEASES. 


iiilial)itaii(s.  So  far  ns  seasonal  and  tulliiric  infhicncos  nrc  concerned,  it  ig 
a  disease  \vlii<'h  resembles  nialaria,  with  wiiic'li,  in  i'act,  some  autliors 
liave  eonroiiiided  it.  Jt  is  ))rol)al(l_v  not  directly  eontai,nons.  On  tiie  other 
liand,  Seheiihe,  Manson  and  others  hrinj;  forward  evidence  t<»  show  tiiat 
])eri-l»eri  may  ])rol)al)ly  be  conveyed  I'roin  one  district  to  another. 
]\Iany  hacteriolo^ieal  studies  have  \K'(.m  made  in  the  disease,  partien- 
larly  hy  Dutch  i)hysicians,  but  there  is  no  nnanimity  as  to  the  results, 
and  we  may  say  that  no  specific  organism  has  as  yet  been  determined 
n])<»n. 

2.  'J'he  food  theory  of  beri-beri  is  widely  held  in  Japan,  some  believing 
that  it  is  due  to  the  eating  of  bad  rice,  and  others  that  it  is  associated  with 
the  nse  of  certain  fish.  In  favor  of  the  dietetic  view  of  its  origin  is  ad- 
duced the  extraordinary  change  which  has  taken  jilace  in  the  Ja])anese 
navy  since  the  introduction  by  Takagi  of  an  im|>roved  diet,  allowing  a 
larger  ])ortion  of  nitrogenons  food,  and  forljidding  the  nse  of  fresh  fish 
altogether.  Subsequent  to  this  there  has  certainly  been  the  most  remark- 
able diminntion  in  the  nnmber  of  cases — a  reduction  from  about  a  fourth 
of  the  entire  strengt^  .ttacked  annually  to  a  ])ractical  abolition  of  the 
disease. 

A  recent  number  of  Janus  gives  the  e.\])erience  of  the  J)utch  physicians 
in  Java,  many  of  whom  regard  rice  as  tlie  important  catise  of  the  disease. 
It  is  stated  that  in  the  ]»risons  of  Java  the  projjortion  of  cases  is  1  to  39 
when  the  rice  is  eaten  completely  shelled,  1  to  10,0(10  Mdien  the  grain  is 
eaten  Avith  its  pericarp:  in  some  ])laces  the  disease  has  disa])peared  when 
the  unsheHed  rice  has  been  sul)stituted  for  the  shelled.  Miura,  with  whose 
stndies  of  the  disease  all  readers  of  Yirchow's  Archiv  are  familiar,  regards 
beri-beri  as  a  form  of  chronic  ])oisoning  due  to  the  use  of  the  flesh  of  cer- 
tain fish  eaten  raw  or  imp-'operly  ])repared.  Grimm,  in  his  recent  mono- 
graph, regards  tlie  immunity  of  luiro])eans  as  in  great  part  owing  to  the 
fact  that  they  do  not  follow  the  Japanese  custom  of  eating  various  kinds  of 
raw  fish. 

Among  the  most  imjiortant  faotors  are  the  following:  Overcrowding, 
ns  in  ships,  jails,  and  asylums,  hot  and  moist  seasons,  and  exposure  to  wet. 
Euro])eans  imder  good  hygienic  conditions  rarely  contract  the  disease  in 
beri-beri  regions.  The  natives  and  tlie  imported  coolies  are  the  most  often 
attacked.  Males  are  more  subject  to  the  disease  than  females.  Young  men 
from  sixteen  to  twenty-five  are  m<ist  often  affected. 

Symptoms. — The  incubation  ])eriod  is  unknown,  but  it  probably 
extends  over  several  months.  The  following  forms  of  the  disease  are  recog- 
nized by  Scheube: 

1.  The  incomplete  or  rudimentary  form  which  often  sets  in  with  ca- 
tarrhal symptoms,  followed  by  ])ains  and  weakness  in  the  lind)S  and  a  lower- 
ing of  the  sensibility  in  the  legs,  with  the  development  of  i)ara^sthesia3. 
Sliglit  o'dema  sometimes  a])]K'ars.  After  a  time  jiarivsthesia^  may  develop 
in  other  parts  of  the  body,  and  the  i)atient  may  comjdain  of  palpitation  of 
the  heart,  uneasy  sensations  in  the  abdonu'U,  and  sometiiiics  shortness  of 
breath.  There  may  be  weakness  and  tenderness  of  the  muscles.  After 
histing  from  a  few  days  to  many  months,  these  symptoms  all  disappear,  but 


BERI-BRRI. 


223 


robably 
rocog- 


ritli   ca- 
ll lowov- 

Idevelop 
lition  o£ 

ItlK'SS    of 

After 
lear,  but 


with  tlic  return  of  the  warm  wontlicr  tliere  may  1)0  a  rocurreiKc.     One  oC 
Scheuhe's  patients  sulfered  in  this  way  for  twenty  years. 

2.  The  atrophic  form  sets  in  with  much  the  same  symptoms,  but  tlio 
loss  of  j)ower  in  the  limits  prot.fresses  more  rajiidly,  and  very  soon  tlio 
patient  is  no  lon<;er  able  to  walk  or  to  move  the  anus.  The  atro|)hy, 
which  is  associated  with  a  jjood  deal  of  pain,  may  extend  to  the  mus- 
cles of  the  face.  The  opdematoiis  symptoms  and  heart  trouhlcs  play 
a  minor  role  in  this  form,  which  is  known  as  the  dry  or  jiaralytic  va- 
riety. 

3.  The  Wet  or  Dropsical  Form. — Setting  in  as  in  the  rudimentary  vari- 
ety, the  a'denia  soon  becomes  the  most  marked  feature,  extending  over 
the  whole  sidjcutaneous  tissue,  and  associati'd  with  elTusicms  into  the  serous 
sacs.  The  atrophy  of  the  muscles  and  disturbance  of  sensation  are  not  such 
prominent  symptoms.  Dn  the  other  hand,  palpitaticni  and  rapid  action  of 
the  heart  and  dyspnwa  are  common.  The  wasting  may  not  be  apparent 
imtil  the  dropsy  disappears. 

4.  The  acute,  pernicious,  or  cardiac  form  is  characterized  by  threat- 
enings  of  an  acute  cardiac  failuic,  d(T\eloping  ra])idly  after  the  existenc(3 
of  slight  symptoms,  such  as  occur  in  the  rudimentary  form.  In  tlie  most 
acute  type  death  may  follow  within  twenty-four  hours;  more  commonly 
the  symptoms  extend  over  several  Meeks. 

The  mortality  of  the  disease  varies  greatly,  from  2  or  3  per  cent  to  -U) 
or  50  per  cent  among  the  coolies  in  certain  of  the  settlements  of  the  Malay 
Archipelago. 

Morbid  Anatomy. — The  most  constant  and  striking  features  are 
changes  in  the  peripheral  nerves  and  degenerative  inllammation  involving 
the  axis  cylinder  and  medullary  sheaths.  In  the  acute  cases  this  is  found 
not  only  in  the  peripheral  nerves,  but  also  in  the  pneumogastrie  and  in 
the  phrenic.  The  fdjres  of  the  voluntary  muscles,  as  well  as  of  the  myo- 
cardium, are  also  much  degenerated. 

Diagnosis. — In  tropical  countries  there  is  rarely  any  diilieulty  in  the 
diagnosis.  In  cases  of  peripheral  neuritis,  associated  with  ojdema,  coming 
from  tropical  ports,  the  possibility  of  this  disease  should  be  rememb('r('(l. 
Scheube  states  that  rarely  any  diflicnlty  olfers  in  the  diagnosis  of  the  dif- 
ferent forms.  An  interesting  (piestion  arises  as  to  the  true  nature  of  the 
endennc  neuritis  in  the  Richmond  Asylum  and  at  Tuscaloosa.  Bondurant's 
rejjort  certainly  shows  a  disease  conforming  with  beri-l)eri  in  a  nnijority 
of  its  features.  The  statement  is  made  that  the  Dutch  committee  which 
studied  the  ejiidemic  at  the  Richmond  Asylum  did  not  regard  the  disease 
as  tpiite  identical  with  the  tropical  bcri-beri. 

Treatment. — ]\ruch  has  been  done  to  prevent  the  disease,  ])articularly 
in  Japan.  There  is  no  more  remai'kablc  triumph  of  modern  hygiene  than 
that  which  followed  Takagi's  dietetic  reforms  in  the  Japanese  navy.  In 
beri-beri  districts  Euro])eans  sliould  use  a  diet  rich  in  nitrogenous  ingredi- 
ents. In  the  dietary  of  prisi  ns  and  asylums  the  exjjerience  of  the  Javanese 
physicians  Avith  reference  to  the  remarkable  diminution  of  the  disease  with 
the  use  of  nnslielled  rice  should  be  borne  in  mind.  In  ships,  prisons,  and 
asylums  the  disease  has  rarely  occurred  excejtt  in  connection  with  over- 


224 


SPECIFIC  INFECTIOUS  DISEASES. 


crowd inrr,  an  eloincnt  wliicli  prevailed  Ijotli  at  the  Richmond  Asylum  and 
at  the  State  llosi)ital  fur  the  Insane  at  Tuscaloosa. 

IJaelz  recommends  in  early  cases  a  i'ree  use  of  the  salicylates,  15  or  20 
grains  four  or  five  times  a  day.  Others  advise  early  free  purgation.  In 
very  severe  acute  cases,  both  Anderson  and  JJaelz  advise  blood-letting. 
The  more  chronic  cases  demand,  in  addition  to  dietetic  measures,  dnigs  to 
sui)i)ort  the  heart  and  treatment  of  the  atrophied  muscles  with  electricity 
and  massage. 


XXVII.   ANTHRAX. 

{Splenic  Fever  ;  Charbon;  Wool-soriei-'s  Disease.) 

Definition. — An  acute  infectious  disease  caused  by  the  laciUiis  an- 
thracis.  It  is  a  widespread  affection  in  animals,  particularly  in  sheep  and 
cattle.  In  man  it  occurs  sporadically  or  as  a  result  of  accidental  inocula- 
tions with  the  virus. 

Etiology. — The  infectious  agent  is  a  non-motile,  rod-shaped  organ- 
ism, the  bacillus  anlhracis,  which  has,  by  the  researches  of  PoUender,  Da- 
vaine,  Koch,  and  Pasteur,  become  the  best  known  perhaps  of  all  })atho- 
genic  microbes.  The  bacillus  has  a  length  of  from  two  to  ten  times  the 
diameter  of  a  red  blood-cor])uscle;  the  rods  are  often  united.  They  mul- 
tii)ly  by  fission  with  great  ra])idity  and  grow  with  facility  on  various  cidture 
media,  extending  into  long  filaments  which  interlace  and  ])roduce  a  dense 
network.  The  si)ore  formation  is  seen  with  great  readiness  in  these  fila- 
ments; but  an  asi)orogenous  variety  is  known,  and  can  be  produced  arti- 
ficially in  cultures.  The  bacilli  themselves  are  readily  destroyed,  but  the 
sjiores  are  very  resistant,  and  survive  after  prolonged  immersion  in  a  o-per- 
ccnt  solution  of  carbolic  acid,  and  resist  for  some  minutes  a  temperature 
of  212°  Fahr.  They  are  capable  also  of  resisting  gastric  digestion.  Out- 
side the  body  the  spores  are  in  all  probability  very  durrible. 

(Jeograiihically  and  zoologically  the  disease  is  the  most  widespread  of 
all  infectious  disorders.  It  is  much  more  ])revalent  in  Europe  and  in  Asia 
than  in  America.  Its  ravages  among  the  herds  of  cattle  in  Russia  and 
Siberia,  and  among  sheep  in  certain  parts  of  Europe,  are  not  equalled  by 
any  otluT  animal  ])lague.  In  this  country  the  disease  is  rare.  So  far  as  I 
know,  it  has  never  prevailed  on  the  ranches  in  the  Northwest,  but  cases 
were  not  infrecpicnt  about  ^fontreal. 

A  protective  inoculation  with  a  mitigated  virus  has  been  introduced  by 
Pasteur,  and  has  been  adopted  in  certain  anthrax  regions.  Ilankin  has 
isolated  from  the  cultures  an  albumose  which  renders  animals  immune 
against  the  most  intense  virus. 

In  animals  the  disease  is  conveyed  sometimes  by  direct  inoculation,  as 
by  the  bites  and  stings  of  insectp,  by  feeding  on  carcasses  of  animals  which 
have  died  of  the  disease,  Init  more  commonly  by  feeding  in  pastures  in 
which  the  germs  have  been  preserved.  Pasteur  believes  that  the  earth- 
worm plays  an  im]-)ortant  part  in  bringing  to  the  surface  and  distributing 
the  bacilli  which  have  been  propagated  in  the  buried  carcass  of  an  in- 
fected animal.     Certain  fields,  or  even  farms,  may  thus  be  infected  for  an 


ANTHRAX. 


225 


[ocl  by 
In  lias 
uuune 

Ion,  as 
Iwhieh 
Ires  in 
loartli- 
Initing 
\n  in- 
fer an 


indefinite  period  of  time,  Tt  seems  pro1)al)lo,  liowevor,  tliat  if  tlie  carcass 
is  not  opened  or  the  l)lood  spilt,  s})orcs  arc  not  formed  in  the  buried  ani- 
mal and  the  bacilli  (piickly  die. 

Animals  vary  in  susceptibility:  the  hcrbivora  come  first,  then  the  om- 
nivora,  and  lastly  the  carnivora.  The  disease  does  not  occur  spontane- 
ously in  man,  but  always  results  from  infection,  either  through  the  skin, 
the  intestines,  or  in  rare  instances  through  the  lungs.  It  is  found  in  per- 
sons whose  occu])ations  Ijring  them  into  contact  with  animals  or  animal 
products,  as  stablemen,  shepherds,  tanners,  butchers,  and  those  who  work 
in  wool  and  hair. 

Various  forms  of  the  disease  have  been  described,  and  two  chief  groups 
may  be  recognized:  the  external  anthrax  and  the  internal  anthrax,  of  which 
there  are  pulmonary  and  intestinal  forms. 

Symptoms.— (1)  External  Anthrax. 

(a)  Malignant  Pustule. — The  inoculation  is  usually  on  an  exposed  sur- 
face— the  hands,  arms,  or  face.  At  the  site  of  inoculation  there  are,  within 
a  few  hours,  itching  and  uneasiness.  Gradually  a  small  ])ai)ule  develops, 
which  becomes  vesicular.  Inllammatory  induration  extends  around  this, 
and  within  thirty-six  hours,  at  the  site  of  inoculation  there  is  a  dark  brown- 
ish eschar,  at  a  little  distance  from  which  there  may  be  a  series  of  small 
vesicles.  The  brawny  induration  may  be  extreme.  The  redema  produces 
very  great  swelling  of  the  parts.  The  inflammation  extends  along  the  lym- 
phatics, and  the  neighboring  lymi)h-glands  are  swollen  and  sore.  The 
fever  at  first  rises  rapidly,  and  the  concomitant  phenomena  are  marked. 
Subsequently  the  temperature  falls,  and  in  many  cases  becomes  subnormal. 
Death  may  take  ])lace  in  from  three  to  five  days.  In  cases  Mhich  recover 
the  constitutional  symptoms  are  slighter,  the  eschar  gradually  sloughs  out, 
and  the  wound  heals.  The  cases  vary  much  in  severity,  In  the  mildest 
form  there  may  be  only  slight  swelling.  At  the  site  of  inoculation  a  pajnile 
is  formed,  which  rapidly  becomes  vesicular  and  dries  into  a  seal),  which 
separates  in  the  course  of  a  few  days. 

(h)  Malignant  Anthrax  (Edema. — This  form  occurs  in  the  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  characterized  by  the  absence  of  the 
pa]nde  and  vesicle  forms,  and  by  the  most  extensive  (edema,  which  may 
follow  rather  than  ])recede  the  constitutional  symptoms.  The  u'deniii 
reaches  such  a  grade  of  intensity  that  gangrene  results,  and  may  involve  a 
considerable  surface.  The  constitutional  symptoms  then  become  extremely 
grave,  and  the  cases  invariably  prove  fatal. 

The  o-roatcst  fatalitv  is  seen  in  cases  of  inoculation  about  the  bead  and 
face,  where  the  morfality,  accordiug  to  Xasnrow,  is  20  per  cent;  the  least 
in  infection  of  the  lower  extremities,  where  it  is  .5  per  cent. 

In  a  recent  case,  in  a  hair-picker,  there  was  most  extensive  enteritis, 
peritonitis,  and  endocarditis,  which  last  lesion  has  been  described  by 
Eppinger. 

A  feature  in  both  these  forms  of  malignant  pustule,  to  which  many 
writers  refer,  is  the  absence  of  feeling  of  distress  or  anxiety  on  the  part  of 
the  patient,  whose  mental  condition  may  be  perfectly  clear.  lie  may  be 
without  any  apprehension,  even  though  his  condition  is  very  critical. 


226 


SPECIFIC  INFECTIOUS  DISEASES. 


X 


'J'lio  (llfii/iiiisls  ill  most  instances  is  readily  made  from  tlic  cliaracter  of 
the  lesion  and  the  occupation  oi'  the  patient.  \\'heu  in  doul»t,  the  exami- 
nation (j1'  the  llnid  Troni  tiie  jnistuie  may  .sliow  the  presence  of  liie  anthrax 
haeilii.  Cultures  sliould  he  made,  or  a  mouse  or  guinea-pi^'  inoculated 
from  the  local  lesion.  Jt  is  to  be  rememlx'red  that  the  blood  may  not  show 
the  bacilli  in  nunil)ers  until  shortly  i)efore  death. 

(v^)  Internal  Anthrax. 

(a)  Inicstinal  Form,  Mycosis  infest inalis. — Jn  these  cases  the  infection 
usually  is  through  the  stomach  and  intestines,  and  results  from  eating  the 
ik'sli  or  drinking  the  milk  of  diseased  animals;  it  may,  however,  follow  an 
external  infection  if  the  germs  are  carried  to  the  mouth.  I'he  symptoms 
are  those  of  intense  ])oisoning.  The  disease  may  set  in  with  a  chill,  fol- 
lowed by  vomiting,  diarrlnea,  moderate  fever,  and  pains  in  the  legs  and 
back.  Jn  acute  cases  there  are  dyspnwa,  cyanosis,  great  anxiety  and  rest- 
lessness, and  toward  the  end  convulsions  or  S])asnis  of  the  muscles.  Uo-MU- 
orrhage  may  occur  from  the  uincous  membranes.  Occasionally  there  are 
small  ])Iilegmonous  areas  on  the  skin,  or  jietechi.t'  develop,  'i'he  spleen  is 
enlarged.  The  blood  is  dark  and  remains  lluid  for  a  long  time  after  death. 
Late  in  the  disease  the  Ijacilli  may  be  found  in  the  blood. 

This  is  one  of  the  forms  of  acute  ])oisoning  which  may  all'ect  many  in- 
dividuals together.  Thus  Butler  and  Karl  Iluber  describe  an  epidemic 
in  which  twenty-five  ])ersons  were  attacked  after  eating  the  flesh  of  an 
animal  which  had  had  anthrax.  Six  died  in  from  forty-eight  hours  to 
seven  days. 

(h)  Wool-sorter's  Disease. — This  important  form  of  anthrax  is  foujid 
in  the  large  establishments  in  which  wool  or  hair  is  sorted  and  cleansed. 
The  hair  and  wool  imported  into  Europe  from  Eussia  and  South  America 
appear  to  have  induced  the  largest  number  of  cases.  Many  of  these  show 
no  external  lesion.  The  infective  material  has  been  swallowed  or  inhaled 
with  the  dust.  There  are  rarely  premonitory  symptoms.  The  patient  is 
seized  with  a  chill,  becomes  faint  and  prostrated,  has  pains  in  the  back 
and  legs,  and  the  temperature  rises  to  102°  or  103°.  The  breathing  is 
ra])id,  and  he  comi)lains  of  much  i)ain  in  the  chest.  There  may  be  a  cough 
and  signs  of  bronchitis.  So  prominent  in  some  instances  are  these  hron- 
chial  symptoms  that  a  pulmonary  form  of  the  disease  lias  been  described. 
The  ])ulse  is  feel^le  and  very  rapid.  There  may  be  vomiting,  and  death 
may  occur  within  twenty-four  hours  with  symjitoms  of  ])rofound  collapse 
and  })rostration.  Other  cases  are  more  protracted,  and  there  nuiy  be  diar- 
rhci'a,  delirium,  and  unconsciousness.  The  cerebral  symiitoms  may  be 
most  intense;  in  at  least  four  cases  the  brain  seems  to  have  been  chiefly 
alfected,  and  its  capillaries  stuffed  with  bacilli  (^lerkel).  The  recognition 
of  wool-sorter's  disease  as  a  form  of  anthrax  is  due  to  J.  II.  Bell,  of  l^rad- 
ford,  England. 

In  certain  instances  those  profound  constitutional  sym]itoms  of  internal 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

'^riie  rnfi-pirlrrs  disease  has  been  made  the  subject  of  an  exhaustive 
study  by  Epjiinger  (Die  TIadernkrankheit,  Jena,  189^),  who  has  shown  that 
it  is  a  local  anthrax  of  the  hmgs  and  pleura,  with  general  infection. 


IIYDROPHOIUA. 


22; 


tor\' 


The  dlafrnosis  of  jntornal  anthrax  is  l)y  no  iiioans  easy,  unless  the  his- 
ints  (It'dnitfly  to  inlVttion  in  tlic  ufciiiuilicni  of  t!ie  individual. 

Treatment. — In  maliynant  pustule  the  site  of  inoculation  should  he 
destroyed  \)y  the  cuustie  or  hot  iron,  and  [)()\V(h're(l  hi(  ldoi'i(k'  of  nieri'ury 
may  he  s]»riid\led  over  tlie  exposed  surface.  'J'he  hxal  development  of  the 
hacilli  ahont  the  site  of  inoculation  may  he  prevented  ljy  the  sid)eutaneous 
injections  of  sohitions  of  carlxilic  acid  or  l)irhhtride  of  mercury,  'i'iie 
injections  should  he  nuule  at  various  points  around  the  ])ustuh',  and  may 
he  repeated  two  or  three  times  a  day.  'J'he  internal  treatment  shouhl  lie 
conlined  to  the  adndnistration  of  stimulants  and  jtlenty  of  nutritious  food. 
Davies-Colley  advi.ses  i])ecacuanha  i)o\vder  in  doses  of  fi'om  o  to  10  grains 
every  three  or  four  hours. 

In  malignant  forms,  particularly  the  intestinal  cast's,  little  can  he  done. 
Active  pur<:atives  luay  he  given  at  the  outset,  so  as  to  remove  the  infect- 
ing material.     (Quinine  in  large  doses  has  heen  recommended. 


fonncl 

ansed. 

uerica 

how 

laled 

nt  is 

jack 


mg 


IS 


)ron- 

■iDcd. 

death 

lapse 

diar- 

nv   ho 

.•hiefly 

nition 

r.rad- 

tcrnal 
le. 

n.stive 
n  that 


XXVIII.    HYDROPHOBIA. 

{Lyssa ;  liuhifs.) 

Definition. — An  acute  disease  of  warm-hlooded  animals,  dependent 
upon  a  specilic  virus,  and  communicated  hy  inoculation  to  man. 

Etiology. — In  man  the  disease  is  very  variously  distrihuted.  In  lUis- 
sia  it  is  common.  In  Xorth  Germany  it  is  extremely  rare,  owing  to  the 
wise  provision  that  all  dogs  shall  he  muzzled;  in  ]''ngland  and  France  it  is 
much  more  common.  Jn  this  country  the  disease  is  very  rare.  Dulles 
could  collect  only  78  cases  in  the  five  and  a  half  years  ending  Decemher  31, 
181)3. 

Canines  are  sjiecially  lial)le  to  the  disease.  It  is  found  most  frcfpiently 
in  the  dog,  the  wolf,  aiid  the  cat.  All  animals  are,  liov.-ever,  susceplihle; 
and  it  is  commimicahle  hy  inoculation  to  the  ox,  horse,  or  i)ig.  The  dis- 
ease is  propagated  chicily  hy  the  dog,  which  seems  specially  susceptihle. 
In  th*^  Western  States  the  skunk  is  said  to  he  very  liahle  to  the  disease. 
The  nature  of  the  poison  is  as  yet  unknown.  It  is  contained  chielly  in 
the  nervous  system  and  is  met  with  in  some  of  the  secretions,  particularly 
in  the  saliva. 

A  variahle  time  elapses  hetween  the  introduction  of  the  virus  and  the 
appearance  of  the  syin])toms.  Tlorsley  states  that  this  depends  upon  the 
following  factors:  "  (a)  Age.  The  incuhation  is  shorter  in  children  than 
in  adults.  For  ohvious  reasons  the  former  are  nu)re  frequently  attacked. 
{h)  Part  infected.  The  rapidity  of  onset  of  the  symptoms  is  greatly  de- 
termined hy  the  part  of  the  hody  which  may  happen  to  have  heen  Ititten. 
"Wounds  ahout  the  face  and  head  are  es]U'cia]ly  dangei-ous:  next  in  order 
in  degrees  of  mortality  come  hites  on  the  hands,  then  injuries  on  the  other 
parts  of  the  hody.  This  relative  ord(>r  is,  no  douht,  greatly  dejiendent 
upon  the  fact  that  the  face,  head,  and  hands  are  usually  naked,  while  the 
other  parts  are  clothed;  it  would  also  appear  to  depend  somewhat  u])on 
the  richness  in  nerves  of  the  part,     (c)  The  extent  and  severity  of  the 


22S 


SPECIFIC   INFECTIOUS   DISEASES. 


wniiiid.  I'tiiutiirc  \v(Mm<ls  arc  tlio  most  (liui<:c'n>iis;  the  lacerations  are 
faliil  ill  |)ro|i(»rti(in  to  the  extent  of  tlie  .surl'aee  alTorch'd  I'or  al)sor])tion  of 
the  virus.  ((/)  'I'he  aiiiniai  eoiiveying  the  infection.  In  order  of  decreas- 
ing severity  come:  first,  tlie  wolf;  second,  the  eat;  third,  tlie  dog;  and 
fourth,  other  animals."  Only  a  limited  numher  of  those  l)itten  by  rahid 
dogs  become  all'eeted  by  tlie  disease;  according  to  llorsley,  not  more  than 
lo  per  cent.  On  the  other  hand,  the  death-rate  of  those  i)ersons  bitten  by 
■wolves  is  higher,  not  less  than  40  per  cent.  r>al)es  gives  the  mortality  as 
from  no  to  SO  per  cent. 

The  incubation  ])eriod  in  man  is  extremely  variable.  'Die  average  is 
from  six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two  weeks. 
It  may  be  ])rolonged  to  three  months.  It  is  stated  that  the  incnbation 
may  be  ])rolonged  for  a  year  or  even  two  years,  but  this  has  not  been  defi- 
nitely settled. 

Symptoms. — Three  stages  of  the  disease  are  recognized: 

(1)  I'rcindnilorij  stdf/f,  in  which  there  niay  be  irrit..iion  about  the  bite, 
pain,  or  numbness.  The  ])atient  is  depressed  and  melancholy;  and  com- 
]»lains  of  headache  and  loss  of  a])i)etite.  He  is  very  irritable  and  sleepless, 
and  has  a  constant  sense  of  impending  danger.  There  is  often  greatly 
increased  sensi])ility.  A  bright  light  or  a  loud  voice  is  distressing.  The 
larynx  may  be  injected  and  the  first  symptoms  of  difficulty  in  swallowing 
are  experienced.  The  voice  also  becomes  husky.  There  is  a  slight  rise  in 
the  tem))erature  and  the  pulse. 

(■■?)  Sldf/e  of  Excilciiicnt. — This  is  characterized  by  great  excitability 
and  restlessness,  and  an  extreme  degree  of  hyperfesthesia.  "  Any  afferent 
stimidant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  of 
a  verbal  suggestion — will  cause  a  violent  reflex  s])asm.  In  man  this  symp- 
tom constitutes  the  most  distressing  feature  of  the  malady.  The  spasms, 
which  affect  jiarticularly  the  muscles  of  the  larynx  and  mouth,  are  exceed- 
ingly painful  and  are  accompanied  by  an  intense  sense  of  dyspna\i,  even 
when  the  glottis  is  widely  opened  or  tracheotomy  has  been  ])erformed  " 
(llorsley).  Any  attem])t  to  take  water  is  followed  by  an  intensely  painful 
spasm  of  the  muscles  of  the  larynx  and  of  the  elevators  of  the  hyoid  bone. 
It  is  this  which  makes  the  patient  dread  the  very  sight  of  water  and  gives 
the  name  lujilropliobia  to  the  disease.  These  spasmodic  attacks  may  be 
associated  with  inaniacal  symptoms.  In  the  intervals  between  them  the 
])atient  is  (piiet  and  the  mind  unclouded.  The  temperature  in  this  stage 
is  usually  elevated  and  may  reach  from  100°  to  103°.  In  some  instances  tlie 
disease  is  afebrile.  The  patient  rarely  attem]its  to  injure  his  attendants, 
and  in  the  intense  spasms  may  be  ]iarticularly  anxious  to  avoid  hurting 
any  one.  There  are,  however,  occasional  fits  of  furious  mania,  and  the 
])atient  may,  in  the  contractions  of  the  muscles  of  the  larynx  and  ])harynx, 
give  utterance  to  odd  sounds.  This  stage  lasts  from  a  day  and  a  half  to 
three  days  and  gradually  ])asses  into  the — 

(3)  raraJi/tic  Stage. — In  rodents  the  ])reliminary  and  furious  stages 
are  absent,  as  a  rule,  and  the  paralytic  stage  may  be  marked  from  the  out- 
set— the  so-called  dumb  rabies.  Tliis  stage  rarely  lasts  longer  than  from 
six  to  eighteen  hours.     The  patient  then  becomes  quiet;  the  spasms  no 


gives 


id  tb'! 


ha 


If  to 


=ta<rcs 
lie  o\it- 

from 
Ims  no 


IlVDliOl'IlOHIA. 


229 


I 


loiifzcr  occur;  uiiconsciou.*ncss  {gradually  sii|)orvcncs;  the  heart's  action  hc- 
coiiH's  iHore  and  more  eiifeehled,  and  death  occurs  by  syncope. 

Morbid  Anatomy.-  The  K'sions  arc  in  tlic  ccrcl)r<)-spinal  system. 
The  blood-vessels  are  coniicsted;  tiicro  is  jicrivascuhir  cxuchition  of  leuco- 
cytes; and  there  arc  minute  ha-niorrhagcs.  Accordinj^  to  (lowers,  these 
are  ])articularly  intense  in  the  nicdidla.  The  pharynx  is  congested,  the 
mucous  mend)rane  of  the  stomach  is  hyperuMuic,  and  not  infre(piently  cov- 
ered with  a  blood-stained  mucus.  The  larynx,  trachea,  and  bronchi  show 
acute  congestion.  There  are  no  special  changes  in  the  abdominal  or  tho- 
racic viscera.  The  inoculation  experiments  show  that  the  virus  is  not  pres- 
ent in  the  liver,  spleen,  or  kidneys,  but  is  abundant  in  the  si)innl  cord, 
brain,  and  jjcripheral  nerves. 

Treatment. — Prophylaxis  is  of  the  greatest  importance,  and  by  a 
systematic  muzzling  of  dogs  the  disease  can  be,  as  in  CJermany,  jjractically 
eradicated. 

The  l)ites  should  be  carefully  washed  and  thoroughly  cauterized  with 
caustic  ])otash  or  concentrated  carbolic  acid.  It  is  best  to  keep  the  wouml 
constantly  open  for  at  least  five  or  six  weeks.  When  once  estal)lished  the 
disease  is  hopelessly  incurable.  Xo  measures  have  been  found  of  the  slight- 
est avail,  conse(iuently  the  treatment  must  be  ])alliative.  The  patient 
should  be  kept  in  a  darkened  room,  in  charge  of  not  more  than  two  care- 
ful attendants.  '^J'o  allay  the  spasm,  chloroform  may  be  administered  and 
morphia  given  hy])oderniically.  It  is  l)cst  to  use  these  powerful  remedies 
from  the  outset,  and  not  to  temporize  with  chloral,  broudde  of  })otassium, 
and  other  less  potent  drugs.  }\y  the  local  ajiplication  of  cocaine,  the  sensi- 
tiveness of  the  throat  may  be  diminished  suHiciently  to  enal)le  the  ])atient 
to  take  liquid  nourishment.  Sometimes  he  can  swallow  readily.  Xutrient 
cnemata  should  l)e  administered. 

Preventive  Inoculation. — Pasteur  has  found  that  the  virus,  when  ])ropa- 
gated  through  a  series  of  rabbits,  increases  rai)idly  in  its  virulence;  so  that 
whereas  subdural  inoculation  from  the  brain  of  a  mad  dog  takes  from  fif- 
teen to  twenty  days  to  produce  the  disease,  in  successive  inoculations  in  a 
series  of  rabljits  tlie  incidjation  ])eriod  is  gradually  reduced  to  seven  days 
(rirvs  fixe).  The  s))inal  cords  of  these  rabbits  contain  the  virus  in  great 
intensity,  but  when  tliey  are  ])reservcd  in  dry  air  this  gradually  dinunishcs. 
If  now  dogs  are  inoculated  from  cords  preserved  for  from  twelve  to  fifteen 
days,  and  then  from  cords  preserved  for  a  shorter  period,  i.  e.,  with  a  pro- 
gressively stronger  virus,  they  gradually  acquire  immunity  against  the  dis- 
ease. A  dog  treated  in  this  way  will  resist  inoculation  with  the  virus  fixe, 
which  otherwise  would  inevitably  have  proved  fatal.  Relying  upon  these 
exiterimcnts,  Pasteur  began  inoculations  in  the  human  subject,  using,  on 
successive  days,  material  from  cords  in  which  the  virus  was  of  varying 
degrees  of  intensity. 

There  is  still  some  discussion  as  to  the  full  value  of  this  method,  but 
the  statistics  published  annually  from  the  Pasteur  Institute  seem  to  prove 
conclusively  its  importance  as  a  protective  measure  in  man.  The  figures 
given  hy  Pottcvin,  being  the  cases  treated  in  Paris  from  ISSfi  to  1894  in- 
clusive, show  that  of  13,817  persons  bitten  the  mortality  was  0.5  per  cent. 


230 


SPECIFIC  INFIX'TIOL'S  DISKASES. 


I 


\ 


Of  tlicso,  1,317  were  l)itt('n  on  the  head,  the  luortnlity  hoinfr  1.-^'  p<'r  cent; 
hi,7".'",'  ou  llio  hands,  with  (>.'(!  per  ci'iit  of  (l"alh.s;  and  .j,TiCi  on  other  parts 
of  tlio  hody,  with  a  ni<»rtality  of  O.'^S  \w\  cent. 

Diagnosis. — AftiT  tiu-  syiii|t|onis  of  the  disease  hav(»  devehipi'd  in 
man  the  diagnosis  shoiihl  otVer  no  t'S|)eeial  dillicidties.  It  is  ndvisal)le,  in 
cases  atlen(k'(l  witii  any  (h)ulits,  as  soon  as  possiMe  after  the  injury  has  heen 
inllieted,  to  secure  the  niedidia  ohion^ata  of  tiie  supposed  rahid  animal  for 
the  pnr]K)so  of  inoculatinjf  rahhits.  The  snlnliiral  inocuhition  of  ral)hits 
uitli  a  small  (piantity  of  the  central  nervous  system  of  a  rahid  aninuil  will 
he  followed  hy  the  development  of  the  paralyti''  form  of  the  disease  in  from 
lifteen  to  twenty  days. 

Pseudo-hydrophobia  (Lyssophobia). — This  is  a  very  interesting 
nll'ection,  which  may  closely  resemhle  hydrophohia,  hut  is  really  nothin^j,' 
more  than  a  TU'urotic  or  hysterical  numifestation.  A  nervous  person  hitten 
liy  a  do<x,  either  i'al)i(I  or  supposed  to  he  rahid,  develo|)s  within  a  few  months, 
or  even  later,  symjitoms  somewhat  resend)lin^y  the  true  disease,  lie  is  irri- 
tahle  and  depressed.  He  constantly  declares  his  condition  to  he  serious 
and  that  he  will  inevitahly  hecome  mad.  He  may  Inive  ])aroxysms  in  which 
lie  says  he  is  unahle  to  drink,  <:ras])s  at  his  throat,  and  hecomes  emotional. 
The  temperature  is  iu)t  elevated  and  the  disease  does  not  proj^ress.  It  lasts 
mucli  lon<fer  than  the  true  ral)ies,  and  is  amenahlc  to  treatment.  It  is  not 
improhahle  that  a  majority  of  the  cases  of  alleged  recovery  in  this  disease 
have  ()een  of  this  hysterical  form.  In  a  case  which  I>urr  reported  from 
my  clinic  a  few  years  ago  the  ])atient  had  ])ar().\ysnuil  attacks  in  which  he 
could  not  swallow.  He  was  greatly  excited  and  alarmed  at  the  sight  of 
water  and  was  extremely  emotional.  The  syni]itoms  lasted  for  a  couple  of 
weeks  and  yielded  to  treatment  with  powerful  electrical  currents. 


XXIX.    TETANUS. 

Definition. — An  infectious  malady  characterized  hy  tonic  spasms  of 
the  muscles  with  marked  exaccrhations.  The  virus  is  ])roduced  hy  a 
hacillns  which  occurs  in  earth  and  sometimes  in  putrefying  fluids  and 
manure. 

Etiology. — It  occurs  as  an  idiopathic  alfection  or  follows  trauma.  It 
is  fre(pient  in  some  localities  and  Ims  prevailed  extensively  in  ejiidemic 
form  among  new-horn  children,  when  it  is  known  as  tetanus  or  trismus 
neonatorum.  It  is  more  common  in  hot  than  in  temjierate  climates,  and 
in  the  colored  than  in  the  Caucasian  race.  This  is  ]»articnlar]y  the  case 
with  tetanus  following  confinement  and  in  tetanus  neonatorum.  In  cer- 
tain of  the  AVest  Indian  Islands  moi'c  than  one  half  of  tlie  mortality  among 
the  lU'gro  children  has  heen  due  to  this  cause.  St.  Hilda,  one  of  the  west- 
ern Hehrides,  had  heen  scourged  for  years  hy  the  "eight  days'  sickness"' 
among  the  new-horn.  Of  r^.5  children,  S4  died  within  fourteen  days  of 
hirth.  Since  the  discovery  of  the  tetanus  hacillns,  some  ])hilanthroiiic  peo- 
ple in  Glasgow  sent  a  nurse  to  the  island,  who  taught  the  midwives  to  uso 


TETANUS. 


231 


ilit  of 
)le  of 


nis  of 
by   a 
and 


la. 


It 
;lonii(.' 

-,  and 
c  case 
n  cer- 
ninnji 

Wl'St- 

nes? "' 
lYS   of 
poo- 
to  nse 


iodoform  nn  the  nav(^l.  Tlic  disi'iisc  lias  now  |)rac'tk'ally  disap|K'arfd 
('riirniT).  In  a  majdrity  <d'  the  lases  tlieiv  is  an  injury  which  may  bo  ol' 
tiic  most  trillinjf  character.  It  is  more  common  after  punctured  and  con- 
tused tiian  alter  incised  wounds,  and  l"re(|Uentiy  I'oihtws  those  of  tlie  iuinds 
and  feet.  The  symptoms  usually  appear  within  two  weeks  of  liie  injury.  In 
some  military  campaif,Mis  tetanus  has  prevailed  extensively,  hut  in  otiu-rs, 
as  in  the  late  civil  war,  the  cases  have  heen  comparatively  few.  Idiopathic 
tetanus  is  rare  in  man,  hut  it  has  sometimes  followed  exposure  to  cold  or 
sleepin<j:  on  the  damp  <,'round.  The  disease  has  occurred  after  })rolonged 
nse  of  the  hy])()denine  needle  for  mor|»hia  and  (pdniiu;  injections. 

The  infectious  nature  of  tetanus  was  su<,fgested  by  its  endemic  occur- 
rence and  from  the  manner  of  its  behavior  in  certain  institutions.  Vet- 
erinarians have  lonf,'  been  of  this  belief,  as  cases  are  apt  to  occur  toj^ether 
in  horses  in  one  stable.  On  the  eastern  end  of  Lonj,'  Island,  where  formerly 
the  disi'ase  was  very  ))revalent,  it  is  now  rarely  seen. 

The  Tetanus  Bacillus. — The  observations  of  I'osenbach,  Xicola'ier,  and 
Kitasato  have  demonstrated  that  there  is  in  connection  with  the  disease  a 
specific  orjianism  which  can  be  isolated  and  cnltivaled.  The  bacillus  forms 
a  slender  rod,  which  may  "^-row  into  lon;^'  threads.  One  end  is  often  swollen 
and  occu])ied  by  a  spore.  It  is  motile,  ^^rows  at  ordimiry  temperatures,  and 
is  anai'robic.  The  bacilli  develop  at  the  site  of  the  wound  (and  do  not  in- 
vade the  blood  and  orj^ans),  where  alone  the  toxine  is  manufactured.  With 
small  qnantities  of  the  culture  the  disease  may  be  transnutte(l  to  aiumals, 
which  die  with  symptoms  of  tetanus.  The  poison  is  a  tox-all)umin  of 
extraordinary  ])olency,  which  luis  been  separated  by  IW'iej^er  and  Colin 
in  a  state  of  tolerable  purity,  it  is  ])erliaps  the  most  virulent  poison  known. 
Whereas  the  fatal  dose  of  strychnine  for  a  man  weighinji;  70  kilos  is  from 
30  to  100  milligrammes,  that  of  the  tetanus  toxine  is  estimated  at  0.'^3 
milligrammes,  i'hery  feature  of  the  disease  can  be  produced  by  it  exi)eri- 
mentally  without  the  ])resence  of  the  bacilli.  The  symptoms  do  not  develop 
imniediately,  as  in  the  case  of  ordinary  ])oisons,  but  slowly,  and  it  has  been 
suggested  that  it  acts  only  after  nndergoing  some  further  changes  in  the 
body.  Another  ])o;nt  of  interest  is  the  fact  that  immunity  can  be  jirocured 
by  inoculating  an  animal  with  the  blood  of  another  which  has  had  the 
disease.  The  organism  has  been  fonnd  in  the  earth  and  in  initrel'ying  tluids, 
and  Xicolai'er  has  caused  the  disease  by  inoculating  with  did'erent  sorts  of 
surface  soil.  Animals  have  been  rendered  immune  to  the  tetanus  poison 
and  a  curative  serum  has  been  jirejiared.  This  serum  has  .'U  used  suc- 
cessfully in  ])reventing  and  even  curing  the  ex])eriiiiental  form  of  the  dis- 
ease,    '^riie  results  in  man  are  as  yet  doubtful. 

Morbid  Anatomy. — Xo  characteristic  lesions  liav(>  lieen  found  in 
the  cord  or  in  the  brain.  Congestions  occur  in  ditterent  parts,  and  peri- 
vascular exudations  and  granular  changes  in  the  nerve-cells  have  been 
found.  The  condition  of  the  wound  is  variable.  The  nerves  are  often 
found  injured,  reddened,  and  swollen.  In  the  tetanus  neonatorum  tlic  um- 
1  ilicus  may  be  inflamed. 

Symptoms. — After  an  injury  the  disease  sets  in  usually  within  ton 
days.    In  Yandeirs  statistics  iu  at  least  two  fifths,  and  in  Joseph  Jones's 


l> 


232 


Sl'KCn'MC   INKKCTIOUS   DlSKASIX 


/ 


in  four  fit'tlis,  the  syiii|it(iiiis  occiirrcfl  hcforc  (lii>  lil'U'ciilli  diiy.  The  pn- 
tic'iit  coiiiplaiiis  at  \'\\A  u[  hli^flil  stilViicss  in  (lie  neck,  or  a  IVi'linj,'  o|'  ti;;lit- 
nt'SH  in  tiic  jnwH,  or  (liHii'iilty  in  mastication.  Occasionally  chilly  ffclin;;s 
or  actual  rij,'ors  may  |u'c((m|c  these  symptoms,  (jradually  a  tonic  spasm 
of  the  muscles  of  these  jtiirts  des'elops,  pnujueinj,'  the  condition  of  trismus 
or  lockjaw.  The  eyehrows  may  he  raised  ami  the  an;,des  of  the  mouth 
drawn  old,  causing  the  so-called  sardonic  grin — riann  sitnloiiicus.  In  chil- 
dren the  spasm  may  he  confined  to  these  parts.  Sometimes  the  attack 
is  associated  with  paralysis  of  the  facial  muscles  and  ditVieidty  in  swallow- 
ing— the  head-tetanus  ol'  Hose,  which  has  most  commonly  followed  injuries 
in  till'  ni'ighhorhood  of  the  fifth  ni-rve.  (Jradiudly  the  process  extends 
and  involves  the  muscles  of  the  body.  Those  of  the  hack  are  most  ntrectcd, 
BO  that  during  the  spasm  the  unfortunate  victim  nuiy  rest  upon  the  head 
and  heels — a  position  known  as  ojtlsllnttoiUDi.  'V\\o  rectus  ahdonnnalis  mus- 
cle has  heen  torn  across  in  the  spasm.  The  entire  truidc  and  liiid)s  may 
he  |)erl'ectly  rigid — orlholoims.  Flexion  to  one  side  is  less  common — plcuro- 
{lidloiiiis;  while  spasm  of  the  muscles  of  the  ahdomen  may  cause  the  body 
to  be  bent  forward — niiprDsllioloiKis.  In  very  violent  attacks  the  thorax  is 
comi)ressed,  the  res|)irations  are  rapid,  and  spasm  of  the  glottis  may  occur, 
causing  as|)hyxia.  'J'he  ]»aroxysms  last  for  a  variable  jieriod,  but  even  in 
the  intervals  the  relaxation  is  not  com])lete.  The  slightest  irritation  is 
puflicient  to  cause  a  spasm.  The  ])aroxysms  arc  associated  with  agonizing 
jiain,  and  the  ])atient  nuiy  be  held  as  in  a  vice,  iniable  to  utter  a  word. 
I'sually  he  is  bathed  in  a  ])rofuse  sweat.  The  temperature  may  remain 
iiornuil  throughout,  or  show  only  a  slight  elevation  toward  the  close.  In 
other  cases  the  pyrexia  is  marked  from  the  outset;  the  temjjerature  reaches 
105°  or  10()°,  and  before  death  10!)°  or  110°.  In  rare  instances  it  may  go 
still  higher.  iJeath  either  occurs  during  the  })aroxysm  from  heart-failure 
or  as])hyxia,  or  is  due  to  exhaustion. 

The  ce])]ialic  tetanus  {I\oj)ffrtnniis  of  Kose)  originates  usually  from  a 
wound  on  one  side  of  the  liead,  and  is  characterized  by  stiffness  of  the 
muscles  of  the  jaw  and  paralysis  of  the  facial  muscles  on  the  same  side  as 
the  wound,  with  dilliculty  in  swallowing. 

The  prognosis  is  good  in  the  chronic  cases;  of  these,  in  Willard's  table 
only  8  of  32  died;  but  in  the  acute  form,  of  45  cases,  only  -1  recovered. 

Diagnosis. — Well-developed  cases  following  a  trauma  could  not  ];e 
mistaken  for  any  other  disease.  The  spasms  are  not  unlike  those  of 
strychnia-])oisoning,  and  in  the  cek'brated  Palmer  murder  trial  this  was 
the  plea  for  the  defence.  The  jaw-muscles,  however,  are  never  involved 
early,  if  at  all,  and  between  the  paroxysms  in  strychnia-poisoning  there 
is  no  rigidity.  In  tetany  the  distribution  of  the  s]iasm  at  the  extremities, 
the  ])eculiar  position,  the  greater  involvement  of  the  hands,  and  the  con- 
dition under  which  it  occurs,  are  sufTicient  to  make  the  diagnosis  clear.  In 
doubtful  cases  cultures  should  be  made  from  the  pus  of  the  wound. 

Prognosis. — Two  of  the  ITippocratic  aphorisms  express  tersely  the 
general  prognosis  even  at  the  present  day:  "  The  s])asm  su])ervening  on  a 
wound  is  fatal,"  and  "  such  persons  as  are  seized  with  tetanus  die  within 
four  days,  or  if  they  pass  these  they  recover." 


UliANDKIlS. 


s^aa 


Til 


_  lie  iiioriiility  in  tlio  triiiiiiiiilic  ciihos  i«  not  li'ss  tliaii  SO  pi-r  cvut  (f'nn- 
iht);  i'l  tilt'  i«li«>|tatlii('  {'iisi'S  it  is  iiiukT  ."iO  |»,'r  cent.  Acconliii;,'  (o  Yiiiitlcll, 
the  niorlnlily  is  j:r<'iitcst  in  cliililrcn.  l-'avurnliit'  indiciitions  an-:  late  (tnsct 
di"  till'  altacix,  lo;  iiii>)itii)n  ol'  llu'  spacnis  to  liii'  niiiMlcfj  (tf  tlic  ncik  and  jau, 
and  nn  altncnco  of  I'cvcr. 

Treatment.  —  Local  trcatmont  of  the  wound  is  osscntial,  ns  tho  poison 
is  niaiiiifactin'cd  here,  'riz/mii  advises  nitniti'  of  silver  as  the  licst  ^ernii- 
I'ide  for  the  tetanus  bacillus.     'l'liorou;,di  excision  and  antiseptic  treatnuMil 

should  1)0  carried  out.     The  patient  should  he  kept  in  a  darkened  i ni, 

ahsojutely  (|uiet,  and  attended  hy  ojdy  oiu'  ]»erson.  .\ll  possihli-  sources 
of  irritation  should  he  avoided.  \'eterinarians  appreciate  the  importance 
of  this  complete  seclusion,  and  in  well-ecpiipped  inliniuiries  there  may  he 
seen  a  brick  pa<lded  chamber  in   which  the  horses  are  treated. 

When  the  lockjaw  is  extreme  the  patient  may  not  be  able  to  take  food 
hy  the  nH)uth,  under  which  circiinistam-es  it  is  best  to  use  rectal  injections, 
or  to  feed  by  ii  catheter  jtassed  throujih  the  nose.  The  spasm  sluudd  be 
controlled  hy  chloroform,  which  may  be  rt'peatcdly  exiiibited  nt  intervals. 
It  is  nioro  satisfactory  to  keep  the  patient  thorou^ihly  under  the  inllueiu'e 
of  morphia  jiiveii  hypoderndcally.     Chloral  hydrate,  bromide  of  potassium. 

Calabar  beau,  curara,  liuliau  hemp,  belladonna,  and  other  dru;^s  have  I n 

rcfommended,  and  recovery  occasionally  follows  their  use.  It  is  very  dilli- 
cult  to  estinude  the  value  of  the  blood-serum  therapy  in  this  disease,  'i'iz- 
zoni  and  Cantani  have  xi.sed  an  antitoxino  ])repare(l  from  the  blood-serum 
of  immunized  aiunuds.  The  material,  which  is  now  to  be  obtained  from 
]\rerck,  is  in  the  dried  state,  and  comes  in  tubes  containing  4  to  o  <rrammes. 
It  can  he  bou<,dit  in  this  country  from  his  a<;ents.  An  antitoxino  si'rum 
is  also  prepared  hy  JJehrinf?  and  hy  Ifonx.  Of  the  fluid  scrum  20  to  30  cc. 
may  he  used  for  the  first  dose  and  lo  to  20  oc.  every  five  or  ten  hours  after. 
Tizzoni  advises  2.25  <>:rammes  of  his  antitoxino  for  the  first  dose  and  O.H 
gramnu'S  for  snl)SO<|uent  doses.  (Jooderich  has  collected  11:?  cases  treated 
with  the  antitoxino,  with  n3  per  cent  of  recoveries.  The  Tizzoni  product 
has  been  the  most  successful. 


» 


table 
•od. 
not  he 
ose  of 
lis  was 
ivolved 

there 
Imities, 
[o  con- 
ir.    In 

[ly  the 
on  a 


Iw 


ithin 


XXX.    GLANDERS   (Farcy). 

Definition. — An  infections  disease  of  the  horse,  communicated  occa- 
sionally to  man.  In  the  horse  it  is  clinractorized  by  the  formation  of 
nodules,  chiefly  in  the  naros  ("landers)  and  beneath  the  skin  (farcy). 

Etiology. — The  disease  belon<;s  to  the  infective  granulomata.  The 
local  manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to 
one  and  the  same  cause.  Tlie  specific  <:erm,  harilliis  mallei,  was  discovered 
hy  Loofller  and  Schiitz.  It  is  a  shoi't,  non-motilo  bacillus,  not  unlike  that 
of  ^-uhcrclo,  hut  exhibits  dill'erent  staiidntr  reactions.  It  fjrows  readily  on 
the  ordinary  culture  media.  For  the  full  recofrnition  of  j^landors  in  man 
Ave  are  indebted  to  the  labors  of  IJayer,  whose  mono<>raph  remains  one  of 
the  best  (h'scriittions  ever  piven  of  the  disease.  ^Fan  becomes  infected  l)y 
contact  with  diseased  animals,  and  usually  by  inoculation  on  an  abraded 


284 


SPKCIITC   INFKfTlorS  PISKASKS. 


X 


hlirfiico  of  llic  sixiii,  'I'lic  toiitfi^'ioli  iiiilV  lllx)  lie  rcccivnl  oil  llic  milcoiH 
iiu'iiiliiaiic.  Ill  «iiit'  (»r  till'  Muiitri'ul  lascH  a  ^ii'iitlciiiun  was  |»n»l»alily  iii- 
iVctt'd  l»y  the  material  cxiicllcd  I'min  the  iKwtril  of  liin  Imrsi",  wliitli  uns 
not  ^iis|ir(tc(l  til"  liaviii;,'  the  disease. 

Morbid  Anatomy. — As  in  tlie  hoiv-e,  the  disease  may  he  loeali/ed 
ill  till'  nose  (;:laiideis)  or  heneatli  the  skin  (I'arey).  Tho  csHeiitial  lesion 
is  tho  jrramiloiiiatoiis  tumor,  cliaraeterizeil  hy  the  presonet'  <d'  iiiimeroiirt 
lyiii|>lioid  and  epithelioid  cells,  amon|f  and  in  wliieh  are  seen  the  ^danders 
haeilli.  'I'lu'se  nodular  masses  tend  to  hreak  down  riipidly,  and  on  the 
liiiieons  nieiiiliniiie  roiill  in  ulcers,  while  heiiealh  the  skin  they  lonn  ah- 
Ht't'sses.     The  t:landers  immIiiIcs  may  also  occur  in  the  internal  <ir;.nins. 

Symptoms. — An  acute  and  a  ehroiiie  form  of  ^.danders  may  he  reco;,'- 
ni/cd  in  iiiiin,  mid  an  aeiite  and  a  chronic  i.triii  oi'  farcy. 

Acute  Glanders. — The  period  of  incuhation  is  rarely  more  than  three 
or  four  days.  There  arc  sijims  vi  ^a-neral  IVhrile  distnrhance.  At  the  nite 
<d'  infection  there  nre  .^wellin;;,  redness,  and  lymphan^ritis.  Within  two  (tr 
three  days  there  is  invtdveiiient  <d'  the  iniicoiis  inenihrane  of  the  nose,  the 
nodules  hreak  down  rapidly  to  ulcers,  and  there  is  a  mnco-piiruleiit  dis- 
charjre.  i\ii  eruption  of  papules,  which  ra|»idly  hccome  pustules,  hri-aks 
out  over  the  face  and  altout  the  joints,  it  has  hccii  mistaken  for  variola. 
This  was  carefully  studied  hy  Uayer  and  is  (i<;ured  in  his  nionof,n'apli.  In 
n  ^lontrcal  case  this  copious  eruption  h'd  the  attending,'  physician  to  sns- 
jiect  siiiall-po.\.  and  the  patient  was  isolated.  'I'liere  is  ^jreat  swcllin;^  of 
the  nose.  The  ulceration  may  ^^o  on  to  necrosis,  in  which  case  the  discharf^e 
is  very  otVcnsivc.  The  lyin|)h-j'laiids  of  tin  neck  are  usually  much  en- 
lar;,fcd.  Siihaciitc  ])iiciinionia  is  very  apt  to  develop.  This  form  runs  itn 
course  in  ahout  ci<:lit  or  ten  days,  and  is  invariaiily  fatal. 

Chronic  glanders  is  rare  and  dilV'cnlt  to  dia^nio.«e,  as  it  is  nsnally  nii.s- 
takeii  lor  a  chronic  coryza.  There  are  nlccrs  in  the  nose,  and  often  laryn- 
•."■eal  symptoms,  it  may  last  for  months,  or  even  loii.uer,  and  recovery  some- 
tiiiu's  takes  place.  Tcdeschi  has  descrihed  a  case  of  chronic  ostecjinyelitis. 
i]uv  to  the  hacilliis  iiiiillei.  which  was  lollowed  hy  a  fatal  glanders  menin- 
gitis. The  diajrnosis  may  Ik'  extremely  dillicult.  In  such  cases  a  suspen- 
sion of  the  secretion,  or  of  cultures  upon  ajjjar-a^jar  made  from  the  secre- 
tion, should  he  injected  into  the  peritoneal  cavity  of  a  male  ;,niinca-pi,ir. 
At  the  end  of  two  days,  in  positive  cases,  the  testicles  are  found  to  he 
swollen  and  the  skin  of  the  scrotum  reddened.  The  testicles  continue  to 
increase  in  size,  and  (inally  fup])urate.  Death  takes  place  after  the  lapse 
of  two  or  three  weeks,  and  freneralized  ^danders  nodules  are  found  in  the 
viscera.  The  use  (d'  niallcin  for  diagnostic  purposes  is  hij^hly  recommended. 
The  ])rinci|)lcs  and  methods  of  apjjlication  are  the  same  as  for  tuherciilin. 

Acute  farcy  in  num  results  usually  frcun  the  inoculation  of  the  virus 
into  the  skin.  There  is  an  intense  local  reaction  with  a  ])hle<;inonous  in- 
flammation. The  lymphatics  are  early  ail'ct-ted.  and  alonsr  their  course 
there  are  nodular  suixiitaneous  cnlar^jfcmeuts,  the  so-called  farcy  Inids, 
•which  may  rajiidly  <ro  on  to  suppui'ation.  There  are  ])ains  and  swelling 
in  the  joints  and  abscesses  may  form  in  the  muscles.  The  symptoms  are 
those  of  an  acute  infection,  almost  like  an  acute  septicaemia.     The  nose  is 


ACTINOMYCOSIS. 


235 


iiof  iiivttlvcfl  luul  llic  sii|H'rn(iiiI  .<l<in  <'ni|»tion  is  not  fomiiKUi.  'I'lic  'uu-illi 
liiive  liccii  t'oiiinl  in  tli<'  urine  in  iiciitc  cnsrs  in  niiin  ami  aninials. 

Till'  (lix'a.-r  is  fatal  in  a  lai';;t'  |trn|i<»iliiin  <>1'  ihc  tafff*,  UfUally  in  I'niiii 
twt'lvL"  t(»   lirtccn   tlavrt. 

Chronic  farcy  is  cliaractiTizt'd  liy  tlic  prcsfncf  of  I(»cnlizi'(|  Inniors,  usu- 
ally in  lilt'  t'Niri'niitics.  'I'licsr  liiniDi's  lirt'aU  down  inin  aWsccsscs,  and  si»nit'- 
tinii's  I'di'ni  (lt'r|i  ulcers,  uitliniii  uiudi  iullaniniatory  reaction  ami  uitluuit 
s|M'(-ial  involvcnu'nt  of  the  lyui|iluities.  The  disease  may  lust  for  months 
or  i'\en  years.  Death  may  le-ult  I'lom  pyu'inia,  ov  occasionally  aeutt'  jjlan- 
ders  devejoiis.  The  cclcliiiitc(|  |''rcuch  \ clci'inarian  Uouley  hati  it  and  re- 
eovel'ed. 

The  disease  is  ti'aiismissihle  al.-o  IVoni  niiin  to  man.  Washerwomen 
have  heen  infected  fi'om  llie  clothes  (»f  a  |tatieut.  In  the  dia;,'nosis  of  this 
aU'eetion  the  oeeupation  is  very  im|iortant.  Nowadays,  in  eases  of  donht, 
the  iuitculation  shoidd  he  made  in  aniu)als.  as  in  this  way  the  disease  can 
he  readily  deleruniicd.  Mallein,  a  |>i'o(luct  of  the  ^M'owth  of  (he  hacilli.  is 
now  used  for  'le  purpose  of  dia;i'n(»sin«;  f,danders  in  animals.  Sevral  in- 
stances of  cnre.i  ;ilantlers  have  heen  reported  in  animals  treated  wi!h  small 
and  repciitc(|  doves  of  mallein  (I'ilavios,  llahcs). 

Treatment. — If  seen  e!'.rly,  the  wound  ,-liould  hi'  either  cut  out  or 
thorou;^hly  destroyed  hy  eausties  and  an  antiseptic  dressing'  pplied.  The 
farcy  hilds  should  he  early  opened.  In  llie  acute  cases  there  is  very  little 
hope.     In  the  chronic  cases  recovery  is  |ios>ihle.  tli(UiL:ii  (d'ten  tedious. 


■i 


XXXI.   ACTINOIVJYCOSIS. 


'  secre- 
u'a-pi^^ 
1   to   he 
iinie  t<i 
•  lapse 
in  the 
hended. 
•cnlin. 
|e  virus 
Ions  in- 
con  fsc 
l)mls, 
Iwelling 
Inis  are 
nose  iri 


Definition. — A  chronic  infective  disorder  produced  hy  the  actino- 
myces  or  ray-fuiii^us,  the  Slri'jihilliri.r  (tcHiKiiiijitcx. 

Etiology.— The  disease  is  widespread  amou;^  cattle,  and  occurs  also 
in  the  pi.ir.  It  was  lirst  descrihed  hy  riolliii;;er  in  the  o\,  in  which  it  forms 
the  alTeclion  known  in  this  counti-y  as  '*  hiji-jaw."  Ivvamples  of  the  dis- 
ease were  common  in  the  cattle  killed  at  the  ahaltoir  in  .Montreal.  In  man 
it  was  mentioned  hy  von  r.an«:'enheek.  who  oh<er\fd  the  "sulphur  liraius  "' 
in  the  characteristic  purulent  material.  The  first  accurate  description  of 
the  disease  was  «>'iv<'n  hy  d.-mu's  Israel,  and  suiisc(ph'iilly  Tonlick  insisted 
upon  the  identity  of  the  diseasi'  in  man  and  cattle. 

In  this  country  t<i  ^lay  1.  isits,  ahout  II  cases  have  heen  I'eco^iiized 
(Uuhriili);  in  l']ni,dand  the  disease  is  rare.  It  is  not  uneonuiioii  in  (ier- 
luany  and  I'.issia.  To  the  end  of  iS'.ci  .".iioiit  loO  cases  had  heen  descrihed 
(Jjcith,   iMlinhurjih   Hospital    I'epoils,  V(d.  ii).      It  is  nearly  lliree  tinus  as 


common  in  men  as  in  women. 


The  panisilr  l)elon,i;'s  ])rol)a1ily  to  the  Sln'iilnlhri.r  ii'rouj)  of  bacteria. 
Tn  hotli  man  ami  cattle  it  can  he  seen  in  the  pus  from  the  all'ected  rcj^ion 
as  yellowish  or  o|iaipK'  <>Tannles  from  (me  half  to  two  millimetres  in  diam- 
eter, which  are  made  up  of  cocci  and  radiating  threads,  which  ])resent 
hulhous,  club-like  terminations.  The  youngest  fxranulcs  are  jjray  in  color 
and  semi-translucent;  in  these  the  hiilhous  extremities  are  wantin,l,^  It 
15 


236 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


was  shown  l)y  Bostrum  that  the  clubbed  ends  are  the  result  of  a  hyaline, 
degenerative  change  taking  place  in  the  filaments.  The  organism  is  strik- 
ingly pleomorjjhic. 

The  parasite  has  been  successfully  cultivated,  and  the  disease  has  been 
inoculated  both  with  the  natural  and  artificially  grown  organism. 

The  Mode  of  Infection. — There  is  no  evidence  of  direct  infection  with 
the  flesh  or  milk  of  diseased  animals.  The  streptothrix  has  not  been  de- 
tected outside  the  body.  It  seems  highly  probable  that  it  is  taken  in  with 
the  food.  The  site  of  infection  in  a  majority  of  cases  in  man  and  animals  is 
in  the  mouth  or  neighboring  passages.  In  the  cow,  i)ossibly  also  in  man, 
barley  and  rye  have  been  carriers  of  the  germ. 

Morbid  Anatomy. — In  the  earliest  stages  of  its  growth  the  para- 
site gives  rise  to  a  small  granulation  tumor  not  unlike  that  produced  by 
the  haciUiis  tiiherciihsis,  wliich  contains,  in  addition  to  small  round  cells, 
epithelioid  elements  and  giant  cells.  After  it  reaches  a  certain  size  there 
is  great  proliferation  of  the  surrounding  connective  tissue,  and  the  growth 
nnvy,  particularly  in  the  jaw,  look  like,  and  was  long  mistaken  for,  osteo- 
sarcoma. Finally  suppuration  occurs,  which  in  man,  according  to  Israel, 
may  be  produced  directly  by  the  streptothrix  itself. 

Clinical  Forms. — (a)  Alimentary  Canal. — Israel  is  said  to  have 
found  the  fungus  in  the  cavities  of  carious  teeth.  The  jaw  lias  been  in- 
volved in  a  number  of  cases  in  man.  The  patient  comes  under  observation 
Avith  swelling  of  one  side  of  the  face,  or  with  a  chronic  enlargement  of  the 
jaw  which  may  simulate  sarcoma. 

The  tongue  has  been  involved  in  several  cases,  showing  small  growths, 
either  primary  or  following  disease  of  the  jaw.  In  the  intestines  the  disease 
may  occur  either  as  a  primary  or  secondary  affection.  Cases  have  been 
reported  of  perica'cal  abscess  due  to  the  germ.  An  actinomycotic  appen- 
dicitis has  been  described;  primary  actinomycosis  of  the  large  intestine 
with  metastases  has  also  been  described.  Ransom  has  found  the  actinomj-^ces 
in  the  stools.  The  liver  may  be  affected  primarily,  as  in  the  case  reported 
by  Sharkey  and  Acland.  The  actinomycotic  abscesses  present  a  reticular 
or  honeycomb-like  arrangement  (Leith). 

(b)  I  ulmonary  Actinomycosis. — In  September,  1878,  James  Israel  de- 
scril)ed  a  remarkable  mycotic  disease  of  the  lungs,  which  subsequent  ob- 
servation showed  to  l)e  the  affection  described  the  year  before  by  Jjollinger 
in  cattle.  Since  that  date  many  instances  have  been  reported  in  which 
the  lungs  were  affected.  It  is  a  chronic  infectious  pulmonary  disorder, 
characterized  by  cough,  fever,  wasting,  and  a  muco-purulent,  sometimes 
ftt'tid,  expectoration.  The  lesions  are  unilateral  in  a  majority  of  the  cases. 
Ilodenpyl  classifies  them  in  three  groups:  (1)  Lesions  of  chronic  bron- 
chitis; the  diagnosis  has  been  made  by  the  presence  of  the  actinomyces 
in  the  sputum.  (2)  ^Miliary  actinomycosis,  closely  resemlding  miliary  tuber- 
cle, but  the  nodules  are  seen  to  be  made  up  of  groups  of  fungi,  surrounded 
by  granulation  tissue.  This  form  of  pulmonary  actinomycosis  is  not  in- 
frequent in  oxen  with  advanced  disease  of  the  jaw  or  adjacent  structures. 
(3)  The  cases  in  which  there  is  more  extensive  destructive  disease  of  the 
broncho-pneumonia,  interstitial  changes,  and  abscesses,  the  latter 


lungs 


ACTINOMYCOSIS. 


237 


strik- 

s  been 

n  with 
■en  (lo- 
n  with 
umls  is 
a  man, 

e  para- 
icod  by 
d  cells, 
e  tliere 
growth 
,  osteo- 
I  Israel, 

;o  have 
)cen  in- 
ervation 
t  of  the 

Trowths, 
disease 
ve  been 
appen- 
ntestine 
noniyces 
reported 
eticulav 

Irael  de- 
lient  ob- 
iollinfier 
which 
llisorder, 
metimes 
lie  cases, 
ic  bron- 
lomyces 
[y  tuber- 
Iroundi'd 
not  in- 

'UCtlTTOS. 

|e  of  tbe 

le  latter 


forming  cavities  large  enougli  to  be  diagnosed  during  life.  Actinomycotic 
lesions  of  other  organs  are  often  ])resent  in  connection  witii  tlie  jjulmonary 
disease;  erosion  of  the  vertebra',  necrosis  of  the  ribs  and  sternum,  with 
node-like  formations,  subcutaneous  abscesses,  and  occasionally  metastases  in 
all  parts  of  the  body. 

Syinptoins. — The  fever  is  of  an  irregular  type  and  depends  largely  on 
tlie  existence  of  suppuration.  The  cough  is  an  important  symptom,  and 
the  diagnosis  in  18  of  the  cases  was  ma(k'  during  life  by  the  discovery  of 
the  actinomyces.  Death  results  usually  with  septic  symptoms.  Occasion- 
ally there  is  a  condition  simulating  typhoid  fever.  The  average  duration 
of  the  disease  was  ten  months.  Recovery  is  very  rare.  Clinically  the  dis- 
ease closely  rt-sembles  certain  forms  of  pulmonary  tuljcrculosis  and  of  f(etid 
bronchitis.  It  is  not  to  be  forgotten  in  the  examination  of  the  sputum 
that,  as  Bizzozero  mentions,  certain  degenerated  epithelial  cells  nuiy  be 
mistaken  for  the  organism.  The  radia  .g  lei)tothrix  threads  about  the 
ei)ithelium  of  the  mouth  sometimes  present  a  striking  resemblan  "e. 

(c)  Cutaneous  Actinomycosis. — In  several  instances  in  connection  with 
chronic  ulcerative  diseases  of  the  skin  the  "'ly-fungus  has  been  found.  It 
is  a  very  chronic  affection  resembling  tuberculosis  of  the  skin,  associated 
with  the  development  of  tumors  which  suppurate  and  leave  open  sores, 
which  may  remain  for  years. 

(d)  Cerebral  Actinomycosis. — Bollinger  has  reported  an  instance  of 
primary  disease  of  the  brain.  The  symi)toms  were  those  of  tumor.  A 
second  remarkable  case  has  been  reported  by  Ganigee  and  Delcpine.  The 
patient  was  admitted  to  St.  George's  Hospital  with  left-sided  ])leural  effu- 
sion. At  the  post  mortem  three  ])ints  of  ])urulent  fluid  were  found  in  the 
left  pleura;  there  was  an  actinomycotic  abscess  of  the  liver,  and  in  the 
brain  there  were  abscesses  in  the  frontal,  ])arietal,  and  tem))oro-sphcnoidal 
lobes  which  contained  the  mycelium,  but  no  clu1)s.  A  third  case,  reported 
by  0.  B.  Keller,  had  empi/ema  neceitsiUttis,  which  was  opened  and  actino- 
mycetes  were  found  in  the  pus.  Subsequently  she  had  Jacksonian  ejulopsy, 
for  which  she  was  trephined  twice  and  abscesses  opened,  which  contained 
actinomyces  grains.     Death  occurred  after  the  second  operation. 

Diagnosis. — The  disease  is  in  reality  a  chronic  ])yi\}mia.  The  only 
test  is  the  presence  of  the  actinomyces  in  the  pus.  ^letastases  may  occur 
as  in  pyemia  and  in  tumors.  The  tendency,  however,  is  rather  to  the  pro- 
duction of  a  local  jiurulent  affection  which  erodes  the  bones  and  is  very 
destructive.  In  cattle  the  disease  may  cause  metastases  without  any  suppura- 
tion; thus  in  a  ]\Iontreal  case  the  jaw  and  tongue  were  the  seat  of  the  most 
extensive  disease  with  very  slight  suppuration,  while  the  lungs  presented 
numbers  of  secondary  growtlis  containing  the  organisms. 

Treatment. — This  is  largely  surgical  and  is  practically  tliat  of  py- 
rpmia.  Incision  of  the  abscess,  removal  of  the  dead  l)one,  and  thorough 
irrigation  are  ap]iropriate  measures.  Thomassen  has  recommended  iodide 
of  potassium,  which,  in  doses  of  from  40  to  60  grains  daily,  has  proved 
curative  in  a  number  of  recent  cases. 


:^ 


238 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


XXXII.    SYPHILIS. 

Definition. — A  spcoific  dih^easo  of  slow  evolution,  pro])a«:ato(l  by  in- 
ociiliilioii  (iUM|iiiri'(l  svpliilis),  or  by  luTi'ditjii'y  Iriiiisniissiou  ((•on;^"(,'iiilal 
iiyjtliilis).  Ill  tliL'  ac(|iiii'c(l  J'oi'iii  tlu'  Aw  of  iiiociilaliou  hceomt'S  the  seat  of 
a  sfjecial  tissue  ciuui^'e — iirintiinj  Icslnn.  Within  two  or  tliree  mouths  eou- 
slitutioual  syuiptouis  deveio]),  with  atl'cctions  of  the  sl\iu  and  uuieous  uiein- 
hjuues — sicundanj  k'sions.  After  a  period  of  mouths  or  years  yrauuloui- 
atous  growths  develop  iu  the  viscera,  muscles,  bones,  or  skin — Iciiianj 
Irsiiuis.  And.  finally,  tln're  are  certain  diseases,  as  tabes  and  tieueral  |)aresis, 
A\hich  are  ]ieculiarly  j)roue  to  develop  on  the  syphilitic  soil — para-  or  mclu- 
tti/pli  ililir  (I IJ eel  ions. 

I.    GeNICKAL    EtIOLO<!Y    AM)    ]\[()I!H1I)    AXATOMY. 

The  nature  of  the  virus  is  still  doubtful.  Lustirarteu  found  in  the 
hard  chancre  and  in  iiiinunata  a  rod-shai)ed  bacillus  of  ;>  or  4  /a  iu  len<ith, 
which  he  claims  is  specific  and  ]K>culiar  to  the  disease.  Tiiis  ori>anisni 
closely  resend)les  the  sme<,nna  l)acillus,  which  is  found  beneatii  the  ])repuce, 
but  from  its  occurrence  in  gummatous  growths  it  is  hardly  j)ossil)le  that 
they  can  be  identical.  Further  observations  are  required  before  the  (jues- 
tion  can  be  considered  settled. 

Syphilis  is  peculiar  to  man,  and  cannot  be  transmitted  to  the  lower 
iiniuials.     All  are  suscei)tible  to  the  contagion,  and  it  occurs  at  all  ages. 

Modes  of  Infection. — (1)  In  a  large  majority  of  all  cases  the  disease  is 
transmitted  by  sexual  cofKjrrss,  Intt  the  designation  venereal  disease  (/(/cs 
venerea)  is  not  always  correct,  as  there  are  many  other  modes  of  inoculation. 

(2)  Accitlenlal  Infeduni. — In  surgical  and  in  midwifery  practice  ])hy- 
sicians  are  not  infrequently  inoculated,  it  is  surprising  tliat  infection 
from  these  sonrces  is  not  more  common.  I  have  known  personally  of  10 
cases.  ^Midwifery  cliancres  are  nsually  on  the  fingers,  bnt  I  have  met  with 
one  instance  on  the  back  of  the  hand.  The  lip  chancre  is  the  uuist  common 
of  these  erratic  or  extra-genital  forms,  and  may  be  accjuired  in  numy  ways 
apart  from  direct  infection.  Mouth  and  tonsillar  sores  result  as  a  rule 
from  improper  practices.  "Wet-nurses  are  si  letimes  infected  on  the  nijiple, 
and  it  occasionally  ha])]iens  that  relatives  oi  the  child  a.e  accidentally  con- 
taminated. One  of  the  most  lamentable  forms  of  accidental  infect'on  is  the 
Transmission  of  the  disease  in  humanized  vaccine  lymph.  This,  however, 
is  extremely  rnre.  The  conditions  under  which  it  occurs  have  been  already 
referred  to  (see  Vaccination). 

('.\)  Tfcredilarii  7'rn)isnnf:sinn. — This  may  be,  and  is,  most  common 
from  ('0  the  father,  the  mother  being  healthy  (s]ierm  inheritance).  It  is, 
unfortunately,  an  every-day  experience  to  sec  cases  of  congenital  syjdiilis 
in  which  the  infection  is  clearly  ]>aternal.  A  sy])hilitic  father  may.  how- 
over,  beget  a  healthy  child,  even  when  the  disease  is  fresh  and  ftdl-blown. 
On  the  other  hand,  in  very  rare  instances,  a  man  may  have  had  sy])hilis 
Avhen  young.  n)idergo  treatment,  and  for  years  ])resent  no  signs  of  disease, 
sxnd  yet  his  first-born  may  show  very  characteristic  lesions.     Ilappil}',  in  a 


HYrillLIS. 


iio'j 


'aso  IS 
{lues 
at  ion. 
])liy- 
'ection 
ol"  10 
t  with 
muion 
•  ways 
ii   rule 
iiipplc, 

;'     CDU- 

is  the 

Iwover, 

1  ready 


large  majority  of  instances,  \\]\rn  the  treatiiiciil  lias  liccii  tlioiini^li,  the 
otl'spring  escai)C.  The  closer  the  iH'j^ettiii;:'  to  the  i)riiiiary  sore,  the  grealiT 
the  chance  oi'  ini'eclioii.     A  man  with  tertiary  lesions  may  hejiet  heaithv 


cliiklren. 


A> 


a  i;eni'ral  rule  it  may  be  said  that  with  judicious  treatuieiil 


the  transnussnc  i)o\\er  rarely  excee 


ds  th 


ree  or  lour  yean 


(h)  Maternal  trausnussioii  (licriu  iidiciitance).  It  is  a  reniarkahle  and 
intert'stinji;  fact  that  a  woman  who  has  hoi'ne  a  syphilitic  child  is  herst'll' 
immune,  and  cannot  l)e  infected,  tliouiih  she  may  present  no  si<;ns  of  tlie 
disease.  This  is  known  as  ('(dies'  law,  and  was  thus  stated  hy  ihe  dislin- 
i^iiished  Duhlin  sur^'t'on:  "That  a  child  hoi'ii  (if  a  motiiei'  who  is  wilhonl 
obvious   yeucrcal   symptoms,   and    which,    williout    beiny-   exposed    to    any 


infection  subse([nent  to  its  birth,  shows  this  disease  when  a  few  week^ 
this  child   will    infect  the  most  health.v  nurse,  whelhei'  she  suckle   i 


It,   or 


ineicly  handle  and  di'css  it;  and  yet  this  child  is  neyer  known  to  infect  its 
own  mother,  eyen  thougli  she  suckle  it  while  it  has  yenereal  ulcers  of  the 
lips  and  tongue."'  In  a  majority  of  these  cases  the  mother  has  received  a 
sort  of  })rotective  inoculali(jn,  without  liavinu'  had  actual  inan.ifcstations  of 
the  disease. 


A   woman   with   ac(piii'e(l   sy| 


)lllllS     If 


liable    to   bear   infected    childi-en. 


The  father  n 


lay  not 


alfected.     In   a   lari;e  number 


instances 


botl 


jiarents  are  diseased,  the  one  lunin^'  infected  the  other,  in  wliicb  case  the 
chances  of  fa-tal  infection  are  greatly  increased. 

((•)  Placental  transmission.  The  mother  may  be  infecteil  after  con- 
ception, in  which  case  the  child  may  be,  but  is  not  necessarily,  born  syph- 
ilitic. 

Morbid  Anatomy. — The  jiriuKirt/  Icsian,  or  chancre,  shows:   (d)  A  dif- 


fuse infiltration   of  the   connectiye   tissue   with 


-ma! 


rouiK 


c-c 


{!') 


Larimer  e])ithelioid  cells,  (r)  (Jiant  cells.  ((/)  The  Lust<:arten  bacilli,  in 
small  numbers,  (e)  Chaniics  in  the  small  arteries,  chielly  thickening-  (d' 
the  intima,  and  alt.'rations  in  the  nerye-fibres  oojunr  to  tlu>  jiart  (UerkUy). 
The  sclerosis  is  (]\w  in  ]iart  to  this  acute  obliterative  endarteritis.  Asso- 
ciated with  the  initial  lesions  aw  chanjies  in  the  adjacent  lyiiijili-iilands. 
which  nnderji'o  liy])er])lasia,  and  finally  become  indurated. 

The  srrnii(lari/  Iraidiif^  of  syphilis  are  too  yaried  for  description  here. 
They  consist  of  condylomata,  skin  eruptions,  aiTectif)ns  of  the  eye,  etc. 

The  tertiary  lesinns  consist  of  circumscribed  tuiiKtrs  known  as  o;inn- 
mata.  and  of  an  arteritis,  which,  however,  is  not  peculiar  to  the  diseas(>. 

Crininnnta. — Sy])hiloniata  deyelop  in  the  bones  or  ]ieriostenm — here 
they  are  called  nodes — in  the  muscles,  skin,  brain,  luuv:.  liver,  kidneys, 
heart,  testes,  and  adrenals.  They  yary  in  size  from  small,  almost  ndcro- 
sco])ic,  bodies  to  lar»ie.  solid  tumors  from  .'>  to  .")  cm.  in  diameter.  They 
are  usually  firm  and  hard,  Imt  in  the  skin  and  on  the  mucous  mendiranes 
they  tend  to  break  down  ra])idly  and  ulcerate.  On  cross-section  a  modi u in- 
sized  gumma  has  a  grayish-white,  honiouoneons  appearance,  ])reseniiii'_'' 
in  the  centre  a  firm,  caseous  suhstance,  ami  at  the  perijdiery  a  translucent. 
lil)rous  tissue.  Often  there  are  groups  of  three  or  more  surrounded  by 
dense  sclerotic  tissue. 

The  arteritis  will  he  considered  in  a  seiiarate  section. 


240 


If  •*.■! 


P 


$ 

■■iv 


/ 


SPECIFIC  INFECTIOUS  DISEASES. 


II.  Ac(iLini:i)  Syimiilis. 


Primary  Stage. — Tliis  cxtciuls  from  tlio  appt-nrancc  of  tlio  initial  sore 
until  tilt'  onset  of  tiic  constitutional  symptoms,  and  has  a  variahlo  dura- 
tion of  from  six  to  Iwi'lvo  wcoks.  Tlie  initial  sore  appears  within  a  month 
after  inoculation,  and  it  hrst  shows  itself  as  a  small  red  ])apule,  which 
gradually  eidarges  aiul  breaks  in  the  centre,  leaving  a  small  idccr.  The 
tissue  about  tiiis  becomes  indurated  so  that  it  idtinuitely  has  a  gristly,  car- 
tilaginous consistence — hence  the  name,  hard  or  indurated  chancre.  The 
size  attained  is  variable,  aiul  when  snudl  the  sore  may  be  overlooked,  par- 
ticularly if  it  is  just  within  the  urethra.  Tiie  glands  in  the  lym])h-district 
of  the  chancre  enlarge  and  become  hard.  Suppuration  both  in  the  initial 
lesion  and  in  the  glands  nuiy  occur  as  a  secondary  change.  The  general 
condition  of  the  })atient  in  this  stage  is  good.  There  may  be  no  fever  and 
no  im])airmcnt  of  health. 

Secondary  Stage. — The  first  constitutional  symptoms  are  usually  mani- 
fested within  three  months  of  the  aj)pearance  of  the  ])rimary  sore.  They 
rarely  develo])  earlier  than  the  sixth  or  later  than  the  twelfth  week.  The 
synij)tonis  are:  (r/)  Fever,  slight  or  intense,  and  very  variable  in  charac- 
ter. A  mild  continuous  pyrexia  is  not  uncommon,  the  temjierature  not 
rising  above  101°.  The  fever  may  have  a  distinctly  remittent  character; 
but  the  most  remarkable  and  puzzling  type,  which  is  very  apt  to  lead  to 
error  in  diagnosis,  is  the  intermittent  syphilitic  fever.  It  may  come  on 
within  a  month  after  exposure  and  rise  to  104°  or  105°,  with  oscilla- 
tions of  5°  or  G°  (Yeo).  A  remarkable  case  is  reported  by  Sidney 
Phillips,  in  which  pyrexia  persisted  for  months,  with  paroxysms  resem- 
bling in  all  respects  tertian  ague,  and  which  resisted  quinine  and  yielded 
prom])tly  to  mercury  and  potassium  iodide.  Although  usually  a  secondary 
manifestation,  the  fever  of  syphilis  may  occur  late  in  the  disease.  Prac- 
titioners are  scarcely  alive  to  the  frequency  and  importance  of  syphilitic 
fever.  Janeway  has  recently  called  attention  to  cases  in  which  tlie  diag- 
nosis of  pulmonary  tuberculosis  had  been  made. 

(h)  AiKvmia. — In  many  cases  the  sy]diilitic  poison  causes  a  pronounced 
anannia  which  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tingeing  of  the  conjunctiva;  or  of  the  skin,  a  hsematogenous 
icterus.  This  syphilitic  cachexia  may  in  some  instances  be  extreme.  The 
red  l)lood-cor])uscles  do  not  show  any  special  alterations.  The  blood-count 
may  fall  to  three  millions  per  cubic  millimetre,  or  even  lower.  The  anrcmia 
may  develop  suddenly.  In  a  case  of  syphilitic  arthritis  in  a  young  girl 
following  three  or  four  inunctions  of  mercury  the  blood-cbunt  fell  below 
two  millions  per  cul)ic  millimetre  in  a  few  days. 

(r)  Cufaneous  Lesions. — Skin  eruptions  of  all  forms  may  develop.  The 
earliest  and  most  common  is  a  rash — macular  si/ ph Hide  or  syphilitic  roseola 
— which  occurs  on  the  abdomen,  the  chest,  and  on  the  front  of  the  arms. 
The  face  is  often  exem])t.  The  spots,  which  are  reddish-brown  and  svm- 
metrically  arranged,  ])ersist  for  a  week  or  two.  Xext  in  frequency  is  a 
papular  sj/pliilide,  which  may  form  acne-like  indurations  about  the  face 
and  trunk,  often  arranged  in  groups.     Other  forms  are  the  pustular  rash, 


SYPHILIS. 


241 


liag- 


iremia 
(rirl 
below 

The 

roftrnla 

arms. 

pym- 

ly  is  a 

|e  face 

rasli, 


wliieh  may  so  closely  simulate  variola  that  the  ])aticnt  may  be  sent  to  a 
pmall-j)ox  hos])ital.  A  sijiiamous  sijiiliilide  occurs,  not  unlike  ordinary 
])S()riasis,  except  that  the  scales  are  less  ahundant.  Tlu'  rash  is  more  t-opper- 
colored  and  not  specially  conlined  to  the  extensor  surl'aees. 

In  the  moist  regions  of  the  skin,  such  as  the  perinanim  and  groins,  the 
axillie,  between  thr  toes,  and  at  the  angles  of  the  mouth,  the  so-ealK'd 
nnirotis  patches  dev*.  /j),  which  are  flat,  warty  outgrowths,  with  well-dedncd 
uuirgins  and  surfaces  covered  with  a  grayish  secretion.  They  are  among 
the  most  distinctive  lesions  of  syphilis. 

Frequently  the  hair  falls  out  (aloi)ecia),  either  in  ])atche8  or  by  a  gen- 
eral thinning.     Occasionally  the  nails  become  alfected  (syphilitic  onychia). 

{(I)  Mucous  Lesions. — With  the  fever  and  the  roseolous  rash  the  tiiroat 
and  mouth  become  sore.  The  pharyngeal  mucosa  is  hy|)era'mic,  the  ton- 
sils are  swollen  and  often  present  small,  kidney-shaped  ulcers  with  grayish- 
white  borders.  ^lucous  ])atches  are  seen  on  the  inner  surfaces  of  the  cheeks 
and  on  the  tongue  and  lips.  Sometimes  on  the  tongue  there  are  whitish 
si)ots  (leucomata),  which  are  seen  most  frequently  in  smokers,  and  which 
Hutchinson  regards  as  the  joint  result  of  syphilitic  glossitis  and  the  irri- 
tation of  hot  tobacco-smoke.  IIypertroi)hy  of  the  ])a])illiu  in  various  por- 
tions of  the  mucous  membrane  ]n'oduces  the  sy])hilitic  warts  or  eondylo- 
nuita  which  are  most  frcHjuent  about  the  vulva  and  anus. 

(e)  Other  Lesions. — Lritis  is  common,  and  usually  alTects  one  eye  be- 
fore the  other.  It  develops  in  from  three  to  six  months  after  the  chancre. 
There  may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  severer 
forms  there  is  great  pain,  and  the  condition  is  serious  and  demands  care- 
ful management.  Choroiditis  and  retinitis  are  rare  secondary  symi)toms. 
Kar  affections  are  not  common  in  the  secondary  stage,  but  instances  are 
found  in  which  sudden  deafness  develops,  which  may  be  due  to  labyrinth- 
ine disease;  more  commonly  the  imjiaired  hearing  is  due  to  the  extension 
of  inflammcation  from  the  throat  to  the  middle  ear.  Epididymitis  and 
parotitis  are  occasional  secondary  lesious. 

Tertiary  Stage. — No  hard  and  fast  line  can  be  drawn  between  the 
lesions  of  the  secondary  and  those  of  the  tertiary  period;  and,  indeed,  in 
exceptional  cases,  manifestations  which  usually  a])pear  late  may  set  in  even 
before  the  primary  sore  has  pro])crly  healed.  The  s])ecial  affections  of  this 
stage  are  certain  skin  eruptions,  gunnnatous  growths  in  the  viscera,  and 
amyloid  degenerations. 

(a)  The  late  syphitides  show  a  greater  tendency  to  ulceration  and  de- 
struction of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars  are  left. 
They  arc  also  more  scattered  and  seldom  symmetrical.  One  of  the  most 
characteristic  of  the  tertiary  syphilides  is  rupia,  the  dry  stratified  crusts 
of  which  cover  an  ulcer  which  involves  the  deeper  layers  of  the  skin  and 
in  healing  leaves  a  scar. 

(I))  Gummata. — These  may  develo])  in  the  skin,  subcutaneous  tissue, 
muscles,  or  internal  organs.  The  general  character  has  been  already  de- 
scribed. When  they  develop  in  the  skin  thoy  tend  to  break  down  and 
ulcerate,  leaving  ugly  sores  which  heal  with  difTiculty.  In  the  solid  organs 
they  undergo  fibroid  transformation  and  produce  ])uckering  and  deformity. 


V 


242 


SPECIFIC  INFECTIOUS   DISEASES. 


y 


C)n  tlio  nuicoiis  mcmLriiiu's  ilicse  tcrtiiiry  lesions  lead  to  iilccratioii,  in  tho 
'uiiiinff  ol'  wliicli  c'i(,'ii trices  are  formed;  liins,  in  the  larynx  <;reat  narrow- 
ing' may  result,  and  in  the  rectum  ulceration  with  iibroid  thickeninj,'  and 
retraction  may  lead  to  sti'icture. 

(r)  Anii/ldiil  Pri/ciicnilioii. — Syi»hilis  plays  a  most  important  role  in 
tho  jirodiiction  of  this  aU'eetion.  01'  2\\  instances  analyzed  l»y  J"'n^>:e,  7() 
had  syi)hilis,  and  ol'  these  -1:^  iiad  no  hone  lesions.  Jt  follows  the  ac(piired 
form  and  is  veiy  coniuion  in  association  with  rectal  syphilis  in  women.  In 
congenital  lues  amyloid  de<:-eneration  is  rare. 

{(1)  J'ara-  or  Mrliisi/iihllilir  Alfrrliniis. — (,'ertain  disorders  not  actually 
syphilitic,  yet  so  closely  connected  that  a  lai'<,''e  proportion  of  tho  cases  have 
had  the  disease,  are  termed  hy  Fournier  parasyphilitic  (Le.s  All'ections 
.I'arasyphiliti(pies,  LSil-l).  These  ad'ectioiis  are  not  exclusively  and  neces- 
sarily caused  hy  sy])hilis,  and  they  are  not  iniluenced  hy  speciiic  treatment. 
'V\u'  chief  of  them  arc  locomotor  ata.xia,  dementia  jjaralytica,  certain  types 
of  ej)ilepsy,  and,  we  may  atUI,  arterio-sclerosis. 


III.  ('()\(;i;xn'Ai,  Sveiiii.is. 

^\'ith  the  exce])tion  of  the  ])rim;iry  soi'c,  eveiy  feature  of  the  accpnred 
disease  may  be  seen  in  the  congenital  form. 

The  intra-uicrine  conditions  leading  to  the  death  of  the  HetTis  do  not 
here  concern  us.  The  child  may  he  horn  healthy-looking,  or  with  wt-ll- 
marked  evidences  of  tho  disease.  Tn  the  majority  of  instances  tho  former 
is  the  case,  and  within  the  first  month  or  two  the  signs  of  the  disease 
appear. 

Symptoms. — (n)  At  JilHh. — "When  the  disease  exists  at  birth  the  child 
is  feeldy  d('velo])cd  and  wasted,  and  a  skin  eruption  is  usually  ])resent, 
commonly  in  the  form  of  bulhe  abont  the  wrists  and  ankles,  and  on  the 
hands  and  feet  (pem])higus  neonatorum).  The  child  snntlles,  the  lips  are 
nlcerated,  the  angles  of  the  mouth  fissured,  and  there  is  enlargement  of 
the  liver  and  spleen,  '^i'he  hone  symptoms  may  be  marked,  and  the  epiphy- 
ses may  even  be  sejiarated.  In  such  cases  the  children  rarely  survive 
long. 

(b)  Earhj  2f(ntil'rslnliiiiis. — AVhcn  born, healthy  the  child  thrives,  is  fat 
and  ])lum]),  and  shows  no  abnormity  whatever:  then  from  the  fonrth  to 
the  eighth  week,  rarely  later,  a  nasal  catarrh  develops,  si/phiHlir  rhiiiih's, 
which  im])edes  respiration,  and  ]irodnc('s  the  characteristic  symptom  which 
has  given  the  name  sniifjlrs  to  the  disease.  The  discharge  may  be  sero- 
pnrnlent  or  bloody.  The  child  nurses  with  great  ditbculty.  In  severe  cases 
idceration  tak(^s  ])lace  with  necrosis  of  the  bone,  leading  to  a  depression 
at  the  root  of  the  nose  and  a  deformity  characteristic  of  congenital  syphilis. 
This  coryza  may  be  mistaken  at  fli'st  for  an  ordinary  catarrh,  but  the  co- 
existence of  other  manifestations  usually  niak(>s  the  diagnosis  clear.  The 
disease  may  extend  into  the  Eustachian  tubes  and  middle  cars  and  lead 
to  deafness. 

The  ciitnneoii!^  Irslims  develo]i  with  or  shortly  after  the  onset  of  the 
snuHlcs.    The  skin  often  has  a  sallow,  earthy  hue.    The  eruptions  are  first 


I  )oy 


SYPHILIS. 


243 


cliild 

the 
are 
nt  of 

)llY- 

rvive 

fat 

til  t.) 

•11  His, 

Inch 

it^oro- 

casc'S 

?psion 

hilis. 

ic  co- 

Tho 

lead 

f  the 
first 


notiood  altdut  the  natos.  '^I'liiTc  may  he  an  cntlicma  or  an  (•czcinatniis 
condition,  !.iit  more  comnionly  lliorc  arc  irregular  rcddish-ljrown  patches 
A\  ith  \\('ll-(h'lin('(|  cd-rcs.  A  papular  syphilidc  in  this  rc.izion  is  hy  no  means 
uncommon.  Imssuh'S  dcvcio|)  aliont  the  li|)s,  either  at  the  angles  of  the 
mouth  -.!•  in  llio  median  line.  'J'heso  rhfii/ddi's,  as  they  are  called,  are  very 
characteristic.  There  may  he  markeil  ulceration  of  the  inuciy-ciitanoou.s 
sMi'laces.  The  secretions  from  these  mouth  lesions  an;  very  virulent,  and 
i<  is  from  this  source  that  the  wet-nurse  is  usually  inrected.  \ot  only  the 
nurse,  hut  niemhers  of  the  family,  may  he  contaminated.  There  ai'e  in- 
stances in  which  olhcr  cliildi'cn  have  Keen  accidentally  inoculated  from 
a  syphilitic  infant.  The  haii'  (d'  the  head  oi'  of  the  eyei»ro\vs  may  fall  out. 
'i'he  syphilitic  mnirlila  is  not  uncommon.  Ijilargemciil  (d'  the  i;lands  is 
not  so  frecjuent  in  the  congenital  as  in  the  acquired  disease.  When  the 
cutaneous  lesions  are  marked,  the  contiguous  glands  can  usually  he  ftdt. 
A.S  ]ioiiite(|  out  hy  (ice,  the  spleen  is  enlai'gcil  in  many  cases.  The  condi- 
tion may  jiersist  for  a  long  tinif.'.  Mnlargement  of  the  liver,  though  often 
present,  is  less  significant,  since  in  infants  it  may  he  i\\\v  to  various  causes, 
'fhesc  are  anu)ng  the  most  constant  symptoms  (»f  congenita!  syphilis,  and 
usually  develop  hetween  the  third  and  twelfth  weeks.  l^'reipient ly  they 
are  ])receded  hy  a  ])erio(l  of  restlessness  and  wakcd'iilness.  ])ariicularly  at 
night.  Some  authors  have  descrihed  a  ])eculiar  syphilitic  cry,  high-pit<die(l 
and  harsh.  Among  rarer  juanifestations  are  ha'iuorrhages — the  si/iilillis 
li(nii(inii(i(/ir(i  iicoiKildniiii.  'JMie  hl(>eding  nuiy  he  suhcutam'ous,  from  tlio 
uiucous  surfaces,  or,  when  early,  from  the  umhilicus.  All  of  such  cases, 
however,  are  not  syphilitic,  and  the  disease  must  not  he  confounded  with 
the  acute  ha'moglohiiinria  of  new-horn  infants,  which  Winckcl  descrihes 
as  occurring  in  ei)idemic  form,  and  which  is  [)rohahly  an  acute  infectious 
disorder. 

(r)  Ldtc  Manifcsialinnff. — Children  with  congenital  syjjhilis  rarely 
thrive.  Usually  they  present  a  wizened,  wasted  appearance,  and  a  pre- 
maturely aged  face.  Tn  the  cases  which  recover,  the  general  nutrition 
may  remain  good  and  the  child  nuiy  show  lu)  further  numi testations  of 
the  disease;  commonly,  however,  at  the  ])eriod  of  secoiul  dentition  or  at 
puherty  the  disease  reappears.  Although  the  child  may  have  recovered 
from  the  early  lesions,  it  docs  not  (h'velop  like  other  children,  (irowth  is 
slow,  deve]oj)ment  tardy,  and  there  are  facial  and  cranial  chara(deristics 
which  often  render  the  disease  I'ccogiiizahle  at  a  glaiu-e.  .\  young  man  of 
nineteen  or  twenty  may  neither  look  older  nor  he  mon^  devtdojx'd  than  a 
hoy  of  ten  or  twelve.  Fournier  descrihes  this  condition  as  iiifdiitillsni. 
The  foi'chead  is  ])rominent,  the  frontal  eminences  are  inarked,  and  the 
skull  may  he  very  asymmeti'ical.  The  hridge  of  tlie  nose  is  de])ressed.  the 
ti])  1-efrovssf.  The  lips  are  often  pi'onniu'ut.  and  tliere  are  striated  lines 
runninsr  from  the  corners  of  the  mouth.  The  IrcIJi  are  deformed  and  niav 
])res(>nt  a])pearances  which  Jonathan  ]Iut(hinson  claims  are  P]>cciflc  and 
peculiar.  The  up])er  central  incisors  of  the  ]iermanent  set  are  the  teetli 
which  give  information.  The  specific  alterations  are — the  teeth  are  peg- 
shaped,  stunted  in  length  and  hreadth.  and  narrower  at  tlie  cutting  cA^jc 
than  at  the  root.     On  the  anterior  surface  the  enamel  is  well  formed,  and 


I 


24rt 


SPKCIFIC  INFECTIOUS  DISEASES. 


not  crodod  ov  lioiioyconibod.  At  the  cnttinf?  (mI^'c  tlioro  is  n  sinjilo  notch, 
utjiially  sliuUow,  tioiiiutinics  dci']),  in  whii'h  tiiu  (U-ntino  is  exposed. 

Among  late  manifestations,  partieidarly  apt  to  appear  about  puberty, 
is  tlie  interstitial  kcralilis,  whieli  usually  begins  as  a  slight  steaminess  of 
the  corni'ie,  which  present  a  ground-glass  appearanee.  It  all'eets  both  eyes, 
though  one  is  attaeki'd  before  the  other.  It  nuiy  persist  for  months,  aiul 
usually  elears  eompletely,  tiiough  it  nuiy  leave  o))aeities,  which  prevent 
clear  vision.  //•///«  may  also  occur.  Of  ear  affcdiuns,  apart  from  those 
which  develop  as  a  se([uence  of  the  piuiryngeal  disease,  a  form  occurs  about 
the  time  of  puberty  or  i-arlier,  in  which  deafness  conies  on  rapidly  and  per- 
sists in  spite  of  all  treatment.  It  is  uiuissociated  with  ()l)vious  lesions, 
and  is  ])rol)ably  labyrinthine  in  character.  Bone  lesions,  occurring  oftenest 
after  the  sixth  year,  are  not  rare  among  the  late  manifestations  of  hereditary 
syphilis.  The  tibia'  are  most  frecjuently  attacked.  It  is  really  a  chronic 
giimnuitous  ])eriostitis,  which  gradually  leads  to  great  thickening  of  the 
bone.  The  nodes  of  congenital  syphilis,  which  are  often  mistaken  for 
rickets,  arc  more  commonly  diffuse  and  affect  the  bones  of  the  ui)per  and 
lower  extremities.  They  are  generally  symmetrical  and  rarely  i)ainful. 
They  may  develoj)  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.  Clutton  has  described  a  symmetrical  synovitis 
of  the  knee  in  hereditary  syphilis.  Enlargement  of  tlic  sjjleen,  sometimes 
with  the  lym])h-glands,  may  be  one  of  the  late  manifestations,  and  may 
occiu'  either  alone  or  in  connection  Avitli  disease  of  the  liver. 

Clummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late 
hereditary  syphilis. 

Is  syi)hilis  transmitted  to  the  third  generation?  The  general  opinion 
is  that  the  recorded  cases  scarcely  stand  criticism.  Occasioiuilly,  however, 
cases  of  ])ronounced  congenital  syphilis  are  met  with  in  the  children  of 
parents  who  are  jjcrfectly  healthy,  and  who  have  not,  so  far  as  is  known, 
had  sy})hilis,  and  yet,  as  remarked  by  Coutts,  who  reported  such  a  group 
of  cases,  they  do  not  bear  careful  scrutiny.  This  is  the  opinion  of  the  lead- 
ing syphilographers.  Personally,  I  have  never  met  with  even  a  suspicious 
instance.  On  the  other  hand,  I  know  now  a  number  of  perfectly  healthy 
children,  one  of  whose  grandfathers  was  syphilitic. 


or 


IV.  Visceral  Syphilis. 

A,  Syphilis  of  the  Brain  and  Cord. — The  following  lesions  occur: 
(1)  Gummata,  forming  deiinite  tumors,  ranging  in  size  from  a  pea  to 
a  walnut.  They  are  usually  multiple  and  attached  to  the  pia  mater,  some- 
times to  tlie  dura.  Very  rarely  they  are  found  unassociated  with  the  me- 
ninges. When  small  they  present  a  uniform,  translucent  appearance,  but 
when  large  the  centre  undergoes  a  fibro-caseous  change,  while  at  the 
periphery  there  is  a  firm,  translucent,  grayish  tissue.  They  may  closely 
resemble  large  tulierculous  tumors.  The  growths  are  most  common  in  the 
cerebrum.  They  may  be  multi])le  and  may  even  attain  a  considerable  size 
without  becoming  caseous.  Occasionally  gummata  undergo  cystic  degen- 
eration.    In  the  cord  large  gummatous  growths  are  not  so  common.     In 


SYnilLIS. 


245 


lead- 
)ic'ious 
tealtliy 


pea  to 
some- 
tie  mc- 
[c,  but 
it   the 
?]oscly 
in  the 
lie  size 


logon- 


In 


an  instance  recently  rejiorted  l>y  me  a  tumor,  rrorn  three  eighths  to  one 
loiirth  of  an  inch  in  diameter,  waa  completely  within  the  cord  opposite 
the  I'ourtii  cervical  nerve,  and  tiiere  were  numerous  gumnuitu  in  the  eaudu 
etiuina. 

('i)  Ciuiinndlous  Mciiiiujilis. — Tliis  constantly  occurs  in  the  iieighltor- 
liood  of  the  larger  growths,  and  there  nuiy  be  local  meningeal  thickening 
several  centimetres  in  extent,  in  which  the  pia  is  infiltrated  and  the  arteries 
greatly  thickened.  This  by  no  nu'aiis  uncommon  form  may  run  a  subacute 
or  a  chronic  course. 

(3)  GuiiniKiloiis  Arterilis. — The  lesions  nuiy  be  confined  to  the  arteries 
which  present  the  nodular  tinnors  to  be  described  hereafter. 

( t)  Foci  of  ticlcrusis,  which  Lancereaux  holds  may  be  distinguished  from 
non-specific  forms  by  a  inucli  grcjiter  tendency  of  the  neuroglia  elements 
to  undergo  fatty  transformation,  and  by  the  secondary  alterations,  as  areas 
of  softening,  which  occur  in  the  neigliborhood.  Neither  the  dill'use  nor 
the  nodular  cerebral  sclerosis,  met  with  particidarly  in  children,  api)ear9 
to  have  any  special  relation  to  iidierited  syphilis. 

(.3)  Whether  a  localized  encejjhalitis  or  myelitis  can  result  from  the 
action  of  the  syphilitic  })oison  without  involvement  of  the  blood-vessels  is 
doubtful.  In  a  case  of  multiide  arterial  gunnnata  recently  in  my  ward, 
Thonuis  found  in  the  lumbar  region  of  the  cord  foci  of  inflammatory  soft- 


ening. 


Secondary  Chanr/es. — In  the  brain  gummatous  arteritis  is  one  of  the 
common  causes  of  softening,  which  may  be  extensive,  as  when  the  middle 
cerebral  artery  is  involved,  or  when  there  is  a  large  jjatch  of  syphilitic 
meningitis.  In  such  instances  the  process  is  really  a  meningo-encepha- 
litis,  and  the  syni])toms  are  due  to  the  secondary  changes  in  the  brain-sub- 
stance, not  directly  to  the  gumma.  In  the  neighborhood  of  a  gummatous 
growth  intense  encephalitis  or  myelitis  may  develop,  and  within  a  few  days 
change  the  clinical  picture.  Ctummatous  arteritis  may  lead  to  weakening 
of  the  wall  of  the  vessel  and  rupture  with  meningeal  lufmorrhage. 

Syphilitic  disease  of  the  nerve-centres  may  occur  in  the  inherited  or 
acquired  form,  more  commonly  in  the  latter.  In  the  congenital  cases  the 
tumors  usually  develop  early,  but  may  be  as  late  as  the  twenty-first  year 
(II.  C.  "Wood).  In  the  acquired  form  the  nerve  lesions  belong,  as  a  rule, 
to  the  late  manifestations,  and  jiatients  may  have  ijuite  forgotten  the  ex- 
istence of  a  primary  infection,  and  in  very  many  instances  the  secondary 
manifestations  have  been  slight.  IIeid)ner,  to  whom  we  owe  so  much  in 
connection  with  this  subject,  has  seen  them  as  late  as  the  thirtieth  year. 
On  the  other  hand,  in  exceptional  instances,  they  may  occur  very  early,  and 
severe  convulsions  with  hemiplegia  have  been  re])orted  within  three  months 
of  the  primary  sore.  The  discussion  at  the  Eoyal  Medical  and  Chirurgical 
Society  (B.  M.  J.,  1895,  vol.  i),  and  Lydston's  paper  (Jour.  Am.  iMed. 
Aisoc,  1895,  vol.  i),  show  that  various  affections  of  the  nervous  system 
are  by  no  means  uncommon  during  the  secondary  stage  of  the  disease. 

Sipnpfnms. — The  chief  features  of  cerebral  syphilis  are  those  of  tumor, 
which  will  be  considered  subsequently  under  that  section.  They  may  be 
classified  here  as  follows: 


I 


240 


SIMXIFIC  INFECTIOUS  DISKASKS. 


/ 


(1)  I'sycliical  feature's.  A  tJuddun  and  violont  onset  (»f  dclirinin  may 
Itc  tlio  llrst  syinptdiii.  In  other  instiuices  prior  to  tlie  oceiirrence  of  dc- 
lirinin there  have  heen  lieadaehe.  alleratioii  of  character,  and  h)>s  of  mem- 
ory. Tile  condilion  may  he  accompanied  liy  cdnvnlsions.  Tiu're  may  he  no 
neuritis,  ih>  palsy,  and  no  jocaiiziiij,'  symptnnis. 

(".')  .More  comuKudy  followin;,^  liea<hudie,  j^iihliness,  or  an  <'.veited  state 
whieli  may  amount  to  delirium,  llu'  patient  Inis  an  epileptic  seizure  or 
doveh)ps  hemi])le«,da,  or  there  is  iuvolvemeiil  of  the  nerves  of  the 
base.  Some  of  these  eases  display  a  prolon:;cd  torpor,  a  special  IValnic  of 
l)rain  .<y|thilis  to  which  Iioth  liuz/.ard  and  llenl)ner  have  refi'rrcd,  which 
may  persist  i'or  as  lon<''  as  a  month.  II.  ('.  Wood  descrihes  with  this 
a  state  of  nnlomatism  occurrinii:  pai'ticularly  at  ni^^lil,  in  which  the 
patient  hehavcs  like  a  "restless  nocturnal  autoinnt(Ui  rather  than  a 
num."' 

(;5)  A  clinical  ])icture  of  jreneral  ])aralysis — d(>mentia  ]iaralytica.  The 
([uestion  is  still  in  dispute  whether  this  syphilitic  encephalopathy,  which 
so  closely  resend)les  "z'ciici'al  paralysis,  is  a  distiiict  and  indepemleiit  alVec- 
tion.  ]\li(d<le,  who  has  carelMlly  i'eviewe<l  the  suhject,  concludes  tiuit 
syphilis  may  directly  pi'oduce  the  inllammatory  chan^zcs  in  the  hrain,  while 
in  other  instances  it  directly  jtredisposcs  to  this  alfei'tion.  It  is  a  sonu'- 
what  remai'kahl(>  feature  that  the  eases  which  present  the  clinical  pictni'e 
of  ficneral  |iaresis  are  uu>st  rre(piently  those  which  have  not  had  any  lo(;il- 
\7M\]i  symjjtoms,  and  they  may  not  have  convuIsi(uis  until  the  disease  is 
well   advanced. 

(!)  Many  cases  of  cerebral  syphilis  display  the  symptoms  of  lu'ain 
tumor — headache,  optic  neuritis,  vonntiuti'.  ami  convulsions.  Of  these 
sym])toms  convulsions  are  the  most  important,  and  hoth  Foui'ider  and 
AVood  have  laid  ^reat  stress  on  the  value  of  this  symptom  in  ])ersons  over 
thirty.  The  first  sym|)toms  nuiy,  however,  rather  resendjle  those  of  em- 
bolism or  thrombosis;  thus  tbere  may  be  sudden  hemiplegia,  with  or  with- 
out loss  of  consciousness. 

The  .symptoms  of  spinal  si/phUis  are  extremely  varied  and  may  bo 
caused  by  hrgo  jinmmatons  ^i'rowths  attached  to  the  menin<res,  in  which 
case  the  features  are  those  of  tumor;  by  ir'.immatous  arteritis  with  second- 
ary softonin<r;  by  mcnin^iiitis  with  secondary  cord  chnn(,'es;  or  by  sclcro.ses 
developing;  late  in  the  disease,  the  relation  of  which  to  syphilis  is  still  (tli- 
scnre.  Erb's  syphilitic  myelitis  will  be  considered  under  the  s]iastic  para- 
])leji'ias. 

Didipidsls. — The  history  is  of  the  first  importance,  but  it  may  be  ex- 
tremely dilhcnlt  to  get  a  reliable  account.  Carefid  examination  should  be 
made  for  traces  of  the  ])rimary  sore,  for  the  cicatrices  of  bubo,  for  scars  of 
the  skin  eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character 
of  the  synii)toms  is  often  of  trreat  assistance,  '^riiey  are  multiform,  vari- 
able, and  often  such  as  could  not  be  explained  by  a  sinple  lesion;  thus 
there  may  be  anomalous  sjunal  sym]>toms  or  involvenumt  of  the  nerves  of 
the  brain  on  both  sides.  And  lastly  the  result  of  treatment  has  a  defim'te 
bearinrr  on  the  diagnosis,  as  the  symi)toms  may  clear  up  and  disappear  with 
the  use  of  anti syphilitic  remedies. 


SYPHILIS. 


247 


llic  ex- 
liild  lit' 
•;U's  of 
Iractcr 
L  Viiri- 
];  tlui> 

I'VOS   of 

L'finilc 
Ir  with 


It.  Syphilis  of  the  Lung. 

This  is  II  Nfiy  niic  discnsr.  During'  twenty-five  years  I  have  not  seen 
more  tlnm  hull'  a  dozen  s|ieeiniens  in  which  there  wns  no  (|iii'stion  an  to  tiio 
imtlire  of  the  troiilih'.  |''nw|cr  sliites  tiiilt  he  liiis  recently  visited  tile  nilise- 
luiis  of  the  l/Hidon  lios|iitMls  tuid  at  the  Ifoyal  ('olle;:i'  of  Siiri^coiis,  and  can 
lind  only  twelve  >|ieeiiiieiis  i lliist rat injf  sy|thilitie  lesions  of  llie  liinj^s,  two 
of  wliicli  are  donhlfnl.  For  the  ninst  fnll  and  satisfactory  eonsideralion 
of  |iidnioMary  sy|i|iilis,  the  reader  is  referred  to  chapter  xx.wii  of  I^'nwler 
and  (iodlee's  woik  on  J)iseases  ul'  the  l.un;4s. 

Elhibiiiji  (111(1  Mdiliiil  AiKiloini/. — Syphilis  of  tlu'  liin^j;  occurs  umh  r  llio 
follnwinj;  forms: 

(1)  The  ifhilc  pnPKVKiiild  of  llir  f(tiiis.  This  may  nITect  hir^re  areas  or 
an  entire  Innjr,  which  then  is  firm,  heavy,  and  airless,  even  thon^di  the 
child  nniy  have  Keen  horn  alive.  On  section  it  has  a  <:rayisli-white  appear- 
ance— the  so-called  white  hepatization  of  N'ircliow.  The  chief  chanjz'e  is 
in  the  alvi'olar  walls,  which  are  trrcatly  thickened  and  inliltratiMl,  so  that, 
as  \Va;.'-ner  e\i)ressed  it,  the  condition  resemMcs  a  dilVnse  syphilonnu  In 
the  early  sta;^is.  for  example,  in  a  seven  or  eijiht  months"  lo'tiis,  there  may 
he  seattei'cd  miliary  foci  of  this  induration  chielly  aiioiit  the  arteries.  The 
air-cells  are  lillcd  with  des(|namated  and  swollen  epithelium. 

(".')  In  the  foi'in  id'  definite  (jiiniiiKihi,  which  vary  in  size  from  a  pea  to 
a  ;roose-e^-;j:.  They  occur'  irrej^'idarly  scattered  throuj^h  the  lun,i:,  hut,  as 
a  rule,  are  more  numerous  towai'cl  the  root.  They  ])resent  a  ;:rayisli-yellow 
caseous  appearance,  ai'c  dry  and  nsiially  imhedded  iu  a  translucent,  more 
or  less  (irm.  connective  tissue.  In  a  case  from  my  wards  descrihed  liy 
( 'ouncilimin,  there  was  extensive  involvement  of  the  root  of  the  Iuiil's. 
Hands  of  connective  tissue  ]»assed  inward  fi'om  the  thickene(l  pleura  and 
hetwccn  these  strand,s  and  surroundim^-  the  Liummata  tlici'c  was  in  places 
a  mottled  red  jineumonic  consolidation.  Jn  the  caseous  nodules  there  is 
typical  hyaline  deucm'ration.  Councilman  descrihes  as  the  primary  lesion, 
atrojihy  of  the  alveolar  walls  with  hyaline  dc;j,'encration  of  the  capillaries; 
not  the  syphilitic  endarteritis,  which  is  well  marked,  and  to  which  the 
lesions  arc  attrihntcd.  The  lu'onclii  are  usually  iindlvcil,  and  sui'i'oundinff 
tlie  fi'ununata  th(>re  may  he  a  dilTuse  l)roneho-pneum(mia,  which  does  imt 
a))]»ear  to  have  any  ]icculiar  characters. 

(;?)  A  majority  of  authors  hdlow  A'ircliow  in  recouiiizinu'  the  fil)rous 
interstitial  jtnenmonia  at  the  roni  of  (he  luui;'  and  passing'  aloin:  the  hi'on- 
chi  and  ve.«scls  ns  ])rohahly  syphilitic.  This  much  may  he  said,  that  in  cer- 
tain oases  p-imiTnata  ar(>  associated  with  these  liliroid  chanp's.  .Virain,  this 
condition  alone  is  found  in  ]iersons  with  well-marked  sy|iliilitic  liistory  or 
with  other  visceral  lesions.  It  seems  in  many  instances  to  lie  n  ])urely 
sclerotic  ])roccss.  advancini;'  sometimes  fi'om  the  pli'ura.  more  commonly 
from  the  root  of  the  lun<r,  and  invadin,!:-  the  intcrlohnlar  tissue,  trradnally 
producincc  n  more  or  less  extensive  tihroid  chan<^e.  It  rarely  involves  more 
than  a  ])ortion  of  a  lohe  or  portions  of  the  lohes.  at  the  root  of  the  lung. 
The  hronchi  are  often  dilated. 

Sijniptoms. — Is  there  a  sy])hilitic  ])hthisis,  an  ulcerative  and  destructive 
disease,  due  to  lues?     Personally  T  have  no  knowledize  of  such  an  affec- 


» 


IB 


248 


8PWIFIC   INFKCTIOUS  DISKASI'X 


/ 


tioii,  citlicr  cliiiiciilly  or  aiititoinically,  iiml  tlif  ciiiics  which  1  liiivc  hooii 
(U'liionHtratcil  (h)  not  wv\\\  to  \\\v.  to  have  characttTH  diHtiiictivt!  enough  to 
Beparate  them  from  ordinary  tulterciiloiirt  plithisis.  Certain  l-'reneh  writers 
r('co;;ni/e  Hot  only  a  chronic  sypliilitic  phthisis  hut  an  acute  syphilitic 
pneiuiionia  in  adults,  simulating  acute  pneumonic  phthisis.  Clinically, 
pulniomiry  syphilis  is  not  (d'  much  importance,  as  the  cases  can  rarely  he 
diagnosed,  and  the  sym|ttoms  which  arise  :ire  usually  those  of  hronchi- 
ectasis  or  of  chronic  ititerstitial  pneumonia.  The  white  pneumonia  is  usu- 
ully  found  in  the  still-horn. 

Diagnosis.  —  It  is  to  he  home  in  mind,  in  the  first  place,  that  hospital 
physicians  and  pathologists  the  world  over  hear  witness  to  the  e.vtremc! 
rarity  of  lung  syphilis.  In  the  second  |)laee,  the  thera|)eutic  test  upon 
which  so  much  reliance  is  placed  is  hy  no  means  conclusive.  With  pul- 
monary tuhcrculosis  there  should  now  he  no  confusion,  owing  to  the  readi- 
ness with  which  the  presence  of  hacilli  is  determined.  Bronchieetasy  in 
the  lower  lohe  of  a  lung,  dependent  upon  an  interstitial  pneumonia  of 
syphi'litic  origin,  could  not  he  distinguished  from  any  other  form  of  the 
disease.  In  persons  with  well-marked  syphilitic  lesions  elsewhere,  when 
ohscure  ])ulmonary  symptoms  occur,  or  if  there  are  signs  of  chronic  inter- 
stitial pneumonia  with  dilated  hronchi,  and  no  tidiercle  hacilli  are  present, 
the  condition  nuiy  ])ossil)ly  he  due  to  syphilis.  So  far  as  my  experience 
goes,  tuherculous  ])hthisis  occurring  in  a  syphilitic  suhjcct  has  no  sp(>cial 
peculiarities.  The  lesions  of  syphilid  and  tuhcrculosis  could  of  course  co- 
exist in  a  lung. 

c.  Syphilis  of  the  Liver. 

This  occurs  in  three  forms:  {a)  Diffuse  SiijihUUir  TfcpaliHs. — This  is 
most  common  in  cases  of  congenital  syphilis.  The  liver  ])reserves  its  form, 
is  large,  hard,  and  resistant.  Sometimes  it  has  a  yellow  look,  com])are(l 
by  Trousseau  to  sole-leather,  or  an  ai)pcarance  not  unlike  the  amyloid 
liver.  Careful  insjicction  shows  grayish  or  whitish  ])oints  and  lines  cor- 
responding to  the  interlobular  new  growth,  ^ricroscojiically,  great  increase 
in  the  connective  tissue  is  seen,  and  in  numy  ])laces  foci  of  snuill-celled 
infiltration.  Sometimes  these  nodules  are  visible,  forming  firm  miliary 
gumniata  which  in  cicatrizing  produce  more  or  less  deformity.  Larger 
gummata  may  also  be  present. 

{!))  GunniKita. — As  a  result  of  congenital  syjihilis  these  nuiy  occur  in 
childhood  or  in  adult  life.  In  ac(piired  syphilis  they  rarely  come  on  before 
the  second  year  after  infection.  In  the  early  stage  there  are  pale  grayish 
nodules,  varying  in  size  from  a  pea  to  a  marble.  The  larger  present  yellow- 
ish centres  at  first;  but  later  there  is  a  "pale  yellowish,  cheese-like  nodule 
of  irregular  outline',  surrounded  by  a  fibrous  zone,  the  outer  edge  of  which 
loses  itself  in  the  lobular  tis-^ue,  the  lobules  dwindling  gradually  in  its  grasp. 
This  fibrous  zone  is  never  very  broad;  the  cheesy  centre  varies  in  consist- 
ence from  a  gristle-like  toughness  to  a  pulpy  softness;  it  is  sometiuu's 
mortar-like,  from  cretaceous  change"  (Wilks).  When  numerous,  the  most 
extensive  deformity  of  the  liver  is  ])roduced  in  the  gradual  healing  of  these 
gummata.  On  the  surface  there  are  deep,  scar-like  depressions,  and  the  en- 
tire organ  may  be  divided  into  a  cluster  of  irregular  masses,  held  together  by 


.SYFMIM.IS. 


24U 


\vnv  m 
l)eforo 
jrayish 
k-ellow- 
kiodiik' 
\vh  it'll 
gras)). 
IniiPist- 
.'tiinoH 
most 
these 
Ihe  en- 
Iher  by 


nitrous  tiHHUo.  To  tliiH  ronditiuii  tlu'  Iciiii  hnh/miil  has  Iwon  given,  from 
its  rcsciiihhuice  fo  u  l»iiin'h  of  j;ni|u's.  As  a  rulf,  the  guiiimata  gradually 
undcrgi)  lihroid  (fansi'niiiialion.  'I'lii'V  may,  however,  solteii  and  liijuely, 
aud,  according  to  W'ilks,  uuiy  I'oriu  a  Ihictuating  tuuior. 

(r)  OecaHioiuilly  the  rypliihtic  changes  are  cliietly  nuuiifested  in  (His- 
nan's  shciilh,  in  a  thieixening  of  tiu'  capside,  producing  perihepatitis,  and 
increase  in  the  connective  tissue  in  the  jmrhil  cnntils,  so  tiiat  on  section 
the  organ  presents  a  nuinl)er  of  branehiny;  llljroiis  scars  which  nuiy  cause 
consi(h'rahlo  deformity. 

Si/niplonis. — The  symptoms  of  syphilitic  hepatitis  are  very  varial)le. 
In  the  new-horn  icterus  is  not  uiu'oniMion.  hut  the  condition  of  the  liver 
can  scarcely  he  recognized.     In  the  adult  there  are  three  groups  of  cases: 

The  patient  jtresents  a  jticturo  of  cirrhosis  of  the  liver;  there  are  di- 
gestive disturhanees,  sliglit  icterus,  loss  of  weight,  and  ascites.  If  signs 
of  syphilis  are  present  in  other  orgnu-!,  the  condition  may  he  suspected, 
or  if  after  removal  of  the  fluid  the  liver  is  felt  to  he  extrenu'ly  irregular, 
llio  diagnosis  may  he  made  almost  with  I'crtainty.  These  cases  are  com- 
mon, and  with  proper  treatment  get  v>ell;  they  form  an  important  con- 
tingent of  the  reputed  recoveries  in  ordinary  cirrhosis  of  the  liver. 

In  a  second  group  of  oases  the  ])atient  is  ana'mic,  ])asses  large  (|uan- 
tities  of  pale  urine  containing  ali)unun  and  luhe-casts;  the  liver  is  en- 
larged, perhaps  irregular,  and  the  sjileen  also  is  enlarged.  I)roj)sical  sym[)- 
toms  may  supervene,  or  the  patient  may  he  carried  oil'  by  some  intercurrent 
disease.  I'^xtensive  amyloid  degeneration  of  the  spleen,  the  inteslimil  mu- 
cosa, and  of  the  liver,  with  gummata,  are  found. 

Thirdly,  the  gummata  may  form  an  irregular  tumor  on  the  right  or 
left  lobe,  perhaps  with  very  few  or  very  obscure  symptoms.  The  diagnosis 
may  bo  doubtful  until  some  other  evidence  of  syphilis  develops.  I  have 
recorded  several  illustrative  oases  in  my  Lectures  on  Abdominal  Tumors. 

The  iliagnosis  of  syphilis  of  the  liver  is  very  important,  since  upon  it 
the  ])roper  treatment  dei)ends.  If  with  a  history  of  infection  the  liver 
is  enlarged  and  irregular,  and  the  general  health  fairly  good,  the  condi- 
tion is  ])robal)ly  sy])hilonin. 

D.  Syphilis  of  the  Digestive  Tract. 

The  a'sophofjiis  is  very  rarely  all'ectcd.  Stenosis  is  the  usual  result. 
Syphilis  of  the  stomach  is  excessively  rare.  Flexner  has  reported  a  nnnark- 
able  case  in  association  with  gununata  of  the  liver.  lie  has  collected  14 
cases  in  the  literature.  Sy]>hilitic  ulceration  has  been  found  in  the  small 
intestine  and  in  the  otvoum. 

The  most  common  seat  of  syphilitic  disease  in  this  tract  is  the  nrliini. 
The  alTection  is  found  most  commonly  in  women,  and  results  from  the 
develojmient  of  gummata  in  the  submucosn  above  the  internal  sphincter. 
The  process  is  slow  and  tedious,  and  may  last  for  years  before  it  finally 
induces  stricture.  The  symptoms  are  usually  those  of  narrowing  of  the 
lower  bowel.  The  condition  is  readily  recognized  by  rectal  examination. 
The  history  of  gradual  on-coming  stricture,  the  state  of  the  patient,  and 
the  fact  that  there  is  a  liard,  fibrous  narrowing,  not  an  elevated  crater-like 
ulcer,  usually  render  easy  the  diagnosis  from  malignant  disease.    In  modi- 


2j0 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


■:,i\*- 


cal  practice  these  discs  come  uiidci-  uliscrviitiiui  fur  (  'icr  symptoms,  par- 
ticularly amyloid  (lf;4t'iiCTati()ii:  mid  the  redid  disease  may  he  cntii'cly  over- 
looked, and  oidy  diseovt'red  post  iiiorlem. 

E.  Circulatory  System. 

Si/philis  of  llii'  Urart. — A  j'rcsli,  warty  endocarditis  due  to  syphilis  is 
not  recognized,  though  occasionally  in  persons  dead  (d'  llie  disease  tliis 
form  is  present,  as  is  not  uncommon  in  conditions  of  (k'l)ility.  Out^n-owths 
on  the  valves  in  connection  with  eummata  have  heen  I'cported  ])y  Janeway 
and  others.  Jn  a  recent  study  of  the  suhject  Loonns  tiroujis  the  lesions 
into:  (1)  Ciummata.  recent  or  old;  (".')  liiiroid  induration,  localized  or  dif- 
Jiise;  {;!)  amyloid  dcLi'eiieration ;  and  (-1)  endarteritis  ohlitt'iMiis.  J.  Adier 
claims  that  chan^^es  in  the  hlood-vess^ds  of  the  walls  of  the  heart  are  coni- 
inf)n  hotli  in  congenital  and  ac([uired  syphilis,  even  in  cases  without  clin- 
ical symptoms  or  gross  lesions. 

l{ui)ture  may  take  place,  as  in  tlie  cases  reporteil  by  ])andridge  and 
Xalty,  or  sudden  death,  as  in  the  cases  ol'  t'ayk'y  and  J'earce  (.Jould;  in- 
deed, sudden  death  is  l'rc([uent,  occurring  in  21  of  (!.')  cases  (Alracek). 

Supliiiis  of  llic  .\  rlcrlcs. — Sy|)hilis  is  helieved  to  ]ilay  an  important  n'lh' 
in  arterio-sclerosis  and  aneurism.  Its  connection  with  these  processes  will 
be  cousidei'ed  later:  here  we  shall  refer  oidy  to  the  syphilitic  arteritis,  whii'ii 
occurs  in  two  forms: 

(o)  An  ohlilrniliiKj  cinldrlrrilis,  characterized  Ijy  a  proliferation  of  the 
snhendothelial  tissue.  'J'he  new  growth  lies  within  the  elastic  lamina,  and 
may  gradually  (111  the  entii'e  hnnen:  hence  the  term  obliterating.  The 
media  and  adveutitia  "are  also  iidiltrated  with  small  cells.  This  form  of 
endarteritis  described  by  JUnbner  is  not,  however,  characteristic  of  sy])hi- 
lis,  and  its  ])resence  alone  in  an  artery  coidd  not  be  considered  jiathog- 
luimonic.  ]f,  however,  there  are  gummata  in  other  ])arts,  or  if  the  con- 
dition about  to  be  desci'iln'd  exists  in  adjacent  arteries,  the  process  may 
be  regarded  as  syphilitic. 

(/>)  (lininiialoiis  .rcrliirli'rilis. — With  or  without  involvement  of  the 
intinui,  nodular  gummata  may  develo])  in  the  adveutitia  of  the  artery,  pro- 
ducing globular  or  ovoid  swt'Uings,  which  may  attain  considerable  size. 
They  are  not  infret|uently  seen  in  tlu'  cei'cbral  arteries,  which  seem  to  be 
specially  prone  to  this  alfection.  This  form  is  specific  and  distinctive  of 
sy])hilis.  The  disease  irsnally  alTects  tlie  smaller  vessels  and  may  be  found 
in  the  coronary  arteries,  and  ])articularly  in  those  of  the  brain. 

F,  Renal  Syphilis. — (>/)  (Jummata  occasionally  develo])  in  the  kidneys, 
particularly  in  cast's  in  which  there  is  extensive  gunnnatons  he])atitis. 
They  are  rarely  nnmerons,  and  occasi(mally  lead  to  scattered  cicatrices. 
Clinically  the  affection  is  not  recognizable. 

{h)  AckIc  Si/phllHic  XephrHi.^. — This  conditicm  has  been  carefullv 
studied  by  the  French  writers  and  by  I,aflei'r,  (d'  Montreal.  It  is  estimated 
to  occur  in  the  secondary  siage  in  •'•h  ut  ;3.S  per  cent,  and  may  develo])  in 
from  three  to  six  months,  sometimes  later,  from  the  initial  lesion.  The 
outlook  is  good,  though  often  the  albuminuria  may  ])ersist  for  monlhs; 
more  rartdy  chronic  Brighr's  dise.vse  develo])s.  In  a  few  instances  syph- 
ilitic nephritis  has  proved  rapidly  fatal  in  a  fortnight  or  three  weeks.    The 


SYPHILIS. 


251 


syplu- 
atliii'j;- 


)l  the 
rv,  pro- 

■   size. 

to  be 
•ti\e  of 

i'ouml 

;i(1neY>, 
'patitis. 
a  trices. 

iret'ully 
I  mated 
elop  in 
The 
liouihs; 
svi>li- 
"The 


lesions  are  not  ppcciflc,  l)nt  arc  simihir  to   thopo   in   otlicr  acute  infec- 
tions. 

u.  Syphilitic  Orchitis. — 'Hiis  all'eetion  is  of  speoial  si<::ni(i('anoo  to  the 
pliysician,  as  its  detection  trecpicntly  (dinches  tlie  diagnosis  in  obscure 
internal  disorders.     Syphilis  occurs  in  the  testes  in  two  forms: 

((/)  The  (J  u  III  mat  0  us  (jrowth,  forming  an  iiulurated  mass  or  group  of 
masses  in  the  substance  of  the  organ,  and  sometimes  dilhcult  to  distin- 
guish from  tuberculous  disease.  The  area  of  induration  is  harder  and  it 
alfects  the  body  of  the  testes,  ■while  tubercle  more  commonly  involves  tiie 
epididymis.  Jt  rarely  U'uds  to  invade  the  skin,  or  to  break  down,  soften, 
and  supi)urate,  and  is  usually  painless. 

{/>)  There  is  an  iiilcrslHud  (iirhHis  regarded  as  sy[)hilitic,  which  leads 
to  fibroid  induration  of  tiie  gland  and  gradually  to  atrophy.  Jt  is  a  slow, 
progressive  change,  coming  on  without  pain,  usually  involving  one  organ 
more  than  another. 

General  Diagnosis  of  Syphilis. — There  is  seldom  any  doubt 
concerni'g  the  existence  of  syphilitic  lesions.  The  negative  statements 
of  the  patient  must  be  taken  with  extreme  caution,  as  ])ersons  will  lie 
deliberately  with  reference  to  i)rinu\ry  infection,  when  it  is  in  their  best 
interest  to  nmke  a  straightforM-ard  truthful  statement.  It  is  to  ])e  remem- 
bered that  syphilis  is  common  in  the  community,  and  there  are  proljably 
more  families  with  a  luetic  than  with  a  tubercidous  taint.  It  is  i)ossible 
that  the  primary  sore  may  have  been  of  trilling  extent,  or  urethral  and 
nuiskcd  by  a  gonorrhoea,  and  the  patient  may  not  ha^•e  had  severe  secondary 
symptoms,  but  such  instances  are  extremely  rai\..  Inquiries  should  be 
made  iuiO  the  history  to  ascertain  if  the  patient  lias  had  skin  rashes,  sore 
throat,  or  if  the  hair  lias  fallen  out.  Careful  inspection  should  be  made 
of  the  throat  and  skin  for  signs  of  old  lesions.  Scars  in  the  groins,  the 
result  of  buboes,  may  be  taken  as  positive  evidence  of  infection  (Hutchin- 
son). The  cicatrice  on  the  legs  are  often  co])per-colored,  though  this  can- 
not be  regarded  as  peculiar  to  syphilis.  The  bones  should  be  examined  for 
nodes.  In  doubtful  cases  the  scar  of  the  primary  sore  may  be  found,  or 
there  may  be  signs  of  atrophy  or  of  hardening  of  the  testes.  In  women, 
special  stress  has  been  laid  upon  the  occurrence  of  frecjuent  miscarriages, 
which,  in  connection  with  other  circumstances,  are  always  suggestive. 

In  the  congenital  disease,  the  occurrence  within  the  first  three  months 
of  snutHes  and  skin  rash  is  conclusive.  Later,  the  characters  of  the  syphi- 
litic facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some 
obscure  visceral  lesion.  Otlu-.'  distinctive  features  are  the  symmetrical  de- 
velopment of  node?  on  the  bones,  and  the  interstitial  keratitis. 

In  douljtful  cases  much  stress  is  laid  by  some  writers  u[)on  the  thera- 
])eutic  test,  by  placing  the  ]iatiei''+  U])on  antisy])hilitic  treatme  In  the 

case  of  an  obstinate  skin  rash  of  doulitful  character,  which  has  ted  all 

other  forms  of  medication,  this  has  much  greater  weiglit  than  m  obscure 
visceral  lesions.  I  have  on  several  occasions  known  such  mari:ed  im])rove- 
ment  to  follow  large  doses  of  iodide  of  potassium  that  the  diagnosis  of 
sv]ihilitic  lesion  was  greatly  »-er.gthencd,  but  the  subsequent  course  and 
the  post  mortem  have  shown  that  the  disease  was  not  sy[)hilis. 
IG 


252 


SPECIFIC  IXFECTIOUS  DISEASES. 


/ 


Prophylaxis. — Trr(.'<,ai]iir  intercourse  has  existed  from  the  beginning 
of  recorded  history,  and  unless  man's  nature  wholly  changes — and  of  tins 
we  can  have  no  hope — will  continue.  Resisting  all  attempts  at  solution, 
the  social  evil  remains  the  great  blot  upon  our  civilization,  and  inextricably 
blended  with  it  is  the  questiou  of  the  prevention  of  syphilis.  Two  meas- 
ures are  available — the  one  persouid,  the  other  administrative. 

Personal  purity  is  the  j)rnphylaxis  which  we,  as  physicians,  are  espe- 
cially bound  to  advocate.  Continence  may  be  a  hard  condition  (to  some 
harder  than  to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this 
lesson  upon  young  and  old  wlio  seek  our  advice  in  matters  sexual.  Cer- 
tainly it  is  better,  as  St.  Paul  says,  to  marry  than  to  Inirn,  but  if  the  former 
is  not  feasible  there  are  other  altars  than  those  of  A'enus  upon  which  a 
young  man  may  light  fires.  lie  may  practise  at  least  two  of  the  five  means 
by  which,  as  the  physician  Pondibilis  counselled  Panurge,  carnal  concupis- 
cence may  be  cooled  and  quelled — hard  work  of  body  and  hard  work  of 
mind.  Idleness  is  the  mother  of  lechery;  and  a  young  man  will  find  that 
absorption  in  any  pursuit  will  do  much  to  cool  passions  which,  though 
natural  and  proper,  cannot  in  the  exigencies  of  our  civilization  always  ob- 
tain natural  and  proper  gratification. 

The  second  measure  is  a  rigid  and  systematic  regulation  of  prostitu- 
tion. The  state  accepts  the  res])onsibility  of  guarding  citizens  against 
small-pox  or  cholera,  but  in  dealing  with  syphilis  the  i)roblem  has  been 
too  comi)lex  and  has  hitherto  baffled  solution.  On  the  one  hand,  inspec- 
tion, segregation,  and  regulation  are  difficult,  if  not  impossible,  to  carry 
out;  on  the  other  hand,  public  sentiment,  in  xVnglo-Saxon  communities 
at  least,  is  as  yet  bitterly  opposed  to  this  plan.  AVhile  this  feeling,  tliough 
unreasonable,  as  I  think,  is  entitled  to  consideration,  the  choice  lies  be- 
tween two  evils — licensing,  even  imperfectly  carried  out,  or  widespread 
disease  and  misery.  If  the  offender  bore  tlie  cross  alone,  I  would  say, 
forbear;  but  the  physician  behind  the  scenes  knows  that  in  countless  in- 
stances syphilis  has  wrought  havoc  among  innocent  mothers  and  helpless 
infants,  often  entailing  life-long  suffering.  It  is  for  them  he  advocates 
protective  measures. 

Treatment. — AVe  must  admit  that  various  constitutions  react  very 
differently  to  the  ]ioison  of  syphilis.  There  are  individuals  who,  although 
receiving  brief  and  unsatisfactory  treatment,  display  for  years  no  traces  of 
the  disease.  On  the  other  hand,  there  are  persons  thoroughly  and  sys- 
tematically treated  from  the  outset  who  from  time  to  time  show  well- 
marked  indications  of  syphilid.  Certainly  there  are  grounds  for  the 
opinion  that  persons  who  have  suffered  very  slightly  from  secondary  symp- 
toms are  more  prone  to  have  the  severer  visceral  lesions  of  the  later  stage. 

When  we  consider  that  syphilis  is  one  of  the  most  amenable  of  all  dis- 
eases to  treatment,  it  is  lamentable  that  the  later  stages  which  come  under 
the  charge  of  the  physician  are  so  common.  This  results,  in  great  part, 
from  carelessness  of  the  patient,  Avho,  wearied  with  treatment,  cannot  un- 
derstand why  he  should  continue  to  take  medicine  after  all  the  symptom? 
have  disappeared;  but,  in  part,  the  ])rofession  also  is  to  blame  for  not 
insisting  more  urgently  in  every  instance  that  acquired  syphilis  is  not  curefl 


I 


■; 


rai 

Wat 
^dy( 

a  IK 
uiea 
witi 
vaj)o 
tlie 
■'■Ivin. 
live 
<al>I(. 
t<v(i 
'iroaf 
I'endc 
Ir 
^i.iins 

fi'W   f( 

iT  thi 
f^Iinuk 


SYPHILIS. 


2')'S 


i  tiuri 

Litiou, 
ieably 

lUt'lls- 

I  espe- 
)  some 
ire  this 
,     Ccr- 
former 
rhich  a 
;  means 
)ncui)is- 
^vork  of 
md  that 
though 
A'ays  ob- 

prostitu- 

j  against 

has  hccn 

1,  inspec- 
to  carry 

imunities 

g,  though 

0  lies  bc- 
idcspread 
ould  say, 
ntle?s  in- 
a  helpless 
advocates 

react  very 
although 
traces  of 
and  sys- 
Jhow  well- 
for   the 
lary  symp- 
latoT  stage, 
of  all  dis- 


lome 


under 
rreat  part, 
cannot  im- 


I 


sy 


m 


ptom> 
for  not 
not  cured 


in  a  few  montlis,  but  takes  at  least  two  years,  during  which  time  the  pa- 
tient should  be  under  careful  sui)ervision.  The  treatment  of  the  disease 
is  now  i)ractically  narrowed  to  the  use  of  two  remedies,  justly  ternu'd  sjjc- 
cifics — namely,  mercury  and  iodide  of  potassium.  The  fornu'r  is  of  special 
service  in  the  secondiwy,  the  latter  in  the  tertiary  nuuiifestations  of  the 
disease;  but  they  are  often  combined  with  advantage. 

Mercury  may  be  given  by  the  mouth  in  the  form  of  gray  powder,  the 
hydrargyrum  cum  crtta,  which  Jliitehinson  recommends  to  be  given  in 
})ills,  one-grain  doses  with  a  grain  of  Dover's  j)o\v(ler.  One  i)ill  from  four 
to  six  times  a  day  will  usually  suilice.  I  warmly  endorse  the  excellent 
results  which  are  obtained  by  this  method,  under  which  the  patient  often 
gains  rajjidly  in  weight,  and  the  general  health  imi)roves  remarkably,  it 
may  be  continued  for  months  without  any  ill  effects.  Other  forms  given 
by  the  mouth  are  the  ])ilules  of  the  biniodide  (gr. -yV)^  ''r  ^^  the  protiodide 
(gr.  ^),  three  times  a  day.  "If  mercuiy  be  begun  as  soon  as  the  state  of 
the  sore  permits  of  diagnosis,  and  continued  in  small  but  adequate  doses, 
the  patient  will  usually  escape  both  sore  throat  and  eruption"  (Jonathan 
Hutchinson). 

Inunction  is  a  still  more  effective  means.  A  tlrachm  of  the  or«.  ry 
mercurial  ointment  is  thoroughly  rubbed  into  the  skin  every  evening  for 
six  (lays;  on  the  seventh  a  warm  bath  is  taken,  and  on  the  eighth  tlie  mer- 
curial course  is  resumed.  At  least  half  an  hour  should  be  given  to  each 
inunction.  It  is  well  to  apply  it  at  different  places  on  successive  days. 
The  sides  of  the  chest  and  abdomen  and  the  inner  surfaces  of  the  arms 
and  tliighs  are  the  best  positiojis. 

The  mere  v  may  be  given  by  direct  injection  into  the  muscles.  If 
proper  precautions  are  taken  in  sterilizing  the  syringe,  and  if  the  injec- 
tions are  made  into  the  muscles,  not  into  the  su])cutaneous  tissue,  abscesses 
rarely  result.  One  third  of  a  grain  of  the  bichloride  in  twenty  drops  of 
water  may  be  injected  once  a  week,  or  from  one  to  two  grains  of  calomel  in 
glycerin  (20  minims). 

Still  another  method,  greatly  in  vogue  in  certain  parts  of  the  Continent 
and  in  institutions,  is  fumigation.  It  may  be  carried  out  effectively  by 
means  of  Lee's  lamp.  The  patient  sits  on  a  chair  wrap]icd  in  blankets, 
with  the  head  ex])osed.  The  calomel  is  volatilized  and  de]iosit('d  with  the 
va])or  on  the  patient's  skin.  The  process  lasts  about  twenty  minutes,  and 
the  patient  goes  to  bed  wrapped  in  blankets  without  washing  or  drying  the 
skin.  A  patient  under  mercurial  treatment  should  avoid  stimulants  and 
live  a  regular  life,  not  necessarily  abstaining  from  business.  Green  vege- 
tables and  fruit  should  not  be  taken.  Salivation  is  to  be  avoided.  The 
teeth  should  be  cleansed  twice  a  day,  and  if  the  gums  become  tender,  the 
breath  fetid,  or  the  tongue  swollen  and  indented,  the  drug  should  be  sus- 
jtcnded  for  a  week  or  ten  days. 

In  congenital  syphilis  the  treatment  of  cases  born  Mith  bulhp  and  other 
si,i:ns  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die  within  a 
few  days  or  weeks.  The  child  should  be  nursed  by  the  mother  alone,  or, 
if  this  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances 
pliould  a  wet-nurse  be  employed.     The  child  is  most  rapidly  and  thor- 


251 


SriX'IFIC  INFECTIOUS  DISEASES. 


/ 


oiiglily  1)roiifrIit  imdcr  tlio  influoiu'c  of  llie  driiif  by  inunction.  The  mer- 
curial oiutiiicnt  juiiy  be  siiicari'd  on  the  llainiL'l  roller.  This  is  not  a  very 
cleanly  method,  and  someliuieri  rouses  the  suspicion  of  the  mother.  It 
is  i)rel'erable  to  ^ive  the  drug  by  the  mouth,  in  the  form  of  gray  powder, 
half  a  grain  three  times  a  day.  In  the  late  manifestations  associated  with 
l)ou{'  lesions,  the  coml)ination  of  mercury  and  iodide  of  potassium  is  jnost 
suitable  and  is  well  given  in  the  form  of  (Jilljert's  syrup,  which  consists 
of  the  biniodide  of  mercury  (gr.  j),  of  potassium  iodide  (  §  es.),  and  water 
(  3  ij).  Of  this  a  dose  for  a  child  under  three  is  from  live  to  ten  drops  three 
times  a  day,  gradually  increased.  Under  tlv'se  measures,  the  cases  of  con- 
genital syi)hilis  usually  imj)rove  with  great  rapidity.  The  medication 
should  be  continued  at  intervals  for  many  months,  and  it  is  well  to  watch 
these  ]>atients  carefully  during  the  period  of  second  dentition  and  at 
puberty,  and  it'  necessary  to  jdace  them  on  specific  treatment. 

In  the  treatment  of  the  visceral  lesions  of  syphilis,  which  come  more 
distinctly  within  the  province  of  the  physician,  i(xlide  of  potassium  is  of 
equal  or  even  greater  value  than  mercury.  Under  its  use  ulcers  rajjidly 
heal,  gununatous  tumors  melt  away,  and  we  have  an  illustration  of  a  si)e- 
citic  action  only  equalled  by  that  of  mercury  in  the  secondary  stages,  by 
iron  in  certain  forms  of  anamiia,  and  by  quinine  in  nudaria.  It  is  as  a 
rule  well  borne  in  an  initial  dose  of  10  grains,  or  10  minims  of  the  saturated 
solution;  given  in  milk  the  patient  does  not  notice  the  taste.  It  should 
be  gradually  increased  to  30  or  more  grains  three  times  a  day.  In  syphilis 
of  the  nervous  system  it  may  be  used  in  still  larger  doses.  Seguin,  who 
specially  insisted  u])on  the  advantage  of  this  ])lan,  urged  that  the  drug 
should  be  pushed,  as  good  elfects  were  not  obtained  with  the  moderate  doses. 

When  syi)hilitic  hepatitis  is  suspected  the  combination  of  mercury  and 
iodide  of  potassium  is  most  satisfactory.  If  there  is  ascites,  Addison's  or 
Xiemeyer's  ])ill  (as  it  is  often  called)  of  calomel,  digitalis,  and  squills  will 
be  found  very  u.«eful.  \  patient  of  mine  with  recurring  ascites,  on  whom 
paracentesis  was  repeatedly  performed  and  who  had  an  enlarged  and  irregu- 
lar liver,  took  this  pill  for  more  than  a  year  with  occasionally  intermissions, 
and  ultimately  there  was  a  comjdete  disappearance  of  the  dro])sy  and  an 
extraordinary  reduction  in  tlie  volume  of  the  liver.  Occasionally  the  iodide 
of  sodium  is  more  satisfactory  tlian  the  iodide  of  potassium.  It  is  less 
depressing  and  agrees  better  with  the  stomach.  ^Nfany  ])atients  possess  a 
reuuirkable  idiosyncrasy  to  tiie  idodide,  but  as  a  rule  it  is  well  borne.  Severe 
coryza  Avitli  salivation,  and  oedema  about  the  eyelids,  are  its  most  common 
disagreeable  effects.  Skin  eruptions  also  are  frequent.  I  have  known  pa- 
tients unable  to  take  more  than  from  20  to  30  grains  without  suffering 
from  an  erythematous  rash;  much  more  common  is  the  acne  eru])tion. 
Occasionally  an  urticarial  rash  may  develo]i  with  spots  of  purjmra.  Somo 
of  these  iodide  eru]itions  may  closely  resemble  syphilis.  Hutchinson  has 
re])orted  instances  in  which  they  have  proved  fatal. 

Upon  the  question  of  syphilis  and  marriage  the  family  physician  is 
often  called  to  decide.  He  should  insist  upon  the  necessity  of  two  full 
years  elapsing  between  the  date  of  infection  and  the  contracting  of  mar- 
riage.   This,  it  should  be  borne  in  mind,  is  the  earliest  possible  limit,  and 


GONOllRIICEAL  INFECTION. 


255 


nier- 
very 
.  It 
kvder, 
with 
most 

water 
three 
i  con- 
eation 
watch 
nd   at 

!  more 
1  is  of 
rapidly 

a  si)e- 
ges,  by 
is  as  a 
titrated 
should 
syphilis 
in,  Avho 
le  drug 
e  doses, 
ury  and 
ion's  or 
lills  will 
W  whom 

irregu- 
liissions, 

and  an 
iodide 
is  less 

[ossess  a 
Severe 

;ommon 

iwn  pa- 
liTering 

lru])tion. 
Some 

lison  luis 

^ician  i?^ 
two  full 
Jof  mar- 
Init,  and 


there  should  ho  at  least  a  year  of  coni})letc  inuuunity  from  all  manifesta- 
tions of  tlie  disease. 

In  relation  to  life  insurance,  an  individual  with  syphilis  cannot  he  re- 
garded us  a  iirst-elass  risk  unless  he  can  furnish  evitlence  of  ])rolon^H'd  and 
thorough  treatment  and  of  immunity  for  two  or  three  years  from  all  mani- 
festations. Even  tiien,  when  we  consider  the  extraordinary  frecpiency  of 
the  cerebral  and  other  complications  in  ju'rsons  who  have  had  this  disease 
and  who  may  even  have  undergcme  thorough  treatment,  the  risk  to  tho 
company  is  certainly  increased. 


XXXIII.    GONORRHCEAL    INFECTION. 

Gonorrhoea,  one  of  the  most  widespread  and  serious  of  infectious  dig- 
cases,  presents  many  features  for  consideration.  As  a  cause  of  ill-health 
and  disability  the  gonococcus  occu])ies  a  position  of  the  very  first  rank 
among  its  fcHows.  While  the  local  lesion  is  too  often  thought  to  he  trilling, 
in  its  singular  obstinacy,  in  the  possibilities  of  permanent  sexual  damage 
to  the  individual  himself  and  still  more  in  the  "  grisly  troop  "  which  may 
follow  in  its  train,  gonorrheal  infection  does  not  fall  very  far  short  of 
syphilis  in  im])ortance. 

The  immediate  and  remote  effects  of  the  gonococcus  may  be  considered 
under — 

I.  The  primary  infection. 

IT.  The  spread  in  the  genito-urinary  organs  by  direct  continuity  of 
surface. 

III.  Systemic  gonorrhceal  infection. 

I.  The  primary  lesion  we  need  not  here  consider,  but  we  may  call 
attention  to  the  frequency  of  the  complications,  such  as  ])eriurethral  ab- 
scess, gonorrhoeal  prostatitis  in  the  male,  and  vaginitis,  ondocervicitis,  and 
inflammation  of  the  glands  of  Bartholini  in  the  female. 

il.  Perhaps  the  most  serious  of  all  the  se(iuels  of  gonorrhoea  are  those 
which  result  from  the  spread  by  direct  continuity  of  tissues,  particularly 
in  women,  in  Avhom  gonorrhceal  salpingitis  has  been  shown  to  be  a  not 
infrequent  event.  Metritis  and  ovaritis  are  also  occasionally  met  Avith, 
and  peritonitis,  due  to  the  escape  of  pus  from  the  Fallo])ian  tubes,  has  been 
described.  Ecjually  important  is  the  development  of  cystitis,  which  is 
probably  much  more  frequently  the  result  of  a  mixed  infection  than  flue 
to  the  gonococcus  itself.  A  great  risk  is  the  extension  upward  through 
the  ureters  to  the  kidneys.  The  iDyelitis,  like  the  cystitis,  is  usually  a 
mixed  infection. 

III.  Systemic  Gonorrhceal  Ixeectiox. 

1.  Gonorrheal  Scpticcvmia  and  Pi/a'mia. — The  fever  associated  with  the 
primary  disease  is  not  an  indication  of  a  general  infection,  but  ])robably 
follows  the  absorption  of  toxines.  The  presence  of  the  gonococcus  has 
been  demonstrated  in  the  blood  in  a  few  cases,  usually  in  connection  w'^h 
some  local  lesion,  as  in  Thayer's  and  Blumer's  case  from  my  wards,  xU 


1  i  WP- 


256 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


which  tlio  patient  siiccimihcd  to  nn  acute  endocarditis.  Instances  of  se- 
vere, rapidly  fatal  general  infection  in  gonorrlueii  are  probably  alwaya 
nssociatetl  with  foci  of  suppuration  in  the  urinary  tract.  1  held  an  autoi)sy 
in  ^lontreal  on  a  remarkable  case  of  rai)id  gonorrhu'al  sepsis  in  a  young 
man,  who  within  ten  days  of  the  |)rimary  lesion  was  seized  with  severe 
chills  and  high  fever.  Jle  rapidly  became  unconscious,  the  fever  i)ersisted, 
and  he  fell  into  a  ct)n(lition  of  ])rofound  toxiemia  and  died  early  on  tiio 
morning  of  the  fourth  day  from  tlie  chill.  At  the  autopsy,  which  was  made 
about  twelve  hours  after  death,  there  was  an  acute  urethritis  and  a  small 
])rostatic  abscess  not  more  than  *i  or  3  cm.  in  diameter.  The  blo()d  was 
iluid,  tarry  black,  and  unlike  anything  1  have  ever  seen  before  or  since. 

Gonurrha-dl  Endocarditis. — li.  L.  MacDonnell  found  4  cases  of  endo- 
carditis in  ^7  instances  of  gonorrlucal  arthritis.  Two  rcnuirkable  cases 
have  been  re))orted  from  my  wards  lately  by  Thayer  and  lilumer  and 
Thayer  and  Lazear.  They  are  of  special  interest,  as  in  both  the  gonocoeci 
were  isolated  from  the  blood  during  life  and  after  death  from  the  affected 
valves.  Thayer  and  Lazear  have  analyzed  30  instances  of  fatal  ulcerative 
endocarditis  in  gonorrluini.  Of  these,  22  were  in  men,  8  in  women.  As  a 
rule,  the  arthritis  preceded  the  cardiac  aifection,  but  in  a  nund)er  of  in- 
stances the  cardiac  complication  occurred  without  or  before  the  develop- 
ment of  joint  symptoms. 

Of  other  cardiac  lesions,  pericarditis  occurred  in  7  of  the  fatal  cases. 
Acute  myocarditis  was  present  in  Councilman's  case. 

2.  Gonurrhival  Arthritis. — In  many  respects  this  is  the  most  damaging, 
disabling,  and  serious  of  all  the  complications  of  gonorrhoea.  It  not  only 
occurs  in  the  adult,  but  in  children  after  the  gonorrlucal  conjunctivitis. 
It  occurs  more  frequently  in  males  than  in  females.  In  a  series  of  253 
cases  collected  by  Northrup,  230  were  in  males;  130  cases  were  between 
twenty  and  thirty  years  of  age.  It  occurs,  as  a  rule,  during  an  acute  attack 
of  gonorrhoea.  In  208  of  Northrup's  series  there  was  a  urethral  discharge 
while  in  hospital.  It  may  occur  as  the  attack  subsides,  or  even  when  it  has 
become  chronic.  A  gonorrheal  arthritis  of  great  intensity  may  develop 
in  a  newly  married  Avoman  infected  by  an  old  gleet  in  her  husband.  As  a 
rule,  many  joints  are  affected.  In  Northrup's  series  three  or  more  joints 
were  affected  in  175  cases,  one  joint  in  56  cases.  It  is  peculiar  in  attack- 
ing certain  joints  which  are  rarely  involved  in  acute  rheumatism,  as  the 
eterno-clavicidar,  the  intra-vertebral,  the  temporo-maxillary  and  sacro- 
iliac. 

The  anatomical  changes  are  variable.  The  inflammation  is  often  peri- 
articular, and  extends  along  the  sheaths  of  the  tendons.  When  effusion 
occurs  in  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly 
the  characters  of  a  synovitis.  About  the  wrist  and  hand  suppuration  some- 
times occurs  in  the  sheaths.  It  has  been  suggested  that  the  simple  arthritis 
or  synovitis  follows  absorption  of  ptomaines  from  the  urethral  discharge, 
while  the  more  severe  suppurating  forms  are  due  to  infection  with  pus  or- 
ganisms. It  has  now  been  definitely  show  it  the  gonococcus  itself  may 
be  present  in  the  inflamed  joint  or  in  the  pc-ri-arthritic  exudate.  Within 
the  past  eighteen  months  Young  has  obtained  the  gonococcus  in  pure  cnl- 


GOXORRIKEAL  INFECTION. 


257 


ot  only 
ctivitis. 
of  2o'Z 
jotwoen 
attack 
diarge 
it  has 
develop 
As  a 
joints 
attack- 
as  the 
sacro- 

n  peri- 
}ffiision 
nmonly 
some- 
rthritis 
charge, 
pus  or- 
ilf  may 
Within 
tire  cxil- 


ture  in  7  cases  of  gonorrhd'ul  arthritis  in  the  Jolins  IIo[)kin3  Hospital. 
Sonietinies  the  cultures  are  negative;  in  other  instances  there  is  a  mixed 
infection  witli  stapliylococei  or  slre[»tococci. 

Clinical  Course. — \'arial)ility  and  ohstinacy  are  the  two  most  dis- 
tinguishing features.    The  following  are  the  most  important  clinical  forms: 

((/)  Arl/ii'dlijir,  in  wiiich  tiu're  are  wandering  paius  al)out  the  joints, 
without  redness  or  swelling.    These  persist  for  a  long  time. 

(h)  ruli/arllirilic,  in  wiiich  several  joints  l)ecome  aiVectcd,  just  as  in 
subacute  articular  rheumatism.  The  fever  is  slight;  tlie  local  intlamuui- 
tion  may  fix  itself  in  one  joint,  but  more  commonly  several  become  swollen 
and  tender.    In  this  form  cerebral  and  cardiac  comi)lications  may  occur. 

{(■}  Acute  (/oiiorrho'al  (irlltrilis,  in  which  a  single  articulation  l)ecomc3 
suddenly  involved.  The  \)ixin  is  severe,  the  swelling  extensive,  and  due 
cliielly  to  peri-articular  (cdema.  The  general  fever  is  not  at  all  i)rop(n-tion- 
ate  to  the  intensity  of  the  local  signs.  The  exudate  usually  resolves, 
though  sup])uration  occasionally  su])ervencs. 

(d)  Chronic  Jfi/drarlhrosis. — This  is  usually  mono-articular,  and  is  par- 
ticularly apt  to  involve  the  knee.  It  comes  on  often  without  i)ain,  redness, 
or  swelling.  Formation  of  pus  is  rare.  It  occurred  only  twice  in  96  cases 
tabulated  by  Xolen. 

(e)  Ihirsal  and  Si/novial  Form. — This  attacks  chiefly  the  tendons  and 
tlicir  sheaths  and  the  burste  and  the  periosteum.  The  articulations  nuiy 
not  be  affected.  The  bursa?  of  the  patella,  the  olecranon,  and  the  tendo 
Achillis  are  most  apt  to  be  involved. 

(/)  Seplicivnnc. — In  which  with  an  acute  arthritis  the  gonococci  invade 
the  blood,  and  the  picture  is  that  of  an  intense  scptieo-i)y;emia,  usually 
with  endocarditis. 

The  disease  is  much  more  intractable  than  ordinary  rheumatism,  and 
relai)ses  are  extremely  connnon.    It  may  become  chronic  and  last  for  years. 

Complications. — Iritis  is  not  infrequent  and  may  recur  with  suc- 
cessive attacks.  The  visceral  complications  are  rare.  Endocarditis,  peri- 
carditis, and  ])leurisy  may  occur. 

Treatment. — The  salicylates  are  of  very  little  service,  nor  do  they 
often  relieve  the  ])ains  in  this  affection.  Iodide  of  potassium  has  also  })roved 
useless  in  my  hands,  even  in  large  doses.  A  general  tonic  treatment  seems 
much  more  suitable — ([uinine,  iron,  and,  in  the  chronic  cases,  arsenic. 

The  local  treatment  of  the  joints  is  very  im])ortant.  The  thermo- 
cautery may  be  used  to  allay  the  pain  and  reduce  the  swelling.  In  acute 
cases,  fixation  of  the  joints  is  very  beneficial,  and  in  the  chronic  forms, 
massage  and  passive  motion.  I  have  seen  very  good  results  follow  in  a  few 
cases  the  use  of  the  dry  hot  air.  The  surgical  treatment  of  this  affection, 
as  carried  out  nowadays,  is  more  satisfactory,  and  I  have  seen  strikingly 
good  effects  from  incision  and  irrigation. 


258 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


XXXIV.   TUBERCULOSIS. 

I.    CiENEllAL    KtIOLUUV    AND    iMuHUII)    AXATOMY. 

Definition. — aw  infective  disense,  caused  by  the  hacUliis  luhcrcuhsis, 
the  lesions  ol'  which  lU'c  cliiinictcrizcd  hy  nodular  bodies  cuIUmI  tubercles 
or  dill'use  iulilt  nit  ions  of  tuberculous  tissue  which  underj^o  caseation  or 
sclerosis  and  may  linally  ulcerate,  or  in  some  situations  calcify. 

Etiology. — 1.  Zoological  DlBtribution. — Tuberculosis  is  one  of  the 
most  \vidcs|»read  of  nudadies. 

Jn  cold-blooded  animals  it  is  rare,  owin<;  doubtless  to  tem])erature  con- 
ditions unfavorable  to  the  develoiuiient  of  the  bacillus.  Among  rei)tileri 
in  confinement  it  is,  however,  occasionally  seen  (Sibley).  Jn  fowls  it  is  an 
extremely  common  disease,  but  there  are  ditferences  in  avian  tuberculosis 
sulhcient  to  warrant  its  separation  from  the  ordinary  form. 

Among  domestic  aninuds  tuberculosis  is  widely  but  unevenly  distril)- 
nted.  Among  rnminnnts,  bovines  are  chiefly  affected.  The  percentage 
for  oxen  and  co-wp  at  the  Berlin  abattoir  in  the  year  18U'^-'y3  was  15.1.  In 
this  country  nni'h  luis  been  done,  particidarly  in  ^lassachusetts  and  I'enn- 
pylvaiua,  to  detcrnune  the  ])rcsence  of  the  disease  in  the  dairy  herds,  for 
which  i)urpose  the  tuberculin  test  has  been  extensively  employed.  The 
results  show  a  widespread  })revalence  of  the  disease. 

Of  5,2*J7  cattle  slaughtered  in  Maryland  only  159  were  tul)erculous 
(A.  W.  Clement).  Of  15,5()()  slaughtered  at  the  Brighton  abattoir,  Boston, 
only  2d  were  tubcrcidous  (A.  Burr).  The  tuberculin  test  has  shown  in 
some  phices  a  ])ercentage  of  from  15  to  30, 

In  sheep  tlie  disease  is  very  rare.  In  pigs  it  is  common,  but  not  so 
common  in  this  country  as  in  Euro])e.  In  the  inspection  of  1,000  hogs, 
which  was  made  by  A.  W.  Clement  and  myself  in  Montreal  in  1880,  tuber- 
culosis was  seen  only  once  or  twice.  At  the  Bevlin  abattoir  in  1887-88 
there  were  G,393  ])igs  affected  with  the  disease. 

Horses  are  rarely  attacked.  Dogs  and  cats  are  not  prone  to  the  disease, 
but  cases  are  described  in  which  infection  of  pet  animals  has  taken  place 
from  ])hthisical  masters.  Among  the  semi-domestic  animals,  such  as  the 
rabbit  and  guinca-i)ig,  the  disease  under  natural  conditions  is  rare,  al- 
though these  animals,  particularly  the  latter,  are  extremely  susceptible  to 
the  disease  when  inoculated.  Anu)ng  ajies  and  monkeys  in  the  wild  state, 
tuberculosis  is  unknown,  but  in  confinement  it  is  the  most  formidable  dis- 
ease with  which  they  have  to  contend. 

The  important  etiological  fact  in  connection  with  tuberculosis  in  ani- 
mals is  the  widesjiread  occurrence  of  the  disease  in  bovines,  from  which 
class  we  derive  nearly  all  the  milk  and  a  very  large  proportion  of  the  meat 
used  for  food. 

2,  General  Statistics  of  the  Disease  in  Man. — Tuberculosis  is  the  most 
universal  >courge  of  the  human  race.  It  ])revails  more  ])articularly  in  the 
large  cities  and  wherever  the  nomilation  is  mussed  tosrether.  One  seventh 
of  all  deaths  are  due  to  It.  in  the  United  States  Census  I{e])ort  for  1890, 
102,188  deaths  were  reported  to  be  due  to  consumption.     At  a  low  esti- 


TUBEIICI'LOSIS. 


260 


587-SS 


111  ain- 

wliieh 

lie  meat 

lie  most 

ill  the 

Iseveiith 

Ir  1800, 

)W  csti- 


iiiate  one  can  sny  that  at  least  l.'iOjdOO  ])ers()ns  die  annually  in  the  T'nited 
States  oi'  some  I'orm  of  tiiheniilotiis.  An  estimation  hasecl  on  the  C'en.sii.s 
lit'port  gives  the  total  miiiiher  ot  persons  in  this  country  infected  with 
tuberculosis  as  l,(io(),i)0(»,  or  i  in  every  GU  of  tiie  [»o|iulatioii  (\'au<;hau). 

(Jeoyrapliical  position  has  very  little  inlluenee.  Tlu'  tiisease  is  perhaps 
more  prevalent  in  the  temperate  re«,Mons  tium  in  the  tropics,  hut  aUitudo 
is  a  more  potent  factor  than  latitude;  in  the  hij-h  rc/^ions  of  the  Alps  and 
Amies  and  in  the  central  plateau  of  Mexico  the  death-rale  from  tubercu- 
losis is  very  low. 

21ie  infhiciire  of  rare,  which  has  been  much  studied,  is  ])robablN  less 
owing  to  any  inherent  dill'erences  than  to  the  conditions  under  which  the 
individuals  live.  I'lie  Indians  of  this  continent  are  very  ju'one  to  the  dis- 
ease. jMatthews  states  thai  the  death-i'ate  in  the  older  reservations  in  the 
East  was  three  times  as  great  as  that  of  the  Indians  still  living  in  the 
Northwest.  In  this  country  Ihe  Irish  and  the  negroes  appear  specially 
jU'one  to  the  disease;  on  the  other  hand,  the  lli'brews  possess  a  relative 
immunity.  For  the  six  years  ending  May  31,  ISDU,  the  average  annual 
death-rate  from  consumption  in  New  York  city  ])er  100,0(10  of  population 
was:  For  the  Irish,  Glo.Ti?;  for  the  colored,  531.35;  for  the  Germans, 
35S..S0;  for  the  American  whites,  5i05.11;  and  for  the  Kussiau-l'olish  Jews, 
70.T•^  (J.  S.  Billings). 

The  Decrease  of  Tuberculosis. — F.  F.  Wells,  who  has  tahulated  an  im- 
mense hody  of  statistics  on  this  suhject,  states  that  the  evidence  is  in  favor 
of  a  very  positive  decline  in  the  ])revalence  of  the  disease.  While  the  last 
decennial  census  of  the  United  Slates  does  not  show  anv  decrease,  vet  in 
many  of  the  larger  cities  there  has  been  a  striking  diminution.  The  question 
has  been  considered  very  carefully  hy  James  IJ.  Russell,  of  Glasgow,  in  his 
Sanitary  History  of  that  city.  One  or  two  of  the  sentences  from  his  report 
may  he  cpioted  with  advantage:  "  Between  the  five  years  1S?0-'71  and  the 
live  years  1SL>0-'D4  there  was  a  decrease  of  41  ])er  cent  in  the  death-rate. 
If  we  start  from  the  maximum  peri(jd  of  fatality  (ISdO-'G-l),  the  decrease 
amonnts  to  44  ])er  cent.  The  acceptance  of  the  doctrine  that  every  case 
of  ])htliisis  is  the  result  of  a  specific  infection — that,  consecpienlly,  no  one 
is  foredoomed  to  have  ])hlhisis  or  any  other  form  of  tuherculous  disease — 
gives  great  precision  to  our  ideas  of  prevention."'  He  attributes  a  good  deal 
to  the  dilfusion  of  the  knowledge  that  the  existence  and  distribution  of  the 
tuhercle  hacillus  is  the  first  condition  of  infection,  and  also  to  the  success- 
ful administralivo  efforts  in  securing  "  ventilation,  especially  of  houses  and 
byres;  the  removal  of  dam])ness  hy  sul)soil  drainage  and  precautions  adaptecl 
to  the  foundations  and  walls  of  houses;  the  aholilion  of  dark  spaces  and 
inclosures;  the  dissemination  of  direct  sunlight." 

The  diminution  of  pulmonary  tuberculosis  in  ^rassachusetls  is  remark- 
able, the  death-rate  having  fallen  from  42  ])er  1(),(M)()  inhabitants  in  1853 
to  ,21.8  per  10,000  in  1895.  A  remarkable  reduction  has  also  taken  place  in 
New  York. 

3.  The  Bacillus  Tuberculosis. — The  history  of  the  discovery  of  the 
bacillus  presents  many  points  of  interest,  ronfideutly  expected  by  such 
observers  as  Yillemin,  Chauveau,  Cohiiheim,  and  others,  and  claimed  to 


i 


2r,o 


Si'l-XIFIC  IN'KK(rn(»L'S  DISKASES. 


Imvo  liccn  (Iciiinnstrntcd  liy  innny,  notalily  l»y  Kldts  nnd  Aiifnclit,  it  rc- 
iiiiiiiKMl  I'or  Kiich  to  (l('llloIl^t^all•  il.s  t'xisd'iH-c  iiiid  its  invariable  a.-socialion 
witii  tiic  disease.  The  Ir.veHtipitions  wliicli  lie  had  previously  huule  ujm)!! 
anthrax  and  exiieriinental  traumatic  infections,  hy  perl'eetin;,'  the  nielhodd 
(»!'  researcii,  jtaved  the  way  Tor  this  liriUiant  discovery.  His  preliminary 
article*  and  his  more  elal)orati'  later  work  f  should  he  carei'ully  studied  hy 
any  one  who  wishes  to  apju'cciate  the  value  (d'  scientilic  methods.  It  forms 
one  of  the  most  ninsterly  denu)nstrations  of  moih'rn  nu'dicine.  Its  thor- 
ou<,diness  ni)))ears  in  the  fact  that  in  the  years  which  have  elapsed  since  its 
appearance  the  innumcrahle  workers  on  the  suhjcct  have  not,  so  far  as 
1  know,  addi'd  a  s(»litary  essential  fact  to  those  prescnteil  hy  Koch. 

Mdr/iliiiloi/icdl  Clianirlrrs. — The  tid)crcle  hacillus  occurs  usually  as  a 
short,  fine  rod,  often  sli^ditly  hent  or  curved,  and  has  an  avera;,'e  len^'th  of 
nearly  half  the  diameter  of  a  red  hlood-corpus<'le  {'.\  to  I  //);  more  rarely  it 
shows  lateral  outj^rowtjis  or  simple  hranches.  When  stained  it  often  presents 
a  headed  appearance,  which  some  have  attrihuted  to  the  presence  of  spores. 

With  the  hasic  ainline  dyes  it  stains  slowly,  except  at  the  hody  tem- 
perature, hut  retains  the  dye  after  treatment  with  acids — n  characteristic 
Mhich  se])arates  it  from  all  other  known  forms  of  bacteria  with  the  exc(>p- 
tion  of  the  hacillus  of  le|)rosy. 

Modes  of  Growth. — It  grows  on  blood-serum,  glycerin-agar,  bouillon,  or 
on  i)ot.?to — most  readily  on  the  first.  The  cultures  must  be  kept  at  blood- 
licat.  They  grow  slowly,  and  do  not  appear  until  about  the  eiul  of  the 
second  week.  The  colonies  form  thin,  grayish-white,  dry,  scale-like  masses 
on  the  surface  of  the  culture  medium.  Successive  inoculations  nuiy  bo 
made  from  the  cultures,  and  at  the  end  of  an  iiulefinite  series  material 
from  cue  of  them  inocidated  into  a  guinea-pig  will  produce  tuberculosis. 

Variations. — (a)  In  Form. — The  small  branching  forms  are  found  not 
infreciuently  in  tuberculous  lesions.  Some  investigators  claim  to  have  jiro- 
duced  more  com})lex  structures,  resend)ling  the  "  driisen ''  of  the  actino- 
myces. 

(h)  In  Viriilcnrc — Xoch  was  of  the  opinion  that  tubercle  bacilli  from 
various  sources  pos.scss  the  same  degree  of  virulence.  Theobald  Smith  iuis 
found  cndturcs  of  bovine  tuberculosis  more  highly  virulent  for  rabbits 
than  cultures  of  sputum  bacilli.  The  mor])hology  of  the  organisms  fi'om 
the  two  sources  was  also  different.  Arloing  and  his  students  have  long 
claimed  that  material  from  scrofula  aiul  bone  tuberculosis  is  less  virulent 
than  from  other  varieties  of  human  tuberculosis. 

The  bacillus  tuberculosis  avium  tends  to  appear  in  more  irregular 
forms,  grows  more  readily  and  more  rapidly  in  artificial  cultures,  and  is 
more  resistant  to  age  and  high  temperature,  and,  while  highly  pathogenic 
for  the  hen,  produces  only  local  inflammatory  processes  in  mammals.  It 
is  probable  that  infection  with  avian  tuberculosis  sometimes  occurs  in  man 


(Pi 


uisini 


). 


Products  of  the  Growth. — Little  is  yet  known  of  the  chemical  charac- 


*  Berliner  klinische  Woohcnsohrift,  1882. 

f  Mittheilungen  a.  d.  k.  Gesundheitsamte,  Bd.  2. 


TUnKUCULoSIS. 


2fil 


A  from 
lith  liii^ 
iral)l)itrf 
Is  from 
ro  lonjT 
irulont 

Irogular 
and  is 
lingenip 
Ills.  It 
lin  man 

Icharac- 


Icrs  (»f  Uic  rnatcrials  which  result  from  the  jjrowth  of  the  tuhoiTlo  bacilli. 
Koth's  tiilicrciiiiii  is  stated  to  he  a  i^lyeerin  extract  of  the  eidtiires.  Crook- 
hluiiik  and  llerroiiii  have  sejiarated  an  allMiiiiose  ami  a  ptoinaiiie. 

Pi.slrihiilinii  iif  llir  lltitilli. — The  haeilli  are  found  in  all  t uln'rculoua 
lesions;  in  some  in  great  ahiindanee,  in  otIu'r«  sparsely.  They  are  par- 
tieularly  numerous  in  actively  developinj;  tuhi-rcles,  hut  in  the  chronic 
liihereidoiis  processes  of  lympli-ji'lands  and  of  the  joints  they  are  scanty. 
When  a  tuherculous  focus  communicates  with  a  vein  ov  with  lymph-ves- 
sels, the  haeilli  nuiy  he  spread  widely  tliroughout  the  hody.  in  old  lesions 
they  may  not  lie  found  in  the  sections,  and  the  demonstration  of  the  true 
nature  may  he  possihie  only  hy  culture  or  inoculation. 

Till'  lliioilli  nitlsiile  llic  Jloilij. — Patients  with  ailvaneed  |)uhuonary 
tuhi'rculosis  throw  oil*  in  the  expectoration  countless  millions  of  the  haeilli 
(hdly.  Sonu'  idea  of  the  extraordinary  numhers  nniy  he  piined  from  the 
studies  of  Xuttall.  From  a  patient  with  moderately  advanced  disease, 
the  amount  of  whose  expectoration  was  from  To  to  \'M)  cc.  daily,  he  esti- 
mated hy  his  nu'thod  that  there  were  in  sixteen  c(tunts,  hetween  .lanuary 
Hull  and  March  1st,  from  one  and  a  half  to  four  and  a  third  hillions  of 
l)acilli  thrown  olf  in  the  twenty-four  hours.  These  figures  emphasize  the 
danger  associated  with  ]ththisical  sj)uta  unless  nutst  carefully  dealt  with. 
\\'hen  expectorated  and  allowed  to  dry,  the  sputum  rapidly  heccmu's  (hist, 
and  is  distrih\ited  far  and  wide.  The  ohservations  made  hy  Cornet  under 
Koch's  supervision  arc  in  this  connection  most  instructive.  lie  collected 
the  dust  from  the  walls  and  hedsteads  of  various  localities,  and  determined 
its  virulence  or  innocnousness  hy  inocuIati(m  into  susceptil)le  animals. 
Material  was  gathered  from  'i\  wards  of  T  lios|)itals,  W  asylums,  "i  prisons, 
from  the  surroundings  of  G2  i>hthisical  patients  in  private  ])ractice,  and 
from  21)  other  localities  in  which  tul)ercul(uis  ])atients  were  only  transient 
frcipienters  (out-patient  (h'|»artinents,  streets,  etc.).  Of  IIM  dust  samples 
from  hospital  wards  or  the  rooms  of  phthisical  patients,  40  were  infective 
and  jjroduced  tuberculosis.  Negative  results  were  obtained  with  the  29 
dust  samples  from  the  localities  occasionally  occupied  by  consumptives. 
\'irulent  bacilli  were  obtained  from  the  dust  of  the  walls  of  1.")  out  of  21 
medical  wards.  It  is  interesting  to  note  that  in  2  wards  with  many  phthis- 
ical i)atients  the  results  were  negative,  indicating  that  tlu'  dust  in  such 
regions  is  not  necessarily  infective.  The  infectiousness  of  the  dust  of  the 
medical  and  surgical  divisions  of  a  hos])ital  is  in  the  ])roportion  of  7(i.(>  to 
12..").  In  a  room  in  which  a  tuberculous  woman  had  lived  the  dust  from 
the  wall  in  the  neighborhood  of  the  bed  was  infective  six  weeks  after  her 
death.  Xo  bacilli  were  found  in  the  dust  of  an  inhalation-chand)er  for 
consumptives.  The  experiments  of  Strauss  at  the  Charite  Hospital,  Paris, 
are  important.  In  the  nostrils  of  29  assistants,  nurses,  and  ward-tenders 
he  placed  plugs  of  cotton-wool  to  collect  the  dust  of  the  wards.  In  9  of 
the  29  cases  these  contained  tubercle  bacilli  and  proved  infective  to  ani- 
mals. The  question  of  the  increase  of  tul)erculosis  among  the  permanent 
residents  of  health  resorts  frc(|uented  by  consumptives  is  one  of  great 
interest.  Gardiner  has  studied  the  problem  at  Colorado  Springs,  in 
which  for  twenty  years   tuberculous  jiatients  have   been   living,   and  he 


IMAGE  EVALUATION 
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Hiotographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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262 


SPECIFIC  INFECTIOUS  DISEASES. 


finds  tlio  number  of  cases  of  tiiltorculosis  oriirinatinj,'  in  tlic  city  to  lie  very 
small. 

Psendo-hiberculn^iK. — While  lesions  resembling  the  nodules  of  tubercu- 
losis, but  due  to  a  variety  of  bacteria,  protozoa,  and  nematodes,  are  not  un- 
common in  animals,  ])seudo-tul)ercul()Us  ]»rocesses  are  very  rare  in  human 
bein/is.  Flcxner  *  luis  described,  untler  the  name  })svudo-tubcrcuhms 
hominis  strvptoihricn,  a  condition  in  human  beings  in  which  the  lungs  jire- 
sented  the  a])pearance  of  a  caseous  pneumonia  and  numerous  tubercle-like 
nodules  existed  in  the  ])eritonanim.  The  micro-organism  found  in  the 
lesions  was  a  streptothrix,  which  ditfered  greatly  from  the  known  forms 
of  the  bacillus  tuberculosis  and  streptothrix  actinomyces. 

4,  Modes  of  Infection. — {a)  Ihreditanj  Transmission. — The  possible 
methods  of  transmission  of  the  germ  in  direct  inheritance  are  three — 
transmission  by  the  sperm,  transmission  by  the  ovum,  and  transmission 
through  the  blood  by  means  of  the  placenta. 

There  is  no  clinical  evidence  to  sui)port  the  view  that  direct  transmis- 
sion can  occur  through  the  sperm.  In  order  that  the  disease  could  be  trans- 
mitted by  the  si)erm  it  would  be  necessary  that  the  tubercle  bacilli  should 
lodge  in  the  individual  spermatozofin  which  fecundates  the  ovum.  Th.o 
chances  that  such  a  thing  could  occur  are  extremely  snuill,  looking  at  the 
subject  from  a  numerical  point  of  view,  altliough  we  know  that  tubercle 
bacilli  do  occasionally  exist  in  the  semen;  they  become  still  smaller  Avhen 
we  consider  that  the  spermatozoon  is  made  up  of  nuclear  material,  which 
the  tubercle  bacillus  is  never  known  to  attack.  Experimentation  is  all 
oi)posed  to  sperm  transmission,  the  work  of  Gartner  and  others  showing 
that  the  young  of  healthy  female  rabbits  impregnated  by  tuberculous  males 
are  never  tuberculous,  even  though  the  females  themselves  often  contract 
the  disease. 

The  possibility  of  transmission  by  the  ovum  must  be  accepted.  Baum- 
garten  has  in  one  instance  been  aide  to  detect  the  txdjerele  bacillus  in  the 
ovum  of  a  female  rabbit  which  he  had  artificially  fecundated  with  tubercu- 
lous semen.  The  work  of  Pasteur  on  pchrine  has  shown  the  possibility  of 
this  form  of  transmission  in  the  lower  forms,  though  the  question  as  to 
Avliat  effect  such  inoculation  would  have  u])on  the  human  ovum  cannot  of 
course  be  answered. 

Probably  the  almost  constant  method  of  transmission  in  congenital 
tuberculosis  is  through  the  blood  current,  the  tubercle  bacilli  penetrating 
by  way  of  the  ])lacenta.  Certain  authors  hold  that  in  these  cases  the  i)la- 
centa  itself  is  invariably  the  seat  of  tuberculosis,  and  tubercles,  indeed, 
have  been  demonstrated  in  several  cases;  but  there  are  undoubted  instances 
in  wliich,  with  an  a])]»arently  sound  placenta,  both  the  ])lacental  blood  and 
the  fd'tal  organs  contained  tubercle  bacilli,  notwithstanding  the  fact  that 
the  organs  also  appeared  normal. 

Possible  Latency  of  the  Tuhercle  Germs. — r>aumgarten  and  his  followers 
■assume  that  the  tubercle  bacilli  can  lie  latent  in  the  tissues  and  subse- 
quently develop  wlien,  for  some  reason  or  other,  the  individual  resistance 

*  Journal  of  Experimental  Medicine,  1898. 


TUBERCULOSIS. 


263 


ic  very 

ibercu- 
lot  un- 
humiin 

gs  i)ro- 

clo-like 

in  the 

I  forms 

possible 
three — 
jinission 

•ansmis- 
)e  traiis- 
i  shouhl 
u.  Tl'.e 
g-  at  tlie 
tubercle 
er  when 
1,  which 
)n  is  all 

showing 
us  males 

contract 

]}aum- 

3  in  the 

ul)ercu- 

ility  of 

on  as  to 

annot  of 

)ngenital 
■trating 
the  pla- 
int! eecl, 
instances 
lood  and 
fact  that 

followers 
1(1  subse- 
resistance 


b 


is  lowered.  He  likens  such  cases  of  latent  tuberculosis  to  the  late  heredi- 
tary forms  of  sy[)]u]is,  and  cxiiiams  the  lack  of  (k-vclopment  of  the  germs 
by  the  greater  resistijig  [tower  of  the  tissues  of  ciiildrcn.  In  the  discussion 
on  latency  before  the  lioyal  Medical  and  C'iiirurgical  Society  of  London, 
Kingston  Fowler  expressed  the  sensil)le  oi)inion  that  it  was  not  necessary 
seriously  to  consider  the  (piestion  of  latency  in  tuberculosis  until  direct 
transmission  from  mother  to  child  was  proved  to  be  of  frequent  occur- 
rence. JJaumgarte]!  bases  his  belief  in  germ  transmission  upon  two  nuiin 
factors — the  great  frequency  of  the  disease  in  forly  life  and  the  localization 
of  tul)erc\dous  lesions  in  children. 

The  mortality  from  tuberculosis  in  the  first  years  of  life  is  relatively 
high.  Of  2,bl:G  autopsies  made  on  children,  :^T.S  per  cent  who  died  in  the 
first  year  were  tuberculons  (Botz).  Of  182  auto])sies  on  children  one  year 
or  under,  17  were  tuberculous  (Comby).  The  localization  of  tuherculous 
lesions  in  children  in  the  bones  or  joints  is  very  common,  C'noi)i)'s  sta- 
tistics showing  that  out  of  21)8  tuberculous  ciiildren  of  from  a  few  davs 
to  twelve  years  of  age,  147  had  bone  or  joint  tul)erculosis,  and  only  8  of 
these  show>.d  evidence  of  visceral  disease.  Baumgarten  is  of  the  opinion 
that  the  accidental  conveyance  of  tubercle  bacilli  to  these  ])oints  would  not 
account  for  such  a  large  proportion  of  cases,  and  expresses  the  view  that 
the  bacilli  have  been  present  since  birth  aiid  have  developed  when  favor- 
able conditions  offered.  The  evidence  in  favor  of  Baumgarten "s  view  is 
both  clinical  and  ex])erimental. 

The  clinical  evidence  exists  in  the  form  of  undoubted  cases  of  con- 
genital tuberculosis,  of  which  there  are  now,  in  man  alone,  about  20  ex- 
amjjles  in  the  literature;  besides  tliese,  a  number  of  spontaneous  cases  of 
congenital  tiiberculosis  in  the  lower  animals  have  been  reported. 

A  number  of  laboratory  workers  have  been  able  to  show  that  congenital 
tuberculosis  can  be  ])roduced  experimentally,  the  most  prominent  of  these 
being  Giirtner,  Avho  was  able  to  cause  tuljcrculosis  in  young  mice  by  inocu- 
lating the  mother  with  tuberculosis,  either  into  the  peritoneal  cavity  or 
into  the  blood  stream.  !Mafucci  has  shown  that  after  injecting  eggs  with 
avian  tuberculosis  the  disease  may  remain  latent  in  the  chick  for  weeks  or 
even  months. 

Against  Baumgarten's  theory  are  the  facts  that  the  percentage  of  cases 
of  congenital  tuberculosis  is  extremely  small,  and  that  in  tli(>  great  majority 
of  instances  the  organs  of  fietuses  born  of  tuberculous  mothers  give  nega- 
tive results  when  inoculated  into  guinoa-]iigs. 

Xo  circumstance,  perhajts,  has  contril)uted  more  to  the  belief  in  the 
hereditary  transmission  of  the  disease  than  the  frequency  with  which  tuber- 
culosis is  met  with  in  the  ascendants  of  those  alTected.  The  estimates  range 
from  10  per  cent  to  25  per  cent,  (-r  even  in  some  instances  to  .50  per  cent. 
Some  of  the  statistics  on  this  point  are  worth  quoting:  In  1,000  cases  Wil- 
liams found  48.4  per  cent  with  family  predisposition,  12  per  cent  with 
]>arental,  1  per  cent  with  grand  parental,  and  34.4  per  cent  with  collateral 
heredity.  Of  250  cases  in  which  Solly  made  very  careful  inquiries  on  this 
]»oint,  there  M-ere  28.8  per  cent  with  ])arental.  7.(1  per  cent  with  grand- 
parental,  and  19.2  per  cent  with  a  history  of  collateral  heredity.     Of  427 


264 


SPECIFIC  INFECTIOUS  DISEASES. 


cases  at  the  Johns  Hopkins  Hospital,  there  were  53  in  which  the  mother 
had  liad  tuberculosis,  5;^  in  which  the  father  had  been  all'ected,  and  1U5  in 
which  a  brother  or  sister  had  had  tiie  disease.  The  question  of  family  in- 
fection is  the  all-important  one,  and  Hilton  Fagge  very  wisely  remark*  that 
it  is  impossible  to  draw  a  line  between  hereditary  and  accidental  tubercu- 
losis, as  naturally  the  children  of  an  aU'ected  parent  are  more  liable  to  acci- 
dental contamination.  In  a  recent  careful  study  of  heredity  in  plithisis, 
Squire  concludes  that  there  is  but  a  small  difference  between  the  incidence 
of  the  disease  in  the  offspring  of  phthisical  and  non-phthisical  parents. 

While  the  demonstration  of  the  contagiousness  of  tuberculosis  has  in 
some  quarters  intensified  the  dread  with  which  the  disease  is  regarded, 
the  terrible  Ate  of  hereditary  transmission  has  been  in  great  part  abolished, 
to  the  great  gain  of  suifering  humanity. 

(b)  Ifioculalion. — The  infective  nature  of  tuberculosis  was  first  demon- 
strated by  Villemin,  who  showed  conclusively  in  ISGo  that  it  could  be  trans- 
mitted to  animals  by  inoculation.  The  l)eautiful  exi)eriments  of  Cohnheim 
and  Salamonson,  who  produced  tuberculosis  in  the  eyes  of  guinea-pigs  and 
raljbits  by  inoculating  fresh  tubercle  into  the  anterior  chamber,  confirmed 
and  extended  Yillemin's  original  observations  ami  paved  the  way  for  the 
reception  of  Koch's  announcement.  It  is  now  universally  conceded  that 
only  tuberculous  matter  can  produce,  when  inoculated,  tid)erculGsis.  In 
man  tuberculosis  is  not  often  transmitted  by  inoculation,  and  when  it  does 
occur  the  disease  usually  remains  local.  This  mode  of  infection  is  seen  in 
persons  whose  occupation  brings  them  in  contact  with  dead  bodies  or  ani- 
mal products.  Demonstrators  of  morbid  anatomy,  butchers,  and  handlers 
of  hides  are  subject  to  a  local  tu1)ercle  of  the  skin,  which  forms  a  reddened 
mass  of  granulation  tissue,  usually  capping  tiie  dorsal  surfaces  of  the  hands 
or  fingers.  This  is  the  so-v.alled  ])ost-mortem  wart,  the  verruca  necroyenica 
of  Wilks.  The  demonstration  of  its  nature  is  shown  by  the  presence  of 
tubercle  bacilli,  and  by  inoculation  experiments  in  animals. 

The  statement  that  Laennec  contracted  jjhthisis  from  this  source  is 
probably  false,  since  he  did  not  die  until  twenty  years  after  the  inocula- 
tion and  in  the  interval  presented  no  manifestations.  The  possibility,  how- 
ever, of  general  infection  must  be  borne  in  mind.  Ger])er  reports  that 
after  accidental  inoculation  in  the  hand  from  a  case  of  phthisis  he  had 
for  months  a  "  Leichen-tubercle,"  which  was  excised.  Shortly  afterward 
the  lymph-glands  of  tlic  axilla  became  enlarged  and  painful,  and  when  re- 
moved showed  characteristic  tuberculous  chauffcs,  with  bacilM. 

In  the  performance  of  the  rite  of  circumcision  children  have  been  acci- 
dentally inoculated.  Infection  in  these  cases  is  probably  always  associated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  of 
cleansing  the  wound  by  suction. 

Other  means  of  inoculation  have  been  described:  as  the  wearing  of 
ear-rings,  washing  the  clothes  of  ])htliisical  patients,  the  bite  of  a  tubercu- 
lous subject,  or  inoculation  from  a  cut*  by  a  broken  spit-glass  of  a  consump- 
tive; and  Czerny  has  reported  two  cases  of  infection  by  transplantation  of 
skin. 

It  has  been  urged  by  the  opponents  of  vaccination  tluat  tuberculosis,  as 


TUBERCJLOSIS. 


205 


ilencd 

hands 

wijenica 

nice  of 

i\irco   is 

lliot'llla- 
:y,  how- 
ts  that 
lie  had 
erwarcl 
len  re- 
en  acci- 
■jociated 
lahit  of 


ring  of 
idjercn- 
msump- 
ition  of 


llosis,  as 


well  as  syj^hilis,  may  bo  thus  conveyed,  hut  of  tliis  there  is  no  evidence, 
and  the  lymjjh  from  the  vesicles  of  revaccinated  consumptives  has  been 
sliown  by  many  observers  to  l)e  non-infective.  It  may  be  said,  on  the  wliole, 
that  inoculation  in  man  plays  a  trilling  rule  in  the  transmission  of  tuber- 
culosis. 

(r)  Iiiferlidii  hi/  Inhahdion. — A  belief  in  t!ie  contagiousness  of  i)ul- 
monary  tuberculosis  has  existed  from  the  days  of  the  early  (ireek  physi- 
cians, and  has  persisted  among  the  Latin  races.  The  investigations  of 
Cornet  all'ord  conclusive  jjroof  that  the  dust  of  a  room  or  other  locality 
frtHpiented  by  patients  with  i)ulmonary  tuberculosis  is  infective.  The 
bacilli  are  attached  to  fine  i)articles  of  dust  and  in  this  way  gain  entrance 
to  the  system  through  the  lungs. 

J''liigge  denies  that  the  ])acil]us-containing  dust  is  the  dangerous  t'le- 
ment  in  infection.  Experimentally  he  has  only  succeeded  in  producing 
the  disease  when  there  is  some  lesion  in  the  respiratory  tract.  He  thinks 
that  the  danger  of  infection  by  the  dry  sputum  is  very  im]>robable.  On 
the  other  hand,  he  thinks  that  the  infection  is  chiefly  conveyed  by  the  free, 
finely  divided  particles  of  si)utum  i)roduced  in  the  act  of  coughing,  and 
that  these  tiny  fragments  are  suspended  in  the  atmosi)here.  Those  who 
cough  very  much  and  with  the  mouth  oi)en  are  most  liable  to  infect  the 
surrounding  air. 

It  is  well  remarked  by  Cornet,  "  The  consumptive  in  himself  is  almost 
harmless,  and  only  becomes  harmful  through  bad  habits."  It  has  been 
fully  shown  that  the  exi)ired  air  of  consumptives  is  not  infective.  The 
virus  is  only  contained  in  the  sputum,  which  when  dry  is  widely  dissemi- 
nated in  the  form  of  dust,  and  constitutes  the  great  medium  for  the  trans- 
mission of  the  disease.  "In  order  to  be  air-borne  the  s])utuni  must  be 
dried  and  broken  up  into  dust.  If  discharged  into  a  handkerchief,  it 
speedily  dries,  esi)ecially  if  it  is  jnit  into  the  pocket  or  beneath  the  pillow. 
In  the  last  stages  of  consumption  the  patient  becomes  weak,  the  sputum 
is  ex])elled  im])erfectly,  i)illows,  sheets,  and  handkerchiefs  are  soiled.  If  a 
male,  the  beard  or  moustache  is  smeared.  Even  in  the  hands  of  the  cleanly, 
without  special  precautions,  such  circumstances  all  tend  to  the  production 
around  the  patient  of  a  halo  of  infected  dust  maintained  by  every  ])rocess 
of  bedmaking  or  of  cleanirg  which  includes  the  pernicious  jirocess  happily 
described  as  '  dusting.'  In  the  hands  of  the  careless  and  the  dirty  the  in- 
fectivity  is,  of  course,  greatly  aggravated.  It  attains  its  maximum  of  in- 
tensity Avhere  the  filthy  habit  of  s])itting  on  the  floor  prevails,  especially 
if  it  is  Ci^rneted  "  (James  B.  I?ussell). 

The  following  are  some  of  the  facts  in  favor  of  infection  by  inhala- 
tion: 

(1)  Primary  tid)ercnlous  lesions  are  in  a  majority  of  all  cases  connected 
with  the  respiratory  system.  The  frequency  Avith  which  foci  are  met  with 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statis- 
tics of  the  Paris  morgue  show  that  a  considerable  proportion  of  all  persons 
dying  of  accident  or  by  suicide  present  evidences  of  the  disease  in  tlieso 
]iarts.  The  post-mortem  statistics  of  lios]iitals  show  the  same  wides)  read 
]>revnlence  of  infection  through  the  air-passages.     Biggs  re]iorts  that  more 


I: 


206 


SPECIFIC  INFECTIOUS  DISPLVSES. 


/ 


than  no  ]icr  cent  of  liis  ])()st  mortcins  showed  losinns  of  ])iilnionary  tuber- 
culosis. In  \'lo  auto|tsics  at  tlie  Foundling  Hospital,  New  York,  the  hron- 
chial  glands  Mere  tuberculous  in  every  case.  In  adults  the  bronchial  glands 
maj  ue  infected  and  the  individual  remain  in  good  health.  11.  1'.  Looniis 
found  in  S  of  ;5()  cases  in  which  there  were  no  signs  of  old  or  recent  tuber- 
culous lesions  that  the  bronchial  glands  were  infective  to  rabbits. 

{'I)  The  greater  j)rcvi  lence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  nnitter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence 
of  the  bacilli  in  the  atmosphere,  and,  on  the  other,  lower  the  vital  resist- 
ance of  the  individual.  The  investigations  of  Cornet  ujion  the  dealh-rate 
from  consum])tion  among  certain  religious  orders  devoted  to  nursing  give 
some  striking  facts  in  illustration  of  this.  In  a  review  of  38  cloisters,  em- 
bracing the  average  nundjcr  of  4,()"-iS  resident-,  among  "-?,()!)9  deaths  in  the 
course  of  twenty-live  years,  \,'i'lK)  ((i'^.88  per  cent)  were  from  'uberculosis. 
In  some  cloisters  more  than  three  fourths  of  the  deaths  are  from  this  dis- 
ease, and  the  mortality  in  all  the  residents,  up  to  the  fortieth  year,  is  greatly 
above  the  average,  the  increase  being  due  entirely  to  the  prevalence  of 
tuberculosis.  It  has  been  stated  that  nurses  are  not  more  ])rone  to  the  dis- 
ease than  other  individuals,  but  Cornet  says  that  of  100  nurses  deceased,  (J3 
died  of  tuberculosis.  The  more  ])erfect  the  prophylaxis  and  hygiciiie  ar- 
rangements of  an  asylum  or  institution,  the  lower  the  death-rate  from 
tnlx'rculoe-is.  The  mortality  in  prisons  has  been  shown  by  JJaer  to  be 
four  times  as  great  as  outside.  The  death-rate  from  phthisis  is  estimated 
at  15  per  cent  of  the  total  mortality,  -while  in  prisons  it  constitutes  from  40 
to  50  per  cent,  and  in  some  countries,  as  Austria,  over  60  per  cent.  Flick 
has  studied  the  distribntion  of  the  deaths  from  tuberculosis  in  a  single 
city  ward  in  I'hiladelphia  for  twenty-five  years.  His  researches  go  far  to 
show  that  it  is  a  house  disease.  About  33  per  cent  of  infected  houses  have 
liad  nu)re  tlian  one  case.  Less  than  one  third  of  the  houses  of  the  ward 
became  infected  with  tuberculosis  during  the  twenty-five  years  prior  to 
1888.  Yet  more  than  one  half  of  the  deaths  from  this  disease  during  the 
year  1888  occurred  in  those  infected  houses.  There  are,  however,  op})osing 
facts.  The  statistics  of  the  Brompton  Consumption  Hos]ntal  show  that 
doctors,  nnrses,  and  attendants  are  rarely  attacked.  Dettweiler  claims  that 
no  case  of  tuberculosis  has  been  contracted  among  his  nurses  or  attendants 
at  Falkenstein.  On  the  other  hand,  in  the  Paris  hospitals  tuberculosis 
decimates  the  attendants. 

(3)  Special  danger  exists  when  the  contact  is  very  intimate,  such,  for 
instance,  as  between  man  and  wife.  On  this  point  much  difference  of 
opinion  exists,  but  the  figures  seem  to  indicate  that  under  these  circum- 
stances the  husband  or  wife  is  much  more  liable  subsequently  to  die  of 
consumption.  Of  427  cases  of  pulmonary  tuberculosis  at  the  Johns  Hop- 
kins nos])ital,  in  25  either  husband  or  wife  had  been  affected  with  it  or 
had  died  of  tuberculosis.  In  response  to  a  (piestion  as  to  contagion,  asked 
by  the  Collective  Investigation  Committee  of  the  llritish  ^Medical  Associa- 
tion, there  were  261  replies  in  the  alTirmative,  among  which  were  15S  cases 
of  supposed  contagion  through  marriage.    "Weber's  cases  arc  of  special  in- 


tubor- 
■  '.  (roll- 
glands 
Looiiiid 
tuber- 

ieh  the 
.  a  free 
rosenco 

[  rosirit- 

ith-rate 

ng  give 

jrs,  ein- 

3  in  the 

rculosis. 

[his  (lirt- 

;  greatly 

lence  of 

the  dis- 

'asod,  G'3 

ieuie  ar- 

ite  from 

er  to  bo 

'stimated 
from  40 

t.  Flick 
a  single 

ro  far  to 
scs  have 
he  ward 
prior  to 

|iring  the 
opposing 
low  that 
ims  that 
tendants 
|)crculosiri 

3nch,  for 
L'rence  of 
circnni- 
to  die  of 
Ims  Hop- 
}ith  it  or 
)n,  asked 
Associa- 
[58  cases 
lecial  in- 


TUBEltCULOSIS. 


267 


tercst.  One  of  liis  patients  k)st  four  wives  in  sncccssion,  one  lost  three, 
and  four  lost  two  each. 

((/)  Jnfcclion  hi)  Milk. — 'J'lie  milk  of  an  animal  siilVcring  I'loni  tulter- 
culosis  may  contain  the  virus,  and  is  capahie  ol'  eonimunieating  the  dis- 
ease, as  shown  liy  (ierlaeli,  I'.ang,  Jiollinger,  and  others.  Striking  illustra- 
tions of  this  ai'e  sometimes  all'orded  in  the  lower  animals,  'i'he  pigs,  for 
instance,  of  a  tuhereulous  sow  have  heen  shown  to  })resent  intestinal  tuher- 
eidosis  of  the  most  e.\(|uisite  form.  Of  late  years  the  expei'imental  ])roof 
has  been  entii'cly  eonehisive.  Jt  was  formerly  thought  that  the  eow  must 
present  tuhereulous  disease  of  the  udder,  hut  J-lrnst  Jias  shown  that  the 
l)aeilli  may  he  present  and  the  milk  he  infective  in  a  large  pro])ortion  of 
cases  in  which  thci'j  is  no  tuberculous  mammitis;  an  ohsi'rvation  made  also 
hy  JJirschberger  and  others.  'J'his  author  states  the  interesting  fact  that 
an  owner  of  a  herd  known  to  he  tuhereulous  withdrew  the  milk  from 
market  and  iised  it  without  boiling  to  fatten  his  pigs,  which,  almost  with- 
out exception,  became  tuberculons,  so  that  the  whole  stock  had  to  be 
slaughtei'cd.  Sidney  Mai'tin  could  not  induce  the  disease  artiticially  in 
animals  inoculated  or  h'(\  witli  milk  of  tubci'cidous  cows  with  healthy 
luhlers.  J  hitter  made  from  tJie  milk  of  tuberculous  cows  Iws  j)roved  in- 
fective (lUmg).  There  is  no  reason  to  believe  that  young  children,  or 
even  adults,  are  k'ss  susce])tible  to  the  virus  than  calves  or  ])igs,  to  that  the 
danger  of  the  disease  from  this  source  is  real  and  serifuis.  The  great  fre- 
([uency  of  intestinal  and  mesenteric  t'iil)erculosis  in  children  no  (L)ubt  liiids 
here  its  explanation.  As  noted  in  Woodhead's  analysis  of  1:*T  cases  of  fatal 
tuberculosis  in  children,  the  mesenteric  glands  were  involved  in  100. 

(V')  In  feci  inn  hij  Meat. — The  meat  of  tuberculous  animals  is  not  neces- 
sarily infective,  'fhe  results  of  experiments  with  the  llesh  of  cows  are 
not  in  accord.  This  mode  of  infection  ])rohably  ])lays  a  minor  rule  in  the 
etiology  of  human  tuberculosis,  as  usually  the  tlesh  is  thoroughly  cooked 
before  eating.  The  ])ossibi]ity,  however,  must  l)e  borne  in  mind,  and  it 
would  certainly  be  safer  in  the  interests  of  a  commnnity  to  confiscate  the 
carcasses  of  all  tuberculous  animals.  Experiments  in  liollinger's  labora- 
tory show  that  the  flesh  of  tuberculous  subjects  is  very  infective  to  guinea- 
Itigs.  Martin  suggests  that  when  the  meat  is  infective  it  commonly  ac- 
(juires  this  proi)erty  by  accidental  contamination  with  tuberculous  matter 
during  its  removal. 

5.  Conditions  Influencing  Infection. — (a)  Gcnwal. — T*]nvironnient  is  an 
nll-im])ortant  ])redis])osing  factor.  Dwellers  in  cities  are  much  more  ])r()no 
to  the  disease  than  residents  of  tlie  country.  Xot  only  is  the  liability  to 
infection  very  much  greater,  but  the  coiKbtions  of  life  are  such  that  the 
])owers  of  resistance  are  apt  to  be  weakened.  As  already  stated,  sunlight 
is  one  of  the  most  ]iowerful  agents  in  destroying  the  tubercle  bacillus,  so 
that  in  imperfectly  ventilated  dwellings  and  workshops,  and  in  residences 
in  close,  dark  alleys,  and  in  tenement  houses  the  liability  to  infection  is 
very  much  increased.  The  influence  of  environment  was  never  Itetter 
demonstrated  than  in  the  now  well-known  experiment  of  Trudeau.  who 
found  that  rabbits  inoculated  with  tuberculosis  if  confined  in  a  dark,  damp 
place   without   sunlight   and   fresh   air  rapidly   succumbed,   Avliile   others 

ir 


208 


SPECIFIC  INFECTIOUS  DISEASES. 


treated  in  the  same  way,  but  allowed  to  run  wild,  either  recovered  or  showed 
very  slight  lesions.  The  occupants  of  prisons,  asylums,  and  poorhouses, 
too  often,  indeed,  in  barracks  and  large  workshops,  are  in  the  position  of 
Trndeau's  ral)bits  in  tlie  cellar,  and  under  conditions  most  favoral^le  to 
foster  tiie  development  of  tlie  bacilli  which  may  have  lodged  in  their  tissues. 
The  frequent  rcs])irati()n  of  air  already  breatlied,  upon  which  ]\IacL'orinao 
of  Belfast  laid  so  much  stress,  appears  to  render  the  lungs  less  ca})able  of 
resisting  infection. 

Soil  and  locality  are  believed  l)y  many  to  have  a  very  important  bearing 
on  the  develo])ment  of  tuberculosis.  The  observations  of  Jlenry  I.  Bow- 
ditch  in  this  country  and  of  Buchanan  in  England  show  that  the  disease 
prevails  more  widely  in  the  wet,  ill-drained  districts — an  increase  which  is 
associated  with  heightened  vulnerability  and  greater  liability  to  catarrhal 
alfections  of  all  kinds.  The  influence  ol  the  dwelling  has  been  already 
referred  to  in  connection  with  Flick's  work.  No  single  condition  is  of 
greater  importance  than  that  which  r','lates  to  the  proper  arrangement  and 
ventilation  of  the  dwelling  houses. 

(h)  Individual  Predia position. — The  fathers  of  medicine,  more  particu- 
larly Hippocrates,  Areta}us,  and  Galen,  laid  great  stress  \\\w\\  the  bodily 
conformation  of  those  prone  to  consumption.  A  great  deal  was  written 
on  the  so-called  habitus  phthisicus,  which  Hippocrates  described  in  the  fol- 
lowing terms:  "  The  form  of  body  peculiar  to  subjects  of  phthisical  com- 
plaints was  the  smooth,  the  whitish,  that  resembling  the  lentil;  the  red- 
dish, the  blue-eyed,  the  leuco-phlegmatic;  and  that  with  the  scapula)  hav- 
ing the  ap])earance  of  wings."  Undoubtedly  the  long,  narrow,  flat  chest 
with  depressed  sternum  is  commonly  enough  seen  in  tuberculous  patients, 
but  there  are  only  too  many  individuals  with  perfectly  well-shaped  chests 
who  fall  victims  annually  to  the  disease.  The  tuberculous  or  scrofulous 
diathesis,  upon  which  formerly  so  much  stress  was  laid,  is  now  regarded 
simply  as  an  indication  of  a  type  of  conformation  in  which  the  tissues  are 
more  vulnerable  and  less  capable  of  resisting  infection.  Beneke's  investi- 
gations on  the  viscera  of  phthisical  patients  indicate  that  the  heart  is  rela- 
tively small,  the  arteries  proportionately  narrow,  and  the  pulmonary  artery 
relatively  wider  than  the  aorta.  He  suggests  that  this  may  lead  to  increase 
in  the  intrapulmonary  blood  pressure,  and  so  favor  catarrhal  processes. 
The  lung  volume  he  found  rel  lively  greater  in  those  affected  with  tubercu- 
losis. A  study  of  the  composite  portraiture  of  pulmonary  tuberculosis  has 
been  made  by  Galton  and  ]\rahomed.  Tn  443  patients  they  separated  two 
types  of  face — one  ovoid  and  narrow,  the  other  broad  and  coarse-featured. 
This  corresponds  in  an  interesting  way  to  the  diathetic  states  formerly 
recognized — namely,  the  tuberculous,  with  thin  skin,  bright  eyes,  oval  face, 
and  long,  thin  bones;  and  the  scrofulous,  with  thick  Lps  and  nose,  opaque 
skin,  large,  thi(k  bones,  and  heavy  figure.  These  conditions,  on  which  so 
much  stress  was  formerly  laid,  indicate,  as  Fagge  states,  nothing  more  than 
delicacy  of  constitution,  incomplete  growth,  and  imperfect  development. 

(r)  Tnfuencp  of  Ar/e. — Xo  age  is  exempt.  The  disease  is  met  with  in 
the  suckling  and  in  the  octogenarian.  Pulmonary  tuberculosis  occurs  most 
frequently,  as  stated  by  Hippocrates,  from  the  eighteenth  to  the  thirty- 


TUBKRCULOSIS. 


201> 


howcd 

lOUSCS, 

tion  of 
ible  to 
tissues. 
Jonnao 
laljlc  of 

bearing 
I.  Bow- 
:  disease 
A-hieh  is 
■atarrlial 
already 
on  is  oi 
lont  and 

particu- 
le  bodily 
3  written 
1  the  fol- 
ical  com- 
the  red- 
pula3  Ixav- 
lilat  cliest 
patients 
)ed  chests 
scrofulous 
regarded 
issues  are 
investi- 
rt  is  rela- 
ry  artery 
o  increase 
processes, 
tuhercu- 
iilosis  has 
rated  two 
-featured, 
formerly 
oval  face, 
se,  opaque 
which  so 
..lore  than 
opment. 
tt  with  in 
incurs  most 
(he  thirty- 


fifth  year.  From  the  fifth  to  tlie  tenth  year  individuals  are  less  prone  to 
the  disease.  At  diil'crent  ages  dill'erent  organs  are  more  prone  to  be  in- 
volved. During  the  first  (K'cade  the  bones,  uu'iiinges,  and  lympii-glands 
are  more  frt'cinciitiy  all'ccted  than  at  suljsccpk'nt  periods. 

{<])  Scr. — The  inlliicncu  of  se.K  is  very  sligiit.  Women  are  perlia|»s 
somewhat  more  fre(iuently  attacked  tiuin  men,  possibly  i'ron\  the  fact 
that  in  a  more  sedentary,  indoor  life  they  are  more  liable  to  infection. 
Pregnancy  and  lactation  also  are  two  conditions  which  are  a[)t  to  lower, 
perhaps,  tiic  resistance  of  tiie  organism. 

{(•)  lidcr. — The  negro,  who  it  is  stated  is  not  specially  prone  to  the  dis- 
ease in  Africa,  is  in  America  and  in  the  West  Indies  very  subject  to  tuber- 
culosis. The  relative  immunity  of  the  Jews  has  been  mentioned  (page 
259). 

(/■)  Occiipalioti  is  an  important  predisposing  factor.  The  inhalation 
of  impure  air  in  occupations  associated  with  a  very  dusty  atmosphere 
renders  tlie  lungs  less  capable  of  resisting  infection.  The  incidence  of 
pulmonary  tuberculosis  among  the  workers  in  mills  and  factories  is  very 
high,  and  certain  occu])ations,  such  as  those  of  glass-workers,  stone-cutters, 
and  coal-miners,  and  the  whole  group  of  trades,  which  lead  to  pneumono- 
voniosis,  favor  the  development  of  tuberculosis. 

({/)  Certain  local  cundilioiis  influence  infection,  among  which  the  fol- 
lowing are  the  most  important: 

Catarrhal  bronchitis.  The  influence  of  catarrh  of  the  respiratory  pas- 
sages in  pulmonary  tuberculosis  is  well  recognized.  How  often  is  a  neg- 
lected cold  blamed  as  the  starting-point  of  the  disease!  It  seems  to  act 
by  lowering  the  resistance  and  favoring  the  conditions  which  enable  the 
bacilli  either  to  enter  the  system  or,  when  once  in  it,  to  develo)).  The 
liability  of  lymphatic  tuberculosis  in  children  is  probal^ly  associated  with 
the  common  catarrhal  jirocesses  in  the  tonsils,  throat,  and  bronchi. 

Certain  of  the  specific  fevers  ]n'edis])ose  to  tuberculosis,  among  which 
measles  and  wlioo])ing-cough  stand  ])re-eminent.  They  are  often  associ- 
ated with  a  bronchial  catarrh.  In  some  of  the  cases  it  is  prol)ably  not  a 
fresh  infection  which  follows,  but  the  blazing  of  a  smouldering  fire.  Ty- 
])hoid  fever  is  thought  by  some  to  ]>redis]iose  to  tuberculosis,  but  my  experi 
ence  is  opposed  to  this  view.  Of  other  affections,  influenza,  variola,  ard 
syphilis  are  all  believed  to  favor  the  develo])ment  of  the  disease.  Diabetes, 
as  is  well  known,  very  often  terminates  in  pulmonary  tuberculo>3is,  par- 
ticularly in  young  persons. 

Chronic  lieart-disease,  arterio-sclerosis,  aneurism  of  the  aorta,  forms  of 
chronic  ne])hritis,  cirrhosis  of  the  liver,  and  the  various  forms  of  cerebro- 
spinal sclerosis,  all  are  conditions  which  favor  infection.  It  is  remarkable 
in  how  many  of  the  subjects  of  these  disorders  in  general  hospital  practice 
tlie  fatal  event  is  a  terminal  acute  tuberculosis,  most  frequently  of  the 
serous  membranes.  Subjects  of  congenital  or  actjuired  contraction  of  the 
(u-ifice  of  the  pulmonary  artery  usually  die  of  tuberculosis.  On  the  other 
hand,  mitral  valve  disease,  particularly  stenosis,  is  stated  to  anta?onize  the 
disease  (J.  E.  Graham).  In  children  catarrhal  entero-colitis  i)robably  favors 
the  development  of  tabes  mesenterica. 


I 


270 


HPKt'IKlC  INFKCTIOUS   DISIIASHS. 


/ 


Tlic  iiilliiciicc  of  li!i'm<)]itysis  hikI  jilciirisy  v  ill  he  rcfcrnMl  io  Inter. 

'rriiiiiim.  Siirjicous  liiive  laid  great  stress  U]m)ii  tiiis  as  an  etioloj^iea! 
i'iictor  in  ttilxTciiloiis  iirocesses.  Iv\|teriiiieiits  iiKJicatc  tiiat  tissues  wliicli 
have  lieeii  liriii,-e(l,  and  wliicli  woidd  in  licallli  liave  readily  and  rapidly 
(leslroyecl  ()r<;anisnis,  promote  their  jirowth  under  the  altered  eonditions. 
i'rohahly  in  the  ea+^e  of  tnhereulosis  following  li'aiinui  tli"  injured  part  is 
for  a  time  a  luriis  iiniitiris  rvsislciili(i\  and  if  haeilli  are  present  they  may 
liy  it  receive  a  stinudns  to  grow  ill  or  under  the  allei'ed  (•ondili(nis  he  eapahle 
of  mulliplying.  Not  only  in  arthritis,  hut  in  pulmonary  t  uhci'cuiosis,  trau- 
matism niiiy  play  a  part,  'j'he  (pu'sticm  has  heeu  tlioi'oughly  studiei]  hy 
Mendelssohn,  who  reports  D  eases  in  which,  without  fi'acture  of  the  rih  or 
laceration  of  the  lung,  Inhercnlosis  developed  shortly  after  contusion  of 
the  chest.  ()per;iti(Wi  upon  t  uhei'culous  le>ions  may  he  followed  hy  a  gen- 
eral infection.  K'esection  of  a  sti'umims  joint  is  occasioiudly  followed  hy 
acute  tuhercniosis.  Of  s;!T  resi'ctions,  '.I'l')  ended  fatally,  ;Hi  with  acute 
tidx'rcnlosis  (W'ai't maun). 

General  Morbid  Anatomy  and  Histology  of  Tuberculous 
Lesions. 

(1)  Distribution  of  the  Tubercles  in  the  Body. — The  organs  of  the 
l)ody  are  variously  alVecled  hy  tuln'rculosis.  In  adults,  the  lungs  may  he 
regarded  as  the  seat  of  election;  in  childri-n,  the  lymph-glands,  hones,  and 
Joints,  in  l,(ii)0  autopsies  there  wci'e  ■.'*.")  cases  -with  tuhercuhms  lesions. 
With  hut  two  or  three  exceptions  the  lungs  were  all'ected.  The  distrihu- 
tion  in  the  other  oi'gans  was  as  follows:  1 'erica rdiun^.,  T;  ])eritona'um,  3'!; 
hrain,  31;  spleen,  'i'.\;  liver,  VI;  kidneys,  32;  intestines,  G.j;  heart,  4;  and 
generative  organs,  H. 

The  tuhercniosis  which  conies  nnder  the  care  of  the  snrgeon  has  a  dif- 
ferent distrihution,  as  shown  hy  the  following  figures  from  the  AViirzhurg 
clinic.  Among  8,<ST3  patients,  1,287  M'ere  tnherculons,  with  the  following 
distrihntion  of  le.sions:  IJones  and  joints,  1,037;  lymi)h-glands.  19G;  skin 
and  connective  tissues,  77;  nuicons  memhranes,  10;  genito-nrinary  or- 
gans, 20. 

(2)  The  Changes  produced  by  the  Tubercle  Bacilli. 

{(i)  The  Xdduhtr  Tiihrrrlc. — The  hody  which  we  term  a  "  tubercle  " 
prespiiis  in  Us  carli/  [(jrnitilioii  nolhiiir/  (lislincliic  or  peculiar,  either  in  il-^ 
companrnls  or  In  llirir  arrani/riiirni.  Identical  structures  ai'e  ])roduced  hy 
other  i)arasites,  such  as  the  actinomyces,  and  hy  the  strongylus  in  the  lungs 
of  sheep. 

The  researches  of  r»anmgarten  have  enabled  us  to  follow  in  detail  the 
evolution  of  a  tubercle. 

(a)  The  multiplication  of  the  tubercle  bacilli,  which  is  ra])id  and  i> 
accompanied  hy  their  dissemination  in  the  ;  urrounding  tissues  partly  by 
gro,,(.  ,  partly  in  the  lynqdi  cuiTcnts. 

(^)  The  multiplication  of  the  fixed  cells,  especially  those  of  connective 
tissue  and  the  endothelium  of  the  capillaries,  and  the  gradual  production 
from  them  of  rounded,  cuboidal,  or  ])olygonal  bodies  with  vesicular  nuclei 
— the  epUhrJinid  cells — inside  some  of  which  the  bacilli  are  soon  seen. 

(y)  From  the  vessels  of  the  infected  focus,  leucocytes,  chiefly  poly- 


Tl'BKUCULOSIS. 


271 


■r. 
il()}j;icul 

whicli 
rniiidly 
I  lit  ions. 

imrl  iri 
oy  iiiiiy 
c-aiiiilili' 

is,  IfilU- 

(liod  l)y 

(■  ril)  or 
ision  of 
S-  a  ^'cn- 

f)\V('(l    liV 

ih   nciiU' 

rculous 

i  of  the 
;  iiuiy  Ix' 
)n('s,  aiitl 
s  k'sioHs. 
(list  I'll  )U- 
teum,  ;>•>■. 
t,  i;  iuul 

las  a  (lif- 
A'iirzlxir;:- 
[followiii!:!; 
|l!t();  skin 
linary   or- 


hibcrcle  " 
irr  in  //>" 

1(1  need  liv 
tlie  luiig>= 

Idciail  the 

lid   and  i-^ 
[partly  hy 

^nnncc'tiv(■ 
L-oductinn 
liar  nuclei 

seen. 
Icfly  poly- 


nuclear,  nii<;rnto  in  numbers  and  accuinulato  ahout  the  focus  of  infection. 
'I'hey  do  n(»t  sid)(livide.  .Many  UM(h'r;;o  rapid  (h'>tru(iion.  Later,  as  tiie 
little  lubereU'  ^rows,  tin;  li'iicocvtes  are  ehielly  of  ilir  mononuclear  variety 
(lymi»li()cytes),  which  do  not  un(k'r^'o  the  rapid  (K'^i'eneratiou  of  the  poly- 
iiueh'ar  forms. 

(<5)  A  reticulum  of  fihres  is  formed  liy  the  lihrillation  and  rarefaction 
of  the  couiu'ctive-tissue  matrix.  This  is  most  a[i|»arent,  as  u  ride,  at  the 
margin  of  the  ^rroulh. 

(«)  In  sonu.',  hut  not  all,  tuhercles  fjiaiil  ccllx  are  fornu'tl  hy  an  increase 
in  the  protoplasm  and  in  the  niudci  of  an  individual  cell,  or  possihiy  hy 
the  fusion  of  several  cells.  The  ^iant  cells  seem  to  l)e  in  inverse  ratio  to 
the  nuudier  and  viridence  of  the  hacilli.  In  lupus,  joint  tulierculosis, 
aiul  sci'ofuloua  jilands,  in  which  the  liacilli  are  scanty,  the  jiiant  cells  aro 
lunuerous;  while  in  miliary  tubercles  and  all  lesions  in  which  the  hacilli 
are  ahuiulant  the  ^iant  cells  are  few  in  lunuher. 

The  hacilli  then  cause,  in  the  first  place,  a  prolifi'ralion  of  the  li\ed 
elements,  with  the  production  of  epithelioid  and  <,Mant  cells;  and,  seei)ndly» 
an  inllammatory  rt'action,  associated  with  exudation  of  leucocytes,  llow 
far  the  leucocytes  altai-k  and  destroy  the  hacilli  has  not  been  delinitely 
settlecl — .Mctschnikoll'  claiming:-,  llaum^arten  denying',  an  active  pha,^'o- 
cytosis. 

{'.))  The  Degeneration  of  Tubercle. 


-There   are    two   chief    forms    of   de- 


generatu)n: 

(ii)  ('ttscalimi. — At  the  central  part  of  the  <:rowtli,  owin<;  to  the  direct 
action  (d'  the  hacilli  or  their  products,  a  ])rocess  of  coa<iulation  necrosi.s 
goes  (Ml  in  the  cells,  which  lose  their  outline,  become  irref^ular,  no  longer 
take  stains,  and  are  finally  converted  into  a  honu)geneous,  structureless 
subsliince.  I'roceediuy  from  the  centre  outward,  the  tid)ercle  may  be  grad- 
ually convei'tcd  Into  a  yellowish-gray  body,  in  which,  however,  the  bacilli 
are  still  alnindant.  Xo  blood-vessels  are  found  in  them.  Aggregated  to- 
gether these  form  the  cheesy  masses  so  common  in  tuberculosis,  which 
nuiy  undergo  softening,  fibroid  limitation  (encapsulation),  or  calcilication. 

(Ii)  Sch'rusis. — ^^'ith  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  proceeds,  together  with  great  increase  in 
the  flln'oid  elements;  so  that  the  tubercle  is  converted  into  a  firm,  hard 
strncture.  Often  the  change  is  rather  of  a  tibro-caseous  nature;  l)ut  the 
sclerosis  ])redominates.  In  some  situations,  as  in  the  ])eritona'um,  this 
seems  to  be  the  mitural  transformation  of  tubende,  and  it  is  by  no  means 
rare  in  the  lungs. 

In  all  tubercles  two  processes  go  on:  the  onc^ — caseation — destrnctive 
and  dangerons;  and  the  otlier — sclerosis — conservative  and  healing.  The 
ultimate  result  in  a  given  case  depends  ni)on  the  capabilities  of  the  body 
to  restrict  and  limit  the  growth  of  the  bacilli.  There  are  tisstie-soils  in 
which  the  bacilli  are,  in  all  ]irobability.  killed  at  once — tJir  seed  has  fullni 
hi/  the  iraijside.  There  are  others  in  which  a  lodgment  is  gained  and  miu'(; 
or  less  damage  done,  but  finally  the  day  is  with  the  conservativ(\  ])rotectiug 
forces — Ihe  seed  has  fallen  upon  sloni/  i/round.  Thirdly,  there  are  tissne- 
!*oil3  in  which  the  bacilli  grow  luxuriantly,  caseation  and  softening,  not 


272 


SPFX'IPIC  INFECTIOUS  DISEASES. 


/ 


limitation  nnd  sc-U'rosin,  prrviiil,  mid  the  diiy  is  with  the  invaders — Ihc  sud 
has  fallen  ii/ioii  ijnud  yrouiid. 

The  action  of  the  Imcilli  injected  directly  into  the  blood-vessels  illus- 
trates many  points  in  the  liistoht^^y  and  iiath(do«:y  of  tul)ercidosis.  If  into 
the  vein  of  a  lahhit  a  pure  culture  of  tiie  hacilli  is  injected,  the  mierohes 
accumuhite  chielly  in  the  liver  and  spleen.  The  animal  dies  usually  with- 
in two  weeks,  and  the  or<fans  apparently  show  no  trace  of  tul)ereles.  Miero- 
scopically,  in  both  s|)le,'n  and  liver  the  youn<,'  tuhercles  in  process  of  forma- 
tion are  very  numerous,  and  karyokinesis  is  ijoing  on  in  the  livur-eella. 
After  an  injection  of  a  more  dilute  culture,  or  one  whose  virulence  has 
been  miti^^ited  by  age,  instead  of  dyin^f  within  n  fortni^dit  the  animal  sur- 
vives for  livt'  or  six  weeks,  by  which  time  the  tubercles  are  apparent  in  the 
spleen  and  liver,  and  often  in  the  f)ther  or^MUis. 

(4)  The  diffused  Inflammatory  Tubercle.— This  is  most  frequently  seen  in 
the  luuffs.  Only  a  great  master  like  \'irchow  could  have  won  the  profes- 
sion from  a  belief  in  the  iiiiih/  of  jihlliisis,  which  the  }>;onius  of  Laennec 
had,  on  anatomical  ground,  announced.  Here  and  there  a  teacher,  as 
Wilson  Fox,  protested,  Init  the  heresy  prevailed,  and  we  repeated  the  strik- 
ing a])horism  of  Niemeyer,  "  The  greatest  evil  which  can  happen  to  a  con- 
sumptive is  that  he  should  become  tuberculous."  It  was  thought  that  the 
products  of  any  sim])le  inflammation  might  become  caseous,  and  that  ordi- 
nary catarrhal  |)neumonia  terminated  in  phthisis.  It  was  jieculiarly  fitting 
that  from  CJermany,  in  which  the  dualistic  heresy  arose,  the  truth  of  Laen- 
nec's  views  shonld  receive  incontestable  ])ioof,  in  the  demonstration  by 
Koch  of  the  etiological  unity  of  all  the  various  jirocesses  known  as  tuber- 
culous and  scrofulous. 

Infiltrated  tubercle  rcsnlts  from  the  fusion  of  many  small  foci  of  in- 
fection— so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but 
which  histologically  are  seen  to  be  composed  of  scattered  centres,  svi- 
ronnded  by  areas  in  which  the  air-cells  are  filled  with  the  ])roducts  of  exu- 
dation and  of  the  proliferation  of  the  alveolar  epithelium.  Under  the  inllu- 
ence  of  the  bacilli,  caseation  takes  place,  nsually  in  small  groups  of  lobules, 
occasionally  in  an  entire  lobe,  or  even  the  greater  ])art  of  a  lunj.  In  the 
early  stage  of  the  process,  the  tissne  has  a  gray  gelatinous  ai)pearance,  the 
(jrai/  in/iUralion  of  Laennec.  The  alveoli  contain  a  ser()-fd)rinous  fluid  with 
cells,  and  the  septa  are  also  infdtrated.  These  cells  accumulate  and  undergo 
coagulation  necrosis,  forming  aT-cas  of  caseation,  the  infiUratwn  lube  re  ule  use 
jauue  of  Laennec,  the  scrofulons  or  cheesy  pnenmonia  of  later  writers. 
There  may  also  be  a  diffuse  infiltration  and  caseation  without  any  special 
foci,  a  widespread  tubercnlons  pnenmonia  induced  by  the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Banmgarten  states: 
"There  is  no  well-marked  difterence  between  miliary  tubercle  and  chronic 
caseous  pnenmonia.  Speaking  histologically,  miliary  tuberculosis  is  noth- 
ing else  than  a  chronic  caseous  miliary  jinenmonia,  and  chronic  caseous 
pneumonia  is  nothing  but  a  tuberculosis  of  the  lungs." 

(5)  Secondary  Inflammatory  Processes — {a)  The  irritation  cansed  by 
the  bacilli  invariably  prodnces  an  inflammation  which  may,  as  has  been 
described,  be  limited  to  exndation  of  leucocytes  and  serum,  but  may  also  bo 


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TUnKRCULOSIS. 


273 


10 


nuuh  more  oxtcnsivo.  nii<l  wbicb  varies  with  varying'  (f)iiditions.  AVi>  find, 
I'or  i'.\ani|ile,  alxmt  the  smaller  liiln'rcles  in  the  hings,  pneiinionia — either 
catarriial  or  (il)rinous,  prolireralion  of  the  eonneetive-tissiie  ek'nients  in  the 
M'|tta  (which  also  become  inliltrated  with  round  ceils),  and  ehanjies  in  the 
))lood  and  lympii-vessels. 

(h)  In  oroeesses  of  minor  intensity  the  inllammation  is  of  (Ik;  slow 
reactive  nature,  which  results  in  the  product  inn  of  a  cicatricial  connective 
tissue  which  limits  and  restricts  tlie  deveK)i)nient  of  the  tidjorcles  and  in 
the  essential  conservative  element  in  the  disease.  It  is  to  l)i'  remembered 
liiat  in  chronic  |iidnioiHiry  tid)ercidosis  much  f)f  tlie  fibroid  tissue  wiiich  is 
l)resent  is  not  in  any  \/ay  associated  with  the  action  of  the  bacilli. 

{(')  Sup|)uratio«.  Do  the  bacilli  themselves  induce  suppuration?  In 
so-called  cold  tid)ercnlou8  abscess  the  material  is  not  his{')lo<,'ically  pus, 
but  a  dvhris  consisting  of  broken-down  cells  and  cheesy  material.  It  is 
moreover  sterile — that  is,  does  not  contain  the  usual  pus  organisms.  The 
l)roducts  of  the  tubercle  bacilli  are  probably  able  to  indu'c  suppuration, 
as  in  joint  and  bone  tuljcrculosis  pus  is  fre((uently  i)roduced,  although  this 
may  be  due  to  a  mi.xed  infection.  Koch,  it  will  bo  remembered,  states 
that  the  "  tubercidin  "  is  one  of  the  l)est  agents  for  the  ])ro(lucti(»n  of  ev- 
jierimental  sujjpuration.  In  tuberculosis  of  the  lungs  the  suppuration  18 
largely  the  result  of  an  infection  with  i)us  organisms. 

II.  Acute  Tubeiiculosis. 

The  truly  infective  nature  of  tubercle  is  best  shown  in  this  afTection, 
which  is  characterized  by  an  eruption  of  miliary  tubercles  in  various  parts 
of  the  body.  The  clinical  picture  varies  with  the  general  or  localized  dis- 
triljution  of  the  growths.  The  tubercles  are  found  upon  the  ])leura  and 
])eritona'um;  in  the  lungs,  liver,  kidneys,  lymph-glands,  and  spleen;  upon 
the  meml)ranes  of  the  brain,  occasionally  in  the  choroid  coat  of  the  eye, 
and  in  the  bone-marrow.  They  may  be  abundant  in  some  organs  and 
scanty  in  others.  Thus,  in  the  meninges  of  the  Ijrain  they  may  bo  thickly 
set,  while  there  are  few^  or  none  in  the  abdominal  viscera  or  in  the  lungs. 
On  the  other  hand,  the  lungs  may  be  studded  with  granulations  while  the 
meninges  of  the  brain  are  free.  In  other  cases,  again,  the  distribution  is 
uniform  in  all  the  viscera. 

The  efiolof/y  has  been  in  part  considered,  and  the  only  additional  state- 
ment necessary  is  that  in  a  great  majority  of  all  cases  it  is  an  auto-infcrtion, 
arising  from  a  pre-existing  tuberculous  focus,  which  may  be  latent  and  un- 
suspected. The  following  are  the  most  common  sources  of  general  infec- 
tion: Local  disease  of  the  lungs,  which  may  bo  quite  limited  and  un])ro- 
ductive  of  symptoms;  tuberculous  alToction  of  the  lym])]i-glands,  ])articu- 
larly  in  children;  and  tuberculosis  of  the  bones  and  of  the  kidneys.  Of 
these  sources  perhaps  the  most  common  arc  the  tracheal  and  bronchial 
lymph-glands,  which  are  so  often  the  seat  of  local  tuberculosis.  AVoigert 
has  shown  that  in  many  cases  the  infection  results  from  the  ru])ture  of  a 
caseous  pulmonary  nodule  into  a  vein,  or  of  a  caseous  bronchial  gland  into 
one  of  the  pulmonary  veins.    A  general  infection  may,  as  shown  by  Pon- 


274 


SrEClFIC  INFFJCTTOUS   DISEASES. 


/ 


fick,  result  from  invni^ion  of  tiie  thoracic  duct  liy  tubercles.  With  si)ecial 
care  the  source  of  infection  can  usually  be  discovered  at  post-mortem  ex- 
aruination.  The  connection  Ijetween  tuberculous  lymph-glands  and  veins 
has  often  Ix'cn  demonstrated.  In  many  instances  it  is  im[)ossil)le  to  say 
what  determines  tlie  sudden  and  violent  onset  of  the  disease.  It  woidd 
seem  sometimes  an  if  general  rather  than  local  conditions  influenced  the 
outbreak.  After  certain  fevers,  particularly  measles  and  whooping-cough 
in  children — alfections,  it  is  true,  wliich  are  associated  with  long-continued 
bronchitis — miliary  tuberculosis  is  not  uncommon.  The  prostration  and 
constitutional  weakness  which  follow  protracted  fevers  frequerMy  seem  in 
the  adult  to  be  a  predisposing  cans.  . 

Clinical  Forms.  — For  practical  purposes  the  cases  may  be  divided 
into  those  with  tiu'  symptoms  of  nriite  (/eiiprol  infection  without  special 
localization;  cases  witli  marked  pulmonary  sym[)tonis;  and  cases  with  cere- 
bral or  cerehro-spiiial  symptoms. 

Other  forms  luive  been  recognized,  but  this  division  covers  a  large  ma- 
jority of  the  cases. 

Taking  any  series  of  cases  it  will  be  found  that  tlie  meningeal  form  of 
acute  tu1)erculosis  exceeds  in  numbers  the  cases  with  general  or  marked 
pulmonary  symptoms. 

1.  General  or  Typhoid  Fonn. — Sijmpfotns. — The  patieat  here  presents 
the  symptoms  of  an  infectious  disease^  witli  few  if  any  local  signs. 
The  cases  simulate  and  are  frequently  mistaken  for  ty])hoid  fever.  After 
a  period  of  failing  health,  with  loss  of  ap])etite,  the  patient  becomes  fever- 
ish and  weak.  Occasionally  the  disease  sets  in  more  abruptly,  but  in  many 
insta  ices  the  anamnesis  closely  resembles  that  of  typhoid  fever.  Xose- 
bleeding,  however,  is  rare.  The  tem])erature  increases,  the  ])ulse  becomes 
rapid  and  feeble,  the  tongue  dry;  delirium  1)ecomes  marked  and  the  cheeks 
are  flushed.  The  pulmonary  symptoms  may  be  very  slight;  usually  bron- 
chitis exists,  but  not  more  severe  than  is  common  with  typhoid  fever.  The 
pulse  is  seldom  dicrotic,  but  is  rapid  in  proportion  to  the  ])yrexia.  rerha])s 
the  most  striking  feature  of  the  temperature  is  the  irregularity;  and  if 
seen  from  the  outset  there  is  not  the  steady  ascent  noted  in  typhoid  fever. 
There  is  usually  an  evening  rise  to  103°,  sometimes  104°,  and  a  morning 
remission  of  from  two  to  three  degrees.  Sometimes  the  pyrexia  is  interni it- 
tent,  and  the  thermometer  may  register  below  normal  during  the  early 
morning  hours.  The  inverse  type  of  temperature,  in  which  the  rise  takes 
place  in  the  morning,  is  held  by  some  w^riters  to  be  more  frequent  in  gen- 
eral tuberculosis  than  in  other  diseases.  In  rare  instances  there  may  be 
little  or  no  fever.  On  tAvo  occasions  I  have  had  a  patient  admitted  to  my 
wards  in  a  condition  of  jirofound  debility,  with  a  history  of  illness  of  from 
three  to  four  weeks'  duration,  with  rapid  pulse,  flushed  cheeks,  dry  tongue, 
and  very  slight  elevation  in  temperature,  in  whom  (post  mortem)  the  con- 
dition proved  to  be  general  tuberculosis.  In  one  instance  there  was  tol- 
erably extensive  disease  at  the  right  apex.  Eeinhold,  from  Biiumler's 
clinic,  has  recently  called  attention  to  these  afebrile  forms  of  acute  tuber- 
culosis.   In  9  of  52  cases  there  was  no  fever,  or  only  a  transient  rise. 

In  a  considerable  number  of  these  cases  the  respirations  are  increased 


TUBERCULOSIS. 


275 


The 


m  gen- 
may  he 
to  my 
I  of  from 
tongue, 
the  con- 
iwas  tol- 
liiumler's 
tiiber- 

icreasecl 


in  froijncncy,  particularly  in  the  early  stage,  and  there  may  be  signs  of  dif- 
fuse l)r<)iu']iitis  and  sJigiit  cyanosis.  Clicyne-Stolves  in'cathing  devehjps 
toward  the  close. 

Active  delirium  is  rare.  ^More  commonly  there  are  torpor  and  dulness, 
gradually  deepening  into  coma,  in  whicli  the  patient  dies.  In  some  cases 
the  ])ulin()nary  syniiitonis  become  more  marked;  in  others,  meningeal  or 
ccrcln-al  features  ([evclo[). 

Diaijdosis. — The  ditl'erenlial  diagnosis  between  general  miliary  tuber- 
culosis without  local  manifestations  and  ty[)hoid  fever  is  extremely  dilli- 
cult.  A  point  ot"  importance,  to  which  reference  has  already  been  made, 
is  the  irreguhirity  of  the  temperature  curve.  The  greater  freipumcy  of 
the  respirations  and  the  tendency  to  slight  cyanosis  is  mucli  more  con- 
mon  in  tubercidosis.  There  are  cases,  however,  of  typhoid  fever  in  which 
the  initial  broiu-hitis  is  severe  and  may  lead  to  dyspmca  and  disturbed 
oxygenation.  The  cough  may  be  slight  or  absent.  Diarrluea  is  rare  in 
tuljcrculosis;  the  bowels  are  usually  constipated;  but  diarrluwv  may  occur 
and  j)ersist  for  days.  In  certain  cases  tiie  diagnosis  has  been  complicated 
still  further  by  the  occurrence  of  blood  in  the  stools.  Enlargement  of  the 
spleen  occurs  in  general  tuberculosis,  but  is  neither  so  early  nor  so  marked 
as  in  typhoid  fever.  In  children,  however,  the  enlargement  may  be  cou- 
siderabk".  The  urine  may  show  traces  of  albumin,  and  iinl'ortunately 
]']hrlich"s  diazo-reaction,  which  is  so  constant  in  typhoid  fever,  is  also  met 
with  in  general  tuberculosis.  The  absence  of  the  characteristic  roseola  is 
an  impoi'tnnt  feature.  (\'casionally  in  acute  tubi'rculosis  reddish  s])ots 
may  develo|)  and  for  a  time  cause  dilliculty,  Imt  they  do  not  come  out  in 
crops,  and  rarely  have  the  characters  of  the  true  typlioid  eruption.  Herpes 
is  perhaps  more  comuu)n  in  tuberculosis.  Toward  the  close,  petechiie  may 
appear  on  the  skin,  ]iarticularly  about  the  wrists.  A  rare  event  is  jaundice, 
due  ])ossi1)ly  to  the  eru])tion  of  tul)ercles  in  the  liver.  It  is  to  be  rcnum- 
bered  that  the  lesions  of  acute  tuberculosis  and  of  typhoid  fever  have  been 
demonstrated  in  the  same  body. 

In  a  few  instances  the  presence  of  tubercle  bacilli  has  been  demon- 
strated in  the  blood,  which  in  doubtful  cases  should  therefore  be  examined. 
The  spleen  has  been  ])unctured  and  cultivations  made  to  determine  the 
])resence  or  absence  of  the  typhoid  bacilli,  but  in  the  acute  s[)lenie  tumor 
this  is  a  dangerous  procedure.  The  eye-grounds  should  be  carefully  exam- 
ined for  choroidal  tubercles.  The  blood  may  show  a  slight  leucocytosis,  but 
in  the  very  acute  cases  where  there  are  no  suppurating  foci  this  is  absent. 
The  Widal  reactio'n  is  now  a  most  important  hel])  in  the  diagnosis. 

2.  Pulmonary  Form. — Sijinplnnn^. — From  the  outset  the  ])ulmonary 
sym])toms  are  marked.  The  ])atient  may  have  had  a  cough  for  montlis  or 
for  years  without  mucli  im])airment  of  healtli,  or  he  may  be  known  to  be 
the  subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  particu- 
larly in  children,  the  affection  follows  measles  or  whoo])ing-cough,  and 
is  of  a  distinctly  broncho-pnenmonic  type.  The  disease  begins  witli  the 
symptoms  of  diffuse  bronchitis.  The  cough  is  marked,  the  expectoration 
muco-purulent,  occasionally  rusty.  TTamioptysis  has  been  noted  in  a  few 
instances.    From  the  outset  d3'spnira  is  a  striking  feature  and  may  be  out 


, 


HJ' 


276 


SPECIFIC   INFECTIOUS  DISEASES, 


/ 


of  proportion  to  the  intensity  of  the  i)liysical  signs.  There  is  more  or  less 
cyanosis  of  the  Hi)s  and  iingcr-tii)S,  and  the  cheeks  are  sulfused.  Apart 
from  cnipliy-ema  and  the  hiter  stages  of  severe  pneumonia  I  know  of  no 
otlier  i)uliiu)n  ir;'  condition  in  which  the  cyanosis  is  so  marked.  The  phys- 
ical signs  are  these  of  bronchitis.  In  children  there  may  be  defective  reso- 
nance at  the  jases,  from  scattered  areas  of  broncho-pneumonia;  or,  what  is 
equally  suggestive,  areas  of  hyper-resonance.  Indeed,  the  percussion  note, 
l)articularly  in  the  front  of  tlie  chest,  in  some  cases  of  miliary  tuberculosis, 
is  full  and  <.lear,  and  it  will  be  noted  (post  mortem)  that  the  lungs  are 
unusually  voluminous.  This  is  probably  the  result  of  more  or  less  wide- 
spread acute  emi>hysema.  On  auscultation,  the  rales  are  either  sibilant 
and  sonorous  or  small,  fine,  and  crepitant.  There  may  be  fine  crepitation 
from  the  occurrence  of  tubercles  on  the  pleura  (Jiirgensen).  In  children 
there  may  be  high-pitched  tubular  breathing  at  the  bases  or  toward  the 
root  of  the  lung.  Toward  the  close  the  rales  may  be  larger  and  more  mu- 
cous. The  temperature  rises  to  103°  or  103°,  and  may  present  the  inverse 
type.  The  pulse  is  rapid  and  feeble.  In  the  very  acute  cases  the  spleen 
is  always  enlarged.  The  disease  may  prove  fatal  in  ten  or  twelve  days,  or 
may  be  protracted  for  weeks  or  even  months. 

Diagnosis. — The  diagnosis  of  this  form  offers  less  difficulty  and  is  more 
frequently  made.  There  is  often  a  history  of  previous  cough,  or  the  patient 
is  known  to  be  the  subject  of  local  disease  of  the  lung,  or  of  the  lymph- 
glands,  or  of  the  bones.  In  children  these  symptoms  following  measles 
or  whooping-cough  indicate  in  the  majority  of  cases  acute  miliary  tuber- 
culosis, with  or  without  broncho-pneumonia.  Occasionally  the  sputum  con- 
tains tubercle  bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may 
help  the  diagnosis.  More  important  in  an  adult  is  the  combination  of 
dyspnoea  with  cyanosis  and  the  signs  of  a  diffuse  bronchitis.  In  some  in- 
stances the  occurrence  of  cerebral  symptoms  at  once  gives  a  clew  to  the 
nature  of  the  trouble. 

3.  Meningeal  Form  (Tuhcrculoiis  Meningitis,  Basilar  Meningilis). — This 
affection,  which  is  also  known  as  acute  hydrocephalus  or  "  water  on  the 
brain,"  is  essentially  an  acute  tuberculosis  in  which  the  membranes  of  the 
brain,  sometimes  of  tlie  cord,  bear  the  brunt  of  the  attack.  Our  first  ac- 
curate knowledge  of  this  affection  dates  from  the  pidjlication  of  Robert 
"Whytt's  Observations  on  the  Dropsy  of  the  Brain,  Edinburgh,  17(!8.  The 
literature  is  very  fully  given  in  the  last  edition  of  Barthez  and  Sannee. 

Though  Guersant  had  as  early  as  1827  used  the  name  granular  menin- 
gilis for  tliis  form  of  inflammation  of  the  meninges,  it  was  not  until  1830 
that  Pa])avoine  demonstrated  the  nature  of  the  granules  and  noted  their 
occurrence  with  tuliercles  in  other  parts. 

In  1833  and  1833,  W.  W.  Oerhard,  of  Philadelphia,  made  a  very  careful 
study  of  the  disease  in  tlie  Children's  Hospital  at  Paris,  and  his  publica- 
tions, more  than  those  of  any  other  author,  served  to  place  the  disease  on 
a  firm  anatomical  and  clinical  basis. 

There  are  several  special  etiological  factors  in  connection  with  this  form. 
It  is  much  more  common  in  children  than  in  adults.    It  is  rare  during  the 


TUBERCULOSIS. 


277 


s 


iirst  year  of  life,  more  frequent  between  tlie  second  and  tlio  fifth  years. 
In  a  majority  of  the  cases  a  I'oeiis  of  ohl  tiil)erculoiis  disease  will  be  found, 
commonly  in  the  bronchial  or  mesenteric  glands.  In  a  few  instances  the 
all'ection  seems  to  be  primary  in  the  meninges.  It  is  very  ditlicult,  how- 
ever, ill  an  ordinary  post  mortem  to  make  an  exhaustive  search,  and  the 
lesion  may  be  in  the  bones,  sometimes  in  the  middle  ear,  or  in  the  genito- 
urinary organs.  In  those  instances  in  which  no  ])rimary  focus  has  been 
discovered  it  has  been  suggested  that  the  bacilli  reach  the  meninges  through 
the  cribriform  ])late  of  the  ethmoid  from  the  upper  part  of  the  nostrils,  but 
this  is  not  i)robable. 

Morbid  AiKitdiin/. — Tuberculous  meningitis  presents  a  very  character- 
istic picture.  The  meninges  at  the  base  are  most  involved,  hence  the  term 
basilar  meningitis.  Tlie  parts  about  the  optic  chiasm,  the  Sylvian  fissures, 
and  the  interi)eduncular  space  are  affec'ed.  There  may  be  only  slight  tur- 
))idity  and  matting  of  the  mendjranes,  and  a  certain  stickiness  with  serous 
infiltration;  but  more  commonly  there  is  a  turbid  exudate,  fibrino-purulent 
in  character,  which  covers  the  structures  at  the  base,  su'-ounds  the  nerves, 
extends  out  into  the  Sylvian  fissures,  and  appears  on  tiu  lateral,  rarely  on 
the  upper,  surfaces  of  the  hemispheres.  The  tubercles  may  be  very  a])par- 
ent,  particularly  in  the  Sylvian  fissures,  a})pearing  as  small,  whitish  nodules 
on  tho  membn  nes.  They  vary  much  in  number  and  size,  and  may  be 
difficult  to  find.  The  amount  of  exudate  bears  no  definite  relation  to  the 
abundance  of  tubercles.  The  arteries  of  the  anterior  and  posterior  per- 
forated spaces  should  be  carefully  withdrawn  and  searched,  as  ii))on  them 
nodular  tubercles  may  be  found  when  not  present  elsewhere.  In  doubtful 
cases  the  middle  cerebral  arteries  should  be  very  carefully  removed,  spread 
on  a  glass  plate  with  a  black  background,  and  examined  with  a  low  ob- 
jective. The  tubercles  are  then  seen  as  nodular  enlargements  on  the  smaller 
arteries.  The  lateral  ventricles  are  dilated  (acute  hydrocephalus)  and  con- 
tain a  turbid  fluid;  the  ependyma  may  be  softened,  and  the  septum  lucidum 
and  fornix  are  usually  broken  down.  The  convolutions  are  often  flattened 
and  the  sulci  obliterated  owing  to  the  increased  intra-ventricular  pressure. 
There  is  a  tuberculous  endarteritis  with  the  formation  of  intimal  tid)er- 
cles,  due  to  implantation  of  bacilli  from  the  blood  (Ilektoen).  Prolifera- 
tion in  the  adventitia,  with  invasion  of  the  media  and  intima  are  common, 
forming  nodular  circumscribed  tubercles.  The  lumen  of  the  vessel  is  nar- 
rowed and  thrombosis  may  result.  The  meninges  are  not  alone  involved, 
but  the  contiguous  cerebral  substance  is  more  or  less  trdematous  and  infil- 
trated with  leucocytes,  so  that  anatomically  the  condition  is  in  reality  a 
meningo-encephalitis. 

There  are  instances  in  which  the  acute  process  is  associated  with  chronic 
meningeal  tuberculosis;  cases  which  may  for  months  present  the  clinical 
picture  of  brain  tumor. 

Although  in  a  majority  of  instances  the  process  is  cerebral,  the  spinal 
meninges  may  also  be  involved,  particularly  those  of  the  cervical  cord. 
There  are  cases  indeed  in  which  the  sym])toms  are  chiefly  spinal.  A  sailor, 
who  had  fallen  on  the  deck  three  weeks  before  his  death,  was  admitted  to 
the  Montreal  General  Hospital.    He  presented  signs  of  meningitis,  chiefly 


I 


278 


SPECIFIC  IXFECnOUS  DISEASES. 


/ 


spiniil,  wliicli  were  naturally  attril)utL'(l  to  traumatism.  The  jm.'st  moTtom 
t-lio\v((l  ahseiico  of  tubercles  and  lymph  at  the  base  of  the  hrain,  and  an 
extensive  eruj)tion  of  miliary  tubercles  with  much  turbid  lymi)h  over  the 
entire  s|>iiial  im'nin^^cs.  'riieri'  were  small  cheesy  masses  at  the  apices  o! 
the  lun^^s. 

Si/mptoms. — Tubercidous  meninfiitis  presents  an  extremely  complex 
clinical  picture.    It  will  be  best  to  describe  the  form  found  iu  children. 

Prodromal  syni[)t(>ms  are  common.  'I'he  child  may  have  been  in  fail- 
ing health  for  some  weeks,  or  may  be  convalescent  from  measles  or  whoo[)- 
ing-cough.  In  many  instances  there  is  a  history  of  a  fall.  The  child  gets 
thin,  is  restless,  peevish,  irritable,  loses  its  a])petite,  and  the  disposition 
may  completely  change.  Sym[)toms  ])ointing  to  the  disease  may  then  set 
in,  either  (piite  suddenly  with  a  convulsion,  or  more  comnumly  with  head- 
ache, vondting,  ami  fever,  three  essential  symptoms  of  the  onset  which 
are  rarely  absent.  The  pain  may  be  intense  and  agonizing.  The  child 
puts  its  hand  to  its  head  and  occasionally,  when  the  ])ain  l)ecomes  worse, 
gives  a  short,  sudden  cry,  the  so-called  hydrocephalic  cry.  Sometimes  the 
child  screams  coJitinuously  iintil  utterly  exhausted.  I  saw  in  West  Phil- 
adel[)hia  a  case  of  basilar  meningitis  in  a  girl  of  thirteen,  who  for  three 
days,  when  not  under  the  inHuence  of  a  powerful  sedative  or  of  chloro- 
form, screamed  at  the  top  of  her  voice  so  as  to  be  heard  a  sipiare  or  more 
away.  The  vondting  is  without  a])])arent  cause,  and  is  independent  of  tak- 
ing of  food.  ('onsti])ation  is  Tisually  present.  The  fever  is  slight,  but 
gradually  rises  to  102°  or  10;]°.  The  pulse  is  at  first  rapid,  subsequently 
irregular  and  slow.  The  res])irations  are  rarely  altered.  During  sleep  the 
child  is  restless  and  disturbed.  There  may  be  twitchings  if  the  muscles, 
or  sudden  startings;  or  the  child  nuiy  wake  up  from  sleep  i.  u'reat  terror. 
In  this  early  stage  the  pu])ils  are  usually  contracted.  These  uio  the  chief 
symptoms  of  the  initial  stage,  or,  as  it  is  termed,  the  stage  of  irrila''   o. 

In  the  second  period  of  the  disease  these  irritative  symjitoms  su.  side; 
vondting  is  no  longer  marked,  the  abdomen  becomes  retracted,  boat-shaped 
or  carinaled.  The  bowels  arc  obstinately  constipated,  the  child  no  longer 
complains  of  headache,  but  is  dull  and  apathetic,  and  when  roused  is  more 
or  less  delirious.  The  head  is  often  retracted  and  the  child  utters  an  occa- 
sional cry.  The  pui)ils  are  dilated  or  irregular,  and  a  S(iuint  may  develo]). 
Sighing  respiration  is  common.  Convulsions  may  occur  -r  rigidity  of 
the  muscles  of  one  side  or  of  one  limb.  The  temperature  is  variable,  rang- 
ing from  100°  to  102..")°.  A  blotchy  erythema  is  not  uncommon  on  the 
skin.  If  the  finger-nail  is  drawn  across  the  skin  of  any  region  a  red  line 
comes  out  quickly,  the  so-called  iaclic  rcrchrale,  which,  however,  has  no  diag- 
nostic significance. 

In  thv;  final  period,  or  stage  of  piirah/s!s,  the  coma  increases  and  the 
child  cannot  be  roused.  Convulsions  are  not  infrequent,  and  there  are 
spasmodic  contractions  of  the  muscles  of  the  back  and  neck.  S])asms  may 
occur  in  the  limbs  of  one  side.  0])tic  neuritis  and  paralysis  of  the  ocular 
muscle"?  may  be  present.  The  pupils  become  dilated,  the  eyelids  are  only 
partially  closed,  and  the  eyeballs  are  rolled  up  so  that  the  cornere  are  only 
covered  in  part  by  the  upper  eyelids.     Diarrhoea  may  develop,  the  pulse 


TUBERCULOSIS. 


279 


on  the 
red  line 
10  cliair- 

md  the 
lore  are 
us  may 
ocular 
\vG  only 
ire  only 
\q  pulse 


becomes  rai)id,  and  the  cliild  may  sink  into  a  typhoid  state  with  dry  tongue, 
h)\v  delirium,  and  iiivuluiitary  j)assage8  of  urine  untl  laves.  The  tempera- 
ture t)l'tt'ii  becomes  suhuormal,  siuldng  in  rare  instances  to  'J3'^  or  \)A'^.  In 
some  cases  there  is  an  ante-nuulem  elevalioJi  of  temperature,  the  fever  rising 
lo  1(J<J°.  The  entire  duralidii  of  tlie  disease  is  from  a  fortniglit  to  tiiree 
or  four  weelvs.  A  leueocytosis  is  not  infrequently  present  througliout  tlie 
disease. 

Tliere  ai'e  eases  of  tultereuious  meningitis  which  jiursue  a  nu)re  I'a^iid 
course.  Tliey  set  in  with  great  violence,  often  in  persons  api)arently  in 
good  health,  and  may  prove  fatal  within  a  few  days.  In  these  instances, 
more  commonly  seen  in  adidts,  the  convex  surface  of  the  Ijruin  is  usually 
involvecl.  There  are  again  instances  which  are  essentially  chronic  and 
<lisplay  symptoms  of  a  limited  meningitis;  sometimes  with  ju'onounced 
jisychicnl  symptoms,  iind  sometimes  with  those  of  cerebral  tumor. 

There  are  certain  features  w  liich  call  for  sjjecial  comment. 

The  irregidarity  ami  slowness  of  the  ]iulse  in  the  early  and  middle 
stages  of  the  disease  are  ]toints  iipon  which  all  authors  agree.  Toward  the 
close,  as  the  heart's  action  becomes  Aveaker,  the  pulsations  arc  more  fre- 
(pient.  The  temperature  is  usually  elevated,  but  there  are  instances  in 
which  it  does  not  rise  in  the  whole  course  of  the  disease  much  above  100°. 
It  may  be  extremely  irregular,  and  the  oscillations  are  often  as  much  as 
three  or  four  degrees  in  the  day.  Toward  the  close  the  temperature  nuiy 
siidv  to  Ii.")°,  occasionally  to  1)4°,  or  there  may  be  hyperpyrexia.  In  a  case 
of  r.iiumler's  the  temperature  rose  before  death  to  43.7°  "c.  (110.7°  F.). 

The  ocular  symptoms  of  the  disease  are  of  s])ecial  importance.  In  the 
early  stages  narrowing  of  the  pupils  is  the  rule.  Toward  the  close,  with 
increase  in  the  intra-cranial  ])ressure,  the  i)upils  dilate  and  are  irregular. 
There  may  be  conjugate  deA'iation  of  the  eyes.  Of  ocular  ]ialsies  the  third 
nerve  is  most  fre(pu'utly  involved,  sonietinu's  Avith  jiaralysis  of  the  face, 
limbs,  and  hypoglossal  nerve  on  the  opjiosite  side  (syndrome  of  Weber),  due 
to  a  lesion  limited  to  the  inferior  and  internal  ])art  of  the  crus.  The 
changes  in  the  eye-grounds  are  very  important.  Neuritis  is  the  most  com- 
mon. According  to  Gowers,  the  disk  at  first  becomes  full  colored  and  has 
hazy  outlines,  and  the  veins  are  dilated.  Swelling  ami  striation  1)ecome  pro- 
nounced, but  the  neuritis  is  rarely  intense.  Of  'H'>  cases  studied  by  (lar- 
lick,  in  6  the  condition  was  of  diagnostic  value.  The  tubercles  in  the 
choroid  are  rare  and  much  less  fre(picntly  seen  during  life  than  post-mortem 
figures  would  indicate.  Thus  Litten  found  them  (post  mortem)  in  39  out 
of  52  cases.  They  Avere  ])rcsent  in  ouly  1  of  the  2G  cases  of  tuberculous 
meningitis  examined  by  Garlick.  ITeinzel  examined  with  negative  results 
41  cases. 

Among  tlie  motor  symptoms  convulsions  are  most  common,  but  there 
are  other  changes  Avhich  deserve  special  mention.  A  tetanic  contraction 
of  one  limb  may  ])ersist  for  several  days,  or  a  cataleptic  condition.  Tremor 
and  athetoid  movements  are  sometimes  seoTi  The  paralyses  are  either 
hemiplegias  or  monoplegias.  TTemiplegia  mi.j  result  from  disturbance  in 
the  cortical  branches  of  the  middle  cerebral  artery,  occasionally  from  soften- 
ing in  the  internal  capsule,  due  to  involvement  of  the  central  branches. 


380 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


Of  monoplegias,  that  of  the  face  is  perhaps  most  common,  and  if  on  tlio 
riglit  side  it  may  occur  with  aphasia.  In  two  of  ni7  cases  in  adults  a})ha.sia 
developed.  JJrachial  monoideyia  may  he  associated  with  it.  In  the  more 
chronic  cases  the  symptoms  ])ersist  for  montiis,  and  tliere  may  he  a  char- 
acteristic Jacksonian  epilej)sy  when  the  tuhercles  involve  the  meninges 
of  the  motor  cortex. 

The  diagnosis  of  tuherculous  meningitis  is  rarely  diilicult,  and  points 
n])on  which  special  stress  is  to  he  laid  are  the  existence  of  a  tuhercul<;us 
focus  in  the  hody,  the  mode  of  onset  and  the  symptoms,  and  tlie  evidence 
ohtained  on  luml)ar  puncture.  The  fluid  withdrawn  is  usually  turhid,  and 
in  it,  on  centrifugali/ing,  the  hacilli  may  ])c  discovered.  A  sterile  fluid, 
which  is  sometiiues  present,  also  favors  the  diagnosis  of  tuherculous  menin- 
gitis. 

The  prognosis  in  this  form  of  meningitis  is  always  most  serious.  I  have 
neither  seen  a  case  which  I  regarded  as  tuherculous  recover,  nor  have  I 
seen  post-mortem  evidence  of  past  disease  of  this  nature.  Cases  of  recovery 
have  heen  rei)orted  hy  rcliahle  authorities,  but  they  are  extremely  rare,  and 
there  is  always  a  reasonable  doubt  as  to  the  correctness  of  the  diagnosis. 
The  dilferential  features  and  treatment  will  be  considered  in  connection 
with  acute  meningitis. 


III.  Tuberculosis  of  the  LYMniATic  System. 

1.  Tuberculosis  of  the  Lymph-glands  (Scrofula). 

Scrofula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is 
the  essential  element.  Formsrly  special  attention  w^s  given  to  ditferent 
types  of  scrofula,  of  which  two  important  forms  were  recognized — the  san- 
guine, in  which  the  child  was  slightly  built,  tall,  with  small  limbs,  a  fine 
clear  skin,  soft  silky  hair,  anl  was  mentally  very  bright  and  intelligent; 
and  the  phlegmatic  type,  in  which  the  child  was  short  and  thick-set,  with 
coarse  features,  muddy  complexion,  and  a  dull,  heavy  aspect.  It  is  not  yet 
definitely  settled  whether  the  \irus  which  produces  the  chronic  tuberculous 
adenitis  or  scrofula  differs  from  that  which  produces  tuberculosis  in  other 
parts,  or  whether  it  is  the  local  conditions  in  the  glands  which  account 
for  the  sloAV  development  and  milder  course.  The  experiments  of  Arloing 
would  indicate  that  the  virus  ,ras  attenuated  or  milder,  for  he  has  shown 
that  the  caseous  material  of  a  lymph-gland  killed  guinea-pigs,  while  rab- 
bits escaped.  The  guinea-pig,  as  is  well  known,  is  the  more  susceptible 
animal  of  the  two.  The  obser'ations  of  Lingard  are  still  more  conclusive, 
as  showing  a  variation  in  the  virulence  of  the  tubercle  bacillus.  Guinea- 
pigs  inoculated  with  ordinary  tubercle  showed  lymphatic  infection  within 
the  first  week,  and  the  animals  died  within  three  months;  infected  with 
material  from  scrofulous  glands,  the  lymphatic  enlargement  did  not  ap- 
pear until  the  second  or  third  week,  and  the  animals  survived  for  six  or 
seven  months.  ITe  showed,  moreover,  that  the  virulence  of  the  infection  ob- 
tained from  the  scrofulous  glands  increased  in  intensity  by  passing  through 
a  series  of  guinea-pigs.  Eve's  experiments  show  that  scrofulous  material 
invariably  produces  tuberculosis  in  guinea-pigs  and  very  often  in  rabbits. 


TUBERCULOSIS. 


281 


lusive, 

liiinea- 

ivitliin 

with 

)t  ap- 
;  or 

)n  ob- 
Irough 

\terial 

bbits. 


Tuhcrculous  adenitis  is  nu't  vitli  at  all  ages.  It  is  more  ooinmon  in 
cliildri'ii  than  in  adults,  hut  it  is  not  inlri'iiucnt  in  the  middle  iioriud  of 
life,  and  may  occur  in  old  a;j;e. 

The  tuhercle  bacillus  is  uhi(|uit(jus.  All  arc  exposed  to  infection,  and 
upon  the  local  conditions,  whether  favorable  or  unfavorable,  depend  the 
fate  of  those  or<ranisms  which  lind  lodijinent  in  our  bodies.  It  is  ])ossil)le, 
of  course,  that  tuhcrculous  adenitis  nuiy  be  C(jnjj;enital,  but  such  instances 
must  be  extremely  rare.  A  8])ecial  predisposing  factor  in  lymphatic  tuber- 
culosis is  catarrhal  inllamnuition  of  the  mucous  membranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  con- 
stantly recurring  naso-])haryngeal  catarrh,  the  bacilli  which  lodge  on  the 
mucous  membranes  find  in  all  ])robal)ility  the  gateways  less  strictly  guarded 
and  are  taken  uj)  by  the  lymphatics  and  passed  to  the  nearest  glands.  The 
importance  of  the  tonsils  as  an  infection-atrium  has  of  late  been  urged. 
In  conditions  of  health  the  local  resistance,  or,  as  some  would  ])ut  it,  the 
phagocytes,  would  be  active  enough  to  deal  with  the  invaders,  l)ut  the  irri- 
tation of  a  chronic  catarrh  weakens  tbe  resistance  of  the  lymph-tissue  and 
the  bacilli  are  enabled  to  develop  and  gradually  to  change  a  simple  into 
a  tuberculous  adenitis.  The  freipient  association  of  tuberculous  adenitis 
of  the  bronchial  glands  with  whooping-cough  and  with  measles,  and  the 
frecucnt  development  of  tubercle  in  the  mesenteric  glands  in  children  with 
intestinal  catarrh,  find  in  this  way  a  rational  explanation.  After  all,  as 
Virchow  pointed  out,  an  increased  vulnerability  of  the  tissue,  however 
brought  about,  is  the  important  factor  in  the  disease. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  ade- 
nitis: 

(a)  The  local  character  of  the  disease.  Thus,  the  glands  of  the  neck,  or 
at  the  l)ifurcation  of  the  bronchi,  or  those  of  the  mesenterj',  may  be  alone 
involved. 

(h)  The  tendency  to  spontaneous  healing.  In  a  large  proportion  of 
the  cases  the  battle  which  ensues  between  the  bacilli  and  the  tissue-cells  is 
long;  but  the  latter  are  finally  successful,  and  we  find  in  the  calcified 
remnants  in  the  bronchial  and  mesenteric  lymph-glands  evidences  of  vic- 
tory. Too  often  in  the  bronchial  glands  a  truce  only  is  declared  and  hos- 
tilities may  break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(c)  The  tendency  of  tuberculous  adenitis  to  pass  on  to  suppuration. 
The  frequency  with  which,  ]iarticularly  in  the  glands  of  the  neck,  we  find 
the  tuberculous  processes  associated  with  pus  is  a  special  feature  of  this 
form  of  adenitis.  In  nearly  all  instances  the  pus  is  sterile.  Whether  the 
suppuration  is  excited  by  tbe  bacilli  or  by  their  products,  or  whether  it  is 
the  result  of  a  mixed  infection  with  pus  organisms,  which  are  subsequently 
destroyed,  has  not  been  settled. 

(d)  The  existence  of  an  unhealed  focus  of  tuberculous  adenitis  is  a 
constant  menace  to  the  organism.  It  is  safe  to  say  that  in  three  fourths  of 
the  instances  of  acute  tuberculosis  the  infection  is  derived  from  this  source. 
On  the  other  hand,  it  has  been  urged  that  scrofula  in  childhood  gives  a  sort 
of  protection  against  tuberculosis  in  adult  life.  We  certainly  do  meet  w'ith 
many  persons  of  exceptional  bodily  vigor  who  in  childhood  had  enlarged 


282 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


j:liiii<ls,  but  the  cvidciici'  wliit'h  .\lMrruii  Itriiigs  iorward  in  siipixjrt  of  tlii.-* 
\  icw  is  not  coJicluHive. 

Clinical  Forms.— 1.  Generalized   Tuberculous    Lymphadenitis. — Tn 

('\cc|iti()iiijl  instances  wi-  liiid  (.liirii>e  tuld'ivulo.-is  ui'  nearly  all  the  lyni|ih- 
glantlri  ol'  the  body  with  little  or  no  involvement  of  other  i)Ui'ts.  The  most 
extreme  eases  of  it,  wliieh  1  have  iseen,  luive  been  in  negro  patients.  'J'wo 
well-marked  eases  oeeurret]  at  the  J'hiladel|iliia  llosi»ital.  Jn  a  woniiin, 
the  chart  from  Api'il,  IS.SH,  nntil  .March,  JSSK,  showed  persisli'nt  fever, 
ranging  from  JUf"  to  lo;i°,  occasionally  rising  to  10-1°.  C)ji  December  JOth 
the  glands  on  the  right  side  of  the  neck  were  removed.  After  an  attack 
of  erysipelas,  on  ]''i'brnary  ITtli,  she  gradnally  sank  and  died  March  5lh. 
The  huigs  presented  only  one  or  two  puckered  s[)()ts  at  the  a]iiees.  The 
broncliial,  retro-pei'itoneal,  and  mesenteric  glands  were  greatly  eidarged 
and  caseons.  There  was  no  ijitestinal,  uterine,  or  bone  disease.  The  cdu- 
tinuous  lugh  fever  iii  this  case  depended  apparently  upon  the  tuberculous 
adenitis,  which  was  much  more  extensive  than  was  supposed  during  life. 
In  these  instances  the  eidai'gement  is  most  nuirked  in  the  retro-peritojieal, 
bronchial,  and  mesenteric  glands,  but  may  l>e  also  ])resent  in  the  groU])s  of 
external  ghiiuls.  Occurring  acutely,  it  presents  n  i)icture  resend)ling  Jlodg- 
kin's  disease.  Jn  a  case  whicdi  died  in  tlie  ^Tontreal  General  Hospital  this 
diagnosis  was  made.  The  cervical  and  axillary  glands  were  enormously  en- 
hirged,  and  (h'atli  was  caused  by  infiltration  of  the  larynx.  In  infants  and 
children  there  is  a  forju  of  general  tubercidous  adenitis  in  wliicli  the  vari- 
ous groujis  of  glands  are  successively,  more  rarely  simultaneously,  involved, 
and  in  which  death  is  caused  either  by  cachexia,  or  by  an  acute  infection 
of  the  meninges. 

2.  Local  Tuberculous  Adenitis. — Ot)  CerricaJ. — This  is  the  most  com- 
mon form  met  with  in  children.  It  is  seen  particularly  among  the  i)oor 
and  those  who  live  contiinu)Usly  in  the  impure  atmosphere  of  badly  venti- 
lated lodgings.  Children  in  foundling  hosintals  and  asylums  are  specially 
]>rone  to  the  disease.  In  this  country  it  is  most  common  in  the  negro  race. 
As  already  stated,  it  is  often  met  with  in  catarrh  of  the  nose  and  throat,  or 
chronic  enlargement  of  the  tonsils;  or  the  child  may  have  had  eczema 
of  the  scalp  or  a  purulent  otitis. 

The  sul)maxil]ary  glands  are  first  involved,  and  are  popularly  s|)oken 
of  as  enlarged  Icnicls.  They  are  usually  larger  on  one  side  than  on  the 
other.  As  they  increase  in  size,  the  individual  tumors  can  he  felt;  the 
surface  is  smooth  and  the  consistence  firm.  They  may  remain  isolated,  but 
more  commonly  they  form  large,  knotted  masses,  over  which  the  skin  is, 
as  a  rule,  fret'ly  movable.  Tn  many  cases  the  skin  ultimately  beconu's 
adlierent,  and  inflammation  and  sup])uration  occur.  An  abscess  points  and, 
Tinless  opened,  bursts,  leaving  a  sinus  which  heals  slowdy.  The  disease 
is  frequently  associated  with  coryza,  with  eczema  of  the  scalp,  ear,  or  lips, 
and  with  conjunctivitis  or  keratitis.  When  the  glands  are  large  and  grow- 
ing actively,  there  is  fever.  The  subjects  arc  usually  aiia-mic.  ]iarticularly 
if  su]ipuration  has  occurred.    The  ]irogress  of  this  form  of  adenitis  is  slow 

cases 


and  tedious.     Death,  however,  rarelv  folloAvs,  and 


in  children  ultimatelv  cet  well.    Xot  onlv  the; 


man 
submax 


y  a< 


llary 


Cgrav 
group 


a  ted 


but  the 


Tl'BKUCULOSIS. 


2S3 


>l)()k('n 
)n  the 
It;  Ihc 
cl,  but 
Bkin  is, 
becomes 
ts  and. 
disease 
or  lips, 

1    "TOAV- 

icularly 
ig  glow 
i  cases 

but  the 


(ilaiids  h1)()vc  tlio  clnvicle  and  in  the  |)i»sleri«>r  oervical  ti-iaii^de,  may  bo 
iiiNdhed.  In  otiicr  iiistanees  tiie  cervical  and  axillary  j^lands  are  involved 
lo^fcllier,  rorinin^'  a  continiioUM  chain  which  extends  Iteneath  the  clavicle 
and  the  pectoral  innscle.  With  tin  ni  tlu'  lironchial  >ilands  nuiy  also  be 
cniari^cd  and  cascons.  Not  ini'ri'(|ncntly  the  enhuycnieiit  oi  the  siipra- 
clavicnlar  and  a.xillai'y  ^rou])  (d'  ;:li.nds  on  on.'  side  precedes  thr  devidop- 
nient  of  a  tulii'rculons  pleurisy  or  of  pnlnionaiy  t  ulu'rculosis. 

{h)  Tvuchcit-hnntihiitl. — Tlii'  inrdiii>t  inal  lyinph-^dands  ciuistilute  iiltevs 
in  which  lod^iu  the  variiuis  I'oreijiii  pavlicles  which  escape  the  normal 
phap)cytes  oi'  bronchi  and  hin;is.  AnKUi;,'  these  roreiiiii  jiartii  les,  and  proli- 
alily  atlached  to  them,  tubercle  I)acilli  are  not  uiu-onimou,  and  we  lind 
tubercles  and  caseous  matter  with  great  I'reiiueney  in  the  mediastinal 
glands,  particularly  those  alioni  the  bi'oiu'hi.  It  is  stated  that  this  jirocess 
is  always  secondary  to  a  I'ocus,  however  small,  in  the  lungs,  but  my  ex|)eri- 
ence  does  not  bear  out  such  a  statement.  As  already  mentioni'il,  Xorlh- 
rup  found  them  involved  in  every  one  oi"  ViH  cases  at  the  New  York  Found- 
ling llos|)ital.  'i'his  tnbcrcidous  adenitis  may,  in  the  lu'onchial  glands, 
attain  the  dimensions  of  a  tumor  of  large  size  (bit  even  when  this  occurs 
there  may  be  no  pressure  symptoms.  Jn  childi'i'U  the  bronchial  adenitis 
is  apt  to  be  associated  with  suppuration.  The  eil'ects  of  these  enlarged 
glands  are  very  varied,  and  bii'  full  details  the  reader  is  referred  to  the 
elaborate  section  in  the  Traite  of  T>arthez  and  Sannee  (tonu'  iii).  It  is  suf- 
ficient here  to  say  that  tliere  are  instances  on  record  of  compression  of  the 
su|)erior  cava,  of  the  i)ulmonary  artery,  and  of  tlu'  a/.ygos  vein.  The  trachea 
ami  l)ronchi,  though  often  llattened,  are  rarely  seriously  compressed.  The 
])neumogastric  nerve  may  be  involved,  particularly  the  recurrent  laryngeal 
branch.  ]\fore  important  really  are  the  perforations  of  the  enlarged  and 
softened  glands  into  the  lironchi  or  traelu'a,  or  a  sort  of  secondary  cyst 
may  be  formed  between  the  lung  and  the  trachea.  Asphyxia  has  been 
caused  by  blocking  of  the  larynx  l)y  a  caseous  gland  which  has  ulcerated 
through  the  bronchus  (Voelcker),  and  Cyril  Ogle  has  re])orte(l  a  case  in 
which  the  ulcerated  gland  ])raclically  occluded  both  bronchi.  Perfora- 
tions of  the  vessels  are  much  less  common,  Init  the  ])ulmonary  artery  and 
the  aorta  have  been  oi)ened.  Perforation  of  the  o'sophagus  has  been  de- 
scribed in  several  cases.  One  of  the  most  serious  effects  is  infection  of  the 
lung  or  ])leura  by  the  caseous  glands  situated  dee))  along  the  bronchi.  This 
may,  as  is  often  clearly  seen,  be  by  direct  contact,  and  it  may  be  dinicult 
lo  determine  in  some  sections  where  the  caseous  bronchial  gland  terminates 
and  the  pulmonary  tissue  begins.  Tn  other  instances  it  takes  ])lace  along 
the  root  of  the  lung  and  is  sub])leural.  Among  other  sequences  may  be 
mentioned  diverticulum  of  the  (eso])hagus  following  adhesion  of  an  enlarged 
gland  and  its  subsecpient  retraction;  and,  in  the  case  of  the  anterior  medi- 
astinal and  aortic  groups,  the  fre(pient  production  of  pericarditis,  either 
by  contact  or  by  rupture  of  a  softened  gland  into  the  sac. 

A  serious  danger  is  systemic  infection,  which  takes  place  through  the 
vessels. 

(r)   Xfesciitcric:  Taho^   mrxniirnra. — Tn    this   affection,   the   abdominal 
scrofula  of  old  writers,  the  glands  of  the  mesentery  and  retro-peritonoDum 
IS 


i 


2S4 


SPEf'IFK!   INFECTIOUS  DISEASES. 


/ 


boconio  enlarjfod  iiiul  cnscato;  more  rnroly  they  Kiii)i)iirato  or  calcify.  A 
nli^^ht  tul)C'rcul(»us  adenitis  ia  extremely  common  in  children,  and  is  often 
accidentally  found  (post  mortem)  when  the  children  have  died  of  other 
diseases.  Jt  may  he  a  primary  lesion  associateil  with  intestinal  catarrh,  or 
it  may  In'  secondary  to  tuberculous  disease  of  the  intestines. 

Tlio  |)rinuiry  cases  are  very  common  in  children,  as  nuiy  he  gathered 
from  Woodhead's  figures,  already  given.  The  general  involvement  of  the 
glands  interferes  seriously  with  nutrition,  and  the  patients  are  puny,  wasted, 
and  auiemie.  Tlie  aixlomen  is  enlarged  and  tym[iaiiitie;  diarrluea  is  a  con- 
stant feature;  the  sto'»l3  are  thin  and  oll'ensive.  'J'here  is  moderate  fever, 
hut  the  general  wasting  and  debility  are  the  most  characteristic  features. 
The  eidarged  glands  cannot  often  be  felt,  owing  to  the  distended  condi- 
tu)n  of  the  bowels.  'JMiese  cas-es  are  often  s])oken  of  as  consumption  of  the 
howels,  but  in  a  majority  of  them  the  intestines  do  not  present  tul)ereulous 
lesions.  In  a  considerable  nundjcr  of  the  cases  of  tabes  mcscnterica  the 
])eritona'um  is  also  involved,  and  in  such  the  abdomen  is  large  and  hard, 
and  nodules  may  he  felt. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  nuiy  occur  as  a 
primary  all'ection,  or  in  association  with  pulmonary  disease.  Gairdner 
gives  a  remarkable  instance  of  the  kind  in  a  man  aged  twenty-one.  In- 
stances of  this  sort  are  not  iincommon  in  the  literature.  Largo  tumors 
may  exist  without  tuberculous  disease  in  the  intestines  or  in  any  other 
l)art. 

The  diagnosis  of  local  and  general  tuherculous  adenitis  from  lymphade- 
noma  will  be  sul)sequently  considered. 

2.  Tuberculosis  of  the  Serous  Membranes. 

General  Serous  Membrane  Tuberculosis. — The  serous  membranes  may 
be  chielly  involved,  either  simultaneously  or  consecutively,  forming  a  dis- 
tinctive and  readily  recognizable  clinical  type  of  tuberculosis.  There  are 
three  gr'  ps  of  cases.  First,  those  in  which  an  acute  tuberculosis  of  the 
peritonanun  and  i)leunie  develops  ra])idly,  craised  by  local  disease  of  the 
tubes  in  women,  or  of  the  mediastinal  or  bronchial  lymph-glands.  Sec- 
ondly, cases  in  which  the  disease  is  more  chronic,  with  exudation  into  both 
peritonanim  and  pleurae,  the  formation  of  cheesy  masses,  and  the  occur- 
rence of  ulcerative  and  suppurative  processes.  Thirdly,  there  are  cases  in 
which  the  ])leuro-pcritoneal  affection  is  still  more  chronic,  the  tubercles 
hard  and  fdjroid,  the  membranes  much  thickened,  and  Avith  little  or  no 
exudate.  In  any  one  of  these  three  forms  the  pericardium  may  be  in- 
volved with  the  pleura3  and  peritonaeum.  It  is  important  to  bear  in  mind 
that  there  may  be  in  these  cases  no  visceral  tuberculosis. 

Tuberculosis  of  the  Pleura. — 1.  Acute  tuberculous  pleurisy.  It  is  dif- 
ficult in  the  present  state  of  our  knowledge  to  estimate  the  proportion  of 
instances  of  acute  pleurisy  due  to  tuberculosis  (see  Acute  Pleurisy).  The 
cases  are  rarely  fatal.  In  the  study  of  those  in  the  Johns  Hopkins  Hos- 
pital, which  I  made  for  the  Shattuck  Lecture  (Boston  Med.  and  Surg. 
Journal,  LS93),  there  were  three  groups  of  cases:  (a)  Acute  tuberculous 
pleurisy  with  subsequent  chronic  course,  (b)  Secondary  and  terminal 
forms  of  acute  pleurisy  (these  are  not  uncommon  in  hospital  practice). 


f.    A 

(il'tcU 
olluT 

rh,  or 

ol'  11 U' 
nisluil, 
a  con- 
fever, 
atiircs. 
coiuli- 
of  the 
rculous 
ica  the 
d  hard, 

uv  as  a 
lairtlnt'i' 
ic.  Ill- 
tumors 
ly  other 


TL'UEUCULOSIS. 


285 


nil 


ihadc 


lies  may 
r  a  dis- 
lere  are 
s  of  the 
of  the 
s.     See- 
to  both 
e  occur- 
cases  in 
uherclcs 
e  or  no 
be  in- 
lin  mind 

[t  is  dif- 
Ution  of 
[■).  The 
Ins  llos- 
[d  Snrjr. 
lercnlous 
terminal 
Practice). 


And  {(•)  a  form  of  acute  tuhereuloiis  suppurative  jdcurisy.  A  considerable 
numlicr  of  the  purulent  plcurisii-s,  desi^Muited  as  latent  and  ehronie,  are 
caused  hy  tiilicrclc  l)a<'illi,  Itut  the  fact  is  not  so  widely  rec<);,Miizeil  that 
tlu'rc  is  an  acute,  ulcerative,  and  suppurative  disease  whicii  nuiy  run  a  very 
rapid  eourse.  The  pleurisy  sets  in  abruptly,  witii  pain  in  the  side,  fever, 
c'oiif^h,  and  sometimes  with  a  chill,  'i'hcrc  may  he  nothing,'  to  sujrgest  a 
tuherculous  proci'ss,  and  the  suhjcct  uiay  Irivt-  a  line  physiipic  and  come 
of  healthy  stock.  '2.  'J'he  suhacute  and  ehronie  tuhi'rculous  pK'urisies  aie 
more  eommon.  'J'he  largest  group  of  eases  comprises  those  with  sero- 
liltrinous  ell'usion.  The  onset  is  insidious,  the  true  character  of  the  disease 
is  fretpicntly  overlooked,  and  in  almost  every  instance  there  are  tuhercu- 
lous foci  in  the  lungs  and  in  the  hronchial  glands.  These  are  eases  in 
which  the  termination  is  often  in  pulmonary  tnlnTculosis  or  general 
miliary  tuhereulosis.  In  not  a  few  of  them  the  e.viidate  hecomes  puru- 
lent. 

And,  lastly,  there  is  a  ehronie  adhesive  jdeurisy,  a  ])rinuiry  proliferative 
form  which  is  of  long  standing,  nuiy  lead  to  very  great  thickening  of  the 
nu'nd)rane,  and  sometimes  to  invasion  of  the  lung.  For  a  fuller  considera- 
tion the  reader  is  referred  to  my  Shaft uck  Lecture  or  to  the  section  on 
tuhereulosis  in  Loomis  ami  Thompson's  System  of  Medicine. 

SecoiuJari/  tuberculous  ])leurisy  is  very  common.  The  visceral  layer  is 
always  involved  in  ])ulmonary  tuhereulosis.  Adhesions  usually  form  and 
a  chronic  pleurisy  results,  which  nuiy  be  simi)le,  but  usually  tubercles  are 
scattered  through  the  adhesions.  An  acute  tuberculous  pleurisy  may  re- 
sult from  direct  extension.  The  lluid  may  be  sero-fihrinous  or  luvmor- 
rhagie,  or  may  become  })urulent.  And,  lastly,  a  very  common  event  in 
puhnonary  tuberculo.sis  is  the  perfor-tion  of  a  superficial  sj)ot  of  softening, 
and  the  production  of  pyo-piieuvwthorax. 

The  general  symi)tomatology  of  these  forms  will  be  considered  under 
disease  of  the  pleura. 

Tuberculosis  of  the  Pericardium. — ^liliary  tubercles  may  occur  as  a 
part  of  a  general  infection,  but  the  term  is  i)roperly  limited  to  those  cases 
in  which,  either  as  a  piimary  or  secondary  process,  there  is  extensive  dis- 
ease of  the  membrane.  Tuberculosis  is  not  so  eommon  in  the  pericardium 
as  in  the  i)leura  and  peritoni\,nnn,  but  it  is  certainly  more  coiumon  than 
the  literature  would  lead  us  to  suppose.  Seventeen  cases  had  come  under 
my  observation  to  January,  1893  (x\merican  Journal  of  the  ^ledical  Sci- 
ences). 

We  may  recognize  four  grou])s  of  cases:  First,  those  in  which  the  con- 
dition is  entirely  latent,  and  the  disease  is  discovered  accidentally  in 
individuals  who  have  died  of  other  affections  or  of  chronic  pnlmonarv 
tuberculosis. 

A  second  gronp,  in  which  the  symptoms  are  those  of  cardiac  insuf- 
ficiency following  the  dilatation  and  hy])ertro])hy  consequent  upon  a 
chronic  adhesive  pericarditis.  The  symptoms  are  those  of  cardiac  dropsy, 
and  suggest  either  idiopathic  hypertrojihy  and  dilatation,  or,  if  there  is  a 
loud  blowing  systolic  murmur  at  the  apex,  mitral  valve  disease,  either  in- 
snfTiciency  or  stenosis.    There  are  cases  of  adherent  pericardium  in  which 


I 


280 


SI'KCIFIC   INFHCTKH'S   DISHASKS. 


/ 


a  Itriiit  i.>  lirjird  wliith  rociiiliN'.-  tin'  nmililiii;:  |iri'.-v>t<ilic  iiiurMiiir  (Hale 
VVliilc).     Tilt'  ((iiMlitiuii  of  lullicrciil  |K'riranliiiin  is  usually  ovcrlonki'tl. 

Ill  a  tiiinl  gi(ni|i  tin-  clinical  |iicUiri'  is  that  <ii'  an  acute  InlMTcuNtsiH, 
citlicr  p'licral  or  with  ccrcltro-siHnal  iiianirc-latiims,  wliicli  lia>i  had  its 
()i'i>:in  I'mni  the  Inhct'culuiis  peri*  anliuni  or  tuhcrcujous  mediastinal  lyniiih- 
l^lands. 

A  loui'th  ^Tonp,  with  ,-yniptnni-  of  aculc  |icricarditis,  includes  cases  in 
which  the  nll'eetiou  is  acute  and  acconi|»aiiie<l  with  more  or  less  exudation 
of  a  sero-lilirinous,  ha'morrlia;:ic.  or  purulent  character.  There  may  ln'  no 
HU.-picioii  \\liale\ci'  of  the  tuhercnjous  nature  of  tlie  trouhlc. 

{(I)  Tuberculosis  of  the  Peritonaium.-- In  connection  with  miluny  and 
chronic  i)ulm(Uiary  tidieiiul.i.-iri  it  is;  JU)l  unc(»nim">n  to  iiiid  the  pcrilon;euui 
hludded  with  small  <iray  ;;i'annlations.  'J'hey  are  constantly  present  (»n 
the  serous  surface  of  tid)crcid(tus  ulcers  of  the  intestini's.  Apart  J'roni 
tlieso  conditi(Uis  the  nieml»rane  is  often  the  scat  of  extensive  tuherculous 
discnse,  which  occiu,-  in  the  following'  J'onns: 

(1)  Aciilc  iiiilidnj  liilKiruh)iti.s  with  scro-iihrinous  or  hloody  exudation. 

i'i)  Chronic  liiliririihisis,  characterized  hy  larger  ^rrowths,  which  tend 
to  caseate  and  ulcerate.  Jt  nuiy  Jcad  to  perforation  of  the  intestinul  coils. 
The  exudate  is  purulent  or  bero-]»urtil('nt,  and  is  often  saccidaied. 

(.'!)  ('/inniir  /ihrnitl  hihcrctilosis,  which  nuiy  ho  siihaciite  from  the  onset, 
or  which  i  .ay  repi'csent  the  final  staiic  of  an  acute  miliary  eruption.  The 
tubercles  are  Jiard  and  ]ii<:iuentcd.  TJicrc  is  Jittle  or  no  exudation,  and 
the  serone?  surfaces  are  nuitted  tojrether  hy  adhesions. 

'I'he  process  nuiy  he  ]uii  iry  and  local,  which  was  the  case  in  5  of  my 
17  post  niortems.  In  children  the  infection  api)ears  to  pass  from  the  intes- 
tines, and  in  adults  this  is  the  source  in  the  cases  associated  Avitli  chronic 
j)lithisis.  In  women  the  disease  .xtends  commonly  from  the  -dlopian 
ttihcs.  In  at  least  IW  or  10  i)er  cent  of  the  instances  of  laparotomy  in  this 
aircction  rejiorted  hy  jryna'cologists  the  infection  was  from  them.  The 
])rostate  or  the  seminal  vesicles  may  he  the  siartinjr-iioint.  In  many  cases 
the  ])eritoria'uni  is  involved  with  the  jjleura  and  iiericartlium,  ])articularly 
with  the  former  membrane. 

It  is  interesting  to  note  that  certain  niorhid  conditions  oi  the  abdominal 
or^'ans  predispose  to  the  develo])ment  of  the  disease;  thus  patients  with 
cirrhosis  of  the  liver  very  often  die  of  an  acute  tuherculous  peritonitis. 
The  freqnency  with  which  the  cf)ndiiion  is  met  with  in  ojieraiions  upon 
ovarian  tumors  has  been  commented  upon  by  (ryna'colofrists.  ]\Iany  cases 
liave  followed  tranma  of  th'  abdomen.  A  very  interestin,fr  featiire  is  the 
(levelojiment  of  tiihercnlosis  in  hernial  sacs.  The  condition  is  not  very 
nnconmion.  In  a  majority  of  tho  instances  it  has  been  discovered  acci- 
dentally during;  the  operation  for  radical  cure  or  for  strangulation.  In 
7  instances  the  sac  alone  was  involved. 

It  is  generally  stated  that  males  are  attacked  oftener  than  females. 
Tn  my  own  series  of  21  cases,  I.t  were  males.  The  recent  laparotomies, 
however.  Avhich  have  heen  performed  in  this  disease  have  heen  chiefly  in 
females:  so  that  in  the  collected  statistics  T  find  the  cases  to  he  tAvice  as 
nnmerons  in  females  as  in  males;  in  the  ratio,  indeed,  of  131  to  60. 


Tl'lUOUCfL  )SW. 


25i7 


onst't, 
The 


loTlllllill 

with 
honitis. 
B  \\]wn 
Iv  cases 
is  tlic 
[)t  very 
[d  acci- 
m.     In 

fcinalcp. 
|>toTnios, 
liefly  in 
Iwice  as 


TnhcrciilniH  pfrilonitis  occiirM  at  all  ajjcs.  It  i>*  cMiniiiun  in  chililrcn 
a^isociatfil  Willi  iiitt'.«tiiial  ami  iiiofiitrrif  (lii-car-c  Tiu'  iiicnU'iiti'  in  must 
rri't|iu'nt  lit'twrt'ii  tlu'  a;,'f,x  (»['  twenty  a'lil  forty.  It  may  ocfiir  in  utlvaiici'tl 
lilt'.  In  Dili'  (if  my  t'a.'^cs  tlic  jiMiii'iii  wan  i.'ij;lity-t wo  years  of  u;ro.  (M' 
A't",  (•a.«*i's  collected  from  the  liteiatiii'i',*  there  were  iimler  ten  years,  'i'l!; 
Iietuecn  ten  aixl  twenty.  Vr,  I'roin  twenty  to  thirty.  N7;  hetweeii  thirty 
ami  forty,  71;  from  forty  to  lifty.  fil;  from  lifty  to  -ixty,  l!t;  from  .sixty 
to  seventy.  I;  aliove  seventy,  'i.  in  .\iiicri(ii  it  is  more  eoniiiion  in  I  ho 
iH'iiro  than  in  the  white  race. 

Symptoms.-  in  certain  spccirl  features  the  tiihercnloiis  varies  con- 
sideiiihly  from  oilier  forms  of  pcrilonitis.  It  |iresents  a  symptom-eoni[ilex 
of  extraordinary  diversity. 

in  the  llrst  place,  tiie  process  may  1)0  Jolnif  ami  not  cause  u  sin^do 
sympioiii.  Such  are  the  cases  met  with  aceideiilally  in  the  operation  for 
hernia  i>"  for  ovarian  tumor,  in  lirect  contrast  are  the  instam-es  in 
which  the  onset  is  so  sudden  and  I  >lent  that  the  dia>:ii(»sis  of  vnlrrilin 
or  lii'nnii  is  made,  'i'lie  operation  for  stran;.MiIaled  hernia  has,  indeed, 
heeii  performe(i.  Many  eases  set  in  ai'iitely  with  fever,  alxlominal  ten- 
derness, and  the  synifttoms  of  ordinary  acute  peritonitis.  Cases  with 
a  slow  onset,  alidoininal  teiideriH'ss,  tympanites,  and  low  coiitiniiou.s 
fever  resenihlc  /•  ihniil  frrrr  very  closely,  unil  may  h-ad  to  error  in  dia}^- 
nosis. 

Asciirs  is  fiHMpieiit.  hut  tlie  elTiision  is  rarely  lar<r<'.  It  is  sometimes 
hu'iiiocrliaiiic.  In  this  form  the  dia-.Miosis  may  rest  hctween  an  acute  miliary 
ciiiiccr,  cirrhosis  of  the  liver,  and  a  chronic  simple  peritonitis — conditioii.s 
wliich  usually  oU'er  no  special  dilliciilties  in  dill'ereiitiatioii.  A  iimsl  impor- 
tant ])oint  is  tiie  simultaneous  presence  of  a  ])!euri,>iy.  'IMie  tuherculin  test 
may  he  used.  Ti/iii/iiiiiili's  may  he  present  in  the  very  acute  cases,  wlien 
it  is  due  to  h)ss  of  tone  in  the  iiiteslines,  owinj,'  to  inllammatory  iiililtru- 
tion;  or  it  may  occur  in  the  old.  lon«r-standin,<r  eases  wiien  universal  adhe- 
sion Ini.s  taken  place  hctween  the  pariclal  and  visceral  layers.  Frrrr  is  a 
marked  symptom  in  the  acute  cases,  and  tli(>  temperature  may  reach  103° 
or  104°.  [n  many  instances  the  fever  is  sliaht.  In  the  nun'e  chronie  cases 
suhnormal  temperatures  are  common,  and  for  days  the  temperature  may 
not  rise  ahove  97°.  and  the  mornin<r  record  nuiy  be  as  low  as  95.5°.  An 
occasional  symptom  is  ijijinumtation  of  the  skin,  which  in  some  cases  lias 
led  to  the  diajrnosis  of  Addison's  disease.  A  sti'lkin^tr  peculiarity  of  tuber- 
culous peritonitis  is  the  fre([uency  with  wliich  either  the  condition  simu- 
lates or  is  a.spociated  witb  tuivnr.     These  may  be: 

(a)  Ompnfril,  duo  to  pnckcrin,<r  and  rollin,<;  of  this  membrane  until  it 
forms  an  elon.uated  firm  mass,  attached  to  the  transverse  colon  and  lyintr 
athwart  the  npjier  ]iart  of  tlie  abdomen.  This  cord-like  strncture  is  found 
also  with  cancerous  peritonitis,  but  is  mucli  more  common  in  tid)erculosis. 
Gairdner  has  called  special  attention  to  this  form  of  tumor,  and  in  children 
has  seen  it  nndcrjio  prradual  res(dution.  A  resonant  percussion  note  may 
sometimes  be  elicited  above  the  mass.     Though  usually  situated  near  the 

*  Johns  Hopkins  Hospital  Reports,  vol.  ii. 


288 


SPECIFIC  infp:ctious  diseases. 


/ 


iinibilicus,  tlie  oinoutal  mass  may  form  a  prominent  tumor  in  the  right 
iliac  region. 

(h)  iSacculalciI  e.rmhilion,  in  which  the  cfTusion  is  limited  and  confined 
by  adliesions  between  the  coils,  the  parietal  i)eritonaMun,  tlie  mesentery, 
and  the  abtloiiiinal  or  pelvic  organs.  This  eiieysteil  exudate  is  most  com- 
mon in  the  middle  zone,  and  has  frequently  been  mistaken  for  ovarian 
tumor.  It  may  occupy  the  entire  anterior  ])ortion  of  the  peritouivum,  or 
there  may  be  a  more  limited  saccular  exudate  on  one  side  or  the  other. 
It  may  lie  completely  within  the  pelvis  proper,  associated  with  tuberculous 
disease  of  the  Fallopian  tubes. 

(f)  In  rare  cases  the  tumor  formations  may  be  due  to  — eat  retraction 
or  thickening  of  the  intestinal  coils.  The  small  intestine  is  found  short- 
ened, the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  firm 
knot  close  against  the  sj)ine,  giving  on  examination  the  idea  of  a  solid 
mass.  Not  the  small  intestine  only,  but  the  entire  bowel  from  the  duode- 
num to  the  rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 

(d)  Mesenteric  glands,  which  occasionally  form  very  large,  tumor-like 
masses,  more  commonly  found  in  children  than  in  adults.  This  condition 
may  be  confined  to  the  abdominal  glands.  Ascites  may  coexist.  The  con- 
dition must  be  distinguished  from  that  in  children,  in  which,  with  ascites  or 
tyniTanites — sometimes  both — there  can  be  felt  irregular  nodular  masses,  due 
to  large  caseous  formations  between  the  intestinal  coils.  No  doubt  in  a  con- 
siderable number  of  cases  of  the  so-called  tabes  mesenterica,  particularly  in 
those  with  enlargement  and  hardness  of  the  abdomen — the  condition  which 
the  French  call  carreau — there  is  involvement  also  of  the  peritonaeum. 

The  diagnosis  of  these  peritoneal  tumors  is  sometimes  very  difficult. 
The  omental  mass  is  a  less  frequent  source  of  error  than  any  other;  but, 
as  already  mentioned,  a  similar  condition  may  occur  in  cancer.  The  most 
important  problem  is  the  diagnosis  of  the  saccular  exudation  from  ovarian 
tumor.  In  fully  one  third  of  the  recorded  cases  of  laparotomy  in  tuber- 
culous peritonitis,  the  diagnosis  of  cystic  OA'arian  disease  had  been  made. 
The  most  suggestive  ]ioints  for  consideration  are  the  history  of  the  patient 
and  the  evidence  of  old  tuberculous  lesions.  The  physical  condition  is  not 
of  much  help,  as  in  many  instances  the  patients  have  been  robust  and 
well  nourished.  Irregular  febrile  attacks,  gastro-intestinal  disturbance, 
and  pains  are  more  common  in  tuberculous  disease.  Unless  inflamed  there 
is  usually  not  much  fever  with  ovarian  cysts.  The  local  signs  are  very 
deceptive,  and  in  certain  cases  have  conformed  in  every  particular  to  those 
of  cystic  disease.  The  outlines  in  saccular  exudation  are  rarely  so  well 
defined.  The  position  and  form  may  be  variable,  owing  to  alterations  in 
the  size  of  the  coils  of  which  in  parts  the  walls  are  composed.  Nodular 
cheesy  masses  may  sometimes  be  felt  at  the  periphery.  Depression  of  the 
vaginal  wall  is  mentioned  as  occurring  in  encysted  peritonitis;  but  it  is 
also  found  in  ovarian  tumor.  Lastly,  the  condition  of  the  Fallopian  tubes, 
of  the  lungs  and  of  the  pleurre,  should  be  thoroughly  examined.  The  asso- 
ciation of  salpingitis  with  an  ill-defined  anomalous  mass  in  the  abdo;.icn 
should  arouse  suspicion,  as  should  also  involvement  of  the  pleura,  t] 


spicion, 
of  one  lung,  or  a  testis  in  the  male. 


ipex 


TUBERCULOSIS. 


289 


fficult. 
r;  but, 
le  most 
ovarian 
tuber- 
made, 
latient 
is  not 
ist  and 
rbance, 
d  there 
re  very 
0  those 
so  well 
ions  in 
Modular 
of  the 
at  it  is 
tubes, 
lie  asso- 
)do;.icn 
he  apex 


IV.  PcLMONARY  Tlhkkc'Ulosis  {riilhisis,  Coiisum pliuii). 

Tliree  clinical  groups  may  be  conveniently  recognized:  (1)  luhcrcuh- 
pneumoinc  phthisis — acute  jthlliisis;  {'2)  chronic  ukerulivc  phthisis;  and  (3) 
/it) raid  phthisis. 

According  to  the  mode  of  infection  there  are  two  distinct  types  of 
lesions: 

{(i)  When  the  bacilli  reach  the  lungs  through  the  blood-vessels  or  lym- 
l»luitics  the  primary  lesion  is  usually  in  the  tissues  of  the  alveolar  walls,  in 
the  capillary  vessels,  the  epithelium  of  the  air-cells,  and  in  the  connective- 
tissue  framework  of  the  septa.  The  process  of  cell  division  i)ruceeds  as 
already  described  in  the  general  histology  of  tubercle.  The  irritation  of 
the  bacilli  produces,  within  a  iew  days,  the  small,  gray  miliary  nodules, 
involving  several  alveoli  and  consisting  largely  of  round,  cuboidal,  uni- 
nuclear epithelioid  cells.  Depending  njjon  the  nundjcr  of  l)acil]i  which 
reach  the  lung  in  this  way,  either  a  localized  or  a  general  tuberculosis  is 
excited.  The  tubercles  may  be  uniforndy  scattered  through  both  lungs 
and  form  a  part  of  a  general  miliary  tuberculosis,  or  they  may  be  confined 
to  the  lungs,  or  even  in  great  part  to  one  lung.  The  changes  which  the 
tubercles  undergo  have  already  been  referred  to.  The  further  stages 
may  be:  (1)  Arrest  of  the  process  of  cell  division,  gradual  sclerosis  of  the 
tubercle,  and  ultimately  comi)lete  fibroid  transformation.  (2)  Caseation 
of  the  centre  of  the  tubercle,  extension  at  the  periphery  by  proliferation  of 
the  epithelioid  and  lymphoid  cells,  so  that  the  individual  tul)ercles  or 
small  grou})s  become  confluent  and  form  dilfuse  areas  which  undergo  case- 
ation and  softening.  (3)  Occasionally  as  a  result  of  intense  infection  of  a 
localized  region  through  the  blood-vessels  the  tubercles  are  thickly  set. 
The  intervening  tissue  becomes  acutely  inflamed,  the  air-cells  are  filled 
with  the  products  of  a  desquamative  pneumonia,  and  many  lobules  are 
involved. 

(h)  "When  the  bacilli  roach  the  limg  through  the  bronchi — inhalation 
or  as])iration  tuberculosis — the  picture  differs.  The  smaller  bronchi  and 
bronchioles  are  more  extensively  affected;  the  process  is  not  confined  to 
single  groups  of  alveoli,  but  has  a  more  lobular  arrangement,  and  the 
tidjcrculous  masses  from  the  outset  are  larger,  more  diffuse,  and  may  in 
some  cases  involve  an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in 
this  mode  of  infection  that  we  see  the  characteristic  peri-bronchial  granu- 
lations and  the  areas  of  the  so-called  nodular  broncho-pneumonia.  These 
broncho-pneumonic  areas,  with  on  the  one  hand  caseation,  ulceration,  and 
cavity  formation,  and  on  the  other  sclerosis  and  limitation,  make  up  the 
essential  elements  in  the  anatomical  picture  of  tuberculous  phthisis. 

1.  Acute  Pneumonic  Tuberculosis  of  the  Lungs. 

This  form,  known  also  by  the  name  of  gallopinp  cnnsiimptivi,  is  met 
with  both  in  children  and  adults.  In  the  former  many  of  the  cases  are 
mistaken  for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pneumonic  ar.d  hroncho-pneumonic. 


290 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


(a)  111  tlie  iniriuiiiiHic  fann  one  lohe  iiuiy  hv  involvi'd,  or  in  sonic  in- 
stiiiiccs  cin  entire  Jiini:'.  'I'Ih'  oi'i;an  is  lieavv,  the  alTcited  port  ion  airless; 
the  i)leuni  is  usnally  ecjvered  witli  a  thin  exmhite,  and  on  seetion  tlio  pietiire 
rt'senddes  closely  that  ol'  ordinary  heiiatization.  'J'lie  I'oMowinji  is  an  extract 
from  tlic  post-mortem  I'eport  oi'  a  case  in  w  liicli  death  occurred  twenty-nine 
days  after  the  onset  of  the  illness,  havinj;  all  the  characters  of  an  acute 
])neumonia:  "  J^'l't  \un'^  \vci>ihs  1,500  grammes  (double  the  weight  of  the 
other  organ)  and  is  heavy  and  airless,  crepitant  only  at  the  anterior  mar- 
gins. Section  shows  a  small  cavity  the  size  of  a  walnut  at  the  apex,  ab(jut 
which  are  scattered  tubercles  in  a  consolidated  tissue.  The  greater  part 
of  the  lung  presents  a  grayish-white  a})pearance  due  to  the  aggregation 
of  tubercles  which  in  some  j)laces  have  a  continuous,  uniform  appearance, 
in  others  are  surrounded  by  an  injected  and  consolidated  lung-tissue. 
Toward  the  nuirgins  of  the  lower  lobe  strands  of  this  firm  reddish  tissue 
separate  ana-mic,  dry  areas.  Tliere  are  in  the  right  lung  three  or  four 
small  groups  of  tubercdes  but  no  caseous  masses.  The  bronchial  glands 
are  not  tuberculous.''  Jlere  the  intense  local  infection  was  due  to  the 
snudl  focus  at  the  a])ex  of  the  lung,  probably  an  aspiration  process. 

Only  the  most  careful  inspection  nmy  reveal  the  presence  of  miliary 
tubercles,  or  the  attention  may  be  arrested  by  the  detection  of  tubercles  in 
the  other  lung  or  in  the  bronchial  glands.  The  ])rocess  may  involve  oidy 
one  lobe.  There  may  be  older  areas  which  are  of  a  peculiarly  yellowish- 
white  color  and  distinctly  caseous.  The  most  renuirkable  })icture  is  ])re- 
sented  by  cases  of  this  kind  in  which  the  disease  lasts  for  some  months. 
A  lobe  or  an  entire  lung  may  be  enlarged,  lirm,  airless  throughout,  and 
converted  into  a  dry,  yellowish-white,  cheesy  substance.  Cases  are  met 
with  in  which  the  entire  lung  from  ai)ex  to  base  is  in  this  condition,  with 
])erhaps  only  a  small,  narrow  area  of  air-containing  tissue  on  the  margin. 
]\Iore  connnouly,  if  the  case  has  las:ed  for  two  or  three  months,  rapid 
softening  has  taken  place  at  the  a])ex  with  extensive  cavity  formation. 

In  a  recent  study  A.  Fraenkel  and  Troje  found  tubercle  bacilli  alone 
in  11  of  12  cases.  They  suggest  that  in  these  eases  of  infection  by  aspira- 
tion the  large  areas  of  exudative  inflammation,  at  some  distance  even  from 
the  seat  of  growth  of  the  bacilli,  are  due  to  the  presence  of  some  dilfusible 
poison  produced  by  the  germs. 

Symptoms. — The  attack  sets  in  abrujitly  with  a  chill,  usually  in  an 
individual  who  has  enjoyed  good  health,  although  in  many  cases  the  onset 
has  been  preceded  by  exposure  to  cold,  or  there  have  been  debilitating  cir- 
cumstances. The  temperature  rises  rapidly  after  the  chill,  there  are  })ain 
in  the  side,  and  cough,  with  at  first  mucoid,  subseciuently  rusty-colored 
expectoration  which  may  contain  tubercle  bacilli.  The  dys'^nea  may  be- 
come extreme  and  the  ])atient  may  have  suffocative  attacks.  The  physical 
examination  shows  involvement  of  one  lobe  or  of  one  lung,  with  signs  of 
consolidation,  dulncss,  increased  fremitus,  at  first  feeble  or  sup])ressed 
vesicular  murmur,  and  subsequently  well-marked  bronchial  breathing.  The 
upper  or  lower  lobe  may  be  involved,  or  in  some  cases  the  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  mind  of  the  practitioner 
that  the  case  is  anything  but  on<'  of  frank  lobar  pneumonia.     Occasionally 


1.5° 


TUBERCULOSIS. 


201 


m  an 
le  oiiBt't 

ig  cir- 
re  pain 
icolored 

liay  1j<-"- 
Jjhysical 
lions  of 
Dressed 
The 

^n<r. 
tit  ion  er 
kionally 


there  may  he  siispieions  cireunistanees  in  the  history'  of  the  patient 
or  in  liis  taiiiily;  hut,  as  a  rnh",  no  stress  is  hiid  npon  them  in  view  of 
tiie  inte'ise  and  eharaeteristie  mode  of  (niset.  I>el\veen  the  eighth  and 
tenth  day,  instead  of  the  expeeted  crisis,  the  condition  hecomes  aggravated, 
the  temperature  is  irregular,  and  the  pulse  more  I'apid.  There  may  he 
sweating,  and  the  expectoration  becomes  nuico-purulent  and  greenish  in 
color — a  |)oint  of  special  ini])ortance,  to  which  'J'raulie  called  attention. 
Even  in  the  second  or  third  week,  with  the  persistence  of  these  symptoms, 
the  physician  tries  to  console  himself  with  the  idea  that  the  case  is  one  of 
unresolved  i»neunionia,  and  that  all  will  yet  be  well.  (Iradually,  however, 
tlie  severity  of  the  symptoms,  the  ])resence  of  ])hysical  signs  indicating 
softening,  the  existence  of  elastic  tissue  and  tubercle  bacilli  in  the  s[»uta 
present  the  mournful  proofs  that  the  case  is  one  of  acute  ]ineuinonic 
])hthisis.  Death  may  occur  before  softening  takes  ])lace,  e^-en  in  the  second 
or  third  week.  In  other  cases  tliere  is  extensive  destruction  at  the  a])ex, 
vith  rapid  formation  of  cavity,  and  the  case  may  drag  on  for  two  or  three 
months  or  may  become  one  of  chronic  ])hthisis. 

Diagfnosis. — It  is  hy  no  mean!  \'ly  recognized  in  the  ])rofession 
that  there  is  a  form  of  acute  jdithisi,  ich  may  closely  simulate  ordinary 
pneumonia.  AA'aters,  of  Liverpool,  gave  an  admirable  descri[)tion  of  these 
cases,  and  called  attention  to  the  dilliculty  in  distinguishing  them  from 
ordinary  pneumonia.  Certainly  the  mode  of  onset  affords  no  criterion 
Avliatever.  A  healthy,  robust-looking  young  Irishman,  li  cal)-driver,  who 
had  been  ke])t  waiting  on  a  cold,  blu^^tering  night  until  ihrce  in  the  morn- 
ing, was  seized  the  next  afternoon  with  a  violent  chill,  and  the  following 
day  was  admitted  to  my  wards  at  the  University  Hos])ital.  Philadelphia. 
He  was  made  the  subject  of  a  clinical  lecture  on  the  lifth  day.  when  there 
was  absent  no  single  feature  in  history,  symi)toms,  or  ])hysical  signs  of 
acute  lobar  pneumonia  of  the  right  u[iper  lobe.  It  Mas  not  until  ten  days 
later,  when  bacilli  were  found  in  Jiis  exy)ectoration,  that  we  were  made 
aware  of  the  true  nature  of  the  case.  1  know  of  no  criterion  l)y  which 
cases  of  this  kind  can  l)e  distinguished  in  the  early  stage.  The  tubercle 
bacilli  may  not  be  ])resent  at  first,  but  in  one  of  Fraenkel  and  Troje's  cases 
they  existed  alone  in  the  tyi)ical  jmeumonic  s])utum.  A  point  to  which 
Traul)e  called  attention,  and  which  is  also  referred  to  as  important  by 
Herard  and  C'ornil,  is  the  absence  of  breath-sounds  in  the  consolidated 
region;  but  this,  I  am  sure,  does  not  hold  good  in  all  cases.  The  tubular 
breathing  may  bo  intense  and  marked  as  early  as  the  fourth  day;  and 
again,  how  common  it  is  to  have,  as  one  of  the  earliest  and  most  suggestive 
symptoms  of  lobar  pneumonia,  su]ipression  or  enfeeblement  of  the  vesicular 
murmur!  In  many  cases,  however,  there  are  suspicious  circumstances  in 
the  onset:  the  ]iatient  has  been  in  bad  health,  or  may  have  had  ])revions 
pulmonary  trouble,  or  there  are  recurring  chills.  Careful  examination 
of  the  sputa  and  a  study  of  the  physical  signs  from  day  to  day  can  alone 
determine  the  true  nature  of  the  case.  A  point  of  some  moment  is  tie 
character  of  the  fever,  which  in  true  pneumonia  is  more  continuous,  par- 
ticidarly  in  severe  cases,  whereas  in  this  form  of  tuberculosis  remissions  of 
1.5°  or  2°  are  not  infrecpient. 


|V 


292 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


(b)  Acute  liihcrciiluus  hroncho-pncitmonia  is  more  common,  particularly 
in  cliiklrcn,  and  forms  a  majority  of  the  cases  of  phthisis  florida,  or  ''gal- 
loping consumi»tion."  It  is  an  acute  caseous  broncho-pneumonia,  starting 
in  tlie  snuiller  tubes,  which  l)ecome  Ijlocked  with  a  clieesy  substance,  while 
the  air-cells  of  the  lobule  are  filled  with  the  products  of  a  catarrhal  pneu- 
monia. In  the  early  stages  the  areas  have  a  grayish-red,  later  an  opaque- 
white,  caseous  a])pearance.  By  the  fusion  of  contiguous  masses  an  entire 
lobe  may  be  rendered  nearly  solid,  but  there  can  usiudly  be  seen  between 
the  groups  areas  of  crepitant  air  tissue.  This  is  not  an  uncommon  picture 
in  the  acute  phthisis  of  adults,  but  it  is  still  more  frequent  in  children. 
The  following  is  an  extract  from  the  post-mortem  report  of  a  case  on  a  child 
aged  four  mimths,  which  died  in  the  sixth  week  of  illness:  "  On  section,  the 
right  upper  loljc  is  occupied  with  caseous  masses  from  5  to  13  mm.  in  diame- 
ter, separated  from  each  other  by  an  intervening  tissue  of  a  deei)-red  color. 
The  bronchi  are  filled  with  cheesy  substance.  The  middle  and  lower  lobes 
are  studded  with  tubercles,  many  of  which  are  Ijccoming  caseous.  Toward 
the  diaphragmatic  surface  of  the  lower  lobe  there  is  a  small  cavity  the  size 
of  a  marble.  The  left  lung  is  more  crepitant  and  uniformly  studded  with 
tubercles  of  all  sizes,  some  as  large  as  peas.  The  bronchial  glands  are  very 
large,  and  one  contains  a  tuberculous  abscess." 

There  is  a  form  of  tuberculous  aspiration  pneumonia,  to  which  l^iium- 
ler  has  called  attention,  develo])ing  as  a  sequence  of  hix^moptysis,  and  due 
to  the  aspiration  of  blood  and  the  contents  of  pulmonary  cavities  into  the 
finer  tubes.  Following  the  haemoptysis,  which  may  have  occurred  in  an 
individual  without  suspected  lesion,  there  are  fever,  dyspnoea,  and  signs 
of  a  diffuse  broncho-pneumonia.  Some  of  these  cases  run  a  very  rapid 
course,  and  are  examples  of  galloping  consumption  following  haemoptysis. 
This  accident  may  occur  not  alone  early  in  the  disease,  but  may  follow 
haemorrhage  in  a  well-developed  case  of  pulmonary  tuberculosis. 

In  children  the  enlarged  bronchial  glands  usually  surround  the  root  of 
the  lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are  often 
involved  by  direct  contact. 

In  other  cases  the  caseous  broncho-pneumonia  involves  groups  of  alveoli 
or  lobules  in  different  portions  of  the  lungs,  more  commonly  at  both 
apices,  forming  areas  from  1  to  3  cm.  in  diameter.  The  size  of  the  mass 
depends  largely  upon  that  of  the  bronchus  involved.  There  are  cases  which 
])robably  should  come  in  this  category,  in  which,  with  a  history  of  an  acute 
illness  of  from  four  to  eight  weeks,  the  lungs  are  extensively  studded  with 
large  gray  tubercles,  ranging  in  size  from  5  to  10  mm.  In  some  instances 
there  are  cheesy  masses  the  size  of  a  cherry.  All  of  these  are  grayish-Avhite 
in  color,  distinctly  cheesy,  and  between  the  adjacent  ones,  particidarly  in 
the  lower  lobe,  there  may  be  recent  jmeumonia,  or  the  condition  of  lung 
which  has  been  termed  s])lenization.  In  a  case  of  this  kind  at  the  Phila- 
del|)hia  Hospital  death  took  place  about  the  eighth  week  from  the  abrupt 
onset  of  the  illness  with  haemorrhage.  There  were  no  extensive  areas  of 
consolidation,  Init  the  cheesy  nodules  were  uniformly  scattered  throughout 
both  lungs.    Xo  softening  had  taken  place. 

Secondarv   infections   are  not  uncommon;    but  Prudden  was   able   to 


TUBERCULOSIS. 


293 


Iveoli 
both 
mass 
1  which 
acute 
I  with 
Stances 
-white 
Jirly  in 
If  hmg 
Irhila- 
ihriipt 
Teas  of 
Ughoiit 

Ihlc   to 


show  that  tlio  tiihorclc  hac-ilhis  could  ])ro(liico  not  only  distinct  tulii'ivle 
n<)(hilt's,  hut  also  tiio  various  kinds  of  o.\U(hitive  piienoiuona,  the  exudates 
varying  in  appearance  in  diifeivnt  cases,  which  piienoniena  occurred  abso- 
lutely witiiout  the  intervention  of  other  organisms.  The  fact  that  these 
latter  had  not  suhse(|uently  crept  in  was  shown  by  cultures  at  the  autopsy  on 
the  allVcted  animal. 

Symptoms. — The  symptoms  of  acute  broncho-pneunionie  jjlithi-sis 
are  very  variahle.  In  adults  the  disease  may  attack  persons  in  good  health, 
but  who  are  overworked  or  "run  down"  from  any  cause,  lla'morrhage 
initiates  the  attack  in  a  few  cases.  There  nuiy  be  repeated  chills;  the 
temi)erature  is  high,  the  pulse  rapid,  and  the  respirations  are  increased. 
The  loss  of  flesh  and  strcngtli  is  vety  striking. 

The  j)hysical  signs  n'uiy  at  first  be  uncertain  and  indefinite,  but  finally 
there  are  areas  of  imjjaired  resonance,  usually  at  the  apices;  the  breath- 
sounds  are  harsh  and  tubular,  with  numerous  rales.  The  sputa  may  early 
show  elastic  tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three 
weeks,  the  ])aticnt  may  be  in  a  marked  typhoid  state,  with  delirium,  dry 
tongue,  and  high  fever.  Death  may  occur  within  three  weeks.  In  other 
cases  the  onset  is  severe,  with  high  fever,  rapid  loss  of  flesh  and  strength, 
ami  signs  of  extensive  unilateral  or  bilateral  disease.  Softening  takes  i)lace; 
there  are  sweats,  chills,  and  progressive  emaciation,  and  all  the  features  of 
phthisis  fo:i(la.  Six  or  eight  weeks  later  the  patient  may  bogiTi  to  im- 
prove, the  fever  lessens,  the  general  symptoms  abate,  ami  a  case  which 
looks  as  if  it  would  certainly  ternunate  fatally  within  a  few  weeks  drags 
on  and  becomes  chronic. 

In  children  the  disease  most  commonly  follows  the  infectious  diseases, 
particularly  measles  and  whooping-cough.*  The  profession  is  gradually 
recognizing  the  fact  that  a  majority  of  all  such  cases  are  tuberculous. 
At  least  three  (jroups  of  these  tuberculous  broncho-pneumonias  may  be 
recognized.  In  the  first  the  child  is  taken  ill  suddenly  while  teething 
or  during  convalescence  from  fever;  the  temperature  rises  rapidly,  the 
cough  is  severe,  and  there  may  be  signs  of  consolidation  at  one  or  both 
apices  with  rides.  Death  may  occur  within  a  few  days,  and  the  lung  shows 
areas  of  broncho-pneumonia,  with  perha])s  here  and  there  scattered  opaque 
grayish-yellow  nodules.  Macroscopically  the  affection  does  not  look  tuber- 
culous, but  histologically  miliary  granulations  and  bacilli  may  be  found. 
Tubercles  are  usually  present  in  the  bronchial  glands,  but  the  appearance 
of  the  broncho-pneumonia  may  be  exceedingly  deceptive,  and  it  may  re- 
quire careful  microscopical  examination  to  determine  its  tuberculous  char- 
acter. The  second  group  is  represented  by  the  case  of  the  child  previously 
quoted,  which  died  at  the  sixth  week  with  the  ordinary  symptoms  of  severe 
broncho-pneumonia.  And  the  lliird  f/royp  is  that  in  which,  during  the 
convalescence  from  an  infectious  disease,  the  child  is  taken  ill  with  fever, 
cough,  and  shortness  of  breath.  The  severity  of  the  symptoms  abates 
within  the  first  fortnight;  but  there  is  loss  of  flesh,  the  general  condition 
is  l)ad,  and  the  physical  examination  shows  the  presence  of  scattered  nlles 

*  "  Tussis  convulsiva  vestibuhim  tabis  "  (Willis), 


II 


.'!■■■■ 


i, 


29-t 


iSrEClFIC  INFECTIOUS  DISEASES. 


tlir()U<,'li()iil  the  liiii^s,  iiiid  hero  and  tluTo  iirciis  ol"  dt'foctive  resonance. 
'I'lic  cliild  lias  sweats,  the  fever  hcconics  licctic  in  eluiraeter,  and  in  many 
cases  the  eliiiicid  pictiiru  gradually  develojjs  into  that  of  chronic  ])litliisis. 


/ 


3.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs. 

f^nder  this  heading  may  be  grr)U|)ed  the  great  majority  of  cases  of  pul- 
monary tuherctdosis,  in  which  tli  '  -inns  jjroceed  to  ulceration  ami  soften- 
ing, and  ultimately  ])roducc  th  known  picture  of  chronic  phthisis. 
At  first  a  sti'ictly  tuberculous  alfci  i  ,  it  ultimately  Ijccomes,  in  a  majority 
of  cases,  a  mixed  disease,  nuiny  of  tiu'  most  prominent  symptoms  of  Mliich 
are  due  to  septic  injection  from  [)urulent  foci  and  cavities. 

Morbid  Anatomy. — Inspection  of  the  lungs  in  a  case  of  chronic 
phthisis  shows  a  remarkable  variety  of  lesions,  com[)rising  nodular  tuber- 
cles, dilfuse  tuberculous  infiltration,  caseous  masses,  pneunujnic  areas,  cavi- 
ties of  various  sizes,  with  changes  in  the  pleura,  bronchi,  and  bronchial 


glands. 


1.  The  Distribution  of  the  Lesions. — For  years  it  has  been  recognized 
tlmt  the  most  advanced  lesioiis  ai'c  at  the  a[)ices,  and  that  the  disease  pro- 
gresses downward,  usually  more  rapidly  in  one  of  the  lungs.  This  gen- 
eral statement,  which  has  passed  current  in  the  text-books  ever  since  the 
masterly  description  of  Laennec,  has  recently  been  carefully  elaI)oratecl 
l)y  Kingston  Fowler,  Avho  finds  that  the  disease  in  its  onward  i)rogress 
through  the  lungs  follows,  in  a  majority  of  the  cases,  distinct  routes.  In 
the  upper  lobe  the  ])rinun'y  lesion  is  not,  as  a  rule,  at  the  extreme  apex, 
but  from  an  iiU'h  to  an  inch  and  a  half  below  the  summit  of  the  lung,  and 
nearer  to  the  jjostei'ior  and  external  borders.  The  lesion  here  tends  to 
S})rcad  downwai'd,  ])roba1)ly  from  inhalation  of  the  virus,  and  this  accounts 
for  the  fre(i[uent  circumstance  that  examination  behind,  in  the  sujjra- 
spinous  fossa,  M'ill  give  indications  of  disease  before  any  evidences  pxist  at 
the  a])ex  in  front.  Anteriorly  this  initial  focus  corresponds  to  a  spot  just 
below  the  centre  of  the  clavicle,  and  the  direction  of  extension  in  front 
is  along  the  anterior  aspect  of  the  u])])er  loljc,  along  a  line  running  about 
an  inch  and  a  half  from  the  inner  ends  of  the  first,  second,  and  third  inter- 
spaces. A  second  less  common  site  of  the  primary  lesion  in  the  apex  "  cor- 
responds on  the  chest  wall  with  the  first  and  second  interspaces  below  the 
outer  third  of  the  clavicle."  The  extension  is  downward,  so  that  the  outer 
part  of  the  u])y)er  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  disease 
of  the  up])er  lobe  on  the  same  side.  In  the  involvement  of  the  lower  lobe 
the  first  secondary  infdtration  is  about  an  inch  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall  to  a 
spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  greatest 
importance  clinically,  as  "  in  the  great  majority  of  cases,  when  the  i)hysical 
signs  of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  the  diag- 
nosis of  phthisis  being  made,  the  lower  lobe  is  already  affected."  Examina- 
tion, therefore,  shoidd  be  made  carefully  of  this  posterior  apex  in  all  sus- 
picious cases.    In  this  situation  the  lesion  spreads  downward  and  laterally 


TUBERCULOSIS. 


205 


?s.    In 
apex, 
g,  and 
ncls  to 
cf)unts 
ui)r!i- 
i?t  at 
t  just 
front 
aljout 
intor- 
'  cor- 
w  the 
outer 

isease 
lo1)e 
l)el<i\v 
11  to  a 
reate^t 
lysical 
e  diajx- 
amina- 
\11  sus- 
\terally 


"V 


alon^  (lie  line  of  (lie  iiilcrjohular  septa,  a  lino  which  is  marked  by  tlie 
vcrtc'liral  liordcr  oT  I  lie  s(a|iiila,  uiion  tlio  hand  is  ]>lace(l  on  the  o[)i)osite 
si-apuia  and  the  dhow  raisccl  ahovi'  the  levi-l  of  the  shoui(U'r,  Uueu  pres- 
ent in  an  apex,  tlic  disi'ast'  usually  cxtt-nds  in  timi'  to  the  opjiosite  upper 
lolic;  hii!  not,  as  a  rnh',  until  the  apex  of  the  lowei-  lohe  of  the  lung  first 
aireete(|   Inis  heen  attacked. 

Of  IVT  cases  ahove  mentioned,  tiie  right  a|)e.\  was  involved  in  I'l'^,  the 
left  in  i;!(i,  both  in  111. 

Lesions  of  the  base  may  lie  ])rimary,  thongh  this  is  rare.  IVrcy  Kidd 
makes  t!ie  ])r(tportion  of  basic  to  apicic  ])hthisiti  1  to  5UU,  a  snndler  numbei- 
than  existed  in  my  series.  Jn  wry  chroiuc  cases  tiiere  may  be  arrested 
lesions  at  the  apex  and  more  recent  lesions  at  the  base. 

2.  Summary  of  the  Lesions  in  Chronic  Ulcerative  Phthisis. — (a)  Mili- 
ary  Tuhcirlcs. — They  have  one  of  two  distribntions:  (1)  A  dissemination 
(\\\i}  to  asjtiration  of  tuberculous  material,  the  tubercles  being  situated  in  tlie 
air-i-ells  or  the  walls  of  the  smaller  iironchi;  ('.')  the  distribution  due  to 
dissemination  of  tubercle  bacilli  by  the  lymph  cuirent,  the  tubercles  being 
scattei-e(|  about  the  old  foci  in  a  radial  mannei' — the  secondary  croj)  of 
J.aennec.  .Much  more  rarely  there  is  a  scattered  diss'  nination  from  in- 
fection here  and  there  of  the  smaller  vessels,  the  t\  l)ercles  then  being 
situated  in  tlu'  vessel  walls.  Souietimes,  in  cases  with  cavity  formation  at 
the  apex,  the  greater  ])art  of  the  lower  lobes  presents  many  groups  of  iiiui, 
sclerotic,  nuliary  tubercles,  whieh  may  indeed  form  the  distinguishing  ana- 
tomical feature" — a  chronic  miliary  tuberculosis. 

(b)  Tubcrndous  Hnnuhu-pnciimonia. — In  a  large  proportion  of  the  cases 
of  chronic  phthisis  the  terminal  bronchiole  is  the  ]>oint  of  origin  of  the 
process,  conse(|uently  we  find  the  smaller  bronchi  and  their  alveolar  terri- 
tories hlocked  with  the  accumulated  products  of  inllaiumation  in  all  stages 
of  caseation.  At  an  early  period  a  cross-section  of  an  area  of  tul)erculous 
broncho-pneumonia  gives  the  nu)st  characteristic  a]>peai'ance.  The  centi'al 
bronchiole  is  seen  as  a  small  orifice,  or  it  is  jdugged  with  cheesy  contents, 
while  surrounding  it  is  a  caseous  nodule,  the  so-called  ])eribronchial  tuber- 
cle. The  longitudinal  section  has  a  somewhat  dendritic  or  foliaceous  aj)- 
])earance.  The  condition  of  the  picture  depi'uds  mucli  upon  the  slowness 
or  ra])idity  Mith  which  the  process  has  advanced.  The  following  changes 
may  occur: 

rircralion. — When  Ihe  caseation  takes  ])lace  rapidly  or  ulceration  occurs 
in  the  ])ronchial  wall,  the  mass  may  l)reak  down  and  form  a  small  cavity. 

Sclerosis. — In  other  instances  the  ])roct'ss  is  more  chronic.  Fil)roid 
changes  gradually  ]troduce  a  sclerosis  of  the  all'irted  area,  a  condition 
which  is  sometimes  called  cirrlmsis  nodosa  liibercuh)sa.  The  sclerosis  may 
be  confined  to  the  margin  of  the  mass.  f(U'ming  a  limiting  ca])sule,  within 
which  is  a  uniform,  firm,  cheesy  substance,  in  Avhicli  lime  salts  are  often 
de])osited.  This  represents  the  healing  of  one  of  these  areas  of  caseous 
broncho-pneumonia.  It  is  only,  however,  when  complete  fibroid  trans- 
formation or  calcification  has  occurred  that  we  can  really  speak  of  healing. 
Tn  many  instances  the  colonies  of  ndliary  tubercles  about  these  masses 
show  that  the  virus  is  still  active  in  them.     Subsequently,  in  ulcerative 


296 


SPKCIFIC  INFKCTlOrs  DISEASES. 


/ 


proccssca,  tlioso  calcaroous  botlics — liing-stoncs,  as  tlicy  arc  soniftiinos  called 
— may  be  expectorated. 

(c)  Pneuinonia. — An  important  though  secondary  place  in  occupied 
by  inllaninuition  of  the  alveoli  surrounding  the  tubercles,  whicli  become 
filled  with  epithelioid  cells.  The  consolidation  may  extend  for  some  dis- 
tance about  tlie  tul)erculous  foci  and  unite  them  into  areas  of  uniform  con- 
solidation. Although  in  some  instances  thi.s  inihimmatory  process  may  be 
simple,  in  others  it  is  undoubtedly  specific.  It  is  excited  by  tlie  tubercle 
bacilli  and  is  a  manifestation  of  their  action.  Jt  may  ])resent  a  very  varied 
appearance;  in  some  instances  rescnd)ling  closely  ordinary  red  hepatiza- 
tion, in  others  being  more  homogeneous  and  inliltrated,  the  so-called  iii/il- 
trcUion  tvhcrculnisc  of  Jjaennec.  In  other  cases  the  contents  of  the  alveoli 
undergo  fatty  degeneration,  and  appear  on  the  cut  surface  as  opaque  white 
or  yellowish-white  bodies.  In  early  phthisis  much  of  the  consolidation  is 
due  to  this  pneumonic  infdtration,  which  may  surround  for  some  distance 
the  smaller  tuberculous  foci. 

(d)  Cavities. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  by 
necrosis  and  ulceration.  It  differs  materially  from  the  bronchiectatic  form. 
The  process  nsually  begins  in  the  wall  of  the  bronchus  in  a  tuberculous 
area.  Dilatation  is  produced  by  retained  secretion,  and  necrosis  and  idcera- 
tion  of  the  wall  occur  with  gradual  destruction  of  the  contiguous  tissues. 
By  extension  of  the  necrosis  and  ulceration  the  cavity  increases,  contigu- 
ous ones  unite,  and  in  an  affected  region  there  nuiy  be  a  series  of  snuill 
excavations  communicating  with  a  bronchus.  In  nearly  all  instances  the 
process  extends  from  the  bronchi,  though  it  is  possible  for  necrosis  and 
softening  to  take  place  in  the  centre  of  a  caseous  area  without  primary 
involvement  of  the  bronchial  wall.  Three  forms  of  cavities  may  be  recog- 
nized. 

The  fresh  ulcerative,  seen  in  acute  phthisis,  in  which  there  is  no  limiting 
membrane,  but  the  walls  are  made  np  of  softened,  necrotic,  and  caseous 
masses.  Small  vomica;  of  this  sort,  situated  just  beneath  the  pleura,  may 
ruptnre  and  cause  pneiimothorax.  In  cases  of  acute  tuberculo-pneumonic 
phthisis  they  may  be  large,  occupying  the  greater  portion  of  the  up])er 
lobe.  In  the  chronic  ulcerative  phthisis,  cavities  of  this  sort  are  invariably 
present  in  those  portions  of  the  lung  in  which  the  disease  is  advancing. 
At  the  apex  there  may  be  a  large  old  cavity  with  well-defined  walls,  while 
at  the  anterior  margin  of  the  npper  lobes,  or  in  the  apices  of  the  lower 
lobes,  there  are  recent  nlcerating  cavities  communicating  with  the  bronchi. 

Cavities  with  Well-dpfJiicd  Walls. — A  majority  of  the  cavities  in  the 
chronic  form  of  phthisis  have  a  ^^  ell-defined  limiting  membrane,  the  inner 
surface  of  which  constantly  produces  pus.  The  walls  are  crossed  by  trabec- 
ula3  which  represent  remnants  of  bronchi  and  blood-vessels.  Even  the 
vomica?  with  the  well-defined  walls  extend  gradually  by  a  slow  necrosis 
and  destruction  of  the  contiguous  lung  tissue.  The  contents  are  usually 
purulent,  similar  in  character  to  the  grayish  nummular  sputa  coughed  up 
by  phthisical  patients.  Xot  infrequently  the  membrane  is  vascular  or  it 
may  be  hnomorrhagic.  Occasionally,  when  gangrene  has  occurred  in  the 
wall,  the  contents  are  horribly  foetid.    These  cavities  may  occupy  the  greater 


stage? 
discjb 
and  1 
bronc 
of  th( 
the  sr 
bronci 
brane 


TUDEIICL'LOSIS. 


297 


l  t'oll- 

ay  be 
l)i'rc'lo 
varied 
lati/.a- 
l  infil- 
alvt'oli 
white 
tion  is 
istance 

cod  l)y 
c  form, 
rculous 

ulccra- 

tissues. 
!ontigu- 
)f  small 
ices  the 
)!5is  and 

irimarv 
e  recog- 

limiting 
caseous 
ra,  may 
umonic 
c  \ippev 
variably 
ancing. 
s,  while 
e  lower 
ronchi. 
in  the 
le  inner 
trahec- 
ven  the 
necrosis 
iisnally 
hed  np 
r  or  it 
in  the 
greater 


]H)rtion  of  the  apex,  forming  an  irregular  series  which  communicate  with 
each  other  and  with  tlie  hroiu'lii,  or  the  entire  ii|t|ier  lulie  exee[tt  tlie  an- 
terior margin  may  bo  excavated,  forming  a  thin-walled  cavity.  In  rare 
instances  the  process  has  proceedetl  to  total  excavation  of  the  lung,  not  u 
remnant  of  which  remains,  except  perhaps  a  narrow  strip  at  the  anterior 
margin.  In  a  case  of  this  kind,  in  a  young  girl,  the  cavity  held  l(»  lluid 
ounces. 

IJiiicsri'iit  Cavilivs. — When  (piite  small  and  surrounded  by  dense  cica- 
tricial tissue  connnunicating  with  the  bronchi  they  forni  the  cicatrices 
fintuh'vses  of  Laennec.  Occasionally  one  apex  may  be  represented  by  a 
series  of  these  small  cavities,  surrounded  by  dense  lll)roiis  tissue.  The  lin- 
ing membrane  of  these  old  cavities  may  Ije  (juite  smooth,  almost  like  a 
mucous  mendjrane.    Cavities  of  any  size  do  not  heal  com))letely. 

Cases  arc  often  seen  in  which  it  has  been  supposed  that  a  cavity  has 
healed;  but  the  signs  of  excavation  are  notoriously  uncertain,  and  there 
may  Ije  pectoriloquy  and  cavernous  sounds  with  gurgling,  resommt  rfdes 
in  an  area  of  consolidation  close  to  a  large  bronchus. 

In  the  formation  of  vomica}  the  blood-vessels  gradually  become  closed 
by  an  obliterating  inflammation.  They  are  the  last  structures  to  yield 
and  may  be  completely  exposed  in  a  cavity,  even  when  the  circulation  is 
still  going  on  in  them.  Unfortunately,  the  erosion  of  a  large  vessel  which 
has  not  yet  been  obliterated  is  by  no  means  infrecpient,  and  causes  i)r()fu.se 
and  often  fatal  haemorrhage.  Another  common  event  is  the  development 
of  aneurisms  on  the  arteries  running  in  the  walls  of  cavities.  These  may 
be  small,  bunch-like  dilatations,  or  they  may  form  sacs  the  size  of  a  walnut 
or  even  larger.  Rasmussen,  Douglas  Powell,  and  others  have  called  atten- 
tion to  their  importance  in  ha>moptysis,  under  which  section  they  are  dealt 
with  more  fully. 

And  finally,  about  cavities  of  all  sorts,  the  connective  tissue  develops 
and  tends  to  limit  the  extent.  The  thickening  is  particularly  marked  be- 
neath the  r^eura,  and  in  chronic  cases  an  entire  apex  may  be  converted  into 
a  mass  of  fibrous  tissue,  enclosing  a  few  small  cavities. 

(e)  Pleura. — Practically,  in  all  cases  of  chronic  phthisis  the  pleura  is 
involved.  Adhesions  take  place  which  may  be  thin  and  readily  torn,  or 
dense  and  firm,  uniting  layers  of  from  2  to  5  mm.  in  thickness.  This 
pleurisy  may  be  simple,  but  in  many  cases  it  is  tuberculous,  and  miliary 
tubercles  or  caseous  masses  are  seen  in  the  thickened  membrane.  Effusion 
is  not  at  all  infrequent,  either  serous,  purulent,  or  ha^iiorrhagic.  Pneumo- 
thorax is  a  common  accident. 

(/)  Changes  in  the  smaller  hranchi  control  the  situation  in  the  early 
stages  of  tidierculous  phthisis,  and  play  an  imi^ortant  role  throughout  the 
disease.  The  process  very  often  begins  in  the  walls  of  the  smaller  tubes 
and  leads  to  caseation,  distention  with  products  of  inflammation,  and 
broncho-pneumonia  of  the  lobules.  In  many  cases  the  visible  implication 
of  the  bronchus  is  an  extension  upward  of  a  process  which  has  begun  in 
the  smallest  bronchiole.  This  involvement  weakens  the  wall,  leading  to 
bronchiectasis,  not  an  uncommon  event  in  phthisis.  The  mucous  mem- 
brane of  the  larger  bronchi,  which  is  usually  involved  in  a  chronic  catarrh, 


\i'^ 


%■ 


298 


SPECIFIC   INFKCTIOUS  DISEASRS. 


/' 


is  iiiori'  (ir  less  swollrii,  iiml  in  mhiic  iiistiiiucs  ulcci'iittMl.  I\('.sitl<'s  tlitvo 
i^ltc'cilii'  lesions,  tlii'V  iiiiiv  lie  tlic  scat,  c-iiccially  in  cl.iliirrii,  of  iiilliiniina- 
tioii  due  to  sceoiiiiarv  invti>ii(»ii.  iiin>i  Irciiiiciitlv  l)y  the  miiTococriis  laiueo- 
latiis,  willi  till'  |ii'(Hliicti()ii  of  a  liroin'lio-imciiinonin. 

(//)  Till.'  (iniiidiidl  i/ldinls,  in  the  inoiv  m  iiti-  cases,  are  swdUci  ai'ij 
(I'deinatoiis.  Miliary  tuhereles  ami  easeous  loci  are  usnally  present.  In 
1'a.ses  of  chroiiie  |iliilii>is  the  caseoiis  ai'eas  are  eoninion,  ealeiliealioii  may 
oeeur,  an<l  iiol  inlreijuently  ]iiiruleiit  sul'teniii;,'. 

(A)  ('Ikiiiiics  in  llic  ollitr  On/dtis. — Ol'  these,  tnlien  iilosis  is  the  most 
eonunon.  In  my  series  of  autopsies  the  hrain  ])resente(l  tuberculous  lesions 
in  ;>!,  Hie  spleen  in  .".;'..  the  liver  in  1"J,  the  kidiu'y.s  in  ',\'i,  the  intestines 
in  (i.'i,  and  the  perieai'dinm  in  T.  Other  groups  of  lyniphatic  glands  hesides 
the  hi'oiichial  may  he  alVeeled. 

Certain  de^t'iierations  are  common.  Aiin/laid  cIkiikic  is  freijueiit  in 
the  liver,  spleen,  kidneys,  and  iniieoiis  memhrane  of  the  intestines.  The 
///•(7'  is  often  the  seat  of  extensive  hitty  iuliltrat ion,  which  may  caiiM' 
marked  cnlarLicinciit.  'J'he  ///  cliiinl  liihrrrnhisis  ■)ccurs  in  advanei'd  cases 
and  is  respoiisilde  in  <:reat  part  for  the  trouhlesome  diarrhiea. 

J'jiiilocdnlllis  is  not  very  uncommon,  and  was  present  in  1'*  of  my  post 
morteiiis  and  in  '!]  of  Percy  Kidd's  .^Od  cases.  Tubercle  hacilli  have  heeii 
found  in  the  ve<;etations.  'i'jie  suhject  has  been  considered  in  an  inipm-- 
tant  mono,<rraph  by  'I'ei^sier  (I'aris,  iSltl).  Tubercle's  may  he  jm-sent  on 
the  endocardium.  paiM  iciihirly  of  the  ri<!ht  ventricle.  As  pointed  out  hy 
Norman  Clievcrs,  and  coidirmed  by  subsequent  writers,  the  sidijccts  (<( 
con<i'enital  stenosis  of  the  pulmonary  orilice  M-ry  freiiuently  liave  phthisis. 

'J'he  htri/n.r  is  freipieiitly  involved,  and  ulceration  of  the  vocal  cords 
and  destruction  of  the  epi^^lottis  are  not  at  all  uncommon. 

Modes  of  Onset. — W'v  have  already  .<een  that  tuberculosis  of  the 
lunjfs  nuiy  occur  as  the  chief  jiai't  of  a  general  infection,  or  may  set  in 
with  symptoms  which  closely  simulate  acute  ])neumouia.  Jn  the  ordinary 
type  of  pulmonary  tuberculosis  the  invasion  is  gradual  and  less  striking, 
hut  ])resci'its  an  extraordinarily  diverse  picture,  so  that  the  practitioner  is 
often  led  into  error.  Among  the  most  characteristic  of  these  types  of  onset 
are  the  following: 

(a)  There  is  a  small  hut  imjiortant  group  of  cases  in  which  the  disease 
makes  considerable  ]U'ogress  liefoiv  there  are  serious  sym[)toms  to  arouse 
the  attention  of  the  patient.  This  lulriit  form  of  the  disease  is  seen  most 
frequently  in  workingmen,  and  llie  disease  may  even  advance  to  excava- 
tion of  an  ajiex  before  they  seek  advice.  Tn  some  of  these  cases  it  is  not  a 
little  remarkable  how  slight  the  lung  symptoms  have  lieen. 

A  dill'erent  tyjie  of  latent  pulmonary  tuberculosis  is  the  form  in  which 
the  symptoms  are  masked  hy  the  existence  (d'  serious  disease  in  other  organs, 
as  in  the  peritonanim,  intestines,  or  hones. 

(b)  Willi  Siiniploivs  of  Di/sprpsi(t  and  Ancrniia. — The  gastric  mode  of 
on^et  is  very  common,  and  the  early  manifestations  may  be  great  irritahility 
of  Hie  stomach  with  vomiting  or  a  tyjie  of  acid  dyspepsia  with  eructa- 
tions. In  young  girls  (and  in  children)  with  tliis  dyspepsia  there  is  very 
frequently  a  i)ronounced  chloro-anannia,  and  the  patient  complains  of  pal- 


I 


TL'BEIICULOSIS. 


299 


hotso 

111"! 

In 

may 

most 

L'siollri 

slini'S 
(ositled 

■nt    in 
The 

1   CllliOS 

\y  i)()st 

imiMtv- 

si-nt  on 

out  by 

jccls  o1^ 
l)hlhi^is. 
il  fonls 


if  tlu' 
set  in 
linary 
rikin.iT, 

(llU'T    i> 
OUHl-'t 


in 


disease 
arouse 
en  mo!^t 
ex e ava- 
ls nctl  a 


11  wliicli 
•  organs, 

mode  of 
lability 


eruc 


ta- 


is  very 
of  i»ai- 


]iilati(m   of  flie   lienit,    iiicrcasiii^'  weiikness,  sli^rlit   nfternoon   fever,   and 

illiieliorrlKeii. 

{(■)  In  a  coiisidenihlt'  ihiimIic!'  of  cuses  the  onset  of  pulmonnry  tiil)er- 
culosis  is  with  sym|itoins  which  sii;:|f{'st  nniliiridl  frri'r.  The  palieiit  \u\a 
repeated  parttxysiiiH  of  chills,  fevers,  and  sweats,  which  may  recur  with 
;,M'eat  regularity.  In  districts  in  which  intcrniittiMits  prevail  there  is  no 
more  common  mistake  than  to  eonl'onnd  the  initial  rigors  of  pidmonary 
tuherculosis  w  illi  malaria. 

ill)  Ousel  irllli  riiiirlsi/. — The  first  symptoms  may  he  a  dry  pleurisy 
ovci-  an  apex,  with  persistent  ffiction  niurmiii'.  In  other  instances  tho 
pulmonary  symptoms  have  followed  an  attack  of  pleurisy  with  elfusion. 
The  exudate  gradually  disappears,  hut  the  cough  persists  and  the  j)a- 
lient  hcconics  feverish,  and  gradually  signs  of  disease  at  one  apcx  heconio 
maiufcst.  Of  !•()  casi's  of  pleurisy  with  elfusion,  the  history  of  which 
was  j'o|lo\\('(l  liy  II.  I.  Uowdilch.  one  Ihii'd  developed  ](ulnionary  tuher- 
culosis. 

(r)  Willi  Ldi'i/niu'dl  Si/iniihrnis. — The  jiriuiary  localizati<ui  rm>y  hi'  in 
the  larynx,  Ihoiigh  in  a  majority  of  the  instances  in  which  hiiskiness  and 
laryngeal  symptoms  are  the  lirst  iioticealile  features  of  the  disease  there 
are  doiihtless  foci  already  existing  in  the  lung.  The  grouji  of  cases  in 
which  for  many  months  throat  and  larynx  symptoms  precede  tho  graver 
manifestations  of  pidmonary  phtliisis  is  a  very  important  one. 

(/')  OnsrI  irilli  IhniKipliisis. — Freipiently  the  very  first  symi)l<mi  of 
till'  disease  is  a  brisk  ha'Uiorrhage  from  the  lungs,  following  which  the  pul- 
monary symptoms  may  develop  with  great  rapidity.  In  other  cases  the 
lia'mo]ttysis  recurs,  and  it  may  be  months  before  the  symptoms  become 
well  established.  In  a  majority  of  these  cases  the  local  tuberculous  lesion 
exists  at  the  date  of  the  ha'moptysis. 

(//)  Willi  I'lilirmil'.sis  of  llir  ('rrrint-n.vUlnni  (Hands. —  I'reccding  the 
onset  of  ))ulinona''y  jihtliisis  for  months,  or  I'ven  for  years,  the  lymi»b- 
glands  of  the  nek  or  of  the  neck  and  axilla  (d'  one  side  may  he  I'lilarged. 
These  cases  ar'j  by  no  means  infreipient,  and  they  are  of  imjiortance  be- 
cause of  the  latency  of  the  pulmonary  lesions.  Nowadays,  when  operative 
intcrfennce  is  so  common,  il  is  well  to  bear  in  mind  that  in  such  patients 
the  cori'csponding  a])ex  of  the  lung  may  lie  extensively  imdhcd. 

(//)  Aiul.  lastly,  in  by  far  the  lai'gest  numher  of  all  cases  the  onset  is 
with  a  bmiirliilis,  or,  as  tho  ])ati(Mit  e\]iri'sses  it,  a  neglected  cold.  There 
has  l)een,  ])er]iaps,  a  liability  to  catch  cold  easily  or  the  ])atient  has  been 
subject  to  naso-pharyngeal  catarrh;  then,  following  some  unusual  ex])Osure, 
a  bronchial  cough  develops,  which  may  he  frecpient  and  vci'v  irritating. 
The  examination  of  the  lungs  may  reveal  localized  moist  souiv*ls  at  one 
a|»e.\  and  perha]is  wheezing  bronchitic  rales  in  other  jnirts.  In  a  few  cases 
the  early  symptoms  are  often  suggestive  of  asthma  with  marked  whet'zing 
and  dilTuse  juiung  rales. 

Symptoms. — In  discussing  the  sym])toms  it  is  usual  to  divide  the 

disease  into  three  periods:  the  first  embracing  the  time  of  the  growth  anil 

de\-clo)nnent  of  the  tulierclcs;  the  second,  in  which  they  soften;  and  the 

thii'd,  in  which  there  is  a  formation  of  cavities.    Unfortunately,  these  ana- 
19 


300 


Sr»KriFlC  INFRrTIOUS    DISK  ASKS. 


/ 


toinicul  8ta;;<'H  cannot  lie  sntisfiK  l(iry  (((rn'lalol  witli  corroHpomlinK  clinical 
lieriods,  and  we  (tften  fiml  Hint  a  patient  in  the  tiiinl  btaj;e  with  weli- 
niaikcd  cavity  Ih  in  a  far  lu'tter  condition  and  has  j,'reater  prospects  of  ru- 
covery  than  a  patient  in  tlie  lirst  sla;,^'  wil!i  dill'iise  cunHoli(hition.  It  '\i* 
therefore  hetter  pcilinps  to  disrepird  tlieni  altogether. 

1.  Local  Symptoms. — I'tiin  in  the  chent  may  he  early  and  trouhjesotne 
or  aljHent  tliroii<ihont.  It  is  nsnally  associateil  with  plenriny,  and  may  lie 
Hharp  and  ^lahliing  in  cliaracter,  an<l  eitlier  constant  or  felt  oidy  during' 
coii;;hinjf.  I'erhaps  the  commonest  situation  is  in  the  lower  thoracic  /one, 
thonf^h  in  some  instances  it  is  hcneath  the  scapula  or  rcl'erre(l  to  the  apex. 
The  attacks  luay  recur  at  lonj,'  intervals,  lutereostal  ncuraljiia  occasionally 
develops  in  the  course  of  ordinary  phthisis. 

(Unujh  is  one  of  the  earliest  symptoms,  and  is  present  in  the  majority 
of  cases  from  heginnin;;  to  end.  There  is  nolhin;;  peculiar  or  distiuctive 
ahout  it.  At  first  dry  and  hacking,  and  perhaps  scarcely  exciting  the  atten- 
tion of  the  patient,  it  suhse(iuently  hecomes  looser,  more  coiLstant,  and 
associated  with  a  glairy,  muco-piii'uleiit  expectoration.  In  the  early  stages 
of  the  disease  the  cough  is  hronchial  in  its  origin.  When  cavities  have 
formed  it  hecomes  more  paroxysnud,  and  is  most  markctl  in  tin;  nu)rning 
or  after  a  sleep.  Cough  is  ntit  a  constant  symptom,  however,  and  a  patient 
may  ])reseHt  himself  with  well-marked  excavation  at  one  apex  who  will 
declare  that  he  has  had  little  or  no  cough.  So,  too,  there  may  he  well- 
marked  physical  signs,  dulness  and  moist  S(ninds,  without  either  expectora- 
tion or  cough.  In  well-estahlished  cases  the  nocturnal  jmroxysms  are  most 
distressing  and  ]irevent  sleep.  The  cough  may  bo  of  Kueli  i)ersi.stenee  and 
severity  as  to  cause  vomiting,  and  the  patient  Ix'coiaes  rapidly  enuiciated 
from  lo.ss  of  food — Morton's  cough  ( I'hthisiologia,  1()H!>,  |).  101).  The 
laryngeal  com])lications  give  a  ])eculiarly  husky  (piality  to  the  cough,  and 
when  erosion  and  ulceration  have  jjroceeded  far  in  the  vocal  cords  the 
ell'orts  of  coughing  are  much  less  cfTcctive. 

Sjni'um. — This  varies  greatly  in  amount  and  character  at  the  dilterent 
stages  of  ordinary  ))ht]iisis.  There  are  cases  with  well-marked  local  signs 
at  one  apex,  with  slight  cough  and  moderately  high  fever,  without  from 
day  to  day  a  trace  of  expectoration.  So,  also,  there  are  instances  with  the 
most  extensive  consolidation  (caseous  ])neumonia),  and  high  fever,  hut,  as 
in  a  recent  instance  under  ohservation  for  several  months,  without  enough 
exi)ectoratio]i  to  eiud)le  an  examination  for  bacilli  to  be  made.  In  the 
early  stage  of  pidmonary  tuberculosis  the  sputum  is  chielly  catarrhal  and 
has  a  glairy,  sago-like  a])pearauce,  due  to  the  presence  of  alveolar  cells 
which  have  uudcrgone  the  uiyelin  degeneration.  There  is  nothing  dis- 
tinctive or  ])eculiar  in  this  form  of  expectoration,  which  nuiy  ])ersist  for 
months  without  iudicating  serious  trouble.  The  earliest  trace  of  charac- 
teristic sputum  may  show  the  presence  of  small  grayish  or  greenish-gray 
])urulent  masses.  These,  when  coughed  up,  are  always  suggestive  and 
should  be  the  ])ortious  ])icked  out  for  nncroscopical  examination.  As 
softening  comes  on.  the  expectoration  becoiues  more  profuse  and  ]niru- 
lent,  but  may  still  contain  a  consideral)le  (piantity  of  alveolar  epithelium. 
Finally,  when   cavities   exist,   the  sputa   assume   the   so-called   nummular 


UL' 


TUBERCULOSIS. 


301 


h,  ami 
tlu 


I'dri 


illVrent 
il  si^ms 
\t  from 
Ih  the 
l)ut,  an, 
enough 
In  the 
Ihal  and 
lis. 
lis- 


iir  cc 


ling  < 


Irsi 


;t  Tor 


I'lnirac- 
lish-gmy 
live  and 
Jon.  As 
Id  innni- 
Itht'liuni. 
lunniular 


form;  oach  nin«8  Is  inolatcd,  flatti'Mocl,  ^rotMiinh-gray  in  color,  qiiito  airless, 
and  sinks  to  the  liottoni  wlien  s|i»t  into  water. 

My  the  mieros('o|ti(al  cxaiiunatioii  ot'  the  sjiiitnin  we  determine  wiicllu'r 
the  process  is  tuhcrculons,  and  whether  sol'teiung  has  occurred.  l''or  liihrirlit 
hdcilli  the  Khrlich-Weip'rt  method  is  tlie  liest.  I'.le\cn  centimetres  of  a 
Hatnrated  solution  of  fnchsin  in  ahsolute  alcohol  is  added  to  Ini)  cm.  of 
the  saturated  solution  of  counuercial  aniline  oil  (inaile  hy  shaking  up  the 
oil  in  water  and  then  Hltcriug).  'I'his  should  he  made  fresh  every  lliii'd 
or  fourth  day.  A  HUudl  l)it  of  the  sputum  is  picked  out  on  a  needle  or 
j)latinum  wire  and  spread  thin  on  the  top-cover  hd  an  to  n:ake  a  uniforndy 
thin  layer.  'I'lie  top-cowr  is  slowly  dried  ahout  a  foot  ahove  a  Munsen 
burner.  Sullicient  of  the  staining  iluid  is  then  dro|»ped  ujion  the  lop- 
cover,  which  is  held  at  a  little  distance!  ahove  the  llanu!  until  the  Iluid 
boils,  '['he  staining  Iluid  is  then  washed  oil'  in  distilled  water  or  |)ut  umler 
the  tap,  deco|ori/,e(l  in  'M)  per  cent  intric-acid  Iluid,  again  washed  oil'  in 
water,  and  mount"d  on  tlu;  slide.  In  doiddful  cases  the  long  |)rocess  is 
used,  the  cover-slips  remaining  twenty-four  hours  in  the  stain.  Tlu!  bacilli 
are  seen  as  elongate(l,  slightly  curvc(l,  red  rods,  sometimes  presenting  a 
beaded  appearance.  They  are  fret|nently  in  groups  of  three  or  four,  but 
the  nund)er  varies  considerably.  Only  one  or  two  may  be  found  in  a  prep- 
aialion,  or,  in  some  instances,  they  are  so  abundant  that  the  entire  lield  is 
occupied. 

The  iircseiice  of  Ihcsc  hacilli  in  the  simlitiii  is  (in  infallible  indicalion  of 
the  c.rislenre  of  Inhrirnhisis. 

Sometimes  they  are  found  only  after  repeated  (>.\annnation.  They  may 
be  a'  undaiit  early  in  the  disease  and  are  usually  numerous  in  the  num- 
mular sputum  of  the  later  stages. 

Klnslic  tissue  uuiy  be  derived  from  the  bronchi,  the  alveoii,  or  from 
the  arterial  coats;  and  naturally  the  appearance!  of  the  tissue  will  vary  with 
the  Icjcality  from  which  it  comes.  In  the  exannnation  for  this  it  is  not 
necessary  to  boil  the  sputum  with  cuistic  potash.  For  years  I  have  usc(l 
a  simple  plan  which  was  shown  to  me  at  the  London  Hospital  by  Sir 
Andrew  Clark.  This  method  depends  U|)on  the  fact  that  in  almost  all 
instances  if  the  sputum  is  spread  in  a  sulliciently  thin  layer  the  fragments 
of  clastic  tissue  can  be  seen  with  the  naked  eye.  The  thick,  purulent  por- 
tions are  placed  upon  a  glass  ])late  15  X  !•">  t'ni.  and  flatt(!ned  into  a  thin 
layer  by  a  second  glass  ])late  10  X  1'^  fm.  Tn  this  compressed  grayish  layer 
between  the  glass  slips  any  fragments  of  elastic  tissue  show  on  a  black 
background  as  grayish-yellow  spots  and  can  either  be  examined  at  once 
under  a  low  j)ower  or  the  uppermost  piece  of  glass  is  slid  along  until  the 
fragment  is  exposed,  wdien  it  is  picked  out  and  jtlaccd  U])on  the  ordimiry 
inicrosco])ic  slide.  Fragments  of  bread  and  colh'ctions  of  milk-globules 
may  also  present  an  ojtacpu'  white  appearance,  but  with  a  little  practice  th(>y 
can  readily  be  recognized.  Fragments  of  epithelium  from  the  tongue, 
inliltrated  with  nncrococci,  are  still  more  deceptive,  but  the  microscope  at 
once  shows  the  dilTerence. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or 
three  long,  narrow  fdjres  are  found  close  together.    From  the  blood-vessels 


I 


il 


/ 


302 


SPECIFIC  INFECTIOUS  DISEASl'lS. 


a  poiiu'wluil  siinihir  U)v\n  iiuiy  Itc  sct'ii  and  occasioiially  a  distinct  sbocting 
is  round  as  if  it  had  coiik'  Ironi  the  intinia  of  a  good-sized  artery.  TJio 
c'lastie  tissue  of  tiie  alveolar  wall  is  (luite  distinctive;  tlie  llhres  are  hraiieiied 
and  often  show  the  outline  of  the  arrangement  of  the  air-cells.  The  elastic 
tissue  from  hronehus  or  alveoli  indicates  extensive  erosion  of  a  tuhe  and 
sol'teuing  of  the  lung-tissue. 

Another  occasional  constituent  of  the  spiituiii  is  blood,  which  may  be 
present  as  the  chief  characteristic  of  the  expectoration  in  haMuoptysis  or 
may  simply  tinge  the  sputum.  In  chronic  cases  with  large  cavities,  in 
addition  to  bacteria,  various  forms  of  fungi  may  develop,  of  which  the 
aspergillns  is  the  most  important.     Sarcina'  may  also  occur. 

CrJcdrcous  Fnn/iiK'iils. — Formerly  a  good  deal  of  stress  was  laid  upon 
tbeir  i)resence  in  the  spntuni,  a'  1  Morton  described  a  phthisis  a  calniJis  in 
/mhiitinihtis  ijciicvitlis.  !>ayle  also  described  a  separate  form  of  phlhi»ic  cul- 
ciilnisr.  Tlu'  size  of  the  fragments  varies  from  a  small  ]>ea  to  a  large  cherry. 
As  a  rule,  a  single  one  is  ejected:  sometimes  large  numbers  are  coughed 
u])  in  the  course  of  the  disease.  They  are  formed  in  the  lung  by  the  calci- 
fication of  caseons  masses,  and  it  is  said  also  occasionally  in  obstructed 
bronchi.  They  may  come  from  the  bronchial  glands  by  ulceration  into 
the  bronchi,  and  there  is  a  case  on  record  of  sulfocation  in  a  child  from 
this  cause. 

The  daily  amount  of  ex])ectoration  varies.  In  rapidly  advancing  cases, 
Avith  nnich  cough,  it  may  reach  as  high  as  ."idO  cc.  in  the  day.  In  cases  with 
large  cavities  the  chief  amount  is  brought  up  in  the  morning.  The  ex- 
l)ectoration  of  tuberculous  patients  usually  has  a  heavy,  sweetish  odor,  and 
^)ccasionally  it  is  fetid,  owing  to  decomiiosition  in  the  cavities. 

Heemoptysis. — One  of  the  most  famous  of  the  ni])])ocratic  axioms 
says,  '•  From  a  spitting  of  blood  there  is  a  spitting  of  pus."  The  older 
writers  thought  that  the  i)hthisis  was  directly  due  to  the  inllammatory 
or  putrefactive  changes  caused  l)y  the  luvmorrhage  into  the  lung.  Mortt)n, 
however,  in  his  interesting  section,  Phtbisis  ab  JTa'mo])t(le,  r.nther  doubted 
this  sequence.  T.aennec  and  Louis,  and  later  in  the  century  Traube,  re- 
gardt'd  the  hu'inoptysis  as  an  evidence  of  existing  disease  of  the  lung.  From 
the  accurate  views  of  T.aenuec  and  Louis  the  ])rofession  was  led  away  by 
Graves,  aiul  jjarticularly  by  Xiemeyer,  who  held  that  the  blood  in  the  air- 
cells  set  v.\)  an  iidlammatory  ])rocess,  a  common  tcrinination  of  which  was 


caseation. 


Since    Koch's  discovery  we   have   learned   that 


manv  cases  in 


w 


hicli  the  ])hysical  examination  is  negative  show,  either  during  the  ])eriod 


of  ha-morrhaiic  or  immediatelv  after  it,  tubercle  bacilli  in  the  s|)ul 


1,  so 


that 


opinion  has  veered  to  the  older  view,  and  Ave  now  regard  the  appearance  of 
liK'nioiitysis  as  an  indication  of  existing  disease.  Li  young,  aj)parently 
healthy  ])ersons,  cases  of  haMno]itysis  may  be  divided  into  three  groups,  in 
the   lirst   the  bleeding   has  come   on   without   premonition,  Avithout   over- 


exertion  or  1 


niurv.  and   there  is  no  family  historv  of  tubercul 


OSlf 


^r 


jihysical  examination  is  negative,  and  the  exaniinathn  of  the  ex]K'ctoration 
at  the  time  of  the  luvmorrhage  and  siibse(]uently  shows  no  tubercle  bacilli. 
Sucli  instances  are  not  uncommon,  and,  though  one  may  suspect  strongly 
the  presence  of  some  focus  of  tuberculosis,  yet  the  individuals  may  retain 


tubt 


T' 


>('ting 

The 

nclu'il 

10  and 

lay  be 
vsis  or 
ics,  in 
c;li  the 

1  upon 
■ulifi  in 
sie  cal- 
cherry. 
ouglieil 
le  calci- 
itructod 
on  into 
1(1  ti'oni 

i<r  ca^^es, 
isos  \viti^ 
The  ex- 
dor,  and 


lie 


axioms 
ohter 
niatory 
Morton, 
ouhted 
lube,  re- 
Froni 
way  by 
Uu'  air- 
ich  Mas 
eases   in 
)eriod 
,  so  that 
ranee  of 
)arentlY 


)U|)S. 


In 


lilt   over- 
Tlie 
•ctovation 

0  bacilli- 

«lr(>n,Lily 

ay  retain 


TUBERCTLOSIS. 


303 


pond  liealtli  for  many  years,  and  have  no  furllier  trouble.  Ol!  i!ie  380  cases 
of  ]iaMiio|»tysi.s  noted  by  Ware  in  private  f)raetiee,  (i'v*  recovered,  and  pul- 
monary diricase  did  not  sul)setiuently  develop. 

In  a  second  j^roup  individuals  in  api)arently  perfect  health  are  sud- 
denly attacked,  perhaps  after  a  sli«,dit  exertion  or  during  some  athletic 
exercises.  '^^Flie  physical  examination  is  also  negative,  hut  tubercle  bacilli 
arc  found  sometimes  in  the  hloody  s[)Uta,  more  fre(piently  a  few  days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health  for 
a  nionth  or  two,  but  the  symptoms  have  not  been  urgent  and  perha|)S  not 
noticed  by  the  patients.  The  physical  examination  shows  the  ])resence  of 
well-marked  tuherculous  disease,  and  there  arc  both  tubercle  bacilli  and 
elastic  tissue  in  the  s[Uita. 

A  very  interesting  systematic  study  of  the  su1)ject  of  Inemoptysis,  ])ar- 
ticularly  in  its  relation  to  the  (piestion  of  tuberculosis,  has  been  coinplet('(l 
in  the  I'russian  army  by  Franz  Strieker.  During  the  five  years  1890-'1)5 
thei'e  were  !)00  cases  admitted  to  the  lios|)itals,  which  is  a  i)crcentage  of 
CO-JT)  of  the  strength  (1,7:^8,505).  Uf  the  cases,  in  -180  the  hannorrhage 
came  on  without  recognizable  cause.  Of  these  41 T  cases,  8G  per  cent  were 
certainly  or  ])robably  tuberculous.  In  only  '^'.M,  however,  was  the  cvidt'iiee 
conclusive. 

In  a  second  group  of  213  cases  the  haemorrhage  came  on  during  tlu; 
military  exercise,  and  of  these  75  patients  were  shown  to  be  tuberculou.sr. 

In  118  cases  the  Inemorrhage  followed  certain  s])ecial  exercises,  as  in' 
the  gymmisinm  or  in  riding  or  in  consequence  of  swimming.  In  21  cases 
it  developed  during  the  exercise  of  the  voice  in  singing  or  in  giving  com- 
mand or  in  the  use  of  wind  instruments.  A  very  interesting  group  is  re- 
ported of  2-1  cases  in  which  the  haemorrhage  followed  trauma,  either  a  fall 
or  a  blow  upon  the  thorax.  In  7  of  these  tuberculosis  was  positively  pres- 
ent, and  in  6  other  cases  there  was  a  strong  probability  of  its  existence. 

Among  the  conclusions  which  Strieker  draws  the  following  are  the 
most  important:  namely,  that  soldiers  attacked  with  haemoptysis  without 
special  cause  are  in  at  least  80.8  per  cent  tuberculous.  In  the  cases  in 
which  the  hccmoptysis  follows  the  special  exercises,  etc.,  of  military  serv- 
ice, at  least  74.-1  per  cent  are  tuberculous.  In  the  cases  which  come  on 
daring  swimming  or  as  a  consequence  of  direct  injury  to  the  thorax  about 
one  half  are  not  associated  with  tuberculosis. 

IT;enio])tysis  occurs  in  from  GO  to  80  per  cent  of  all  cases  of  ])ulmonary 
tuberculosis.     It  is  more  frecjuent  in  males  than  in  females. 

In  a  majority  of  all  cases  the  bleeding  recurs.  Sometimes  it  is  a  special 
feature  throughout  the  disease,  so  that  a  hjvmorrhagic  or  haemoptysical 
form  has  been  recognized.  The  amount  of  blood  brought  u])  varies  from 
a  cou])le  of  drachms  to  a  pint  or  more.  In  09  per  cent  of  4,125  cases  of 
liaMnoptysis  at  the  Urompton  Hospital  the  amount  brought  up  was  under 
half  an  ounce. 

A  distinction  may  be  drawn  between  the  haemoptysis  early  in  the  dis- 
ease and  that  which  occm-s  in  the  later  periods.  In  the  former  the  bleed- 
ing is  usually  slight,  is  apt  to  recur,  and  fatal  haemorrhage  is  very  rare.  In 
these  instances  the  bleeding  is  usually  from  small  areas  of  softening  or 


^1 
.■  .1-- 


304 


SPECIFIC  INFECTIOUS  DISEASES. 


m 


from  early  erosions  in  tlic  Ijroncliial  mucopa.  In  the  later  periods,  after 
cavities  have  formed,  the  bleeding  is,  as  a  rule,  more  ])r()iiise  and  is  more 
apt  to  be  fatal.  Single  large  haunorrhages,  proving  quickly  fatal,  are  very 
rare,  except  in  the  advanced  stages  of  the  disease.  In  these  cases  the  bleed- 
ing comes  either  from  an  erosion  of  a  good-sized  vessel  in  the  wall  of  a 
cavity  or  from  the  rupture  of  an  aneurism  of  tiie  ])ulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Without  any  warning  the 
l)atient  may  notice  a  warin  «alt  taste  and  the  mouth  tills  with  blood.  It 
may  come  up  with  a  slight  cough.  The  total  amount  may  not  be  more 
than  a  few  drachms,  and  for  a  day  or  two  the  ])atient  may  spit  ilp  small 
quantities.  When  a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount 
of  blood  brought  up  is  large,  and  in  the  course  of  a  short  time  a  pint  or 
two  may  be  expectorated.  Fatal  ha'morrhage  may  occur  into  a  very  large 
cavity  without  any  blood  being  coughed  u}).  The  character  of  the  blood  is, 
as  a  rule,  distinctive.  It  is  frothy,  mixed  with  mucus,  generally  bright  red 
in  color,  except  when  large  amounts  are  expectorated,  and  then  it  may  be 
dark.  The  sputa  may  remain  blood-tinged  for  some  days  or  there  are 
.  brownish-black  streaks  in  the  sputa,  or  "  friable  nodules  consisting  entirely 
of  blood-corpuscles  "  may  be  coughed  up.  Blood  moulds  of  the  smaller 
bronchi  are  sometimes  expectorated. 

The  microscopical  examination  of  the  sputum  in  tuberculous  cases 
is  most  important.  If  carefully  spread  out,  there  may  be  noted,  even  in  an 
api)arently  pure  ha?morrliagic  mass,  little  portions  of  mucus  from  which 
bacilli  or  elastic  tissue  may  be  obtained. 

Dyspnmi  is  not  a  common  accompaniment  of  ordinary  phthisis.  The 
greater  part  of  one  lung  may  be  diseased  and  local  trouble  exist  at  the 
other  apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  of 
very  high  fever  the  respirations  may  not  be  much  increased.  Rapid  ad- 
vance of  a  broncho-pneumonia,  or  the  development  of  miliary  tubercles 
throughout  the  lung,  causes  great  increase  in  the  number  of  respirations. 
A  degree  of  dyspno'a  leading  to  cyanosis  is  almost  unknown,  apart  from 
extensive  invasion  of  the  sound  portions  by  miliary  tubercles. 

In  long  standing  cases,  with  contracted  apices  or  great  thickening  of 
the  pleura,  the  right  heart  is  enlarged,  and  the  dys])neoa  may  be  cardiac. 

3.  General  Symptoms. — Fever. — To  get  a  correct  idea  of  the  tempera- 
ture range  in  ])ulmonary  tuberculosis  it  is  necessary,  as  Einger  pointed 
out,  to  make  tolerably  frecpient  observations.  The  usual  8  a.  m.  and  8  p.  M, 
record  is,  in  a  majority  of  the  cases,  very  deceptive,  giving  neither  the 
minimum  nor  maximum.  The  former  usually  occurs  between  2  and  6  A.  M. 
and  the  latter  between  2  and  6  p.  M. 

A  recognition  of  various  forms  of  fever,  viz.,  of  tuberculization,  of 
ulceration,  and  of  absorption,  emphasizes  the  anatomical  stages  of  growth, 
softening  and  cavity  formation;  but  practically  such  a  division  is  of  little 
use,  as  in  a  majority  of  cases  these  processes  are  going  on  together. 

Fever  is  the  most  important  initial  symptom  and  throughout  the  entire 
course  the  thermometer  is  the  most  trustworthy  guide  as  to  the  progress 
of  the  affection.  With  pyrexia  a  patient  loses  in  weight  and  strength, 
and  the  local  disease  usually  progresses.    The  periods  of  apyiv^xia  are  those 


TUBERCULOSIS. 


305 


It 


•diac. 

['mpera- 

Dointed 

8  P.  M. 

nor  the 

G  A.  M. 

[ion,  of 
Igrowth, 
)f  little 

entire 

[)rogress 
[rcnffth, 
fe  those 


of  gain  in  wci<,'ht  niul  strcnj^tli  and  of  limitation  of  tlio  local  lesion.  It  hy 
no  means  necL'ssariiy  follows  tiiat  a  ])ati(.'nt  with  tuliiirculosis  lias  pyrexia. 
There  may  ho  ({uite  extciisivo  disease  without  coexisting  fever.  At  one  time, 
I  have  had  18  instances  of  chronic  phthisis  under  ohservation,  of  whom 
10  were  practically  free  from  fever.  But  in  the  early  stage,  when  tuhercles 
are  developing  and  caseous  areas  are  in  |)r()cess  of  formation  and  when 
softening  is  in  jjrogress,  fever  is  a  constant  symptom.  It  was  i)resent  in 
100  consecutive  cases  in  my  dispensary  service. 

Two  types  of  fever  are  seen — the  remittent  and  the  intermittent.    These 
may  occur  indifferently  in  the  early  or  in  the  late  stages  of  the  disease 


.' — 

Jan. « 


-v^ 


it 


"N/^ 


^ 


Temp 
101) 


d\  I: 


rn.';  0.': «;  ."•" 


ail'     ;)<'rf:a:  "J:^:"    ^  ^  ai    x    ^  '  I  :  ^  '  :j '  ij :  a  >  :  ^  '  ri  ^  a  ^  ai :  a  : 
■^■.•«««-«.-:a^■■■>;-:•Sv^T••^^■^T<^-4:•2■.•«ri■■":■<C.-«TSviv;(v;<-;■^••^^V 

CO  -  a  'MO,  v:A-«i;s:H:M;«;«;(tt;323|«.'^;„:»;S;S'M'«:»'«: 


Chart  XII.    Three  days.     Chronic  tuberculosis. 

^or  may  alternate  with  each  other,  a  variahility  which  depends  upon  the 
fact  that  phthisis  is  a  progressive  disease  and  that  all  stages  of  lesions  may 
he  found  in  a  single  lung.  Special  stress  should  be  laid  upon  the  fact, 
particularly  in  malarial  regions,  that  tuberculosis  may  set  in  with  a  fever 
typically  intermittent  in  character — a  daily  .'..ill,  with  subsequent  fever 
and  sweat.  In  ^Montreal,  where  malaria  is  practically  unknown,  this  was 
always  regarded  as  a  suggestive  symptom;  but  in  Philadelphia  and  Balti- 


306 


SPECIFIC   INFECTIOUS  DISEASES. 


/ 


more,  where  a^juo  ])revails,  it  is  no  exafrgcration  to  say  that  yearly  scores 
of  eases  o!  early  tuberculosis  are  treated  I'or  ague.  These  are  often  cases 
that  i)ursiie  a  rapid  course.  'J'lie  fever  of  onset — tuberculization — nuiy  be 
almost  continuous,  with  slij^dit  daily  exacerbations;  atul  at  any  time  during 
the  course  of  chronic  phthisis,  if  there  is  rapid  extension,  tlie  remissions 
become  less  marked. 

A  remittent  fever,  in  which  the  temperature  is  constantly  above  normal 
but  drops  two  or  three  degrees  toward  morning,  is  not  uiu'ommon  in  the 
middle  and  later  stages  and  is  us^ually  associated  with  s(jl'tening  or  exten- 
sion of  the  disease.  Here,  too,  a  sim[)le  morning  and  evening  register  nuiy 
give  an  entirely  erroneous  idea  as  to  the  range  of  the  fever.  ^Vith  break- 
ing down  of  the  lung-tissue  ami  formation  of  cavities,  associated  as  these 
processes  always  are  witli  suppuration  and  with  more  or  less  systemic  con- 
tamination, the  fever  assumes  a  characteristically  intermittent  or  hectic 
type.  For  a  large  part  of  the  day  the  patient  is  not  only  afebrile,  but  the 
temperature  is  subnonnal.  In  the  annexed  two-honrly  chart,  from  a  case 
of  chronic  tuberculosis  of  the  lungs,  it  will  be  seen  that  from  lU  p.  M.  to 
8  or  12  A.  M.,  the  tem])erature  contiiniously  fell  and  went  as  low  as  95°. 
A  slow  rise  then  took  })lace  through  the  late  morning  and  early  afternoon 
hours  and  reached  its  maximum  between  G  and  10  r.  M.  As  shown  in  the 
chart,  there  were  in  the  thioe  days  about  forty-three  hours  of  pyrexia  and 
twenty-nine  hours  of  apyr(  Aa.  The  rapid  fall  of  the  temperature  in  the 
early  morning  hours  is  usually  associated  with  sweating.  This  hectic,  as 
it  is  called,  which  is  a  typical  fever  qf  septic  infection,  is  met  with  when 
the  process  of  cavity  formation  and  softening  is  advanced  and  extending. 

A  continuous  fever  with  remissions  of  not  more  than  a  degree,  develop- 
ing in  the  course  of  pulmonary  tuberculosis,  is  suggestive  of  acute  })neu- 
monia.  When  a  two-hourly  chart  is  made,  the  remissions  even  in  acute 
tuberciilous  pneumonia  are  usually  well  marked.  A  continued  fever,  such 
as  is  seen  in  the  first  week  of  tyi)bf)id,  or  in  some  cases  of  inflammation  of 
the  lung,  is  rare  in  tidjerculosis. 

Sweating. — Drenching  perspirations  are  common  in  phthisis  and  con- 
stitute one  of  the  most  distressing  features  of  the  disease.  They  occur  usu- 
ally with  the  drop  in  the  fever  in  the  early  morning  hours,  or  at  any  time 
in  the  day  when  the  i)atient  sleeps.  They  may  come  on  early  in  the  disease, 
but  are  more  persistent  and  frequent  after  cavities  have  formed.  Some 
patients  escape  altogether. 

The  indse  is  increased  in  frequency,  especially  when  the  fever  is  high. 
It  is  often  remarkably  full,  though  soft  and  compressible.  Pulsation  may 
sometimes  be  seen  in  the  capillaries  and  in  the  veins  on  the  back  of  the 
hand. 

Emaciation  is  a  pronounced  feature,  from  which  the  two  common  names 
of  the  disease  have  been  derived.  The  loss  of  weight  is  gradual  hut,  if  the 
disease  is  extending,  progressive.  The  scales  give  one  of  the  best  indica- 
tions of  the  progress  of  the  case. 

3.  Physical  Signs.— (r/)  Inspection. — The  shape  of  the  chest  is  often 
suggestive,  though  it  is  to  be  remembered  that  pulmonary  tuberculosis  may 
be  met  with  in  chests  of  any  build.     Practically,  however,  in  a  consider- 


TUBERCULOSIS. 


3(»; 


scores 
11  cases 
nay  bo 
during 
lissions 

normal 

in  the 

cxtcn- 
;cr  may 

brcalv- 
»s  these 
lie  con- 
•  hectic 
but  the 
I  a  case 
p.  M.  to 

as  Do  . 
'tcrnoon 
1  in  tlie 
ixia  and 
B  in  the 
cctic,  as 
th  wlien 
>nding. 
dcvek)p- 
pneu- 
acute 
er,  such 
iou  of 

nd  con- 
cur 11  su- 
ny  time 
disease, 
Some 

is  high, 
ion  may 
of  the 

n  names 
t,  if  the 
indica- 

is  often 
)sis  may 
onsidcr- 


a1)le  proportion  of  cases  the  thorax  is  long  and  narrow,  witli  very  wide 
intercostal  s|iaces,  the  ribs  nujre  vertieal  in  direction  and  the  costal  angle 
very  narrow.  The  scapuhe  are  "winged,"  a  point  noted  liy  JLippocrutes. 
Anotlier  type  of  chest  which  is  very  common  is  that  which  is  llattened  in 
the  aidero-posterioi"  diameter.  The  costal  cartilages  may  be  prominent 
and  the  sternum  depressed.  Occasionally  the  lower  sternum  forms  a  deep 
concavity,  the  so-called  funnel  breast  {Trivhler-Brasl).  lns[)ection  gives 
valuable  information  in  all  stages  of  the  disease.  Special  examination 
should  be  made  of  the  clavicular  regions  to  see  if  one  clavicle  stands  out 
more  distiiu'tly  than  the  other,  or  if  the  spaces  above  or  below  it  are  more 
nuirked.  Defective  ex])ansion  at  one  a|)ex  is  an  early  and  important  sign. 
The  condition  of  ex|)ansion  of  the  lower  zone  of  the  thorax  may  be  well 
'  timated  by  inspection.  The  condition  of  the  priecordia  should  also  be 
noted,  as  a  wide  area  of  impulse,  particularly  in  the  second,  third,  ami 
fourth  interspaces,  often  results  from  disease  of  the  left  apex.  From  a  point 
behind  the  ])atient,  looldng  over  the  shoulders,  one  can  often  better  esti- 
mate the  relative  expansion  of  the  a[)ices. 

{h)  I'dl/ialion. — Deticiency  in  expansion  at  the  a])ices  or  bases  is  ])er- 
haps  best  gauged  by  placing  the  hands  in  the  subclavicular  spaces  ami  then 
in  the  lateral  regions  of  the  chest  and  asking  the  patient  to  draw  slowly  a 
full  breath.  Standing  behind  the  patient  and  placing  the  thumbs  in  the 
supraclavicular  and  the  fingers  in  the  infraclavicular  spaces  one  can  judge 
accurately  as  to  the  relative  mobility  of  the  two  sides.  Disease  at  an  apex, 
though  early  and  before  dulness  is  at  all  marked,  may  be  indicated  by 
deficient  expansion.  On  asking  the  patient  to  count,  the  tactile  fremitus 
is  increased  wherever  there  is  local  growth  of  tubercle  or  extensive  casea- 
tion. In  comparing  the  apices  it  is  important  to  bear  in  mind  that  normally 
the  frenntus  is  stronger  over  the  right  than  the  left.  So  too  at  the  base, 
when  there  is  consolidation  of  the  lung,  the  fremitus  is  increased;  whereas, 
if  there  is  pleural  effusion,  it  is  diminished  or  absent.  In  the  later  stages, 
when  cavities  form,  the  tactile  frenntus  is  usually  much  exaggerated  over 
them.  When  the  pleura  is  greatly  thickened  the  fremitus  may  be  somewhat 
diminished. 

(c)  Percussion. — Tubercles,  inilammatory  products,  fibroid  changes, 
and  cavities  produce  important  changes  in  the  pulmonary  resonance. 
There  may  be  localized  disease,  even  of  some  extent,  without  inducing 
much  alteration;  as  when  the  tubercles  are  scattered  and  have  air-contain- 
ing tissue  between  them.  One  of  the  earliest  and  most  valuable  signs  is 
defective  resonance  u])()n  and  above  a  clavicle.  In  a  considerable  propor- 
tion of  all  cases  of  phthisis  the  dulness  is  first  noted  in  these  regions.  The 
comparison  between  the  two  sides  should  be  made  also  when  the  breath 
is  held  after  a  full  inspiration,  as  the  defective  resonance  may  then  be 
more  clearly  marked.  In  the  early  stages  the  percussion  note  is  usually 
higher  in  pitch,  and  may  require  an  experienced  Ciir  to  detect  the  dilfcr- 
ence.  In  recent  consolidation  from  caseous  pneumonia  t!ie  ]iercussion  note 
often  has  a  tubular  or  tympanitic  quality.  A  wooden  dulness  is  rarely 
heard  except  in  old  cases  with  extensive  fibroid  change  at  the  apex  or  base. 
Over  large,  thin-walled  cavities  at  the  apex  the  so-called  cracked-pot  sound 


£^^ 


308 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


may  be  ol^taincd.  In  tliin  siilijucts  the  percussion  sliould  be  carefully  prac- 
tised in  the  siipras])inous  fossie  and  tiie  interscajjular  space,  as  they  cor- 
respond to  very  important  areas  early  involved  in  the  disease.  In  cases 
with  numerous  isolated  cavities  at  the  a\)QX,  without  much  fi])roid  tissue 
or  thickening'  of  the  pleura,  the  percussion  note  may  show  little  change, 
and  the  contrast  between  the  signs  obtained  on  auscultation  and  percussion 
is  most  nuirked.  In  the  direct  percussion  of  the  chest,  particularly  in  thin 
patients  over  the  pectorals,  one  frequently  sees  the  phenomenon  known 
as  miioidcma,  a  local  contraction  of  the  muscle  causing  bulging,  which  per- 
sists for  a  variable  period  and  gradually  subsides.  It  has  no  special  signifi- 
cance. 

{d)  AiiscuUalion. — Feeble  breath-sounds  are  among  the  most  charac- 
fferistic  early  signs,  since  not  as  much  air  enters  the  tubes  and  vesicles  of 
the  affected  area.  It  is  well  at  first  always  to  compare  carefully  the  cor- 
responding ])oints  on  the  two  sides  of  the  chest  without  asking  the  ])atient 
either  to  draw  a  deep  l)reath  or  to  cough.  With  early  apical  disease  the 
inspiration  on  (piiet  breathing  may  be  scarcely  audible.  Expiration  is 
usually  ])rolonged.  On  the  other  band,  there  are  cases  in  which  the  earliest 
;sign  is  a  harsh,  rude,  res[)iratory  murmur.  On  deep  breathing  it  is  fre- 
.qucntly  to  be  noted  that  insjiiration  is  jerking  or  wavy,  the  so-called  "  cog- 
•Avhcel "  rhythm;  which,  however,  is  by  no  means  confined  to  tuberculosis. 
With  extension  of  the  disease  the  ins])iratory  murmur  is  harsh,  and,  when 
•consolidation  occurs,  whiffing  and  bronchial.  With  these  changes  in  the 
character  of  the  murmur  there  are  rales,  due  to  the  accompanying  bron- 
-chitis.  They  may  be  heard  only  on  deep  inspiration  or  on  coughing,  and 
€arly  in  the  disease  are  often  crackling  in  character.  When  softening 
occurs  they  are  louder  and  have  a  bul)l)ling,  sometimes  a  characteristic 
clicking  quality.  These  "  moist  sounds,"  as  they  are  called,  when  asso- 
ciated with  change  in  the  percussion  resonance  are  extremely  suggestive. 
When  cavities  form,  the  nllcs  are  louder,  more  gurgling,  and  resonant  in 
■quality.  When  there  is  consolidation  of  any  extent  the  breath-sounds  are 
tubular,  and  in  the  large  excavations  loud  and  cavernous,  or  have  an  am- 
phoric quality.  In  the  unaffected  portions  of  the  lobe  and  in  the  opposite 
lung  the  breath-sounds  may  be  harsh  and  even  puerile.  The  vocal  reso- 
nance is  usually  increased  in  all  stages  of  the  process,  and  bronchophony 
and  pectoriloquy  arc  met  with  in  the  regions  of  consolidation  and  over 
-cavities.  Pleuritic  friction  may  be  present  at  any  stage  and,  as  mentioned 
l)eforo,  occurs  very  early.  There  are  cases  in  which  it  is  a  marked  feature 
throughout.  When  flu  lappet  of  lung  over  the  heart  is  involved  there 
may  be  a  plcuro-])cricardial  friction,  and  when  this  area  is  consolidated 
there  may  1)e  curious  clicking  rales  synchroiious  with  the  heart-beat,  due 
to  the  compression  by  the  heart  of,  and  the  expulsion  of  air  from,  this 
portion.  An  interesting  auscultatory  sign,  met  most  commonly  in  phthisis, 
is  the  so-called  cardio-resjiiratory  murmur,  a  whiffing  systolic  bruit  due 
to  the  propulsion  of  air  out  of  the  tubes  by  the  impulse  of  the  heart. 
It  is  best  heard  during  inspiration  and  in  the  antero-lateral  regions  of  the 
chest. 

A  systolic  murmur  is  frequently  heard  in  the  subclavian  artery  on  either 


are  j: 

and 

two 

cjiigl 

M-all 

to  th 

regur 

alniog 


iii.. 


TUBERCULOSIS. 


3U9 


cog- 


the 


ftening 

;teristic 

n  asso- 

pcstive. 

nant  in 

nds  arc 
an  am- 

)pposite 

al  rcso- 
opliony 
id  over 
ntioncd 
feature 
d  there 
nlidated 
at,  dne 
m,  this 
bhthisis, 
■uit  due 
heart. 
Is  of  the 

In  either 


side,  the  puliation  of  wliicli  may  he  very  visihle.     Tlie  nuiriinir  is  in  all 
probability  due  to  pressure  on  tlie  vessels  by  tlie  Ihii'kenud  pleura. 

The  signs  of  cavity  may  he  here  briefly  enumerated. 

(a)  When  tlure  is  m)t  much  thickeniug  of  the  j)leura  or  condensation 
■of  the  surrounding  lung-tissue,  the  })ereussion  sound  may  he  full  and  clear, 
resembling  tlie  noniud  note.  .More  commonly  there  is  defective  resonance 
■or  a  tymj)anitic  quality  which  may  at  times  be  purely  amphoric.  The  pitch 
of  the  percussion  note  changes  over  a  cavity  when  the  nu)uth  is  opened  or 
closed  (Wintrich's  sign),  or  it  may  be  brought  out  more  clearly  on  change 
of  position.  The  cracked-jjot  sound  is  only  obtaimible  over  tolerably  largo 
cavities  with  thin  walls.  Jt  is  best  elicited  by  a  lirm,  (juick  stroke,  the 
patient  at  the  time  having  the  mouth  open.  In  those  rare  instances  of 
almost  total  excavation  of  one  lung  the  percussion  note  may  he  ami)horic 
in  quality,  (h)  On  auscultation  the  so-called  cavernous  sounds  are  heard: 
(1)  Various  grades  of  modified  breathing — blowing  or  tubular,  cavernous 
or  amphoric.  There  may  he  a  curiously  sharp  hissing  sound,  as  if  the  air 
was  passing  from  a  narrow  ojiening  into  a  wide  space.  In  very  large  cavi- 
ties both  inspiration  and  ex]uration  may  be  typically  amphoric,  {'-i)  There 
are  coarse  bubbling  nllcs  which  have  a  resonant  (piality,  and  on  coughing 
may  have  a  metallic  or  ringing  character.  On  coughing  they  are  often  loud 
and  gurgling.  In  very  large  thin-walled  cavities,  and  more  rarely  in 
medium-sized  cavities,  surrounded  by  recent  consolidation,  the  rales  may 
have  a  distinctly  amphoric  echo,  simulating  those  of  pneumothorax.  There 
are  dry  cavities  in  which  no  rales  are  heard.  (3)  The  vocal  resonance  is 
greatly  intensified  and  whispered  pectoriloquy  is  clearly  heard.  In  large 
apical  cavities  the  heart-sounds  are  well  heard,  and  occasionally  there  may 
be  an  intense  systolic  murmur,  probably  always  transmitted  to,  and  not 
produced  as  has  been  supposed,  in  the  cavity  itself.  In  large  excavations 
of  the  left  apex  the  heart  impulse  may  cause  gurgling  sounds  or  clicks 
synchronous  with  the  systole.  They  may  even  he  loud  enough  to  he  heard 
at  a  little  distance  from  the  chest  wall.  A  large  cavity  with  smooth  walls 
and  thin  fluid  contents  may  give  the  succussion  sound  Avhen  the  trunk  is 
abruptly  shaken  (Walshe),  and  even  the  coin  sound  may  be  obtained. 

rsendo-cavernoiis  signs  may  be  caused  by  an  area  of  consohdation  near 
a  large  bronchus.  The  condition  may  be  most  deceptive — the  high-pitched 
or  tympanitic  percussion  note,  the  tubular  or  cavernous  breathing,  and  tlie 
resonant  rales,  simulate  closely  those-  of  cavity. 

4.  Complications  of  Pulmonary  Tuberculosis. — (1)  In  the 
Respiratory  System. — The  larynx  is  rarely  spared  in  chronic  pulmonary 
tuberculosis.  The  first  symptom  may  be  huskiness  of  the  voice.  There 
are  pain,  particularly  in  swallowing,  and  a  cough  which  is  often  wheezing, 
and  in  the  later  stages  very  ineffectual.  Ajihonia  and  dysphagia  are  the 
two  most  distressing  symptoms  of  the  laryngeal  involvement.  When  the 
epiglottis  is  seriously  diseased  and  the  ulceration  extends  to  the  lateral 
M'all  of  the  pharynx,  the  pain  in  swallowing  may  be  very  intense,  or,  owing 
to  the  imperfect  closure  of  the  glottis,  there  may  be  coughing  spells  and 
regurgitation  of  food  through  the  nostrils.  Bronchitis  and  tracheitis  are 
almost  invariable  accompaniments  of  chronic  pulmonary  tuberculosis. 


IT 


310 


SrKCIFIC  INFECTIOUS   DISHASES. 


J'ncumonia  is  a  iioL  iiirnMnicnt  tfrmiiial  comitlicatioii  of  chronic 
]thtliisis.  It  may  run  u  ijorlcctly  normal  course,  wliilo  in  other  inHtances 
resolution  nmy  be  (lolayed,  and  utie  is  in  doul)!,  in  s[iit(;  ol'  tliu  abruptness 
(d'  the  onset,  as  to  the  presence  ol'  a  simple  or  a  tul)ercnlous  pneumonia. 

Eiiipliiisciiin  of  the  uninvolved  portions  of  the  lunj,'  is  a  common  fi'a- 
ture,  rarely  producing'  any  s[)ecial  symptoms.  There  are,  however,  cases 
(d'  (  lironic  tuberculosis  in  which  eni|)hyscma  donunates  the  picture,  and 
in  which  the  condition  develops  slowly  duriiij,'  a  jjeriod  of  many  years. 
((Jeiieral  subcutaneous  emphysema,  which  has  l)een  met  with  in  a  few 
rare  cases,  is  due  I'ither  to  perforation  of  the  trachea  or  to  the  rupture  of 
a  cavity  closely  adherent  to  the  chest  wall.) 

Gangrene  of  the  lung  is  an  occasional  event  in  chronic  ])ulnionary 
tuberculosis,  due  in  almost  all  instances  \o  sphacelus  in  the  walls  of  the 
cavity,  rarely  in  the  lunjf-tissue  .j^tself. 

CumpJicallons  in  the  Pleura. — \  dry  plenrisy  is  a  very  common  accom- 
paniment of  the  early  stages  of  tidjercnlosis.  It  is  always  a  conservative, 
nsefnl  process.  In  some  cases  it  is  very  extensive,  and  friction  murmurs 
may  be  heard  over  the  si(h's  and  back.  The  cases  with  dry  ])leurisy  and 
adhesions  are  of  course  much  less  liable  to  the  dangers  of  j)neumothorax. 
Plenrisy  wdth  effusion  more  commonly  precedes  than  develops  in  the  course 
of  pulmonary  tuberculosis.  Still,  it  is  common  enough  to  meet  with  cases 
in  which  a  sero-fil)rinous  effusion  develops  in  the  course  of  the  chronic 
disease.  There  are  cases  in  which  it  is  a  special  feature,  and  it  often,  I  think, 
favors  chronicity.  A  ])atient  may  during  a  period  of  four  or  five  years 
have  signs  of  local  disease  at  one  apex  with  recurring  effusion  in  the  same 
side.  Owing  to  adhesions  in  different  parts  of  the  pleura,  the  effusion  may 
be  enca])sulated.  Tla^morrhagie  effusions,  which  are  not  uncommon  in 
connection  with  tul)ercidous  ])leui'isy,  are  com[)aratively  rare  in  chronic 
phthisis,  t'hyliform  or  milky  exudates  are  sometimes  found.  Purulent 
effusions  are  not  frequent  a])art  from  pneunu)thorax.  An  empyema,  how- 
ever, may  develop  in  the  course  of  the  disease  or  as  a  sequence  of  a  sero- 
fibrinous exu(hite.  Pneumothorax  is  an  extremely  common  complication 
of  chronic  pulmonary  tuberculosis.  It  may  occur  early  in  the  disease,  but 
more  frequently  is  late.  It  may  prove  fatal  in  twenty-four  hours.  In 
other  -instances  a  i)yo-pneumothorax  develops  and  the  patient  lingers  for 
weeks  or  months.  In  a  third  group  of  cases  it  seems  to  have  a  beneficial 
effect  on  the  course  of  the  disease. 

(3)  Symptoms  referable  to  other  Organs. — {a)  Cnrdln-vascular. — The 
retraction  of  the  left  ui)per  lobe  ex^  js  a  large  area  of  the  heart.  In  thin- 
chested  subjects  there  may  be  pulsation  in  the  second,  third,  and  fourth 
interspaces  close  to  the  sternum.  Sometimes  w-ith  much  retraction  of  the 
left  up])er  lobe  the  heart  is  drawn  up.  A  systolic  murmur  over  the  pul- 
monary area  is  common  in  all  stages  of  phthisis.  Apical  murmurs  are  also 
not  infrocpumt  and  may  be  extremely  rough  and  harsh  without  necessarily 
indicating  that  endocarditis  is  present.  The  association  of  heart-disease 
with  phthisis  is  not,  how-evcr,  very  uncommon.  As  already  mentioned, 
there  were  12  instances  of  endocarditis  in  Slfi  autopsies.  The  arterial 
tension  is  usually  low  in  phthisis  and  the  capillary  resistance  lessened  so 


TUBERCULOSIS. 


311 


,..__The 
lln  thin- 
fourth 
II  of  the 

the  pnl- 
are  ali^o 
Icepparily 
It-disease 
tn  tinned, 
arterial 
Isened  so 


that  ihe  \n\ho  is  often  full  and  soft  even  in  tlic  later  siapes  of  llie  disease. 
'I'lie  (ii|iiliary  pulse  is  not  iiirre(iueiitly  n)(>t  with,  and  pidsation  oi"  the 
veins  in  the  hack  of  the  iumd  is  oceasionallv  to  he  seen. 

(b)  Bhiixl  (llaniliihtr  Si/slcin. — The  early  anaiuia  ha.s  already  heen  noted. 
It  is  often  more  ajiparent  than  real,  a  eliloro-ana'inia,  and  the  hlood-count 
rarely  sinks  helow  two  millions  |>er  eid)ie  millimetre. 

'JMie  hlood-plates  are,  as  a  rule,  enormously  inei'eased  ami  are  seen  in  the 
withdrawn  hlood  as  the  so-ealled  Sehnlt/.e's  <:ranule  masses.  Without  any 
signifieanee,  they  are  of  interest  ehii'lly  from  the  fact  that  every  few  years 
some  tyro  annouiiees  their  discovery  as  a  new  diagnostic  si^n  of  ])hthisis. 
The  leucocytes  are  <,n'eally  increased,  ])articularly  in  the  later  st.afi'es. 

(r)  (jfislro-iiilrsliiKil  Si/slcni. — The  tongue  is  usually  furred,  hut  may 
he  clean  and  red.  Small  a[)hthous  ulcers  are  sometimes  distressijij;.  A 
red  line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention  was 
])aid  as  a  special  feature  of  ])hthisis,  occurs  in  other  cachectic  states.  lv\- 
tensive  tuherculous  disease  of  the  iiharyr.v,  associated  with  a  similar  aU'ec- 
tion  of  the  larynx,  may  interfere  seriously  with  deglutition  and  j)rove  a 
very  distressing  and  intractahle  symptom. 

Of  late,  s])ecial  attention  has  hi'en  ]>aid  to  the  gastric  symptoms  of  this 
alfection.  Tuberculosis  of  the  stomach  is  I'are.  I'Iceration  may  occur  as  an 
aceidenial  com[)lieation  and  multiple  catarrhal  ulcers  are  not  uncommon. 
Interstitial  and  parenchymatous  changes  in  the  mucosa  are  common  (pos- 
sihly  associated  with  the  venous  stasis)  and  lead  to  atrophy,  hut  these  can- 
not always  he  connoted  with  the  symptoms,  and  they  nuiy  he  found  -when 
not  expected.  On  the  otlu'r  hand,  when  the  gastric  symptoms  'uive  heen 
most  persistent  the  mucosa  may  show  very  little  change.  It  is  impossible 
always  to  refer  the  anorexia,  nausea,  and  vomiting  of  consum])tion  to  local 
conditions.  The  hectic  fever  and  the  neurotic  influences,  upon  which 
Inunernumn  lays  much  stress,  must  he  taken  into  account,  as  they  play 
an  im])ortant  role  The  organ  is  often  dilated,  and  to  muscular  insuffi- 
ciency alone  may  he  due  some  of  the  cases  of  dyspe])sia.  'J'he  condition  of 
the  gastric  secretion  is  not  constant,  and  the  rejxjrts  are  discordant.  In 
the  early  stages  there  nuiy  he  su])eracidity;  later,  a  dt'ficiency  of  acid. 

Anorexia  is  often  a  marked  symptom  at  the  onset;  there  nuiy  he  ])ositive 
loathing  of  food,  aiul  even  small  (luantities  cause  nausea.  Sometinu'S,  with- 
out any  nausea  or  distress  after  eating,  the  feeding  of  the  ])atient  is  a  daily 
hattle.  When  ]>ractical)le.  Dehove's  forced  alinu'utation  is  f)f  great  henelit 
in  such  eases.  Xaus"a  and  vomiting,  though  occasiomdiy  troublesome  at 
an  early  period,  are  more  mai'ked  in  the  later  stages.  The  latter  may  be 
caused  by  the  severe  attacks  of  coughing.  S.  IF.  Habershon  I'cfers  to  four 
different  causes  the  vomiting  in  ])hthisis:  (1)  central,  as  from  tuberculous 
nu'ninu'itis;  ('2)  ])ressure  on  the  vagi  by  caseous  glands;  {'.])  stimulation 
from  the  peripheral  hranches  of  the  vagus,  either  jiulmonary,  phaiTugeal, 
or  gastric;  and  (I)  nuv-hanical  causes. 

Of  the  inlesliiinl  symptoms  diarrluea  is  the  most  serious.  It  may  come 
on  early,  hut  is  more  usually  a  symptom  of  the  later  stages,  and  is  associ- 
ated with  ulceration.  ])articularly  of  the  large  bowel.  Extensive  ulceration 
of  the  ileum  may  exist  without  any  diarrhuea.     The  associated  catarrhal 


312 


SPK(MFI(;   IN  »-'!<:( 'TIOUS   DISK  ASKS. 


.  \ 
/ 


(•(iiidition  may  lU'coiiiit  in  |>iir(  for  it,  mid  in  some  iiislniiccs  llic  niiiyloid  do- 
gciicratidii  of  tlic  iiiucous  iii('iid)iiiiH'. 

{(I)  ^I'crvoiis  i^i/sh'iH. — (1)  Focal  lesions  duo  to  the  dcvcloitnu'iit  of 
coarse  tuherclcs  and  areas  of  tid)erculons  nieninjio-enceplialilis.  Aphasia, 
for  instance,  may  result  fi'om  the  ^M'owth  of  nii'nin;feal  tulx-rcles  in  tiie 
lissure  of  Sylvius,  or  even  hi'nii|ile<,fiu  may  devi'io|).  'i'iie  solitary  tuiiercU'S 
arc  more  common  in  the  chronic  jihthisis  of  children.  (2)  Basilar  menin- 
gitis is  an  oceasionnl  complication.  It  may  he  conlined  to  the  hrain,  though 
more  commonly  it  is  a  (;{)  cerehro-siiinal  meningitis,  which  may  come  on 
in  ])ers()ns  without  well-developed  local  signs  in  the  chest.  Twice  have  1 
known  strong,  rohnst  men  brought  into  hospital  with  signs  of  cerebro- 
spinal meningitis,  in  whom  the  existence  of  |)uImonary  disease  was  not 
discovered  until  the  post-mortem.  (I)  P('t'i])hvml  uctiritis,  which  is  not 
common,  may  cause  an  extensor  paralysis  of  the  arm  or  leg,  nu)ro  com- 
monly the  latter,  with  foot-drop.  It  is  usually  a  late  manifestation.  (.")) 
]\Iental  symptoms.  It  was  noted,  even  by  the  older  writers,  that  consump- 
tives had  a  peculiarly  hopeful  temperament,  and  the  spes  phlliisica  forms 
a  curious  characteristic  of  the  disease.  Patients  with  extensive  cavities, 
high  fever,  and  too  weak  to  move  will  often  make  plans  for  the  future  and 
confidently  ex])eet  to  recover. 

A])art  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic 
])hthisis  a  form  of  insanity  not  unlike  that  which  develoi)s  in  the  con- 
valescence from  acute  alTections.  '^Phe  whole  (piestion  of  the  mutual  rela- 
tions of  insanity  and  j)hthisis  is  dealt  with  at  length  in  jMickle's  (iulstonian 
lectures. 

(e)  A  remarkable  hyprrirnpliy  nf  fJir  mammary  yland  may  occur  in  pul- 
monary tuberculosis,*  most  commonly  in  males.  It  may  l)o  only  on  the 
atl'ected  side.  Two  cases  came  uiuler  my  notice  at  the  University  Hospital, 
Philadelphia,  both  in  young  males.  It  is  a  chronic  interstitial,  non-tuber- 
culous mammitis  (Allot). 

(/')  (lenilo-iirinary  System. — The  urine  presents  no  special  ])eculiari- 
ties  in  amc,  nt  or  constituents.  Fever,  however,  has  a  marked  influence 
upon  it.  Albumin  is  met  with  frefpiently  and  may  be  associated  with  the 
fever,  or  is  the  result  of  definite  changes  in  the  kidneys.  In  the  latter  case 
it  is  more  abundant  and  more  curd-like.  Amyloid  disease  of  the  kidneys 
is  not  uncomuKm.  Its  presence  is  shown  by  albumin  and  tube-casts, 
and  sometimes  l)y  a  great  increase  in  the  amount  of  urine.  In  other 
instances  there  is  dropsy,  and  the  patients  have  all  the  characteristic  fea- 
tures of  chronic  Bright's  disease. 

Pus  in  flip  wine  may  be  due  to  disease  of  the  bladder  or  of  the  pelves 
of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  involved.  In 
pulmonary  ])hthisis,  however,  extensive  tuberculous  disease  is  rarely  found' 
in  the  urinary  organs.  Bacilli  may  occasionally  be  detected  in  the  pus. 
ITa^maturia  is  not  a  very  common  symptom.  It  may  occur  occasionally 
as  a  result  of  congestion  of  the  kidneys,  and  pass  off  leaving  the  urine 
albuminous,      in   other   instances   it    results   from    disease    of   the    pelvis 


*  Allot,  Paris  Thesis,  1887. 


TUBERCULOSIS. 


81  a 


id  ilc- 

Mit  of 

)liiisiii, 
ill  ilu> 

inciiiu- 
Ihongh 
tiiii'  on 
liiivo  1 
ort'bi'o- 
ai8  not 
is  unt 
•c  com- 
)n.     (.•)) 
insump- 
a  forms 
ciivitii's, 
uvc  and 

chronic 
;ho  coii- 
ual  rola- 
ilstonian 

in  pnl- 

on  Il>i3 

ospital, 

iii-tubor- 


{'(• 


iiliari- 
illiR'iioe 
\\\\\\  tiie 
tor  case 
kidneys 
bc-casts, 
n  otlior 
stic  fea- 

iC  pclvcft 
ved.  In 
^y  fonnd' 
(the  pns. 
isionally 
he  urine 
lo    pelvis- 


or  of  tlic  blnddor,  and  is  nnsocinted  cither  with  early  tuhcrrnlosis  of  the 
iiiticoiis  iiiciiilii'imcs  <tr  more  coiiimonly  witii  idccratioii.  In  any  medical 
cliiiic  llic  routine  iiisi)cction  of  the  testes  I'ur  tubercle  will  save  two  or  three- 
mistakes  a  year. 

((/)  Culntu'dus  Sijslem. — The  skin  is  often  dry  and  harsh.  Local  tr.ber- 
clcs  occasioinilly  develop  on  the  hands,  'i'hcre  may  be  pij^Mncntary  sliiininjr, 
the  rlihidsnid  /ililliisir<iriiiii,  whii'h  is  more  common  when  the  |)eritona'iim 
is  involved.  I'pon  the  chest  and  back  the  brown  stains  of  the  iiili/rinsis 
irrsirolor  are  very  freipient.  The  liair  of  the  head  and  beard  may  lieeoine- 
dry  and  lanky.  The  terminal  phalan^'cs,  ii;  chronic  cases,  become  clMl)l>ed 
and  the  nails  inciirvated — tlie  l!i|tpocratic  (in<,fers.  A  remarkable  nnd  iin- 
nsnal  complication  is  <,'enerid  ein|)liys"i!ia,  which  may  result  from  ulcera- 
tion of  an  adherent  lun<;  or  perforation  of  tiie  larynx. 

Diagnosis. — When  well  advanced  there  is'rarely  any  doubt  ns  to  the 
existence  of  tuberculous  phthisis,  for  the  s|)uium  ^ivcs  positive  informa- 
tion, and  the  physical  sij^nis  of  local  disease  are  well  marke(|.  The  bacilli 
f^ive  an  infallible  indication  of  the  existence  of  tuberculosis  aiul  iiuiy  be 
found  in  the  sputum  before  the  physical  sij^ns  nre  at  all  delinite.  On  the 
other  hand,  it  must  be  renu'nd)ered  that  thei'e  are  cases  in  which,  even 
with  tolerably  well-deliiu'd  physical  si<,nis,  the  sputum  is  extremely  scanty 
and  many  examinations  may  be  re(iuired  to  detect  tuberch;  bacilli.  So 
essential  is  the  examination  of  the  sputum  in  the  early  dia<,niosis  of  phthisis 
that  I  would  earnestly  insist  upon  the  more  frecjuent  employment  of  this 
method.  '^Fhcre  is  no  excuse  now  lor  its  omission,  since,  if  the  practitioner 
has  not  command  of  the  necessary  technicpu',  there  are  laboratories  in 
iiuiny  parts  of  the  country  at  which  the  examination  can  l)e  made.  Earli/ 
(k'lecliun  is  of  vital  imparlance,  as  siiccessfnl  (rcatment  depends  upon  the 
nicasnrcs  lalcn  before  the  hnif/s  are  e.rlenslreh/  involved. 

The  presence  of  elastic  tibrcs  in  the  sputum  is  an  indication  of  destruc- 
tion of  the  lung-tissiu'.  In  a  large  proportion  of  cases  it  is  iiulicative,  too, 
of  tuberculous  disease.  It  also  may  be  found  early,  before  the  physical 
signs  are  well  marked.  Its  defection  is  easy  by  the  above-mentioned  method,, 
not  requiring  higli  ])owers  of  the  microscope.  In  cases  of  early  luemoptysis, 
before  there  is  marked  constitutional  disturbance,  or  even  local  signs,  it  is 
very  important  to  make  a  thorough  examination  of  the  s])utum,  from 
which  mucoid  and  purulent  portions  may  be  ])icked  out  for  examination. 
With  localized  and  ])ersistent  signs  in  one  lung,  cough,  fever,  and  loss  of 
flesh,  the  diagnosis  is  rarely  dubious.  It  is  remarkable,  however,  to  what 
an  extent  the  local  process  may  sometimes  proceed  without  disturbance 
of  health  sulFicient  to  excite  the  alarm  of  the  ])hysician  or  friends.  There 
are  puzzling  cases  with  localized  ])hysical  signs  at  one  apex,  chiefly  moist 
rales,  rarely  any  percussion  changes,  pcrha])s  slight  fever,  and  a  glairy 
ex])ectoration  cont  lining  numerous  alveolar  cells.  I  have  seen  several 
cases  of  this  kind  which  have  been  for  a  time  very  obscure,  and  in  which 
re])eated  examinations  failed  to  detect  either  bacilli  or  elastic  tissue.  They 
poem  to  he  instances  of  local  catarrhal  trouble  in  the  smaller  tubes,  some- 
of  which  clear  in  a  few  weeks. 


314 


SriHU'IC   INKECTIOUS  DNKASKS. 


/ 


:j.  Fibroid  Phthisis. 

In  llicir  in()ii(t;j:''ii|ili  on  l-'lhroid  Diseases  of  Iho  liiin;,'  (1S!)I)  Chirk 
lliiillcy  iind  ('iin|)lin  niiikc  tlie  rollowin;^^  cliissirKiit ion:  I.  i'nre  liln'oid; 
lilji'oid  plitliisis — u  condition  in  wliicli  tiiere  is  no  tid)erele.  L'.  'i'nhei'fido- 
liliroid  disease — n  condition  primarily  lidx'renloiis,  Imt  which  has  run  a 
hhroid  conrse.  .'I.  J'"ihro-ttd»ereuloiis  disease — a  condition  primarily  lihroid, 
Imt  wliicli  lias  heconie  tulierculons.  The  tidteniilo-lihroid  form  may  come 
on  liradnally  as  a  sc(|iience  of  a  chnniic  tnhcrcidftns  hronclio-itncnnionia, 
or  follow  a  chronic  t nlicrcnlons  pleurisy.  In  oilier  instances  the  process 
supervenes  npon  nn  ordinary  idcerative  ]>hthisis.  'i'he  disease  hecomes 
limited  to  one  apex,  the  cavity  is  snrrounded  hy  layers  of  dense  lihrons 
tissne.  the  picnra  is  thickened,  and  the  lower  lol>e  is  <:radnidly  invaded  hy 
the  sclcrotii-  chan;;-e.  lllimately  u  picture  is  produced  little  if  at  all  dilVer- 
ent  from  the  comlition  known  as  cirrhosis  of  the  Innjjfs.  it  may  evi'n  he 
dillicult  to  say  that  the  process  is  Inherculous,  hut  in  advanced  cases  the 
hacilli  are  usually  |»reseiit  in  the  walls  of  the  cavity  at  the  apex,  or  old, 
enca]isidated  caseous  areas  exist  in  the  ]x\up,  or  there  may  he  tubercles  at 
the  apex  of  the  other  Inn;,'  aiul  in  the  hronchial  ^^lands.  J)ilalalion  of  the 
liionchi  jp  present;  the  rif,'ht  ventricl",  sometimes  the  eidire  heart,  is  liypcr- 
trophied. 

The  disease  is  clironic,  lasting;  from  ten  to  twenty  or  more  years,  dur- 
ing: which  time  the  |)atient  may  have  fair  health. 

The  chief  pymptoms  are  couph,  -which  is  often  ])aroxysmal  in  character 
and  most  marked  in  the  nu)rninj,'.  The  expectoration  is  i)urulent,  and 
in  some  instances,  when  the  l)ronchif'ctasi<  is  extensive,  fetid.  'Jliere  is 
dyspno'a  on  exertion,  hut  little  or  no  fever. 

'j'he  ])hysical  si^^ns  are  very  characteristic.  ^Phc  chest  is  sunken  and 
the  shoulder  lower  on  the  nft'ected  side;  the  heart  is  often  drawn  over  and 
displaced.  If  the  left  luufj  is  involved  there  may  he  an  nnnsnally  lar<;e 
ai'ca  of  cardiac  ])ulsation  in  the  third,  fourth,  and  fifth  interspaces.  Tleart- 
niurmurs  are  common.  There  is  dulness  over  the  aifected  side  and  defi- 
cient tactile  fremitus.  At  the  apex  there  may  he  well-marlced  cavernous 
sounds;  at  the  hase,  distant  hronchial  hreathin;'-.  The  condition  may  per- 
sist indefinitely.  In  some  cases  th(>  other  Innti  hecomes  involved,  or  the 
])atient  lias  rei)eated  attacks  of  liaMr  Mitysis,  in  one  of  wliich  he  dies.  As 
a  result  of  the  chronic  sn|>])urati'  yloid  defjeneration   of  the  liver, 

s])leen,  and  intestines  may  tak'^  .ropsy  frequently  supervenes  from 

failure  of  the  ri^rht  heart. 

A  more  detailed  account  end   under  Cirrhosis  of  the  Lunir,  with 

■which  this  form  is  clinically  identical. 

Concurrent  Infections  in  Pulmonary  Tuberculosis.— It  has 
lonfr  heen  known  that  in  pulmonary  tuhercidosis  or<:anisms  other  than  the 
specific  hacilli  are  ])resent,  particularly  the  micrococcus  lanceolatus,  the 
stre])tococcus  pyonfcnes,  and  the  staiihylococcus  aureus;  less  frequently  the 
liacillus  pyoeyaneus. 

A  majority  of  all  cases  of  pidmonary  tuherculosis  are  eomhined  infec- 
tions; streptococci  and  pnenmococci  may  he  found  in  the  sputa,  and  tlie 


TL'UEUCL'LOSIS. 


ai5 


(lurk 
hroitl; 

TC'Ulo- 

nm  a 

,■    ('(11110 

iiioniu, 
proi'OHtt 

liliruuH 
1(1. •<!  l)y 

I  (lillVr- 

L'Vt'U    1k! 

^^;('^<  thi! 

or  oM, 

'TC'U's  at 

II  of  the 
ti  hyi)or- 


ars,  (lur- 


harac'tcr 
lent,  aiul 
I'JMicre  1!^ 

ken   ami 

lover  and 

11 V  larjic 

llcart- 

iml  (l<'fi- 
nonioiis 
may  P^'T- 
ll.  ()i-  the 
Ivu's.  As 
Ihc  liver, 
les  I'rom 

lii^S  Avilli 

I— Tt  lias 
lilian  the 
itn?,  the 
'iitlv  the 


'd  infee- 


aiu 


foriiuT  have  lu'cn  isolated  frorii  the  Mood.  I*nid(U'ti,  who  Ims  very  caro- 
t'ldly  htiidied  tins  (|iie>tioii,  arrives  at  tlie  follow  in;;  eoiieliisioiis:  'i'lic  pid- 
Mioiiary  lesi((ns  of  lidtereido.-is  ari'  sidijeet  to  \ariatii>iis  deiieiidin;;  iarj^ely 
on  till'  diirerenl  modes  of  dislrihiition  of  the  liaeilli,  wliellier  liy  the  Mood- 
vessels  or  tliron;;li  llie  lirdnelii,  and  al>o  wliellier  a  eoiKiirrent  infeetion 
with  other  or;:anl>nis  has  taken  pliiee.  The  imeiinionia  eoni|ilieatin;.'  tnhor- 
eulosis  limy  he  the  diri'et  ri'siilt  of  the  tiilierele  hui'illiis  (tr  its  lo.\iin's,  or  it 
may  follow  secondary  infeetion  with  (tiher  ^-crms,  |tarti(iilarly  the  stre|ito- 
eoeelis  |iyo;ienes.  the  liiicroeoceiis  laileeolat  Us,  mid  the  >lil|»liyloeoeeUrt 
|»yojieiU'H.  'J'lie  fi'e(|nen(  y  of  this  .seeoiidnry  infeetion  and  the  indalive  si<,'- 
nilieanee  of  these  ^rernis  nre  not  yet  fully  decided.  The  introduction  oi'  tho 
Inherele  hacilli  into  the  liin^-s  of  a  rahhit  throii^di  the  trachea  induces  the 
various  pliases  of  |mlmonary  tiihi'reulosis,  hut  cavity  formation  is  I'are.  If, 
(111  the  other  hand,  into  the  liiii;.;s  of  ii  rahhit  which  arc  the  seal  of  extensive 
consolidation  the  st re|itoco(ciis  pyo^^cnes  is  iiitro.liieed,  then  ca\iti<'s  Torin 
rapidly,  and  the  anatomical  picture  is  very  similar  to  that  of  chronic  ulcer- 
ative tuherciilosis  in  man.  it  is  very  prohalde  that  in  man,  too,  tlu'  elVcct 
of  coiitaininatioii  with  tlicse  pus  orpiiiisiiis  is  a  very  important  one  in 
Jiasteiiiii;,'  necrosis  and  .soficiiiii;;-,  mid  also  in  the  chronic  cases  they  doiiht- 
less  produce  in  lar;:('  amounts  the  toxiiies  which  are  ri'S|ioiisihle  for  many 
of  the  symptoms  of  tite  disejise. 

Diseases  associated  with  Pulmonary  Tuberculosis.— Zo6r/r 

jini'iinniiiiii  is  a  not  uneoniinoii  cause  cd'  death.  It  is  met  with,  most  fre- 
(piently  indeed,  us  a  terminal  event  in  the  chronic  cases.  It  may,  however, 
occur  early,  and  he  diilicult  to  distin;;uisli  i'rom  an  acute  caseous  pneu- 
monia, 'i'lie  sputa  in  tho  latter  are  rarely  rusty,  whilo  the  I'over  in  the 
formci'  is  more  continuous  and  lii;;her,  hut  in  many  cases  it  is  impossihio 
to  diirereiitiate  hctwi'i'ii  the  two  conditions. 

Tiiphd'ul  frrrr  occasionally  occurs  in  persons  the  snhjccts  of  pulmonary 
(iiherculosis.  In  1  cases  of  SO  autopsies  in  typhoid  fever  tuherciilous  lesions 
were  present.  There  are  cases  on  record  also  of  acute  miliary  tuherciilosis 
and  typhoid  fovor  jirc-^ent  in  the  same  suhject.  There  is  a  wides|)rea(l 
opinion  that  typhoid  fever  ]»redisp()ses  to  tuherciilosis,  and  Wilson  Yok 
in  his  treatise  on  diseases  of  the  lun^is  ^ives  references  to  a  numhor  of 
cases.  In  my  ox))ericnce  it  has  heen  very  rare.  1  luive  no  recollection  of 
an  instance  in  which  tuherciilosis  has  developed  either  during  convalescence, 
or  immediately  after  recovery,  from  typhoid  fever. 

Enjxijwhtx  not  infreipicntly  attacks  old  poll  ri  no  ires  in  hospital  wards 
and  almshouses.  There  are  instances  in  which  the  attack  seems  to  he  heno- 
ficial,  as  tho  eongh  lessens  and  tho  synijitoms  ameliorate.  It  may,  however, 
]irove  fatal. 

The  cruplive  fevers,  ])articularly  measles,  freipieiitly  precede,  hut  raroly 
develop  in  the  course  of  imlmonary  tuherciilosis.  In  the  revaceiJiation  of 
a  tuherculous  suhject  the  vesicles  run  a  normal  course. 

Fistula  in  ano  is  associated  with   phthisis  in  an  interesting  manner. 
In  a  majority  of  such  cases  it  is  a  tuherculous  process.     The  general  affec- 
tion may  progress  rapidly  after  an  operation.     The  question  is  considered 
in  tuherciilosis  of  the  alimentary  canal. 
20 


I 


k ;' 


316 


SPECIFIC  INFECTIOUS  DISEASES. 


■  \ 
/ 


Heart-disease. — I  have  already  referred  (page  298)  to  the  occurrence  of 
endocarditis  in  tuberculosis.  The  antagonism  between  heart  lesions  and 
l)hthisis,  upon  which  Kokitansky  laid  stress,  is  not  pronounced.  Stenosis 
of  tile  i)ulmoiuiry  artery  and  aneurism  of  the  aorta  predispose  to  tubercu- 
losis pulmonum,  probably  by  reducing  the  activity  of  the  lesser  circula- 
tion. In  mitral  stenosis  pulmonary  tuberculosis  is  not  infrequent,  in  9  of 
54:  cases  (Potain).  A  terminal  acute  tuberculosis  of  one  or  the  other  of 
the  serous  membranes  is  a  very  connnon  event  in  all  forms  of  cardio-vascu- 
lar  disease. 

In  chronic  and  arrested  phthisis  arteriosclerosis  and  plileho-sclerosis 
are  uncommon.  Ormerod  noted  30  cases  of  chronic  renal  disease  in  100 
post-mortems. 

The  association  of  tul)erculosis  with  chronic  arthritis,  upon  which  cer- 
tain writers  lay  stress,  finds  its  explanation  in  the  lowered  resistance  of 
these  patients,  and  the  greater  liability  to  infection  in  the  institutions  in 
which  so  many  of  them  live. 

Peculiarities  of  Pulmona'  v^  Tuberculosis  at  the  Extremes 
of  Life. — (a)  Old  Age. — It  is  remarkable  how  common  tuberculosis  is  in 
the  aged,  particularly  in  institutions.  McLachlan  noted  145  cases  in  which 
tuberculosis  was  the  cause  of  death  in  old  persons  in  Chelsea  Hospital. 
All  were  over  sixty  years  of  age.  The  experience  at  the  Salpetriere  is  the 
same.     Laennec  met  with  a  case  in  a  person  over  ninety-nine  years  of  age. 

At  the  Philadelphia  Hospital,  in  the  bodies  of  aged  persons  sent  over 
from  the  almshouse  it  was  extremely  common  to  find  either  old  or  recent 
tuberculosis.  A  patient  died  under  my  care  at  the  age  of  eighty-two  with 
extensive  peritoneal  tuberculosis.  Pulmonary  tuberculosis  in  the  aged  is 
usually  latent  and  runs  a  slow  course.  The  physical  signs  are  often  masked 
by  emphysema  and  by  the  coexisting  chronic  bronchitis.  The  diagnosis 
may  depend  entirely  upon  the  discovery  of  the  bacilli  and  elastic  tissue. 
Contrary  to  the  o})inion  which  was  held  some  years  ago,  tuberculosis  is  by 
no  means  uncommon  with  senile  emphysema.  Some  of  the  cases  of  tuber- 
culosis in  the  aged  are  instances  of  quiescent  disease  which  may  have  dated 
from  an  early  period. 

(b)  Infants. — The  occurrence  of  acute  tuberculosis  in  children  has  al- 
ready been  mentioned,  and  also  the  fact  that  the  disease  is  occasionally 
congenital.  Recent  studies,  particularly  of  French  writers,  have  shown 
that  it  is  a  frequent  affection  in  children  under  two  years  of  age.  Leroux 
has  analyzed  the  statistics  of  the  late  Prof.  Parrot,  embracing  219  cases  in 
children  under  three  years.  Of  these  there  were  from  one  day  to  three 
months,  23;  from  three  to  six  months,  35;  from  six  to  twelve  months, 
53  (a  total  of  111  under  one  year);  and  from  one  to  three  years,  108.  Pul- 
monary cavities  were  present  in  57  of 'the  cases,  and  in  only  50  was  the 
pulmonary  lesion  the  sole  manifestation.  At  the  St.  Petersburg  Foundling 
Asylum,  in  the  ten  years  ending  1884,  there  were  416  cases  of  tuberculosis 
in  16,581  autopsies.  The  observations  of  Xorthrup,  at  the  New  York 
Foundling  Hospital,  are  of  special  interest  in  connection  with  the  mode 
of  infection.  Of  125  cases  of  tuberculosis  on  tiie  records  of  this  institution. 
in  34  the  ravages  were  extensive,  the  seat  of  the  primary  affection  was  not 


TUBERCULOSIS. 


317 


nee  of 
ae  and 
tonosis 
.iborcu- 
:;ircula- 
in  9  of 
tlier  of 
j-vascu- 

sdcrosis 
i  in  100 

licli  ccr- 
tance  of 
itions  in 

:tremes 

osis  is  in 
in  which 
Hospital, 
ere  is  tlie 
rs  of  age. 
sent  over 
or  recent 
-txvo  with 
le  aged  is 
;n  masked 
diagnosis 
;tic  tissue. 
Ilosis  is  by 
of  tuber- 
ave  dated 


en  has  al-  * 
tcasionally 
ive  shown 
Leroux 
19  cases  in 
to  three 
months, 
108.    Pul- 
lo  was  the 
^oiindling 
|iberculosi>; 
few  York 
[the  mode 
istitution. 
In  was  not 


clear,  and  the  broncliial  glands  wore  largo  and  cheesy.  In  20  cases  of 
general  tubereulosis  there  were  elieesy  masses  in  the  bronchial  glands  and 
in  the  lungs.  In  -12  cases  of  general  tuberculosis  the  only  cheesy  nuisses 
were  in  the  bronchial  lym])h-glau(ls.  In  9  cases  the  tubercles  were  limited 
to  the  bronchial  nodes  and  the  lungs;  the  latter  containing  only  discrete 
miliary  bodies,  while  the  ])ronchial  glands  showed  advanced  caseation.  In 
13  cases  there  was  tuberculosis  of  the  bronchial  nodes  only.  In  most  of 
these  cases  the  patients  died  of  infectious  diseases.  These  figures  are  very 
suggestive,  and  point,  as  already  noted,  to  infection  through  the  bronchial 
passages  as  the  most  common  method,  even  in  children.  Of  SOU  autopsies 
in  children  at  the  ^Munich  Pathological  Institute,  in  150  (30  per  cent)  tuber- 
culosis was  present  and  in  over  9:^  per  cent  the  Jungs  were  involved 
(Miiller). 

Modes  of  Death  in  Pulmonary  Tuberculosis. — (a)  Byasilicnia, 
a  gradual  failure  of  the  strength.  The  end  is  usually  peaceable  and  quiet, 
occasionally  disturbed  by  paroxysms  of  cougli.  Consciousness  is  often  re- 
tained until  near  the  close. 

{h)  By  asphyxia,  as  in  some  cases  of  acute  miliary  tidjorculosis  and  in 
acute  pneumonic  phthisis.  In  chronic  phthisis  it  is  rarely  seen,  even  when 
pneumothorax  develops. 

(r)  By  syncope.  This  is  not  common.  I  have  known  it  to  hapi)en  once 
or  twice  in  patients  who  insisted  upon  going  about  when  in  the  .advanced 
stages  of  the  disease.  There  may  be,  but  not  necessarily,  fatty  degeneration 
of  the  heart.  A  rapidly  developing  syrcope  may  follow  haemorrhage  or 
may  be  due  to  thrombosis  or  embolism  of  the  pulmonary  artery,  or  to  pneu- 
mothorax. 

(rf)  From  hamorrliage.  The  fatal  bleeding  in  chronic  phthisis  is  due 
to  erosion  of  a  large  vessel  or  rujjture  of  an  aneurism  in  a  pulmonary 
cavity,  most  commonly  the  latter.  Of  26  cases  analyzed  by  S.  West,  in  1 1 
the  fatal  haemoptysis  was  due  to  aneurism,  and  of  35  cases  collected  by 
Percy  Kidd,  aneurism  was  present  in  30.  In  a  case  of  Curtin's,  at  the 
Philadelphia  Hospital,  the  bleeding  proved  fatal  before  haemoptysis  oc- 
curred, as  the  eroded  vessel  opened  into  a  capacious  cavity. 

(e)  IFiV/i  cnehral  symptoms.  Coma  may  be  due  to  meningitis,  less  often 
to  urfemia.  Heath  in  convulsions  is  rare.  The  ha^morrhagic  pachy-menin- 
gitis  which  develops  in  some  cases  of  phthisis  occasionally  causes  loss  of 
consciousness,  hut  is  rarely  a  direct  cause  of  death.  In  one  of  my  cases, 
death  resulted  from  thrombosis  of  the  cerebral  sinuses  with  symptoms  of 


meningitis. 


Y.    TUBERCULOSTS    OF   THE    AlIMEXTARY   CaXAL. 


(a)  Lips. — Tuberculosis  of  the  lip  is  very  rare.  It  occurs  occasionally 
in  the  form  of  an  ulcer,  either  alone  or  more  commonly  in  association  with 
laryngeal  or  pulmonary  disease.  Two  cases  an  reported  and  the  literature 
is  analyzed  in  Yerneuirs  Etudes.*  The  ulcer  is  usually  very  sensitive  and 
may  he  mistaken  for  a  chancre  or  an  epithelioma.    The  diagnosis  may  be 

*  Tome  iii,  Fasc.  I. 


318 


SrECIFIC  INFECTIOUS  DISEASES. 


/' 


made  in  cases  of  doubt  by  inocidation  or  tlie  examination  of  a  portion  for 
tvdiercle  bacilli. 

(b)  TotKjue. — '■JMie  disease  l)egins  by  an  aggregation  of  small  granular 
bodies  on  tlie  edge  or  doi'sum.  I'lceration  i)roceeds,  leaving  an  irregular 
.sore  with  a  distinct  but  uneven  margin,  and  a  rough,  often  caseous  base. 
The  disease  extends  slowly  and  may  form  an  nicer  of  considerable  size. 
1  have  known  it  to  be  mistaken  f(jr  epithelioma  and  the  tongue  to  be  ex- 
cised. Jt  is  rarely  met  wi'h  excejtt  when  other  organs  are  involved.  The 
glands  of  the  angle  of  the  jaw  are  not  enlarged  and  tlie  sore  does  not  yield 
to  iodide  of  i)otassium,  Mhich  are  points  ot  distinction  between  the  tuber- 
cnlous  and  the  sy])hilitic  nicer.  In  doubtful  cases  the  inoculation  test 
should  be  made,  or  a  i)or(ion  excised  for  nncroscopical  exa?nination. 

((■)  Tlie  salivaiT  glands  belong  to  that  small  grouj)  of  organs  of  the 
body  which  seem  to  ])ossess  an  immunity  against  tuberculous  infection — 
an  immunity,  however,  whidi  in  their  case  is  relative,  not  absolute;  a  few 
cases  liave  been  reported. 

(d)  Tubercles  of  the  hard  or  soft  pahilc  nearly  always  follow  extension 
of  the  disease  from  neighboring  parts. 

(r)  Tuhciriihsis  of  ihv  2'aiifiih. — In  ISSf  Strassmann  fonnd  the  tonsils 
involved  in  13  instances  out  of  21  autopsies.  l)nu)chowski  demonstrated 
tubercle  bacilli  in  the  lymphatics  between  the  tonsils  and  the  cervical 
lymi)h-glands.  The  latter  observation  is  interesting  in  connection  Avith 
the  views  of  Schlenker,  who  claims  that  the  majf)rity  of  the  cases  of  tuber- 
culous cervical  glands  resnlt  from  infection  with  tubercle  bacilli  Avhich 
gain  admission  by  w'ay  of  the  tonsil.  A  large  nnmber  of  his  cases  of  tuber- 
iculous  cervical  adenitis  were  definitely  of  a  descending  variety  and  asso- 
ciated with  tuberculosis  of  these  glands.  The  majority  also  had  pulmonary 
tuberculosis,  and  he  regards  surface  infection  of  the  tonsil  by  tuberculons 
food  and  s])ntum  far  more  common  than  infection  by  way  of  the  circida- 
tion.  The  disease  may  occnr  as  a  snperficial  ulceration.  More  commonly 
there  is  an  infiltration  of  the  tonsil  with  miliary  tubercles,  which  jn'oduces 
a  greater  or  less  hypertrophy  wliich  it  is  practically  impossible  to  distin- 
gnish  from  an  ordinary  enlarged  tonsil  without  a  microscopical  examina- 
tion.    Caseons  foci  occasionally  develop. 

(f)  PJtari/n.r. — In  extensive  laryngeal  tuberculosis  an  eru])tion  of  mili- 
ary granules  on  the  ])Osterior  wall  of  the  pharynx  is  not  very  uncommon. 
In  chronic  phthisis  an  nlcerative  pharyngitis,  due  to  extension  of  the  dis- 
ease from  the  epiglottis  and  larynx,  is  one  of  the  most  distressing  of  com- 
plications, rendering  deglntition  acntely  painful.  Adenoids  of  the  naso- 
pharynx may  be  tuberculons,  as  shown  by  Lermoyez.  Macrosco])ically,  they 
do  not  dill'er  from  the  ordinary  vegetations  fouiul  in  this  situation. 

(fl)  A  few  instances  occur  in  the  literature  of  tuliercnlosis  of  the 
cesopliafius.  The  condition  is  a  pathological  curiosity,  exce])t  in  the  slight 
extension  from  the  larynx,  which  is  not  infrequent:  but  in  a  case  in  my 
wards  described  by  Flexner  the  idcer  perforated  and  caused  purulent  jjleu- 
risy.  The  condition  has  been  fully  considered  by  Claribel  Cone,  who  has 
described  a  second  case  from  the  Johns  Hopkins  Hospital  (Bulletin,  Novem- 
ber, 1897). 


TUBERCULOSIS. 


310 


ion  for 

i-anular 
regular 
IS  base, 
le  size, 
be  ex- 
1.  Tlie 
:)t  yield 
;  tuber- 
on  test 

of  the 
;ctioii — 
•;  a  few 

^tension 

2  tonsils 
nstrateil 
cervieal 
on   with 
)f  tuber- 
li  which 
)f  tubcr- 
nd  asso- 
inonavy 
reiilous 
cireiila- 
)mmonly 
)ro(luce3 
distin- 
xamina- 

of  niili- 
•ornmon. 
the  dis- 
of  coin- 
le  naso- 
lly,  they 

of    the 

le  slight 

;e  in  my 

3nt  ])lon- 

who  has 

Xoveiu- 


(//)  Stnmarli. — Many  cases  are  reported  whic-li  are  douhtful.  Primary 
disease  is  unknown.  .Marfan  was  able  to  c:)llect  only  altout  a  dozen  authentic 
cases.  IVrforatiou  of  the  stomach  occurred  six  times,  thrice  l)y  a  tuberculous 
gland,  in  Oi)i)olzer's  case  an  ulcer  of  the  colon  })erforated  the  organ.  lu 
Musser's  case  there  was  a  large  tuberculous  ulcer  3X1^  inches  in  extent. 
Three  cases  have  I)een  descriljed  from  my  wards  by  xVlice  Hamilton  (J.  ]I. 
II.  P.ulletin,  April,  LSI);). 

(i)  Inlestines. — The  tubercles  may  be  (^1)  primary  in  the  mucous  mem- 
brane, or  more  connnonly  (2)  secondary  to  disease  of  the  lungs,  or  in  rare 
cases  the  alfection  may  (■"))  pass  from  the  peritonanim. 

(1)  I'riimiry  intestinal  tuberculosis  occurs  most  freipiently  in  children, 
in  whom  it  nuiy  ije  associated  with  enlargement  and  caseation  of  the  mesen- 
teric glands,  or  with  peritonitis.  It  may  be  dilHcult  to  say  at  the  time  of 
the  auto])sy  whether  the  i)rimary  lesion  has  been  intestinal  or  peritoneal. 
I  have  already  referred  to  AVoodhead's  statistics  showing  the  remarkable 
freipiency  of  infection  through  the  bowel.  In  adults  primary  intestinal 
tuberculosis  is  rare,  occurring  in  but  1  instance  in  1,000  autopsies  upon 
tuberculous  adults  at  the  Munich  Pathological  Institute;  but  now  and  then 
cases  occur  in  which  the  disease  sets  in  with  irregular  diarrhwa,  moderate 
fcA'er,  and  colicky  ])ains.  In  a  few  cases  hiemorrhage  has  been  the  initial 
symptom.  Pegarded  at  first  as  a  chronic  catarrh,  it  is  not  until  the  emacia- 
tion becomes  nuirked  or  the  signs  of  disease  appear  in  the  lungs  that  the 
true  nature  is  apparent.  Still  more  deceptive  are  the  cases  in  which  the 
tuberculosis  begins  in  the  ca}cuni  and  there  are  symptoms  of  a]ipendicitis — 
tenderness  in  the  right  iliac  fossa,  constipation,  or  an  irregular  diarrhcea 
.'(ud  fever.  These  signs  may  gradually  disappear,  to  recur  again  in  a  few 
Aveeks  and  still  further  complicate  the  diagnosis.  Fatal  hamiorrhage  has 
occurred  in  several  of  my  cases.  Perforation  nmy  occur  with  the  forma- 
ti(m  of  a  i)erica!cal  abscess,  or  perforation  into  the  ])eritomeum  may  take 
l)lace,  or  in  very  rare  instances  there  is  partial  healing  with  great  thicken- 
ing of  the  walls  and  narrowing  of  the  lumen. 

i'i)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic 
1)ulmonary  tuberculosis,  e.  g.,  in  ."jOf!  of  the  1,000  Munich  autopsies  in  tuber- 
culosis just  referred  to.  In  only  three  of  ihese  cases  were  tlie  lungs  not  in- 
volved. The  lesions  are  chiefly  in  the  ileum,  ca'cum,  and  colon.  The 
ad'ection  begins  in  the  solitary  and  agminated  glands  oi-  dh  the  surface 
of  or  within  the  mucosa.  The  ciiseation  and  necrosis  lead  to  ulceration, 
which  may  he  very  extensive  and  involve  the  greater  portion  of  the  mucosa 
of  the  large  and  small  bowels.  In  the  ileum  the  Peyer's  patches  arc  chielly 
involved  and  the  ulcers  may  he  ovoid,  but  in  the  jejunum  and  colon  they 
are  usually  round  or  transverse  to  the  long  axis.  The  tuberculous  ulcer 
has  the  following  characters:  (a)  It  is  irregular,  rarely  ovoid  or  in  the 
long  axis,  more  freciuently  girdling  the  howel;  (h)  the  edges  and  base  are 
infdtrated,  often  caseous;  (c)  the  submucosa  and  muscularis  are  usually 
involved:  and  (il)  on  the  serosa  may  he  seen  colonies  of  young  tubercles  or 
a  well-nuirked  tidjcrculous  lymphangitis.  Perforation  and  peritonitis  are 
not  uncommou  events  in  the  secondary  ulceration.  Stenosis  of  the  bowel 
from  cicatrization  may  occur;  the  strictures  may  be  multiple. 


1 1 


320 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


Localized  clironic  tuberculosis  of  the  ilco-ccrcal  rcrjlun  is  of  great  im- 
portance. The  civcuni  Irequeiilly  ])resents  extensive  ulceration  of  the 
mucous  membrane,  which  not  uncommonly  extends  into  the  a})i)endix.  As 
a,  consequence  of  the  changes  jjroduced  a  definite  tumor-like  mass  develops 
in  the  right  iliac  fossa.  'JMiis  varies  in  size,  is  usiuilly  elongated  in  a 
vertical  direction,  hard,  slightly  movable,  or  bound  down  by  adhesions  and 
very  sensitive  to  pressure.  The  tumor  simulates  more  or  less  closely  a 
true  neoi)lasni  of  this  region,  j)articularly  carcinoma.  The  condition  is 
■characterized  by  gradual  constriction  of  tlie  lumen  of  the  bowel,  periodic 
attacks  of  severe  pain,  and  alternating  diarrhoea  and  constipation.  In  a  few 
cases  extirpation  of  the  ciecum  has  been  performed  with  fairly  successful 
results.  In  a  second  form  of  this  disease,  occurring  less  frequently  than 
the  former,  there  is  no  definite  tumor-mass  to  be  felt,  but  a  general  indura- 
tion and  thickening  in  the  right  iliac  fossa  similar  to  the  local  changes 
produced  by  a  recurring  appendicitis.  In  this  variety  a  fistula  discharging 
fecal  matter  occasionally  results.  Both  forms  may  be  distinguished  from 
the  diseases  they  simulate  by  the  finding  of  tubercle  bacilli  in  the  stools 
or  in  the  discharge  from  the  fistula  when  such  exists. 

Tuberculosis  of  the  rectum  has  a  special  interest  in  connection  with 
fistula  in  ano,  which,  according  to  Spillman's  statistics,  occurs  in  about 
3.5  per  cent  of  cases  of  pulmonary  disease.  In  many  instances  the  lesion 
has  been  shown  to  be  tuberculous.  It  is  very  rarely  primary,  but  if  the 
tissue  on  removal  contains  bacilli  and  is  infective  the  lungs  are  almost 
invariably  found  to  be  involved.  It  is  a  common  opinion  that  the  pul- 
monary symptoms  may  develop  rapidly  after  the  fistula  is  cut.  This  may 
have  some  basis  if  the  operation  consists  in  laying  the  tract  open,  and  not 
in  a  free  excision. 

(3)  Extension  from  the  peritonaeum  may  excite  tuberculous  disease  in 
the  bowels.  The  afTection  may  be  primary  in  the  peritoneum  or  extend 
from  the  tubes  in  women  or  the  mesenteric  glands  in  children.  The  coils 
of  intestines  become  matted  together,  caseous  and  suppurating  foci  de- 
velop between  the  folds,  and  perforation  may  take  place  between  the  coils. 


VI.  Tuberculosis  of  the  Liver. 

This  organ  is  very  conslantly  involved  in  {a)  general  tuberculosis.  The 
miliary  granulation  may  ])e  very  small  and  in  acute  cases  scarcely  percepti- 
ble.   The  liver  is  pale  and  often  fatty. 

{h)  A  remarkable  condition  of  the  organ  is  produced  by  the  develop- 
ment of  the  tubercles  in  the  finer  bile-vessels.  Thoy  may  attain  a  con- 
siderable size  and  are  almost  always  softened  in  the  centre,  resembling 
small  abscesses.  The  contents  are  always  bile-stained.  The  organ  may  be 
honeycombed  with  these  tuberculous  abscesses. 

(r)  Large,  coarse  caseous  masses  are  occasionally  found,  sometimes  in 
association  with  perihepatitis  or  tuberculous  peritonitis.  They  may  attain 
the  size  of  an  orange  or  may  even  be  larger. 

{d)  Tuberculous  cirrhosis.  "With  the  eruption  of  miliary  tubercles  there 
may  be  slight  increase  in  the  connective  tissue,  which  is  overshadowed  by 


TUBERCULOSIS. 


321 


it  im- 
.i'    the 
>w.    As 
velops 
L  in  a 
lis  and 
)soly  a 
tion  is 
eriodic 
\  a  few 
;cessful 
y  than 
indura- 
ihanges 
[larging 
id  from 
e  stools 

Dn  with 
n  about 
le  lesion 
it  if  the 
i  almost 
the  pnl- 
'his  may 
and  not 

lisease  in 
extend 
he  coils 
foci  de- 
he  coils. 


m.    The 
Dercepti- 

develop- 

li  a  con- 

semhling 

may  be 

[times  in 
ly  attain 

hes  there 
lowed  by 


tlie  fatty  change.  In  all  the  dironic  forms  of  tiil)ercle  in  tliis  organ  there 
may  l)e  flbnnis  overgrowth.  JIanot,  wlio  lias  descril)ed  several  varieties, 
slates  tliat  tl.e  condition  may  lie  jjriinary.  I'ractically  it  is  very  rare,  except 
in  connection  with  chronic  tuberculous  ])eritonitis  and  perihepatitis,  when 
the  organ  may  be  much  deformed  by  a  sclerosis  involving  the  portal  canals. 
In  this  last  group  there  may  he  symptoms  of  ascites;  as  a  rule,  tuberculosis 
of  the  liver  has  a  })urely  anatomical  interest. 

VII.  Tuberculosis  of  tiiI':  Braix  and  Cord. 

Tuberculosis  of  the  brain  occurs  as  (a)  an  acute  miliary  infection  caus- 
ing meningitis  and  acute  hydrocephalus;  (h)  as  a  chronic  meningo-en- 
cei)halitis,  usually  localized,  and  containing  small  nodular  tubercles;  and 
{(•)  as  the  so-called  solitary  tubercle.  Between  the  last  two  forms  there 
are  all  gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The 
acute  variety  has  already  been  considered.  I  shall  here  consider  the  chronic 
form,  which  develops  slowly  and  has  the  clinical  characters  of  a  tumor. 

It  is  most  common  in  the  young.  Of  148  cases  collected  by  Pribram 
118  were  under  fifteen  years  of  age.  Other  organs  are  usually  involved, 
particularly  the  lungs,  the  bronchial  glands,  or  the  bones.  In  rare  in- 
stances no  tubercles  are  found  elsewhere.  They  occur  most  frec^uently  in 
the  cerebellum;  next  in  the  cerebrum  and  then  in  the  pons.  The  growths 
are  often  mviltiple,  in  100  out  of  183  cases  (Gowers).  They  range  in  size 
from  a  pea  to  a  walnut;  larger  tumors  occasionally  occur,  and  sometimes 
an  entire  lobe  of  the  cerebellum  is  affected.  On  section  the  tubercle  pre- 
sents X  grayish-yellow,  caseous  appearance,  usually  firm  and  hard,  and  en- 
circled by  a  translucent,  softer  tissue.  The  centre  of  the  growth  may  be 
semi-diflluent.  As  in  other  localities  the  tubercle  may  calcify.  The 
tumors  are  as  a  rule  attached  to  the  meninges,  often  to  the  pia  at  the 
bottom  of  a  sulcus  so  that  they  look  imbedded  in  the  brain-substance. 
About  the  longitudinal  fissure  there  may  be  an  aggregation  of  the  growths, 
with  compression  of  the  sinus,  and  the  formation  of  a  thrombus.  The 
tuberculous  tumor  not  infrequently  excites  acute  meningitis.  In  localized 
meningo-encephalitis  the  pia  is  thickened,  tubercles  ;  e  adherent  to  the 
under  surface  and  grow  about  Ihe  arteries.  It  is  often  combined  with 
cerebral  softening  from  interference  with  the  circulation.  Several  of  the 
most  characteristic  instances  which  I  have  seen  were  on  the  meninges 
covering  the  insula.  This  form  may  develop  in  pulmonary  tuberculosis, 
causing  hemiplegia  or  aphasia  which  may  persist  for  months. 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  i)e  considered  in  the  section  on  the  brain. 

In  tlie  spinal  cord  the  same  forms  are  found.  The  acute  tuberculous 
meningitis  has  been  considered  and  is  almost  always  cerebro-spinal.  The 
solitary  tubercle  of  the  cord  is  rare.  Herter  has  reported  3  cases  and  col- 
lected 24  from  the  literature.  It  was  seconclary  in  all  save  one  case.  The 
symptoms  are  those  of  spinal  tumor  or  meningitis. 


322 


SPECIFIC   liNFWnMOL'S   DISKASKS. 


/ 


VIII.  Tuberculosis  of  tiiI')  (liiNiTo-ruiNAitY  Systeit. 

Tlic  studios  of  the  piist  h'w  yciirs,  mimI  particularly  the  work  of  sur- 
gcrtiis  and  ^^yua-coloj^'ists,  have  tau«iiit  lis  tJR'  yrcat  iiuportaiice  of  tuhcrcd- 
losis  of  tliis  tract.  Any  part  of  the  <^ciiit()-iiririary  system  may  he  iiivath'd. 
Tlie  successive  involvement  of  the  <)r<^aiis  may  he  so  rapid  that  unless  the 
case  has  heen  seen  early  it  may  he  iinpossil)le  to  state  with  any  degree  of 
certainty  wliieh  has  been  (he  i)riinary  seat  of  infection.  Tlu're  may  he 
simultaneous  involvement  of  various  i)ortions  of  the  tract,  in  t uherculosi.-f 
of  the  genito-urinary  system  one  always  has  to  bear  in  mind  the  possibility 
of  latent  disease  elsewhere  in  the  body.  As  fJollinger  says,  tubercle  bacilli 
may  gain  admission  at  some  part  of  the  respiratory  tract  without  produc- 
ing any  lesion  at  the  point  of  entrance,  and  finally  reach  a  bronchial  gland, 
where  they  set  up  a  tuberculous  ])r()cess  of  extremely  slow  development 
without  i)roducing  any  symptoms.  From  this  point  bacilli  nuiy  enter  the 
blood  stream  and  lodge  in  the  cjudidymis  or  testicle  proper,  and  produce 
nodules  which  are  readily  discovered,  owing  to  the  ease  with  which  these 
parts  are  examined.  Such  a  case  might  he  cpiite  easily  mistaken  for  one 
of  jirinuiry  genital  tuberculosis,  whereas  the  true  primary  tuberculous  focus 
is  far  distant. 

infection  of  the  genito-urinary  tract  occurs  in  various  Avays: 

1.  I'll  UcrcdUnrij  Traiif(iiii><s'wn. — It  has  been  met  with  in  the  foetus. 
Tht'  com])arative  fre(iuency  of  tuberculosis  of  the  testicle  in  very  young 
children  suggests  very  strongly  tlii'l  the  uro-genital  organs  may  be  involved 
as  a  result  of  direct  transmission  of  the  disease  from  the  parents. 

'Z.  lUj  infection  from  areas  of  tuhercvhsifi  already  existini/  in  the  patient. 

(a)  Infection  tJirout/h  the  TUood. — In  nL.iny  cases  lu'o-genital  tuberculosis 
is  found  at  autopsy  a.<sociated  with  disease  of  s(jme  distant  organ,  particu- 
larly Die  lungs,  and  it  would  ajjpear  most  probable  that  in  them  infection 
lias  l)een  through  the  blood-vessels.  Jani's  observations,  wliicli  were  pub- 
lished by  AVeigert  after  the  author's  death,  strongly  su])port  this  theory. 
In  studying  sections  of  the  genital  organs  of  })atients  who  died  of  pvd- 
monary  tubercidosis,  he  found  tubercle  bacilli  in  5  out  of  8  cases  in  the 
testicle,  and  in  -1  out  of  G  cases  in  the  ])rostate,  Mithout  in  any  instance 
finding  microscopical  evidences  of  tubercles  in  these  organs.  The  bacilli 
lay,  in  the  testis,  ])artly  within  and  ])artly  close  beside  the  cellular  and 
granular  contents  of  tlie  seminal  tubules,  while  in  the  prostate  they  were 
always  situated  in  the  neighborhood  of  the  glandular  epithelium. 

{b)  Infection  from  the  Peritonamm. — This  source  of  infection,  in  both 
men  and  women,  is  much  more  fre(pient  than  is  commonly  sujjposed.  The 
intinuite  relationshi])  between  the  peritona.nnn  and  l)ladder  in  both  subjects, 
and  M'ith  the  vesicular  senu'nales  and  vasa  deferentia  in  the  male,  allows  of 
a  ready  way  of  invasion  of  these  organs  by  direct  extension  of  the  dis- 
ease. The  peritonamm  is  a  frequent  source  of  genital  tulierculosis  in  the 
female.  Xo  doubt  many  cases  of  tidjcrculosis  of  the  Fallopian  tubes  origi- 
nate from  this  source.  The  fact  that  the  fimbriated  extremity  of  the 
tul)e  is  often  most  seriously  involved  ])oints  rather  strongly  in  this  direc- 
tion, although  the  fact  might  be  taken  as  a  point  in  favor  of  blood  infection, 


TUUHHCULOSIS. 


323 


.[  siir- 
l)orcii- 
vadi'il. 
L'ss  the 
free  of 
nay  1)t' 
•culosi.4 
isibility 
1)acilU 
[iroduc- 
i  gland, 
opment 
iter  the 
produce 
;h  tlieso 
for  one 
us  focus 


e  fcTctus. 
y  young 
involved 

'  patient. 
erculosiri 
larticu- 
i'ectiou 
re  pub- 
theory, 
of  pnl- 
in  the 
instanec 
le  bacilli 
ular  and 
ley  were 

in  both 

ed.    The 

nibjects, 

dlows  of 

the  dis- 

is  in  the 

)cs  origi- 

of   the 

lis  direc- 

.ufectiou, 


fa\orod  l)y  lis  greater  va^ctdai'ity.  A'arii-.is  oliservalions  go  to  sliow  thai  tlio 
action  ol'  the  ciba  lining  the  luniina  of  the  Fallopian  tubes  teuds  to  at- 
tract particles  inlroduced  into  the  peritoneal  cavity.  -lani's  observation 
is  very  interesting  in  this  connection,  as  showing  the  [lossibility  of  tubercle 
bacilli  entering  the  tubes  from  the  |)erit(»neal  cavity  without  there  I)eing 
any  tuberculous  ])eritoin'lis.  lie  found  typical  tubercle  bacilli  in  the  lumen, 
in  iseetions  of  a  normal  I'allopian  lube,  in  a  woman  who  died  of  pulmonary 
and  intestinal  tnberculosis.  The  explanation  advanced  wns  that  the  bacilli 
made  their  way  through  the  thin  peritoneal  coat  from  one  of  the  intestinal 
nlcors,  tlius  reaching  the  peritoneal  cavity,  and  thence  were  atti'acti'd  into 
the  Fallopian  tube  by  the  current  produced  by  the  action  of  the  cilia  lining 
the  hunen.  The  intimate  relationship  between  tul)erculous  peritonitis  and 
tnberculosis  of  the  Fallopian  tubes  is  shown  in  the  fact  that  the  latter  are 
affected  in  from  'M)  to  40  ])er  cent  of  the  cases. 

(r)  Iiifrrlioii  fvotn  other  Ori/ans  hij  Dlrnl  Kxloisiim. — The  occurrence 
of  direct  extension  from  the  ]; 'ritona'um  has  already  been  mentioiu'd.  In 
tuberculous  ulceration  of  the  intestine  or  rectum  atlhesions  to  the  bladdi'r 
in  the  nude  or  to  the  uterus  and  vagina  in  the  female  may  occur,  with 
resulting  iistuhe  and  a  direct  extension  of  the  disease.  Perirectal  liiher- 
culous  abscesses  may  lead  to  secondary  involvement  of  some  ])ortion  of  the 
genito-urinary  tract.  It  must  not  be  forgotten  that  tuberculosis  of  the 
^*t?rtebra'  may  be  followed  1)y  lul)erculosis  of  the  'idney  as  a  result  of  direct 
extension  of  the  disease. 

3.  />//  Iiifi'riioii  from  Wilhoiit. — Whethor  uro-genital  tid)ercnlosis  may 
occur  as  a  result  of  the  entrance  of  tubercle  bacilli  into  the  urethra  or 
vagina  is  still  a  disputed  question.  That  bacilli  gain  admission  to  these 
passages  during  coitus  with  a  i)erson  the  subject  of  uro-genital  tuberculosis, 
or  by  the  use  of  foul  instruments  or  syringes,  seems  (piite  ])robable.  The 
])Ossibility  of  genital  tuberculosis  occurring  in  the  fi'male  as  a  result  of 
coitus  with  a  male  the  subject  of  tubercidosis  in  some  portion  of  the  genito- 
urinary system  was  first  suggested  by  Cohnheim,  who  stated,  however,  that 
it  rarely,  if  ever,  occurred.     Oiirtner's  experiments  have  been  referred  to. 

1  I  a  patient  Avith  intestinal  tid)erculosis  the  tubercle  bacilli  might  acci- 
dentally reach  the  urethra  or  vagina  from  the  rectum. 

Uro-genital  tuberculosis  is  commonest  bet^veen  the  ages  of  twenty 
and  forty  years — that  is,  during  the  period  of  greatest  sexual  activity. 
Males  are  affected  much  more  fretpuuitly  than  females,  the  ])roportion 
being  3  to  1.  This  great  dilference  is  no  doubt  ])artly  due  to  the  more 
int'mrite  relationship  between  the  urinary  and  genital  systems  in  the  former 
than  in  the  latter.  In  the  male  the  urethra  forms  the  common  outlet  for 
the  two  systems,  while  in  the  female  there  is  a  separate  outlet  for  each. 

fMice  the  uro-genital  tract  has  been  invaded,  the  d'sease  is  likely  to 
spread  rapidly,  and  the  method  of  extension  is  an  important  one.  Quito 
frequently  there  is  direct  extension,  as  when  the  bladder  is  involved  sec- 
ondarily to  the  kidney  by  passage  of  the  disease  along  the  ureter,  or  whore 
the  tuberculous  process  extends  along  the  vas  deferens  to  the  vosicula} 
seminales.  Xo  d(nil)t  surface  inoculation  occurs  in  some  instances,  and  to 
this  cause  may  be  attributed  a  certain  percentage  of  cases  of  vesical  and 


32:1 


SPECIFIC  INFECTIOUS  DIHKASES. 


/ 


prostatic  disease  following  tuberculosis  of  the  kidney.  Although  this  prob- 
ability is  acknowledged,  there  is  an  element  of  doubt  as  to  the  possibility 
of  the  kidney  beconiing  all'ected  secondarily  to  the  bladder  or  })rostatc  by 
the  direct  passage  of  tlie  bacilli  up  the  lumen  of  one  ureter;  for  in  such  a 
case  we  have  to  su])pose  that  a  non-motile  bacillus,  contrary  to  the  laws 
of  gravity,  ascends  against  an  almost  constant  current  of  urine  (lowing  in 
the  opposite  direction.  The  lymi)hatic8  may  afford  a  means  for  the  spread- 
ing of  the  disease,  but  in  a  greater  nund)er  of  cases  than  is  generally  sup- 
posed it  lakes  place  by  way  of  the  blood-vessels.  Cystoscopic  examina- 
tions of  the  bladder  not  infrequently  show  the  presence  of  tubercles  beneath 
the  mucous  membrane  before  there  is  any  evidence  of  superficial  ulceration 
— a  fact  suggesting  strongly  a  blood  infection. 

The  discovery  of  tid)ercle  bacilli  in  the  urine  and  the  oI)taining  of 
tuberculous  lesions  in  animals  as  a  result  of  inoculation  with  the  urinary 
sediment  afford  us  the  only  positive  evidence  of  genito-urinary  tubercu- 
losis. So  far  there  are  no  authentic  accounts  of  tubercle  bacilli  having 
been  found  in  the  semen  of  men  with  tuberculosis  of  the  testicle  or  vesicuhi) 
seminales.  Owing  to  the  fact  that  the  smegma  bacillus  has  the  same  stain- 
ing reaction  as  the  tubercle  bacillus,  and,  mor})hologically,  is  practically 
indistinguishable  from  it,  the  greatest  care  must  be  used  in  obtaining 
the  si)ecimen  of  urine  for  examination,  to  eliminate,  if  possilile,  all  chances 
of  contamination.  Thus  the  urine  examined  must  be  a  catheterized  speci- 
men, and  even  then  one  runs  the  risk  of  carrying  back  into  the  bladder 
on  the  end  of  the  catheter  a  few  bacilli  which  may  be  washed  out  in  the 
stream  of  urine  and  be  mistaken  for  tubercle  bacilli  in  the  sediment. 

(a)  Tuberculosis  of  the  Kidneys  {Phthisis  renuvi). — In  general  tuber- 
culosis the  kidneys  frequently  present  scattered  miliary  tubercles.  In  pul- 
monary tuberculosis  it  is  common  to  find  a  few  nodules  in  the  substance 
of  the  organ,  or  there  may  be  pyelitis.  Primary  tuberculosis  of  the  kidneys 
is  not  very  rare.  In  a  majority  of  the  cases  the  process  involves  the  pelvis 
and  the  ureter  as  well,  sometimes  the  bladder  and  prostate.  In  only  1  of 
8  cases  was  the  prostate  involved.  It  may  be  difficult  to  say  in  advanced 
cases  whether  the  disease  has  started  in  the  bladder,  prostate,  cr  vesicles, 
and  crept  up  the  ureters,  or  whether  it  started  in  the  kidneys  and  pro- 
ceeded downward.  In  a  majority  of  cases,  I  believe,  the  latter  is  true,  and 
the  infection  is  through  the  blood.  One  kidney  alone  may  be  involved,  and 
the  disease  creeps  down  the  ureter  and  may  only  extend  a  few  millimetres 
on  the  vesical  mucosa.  A  man  with  aortic  insufRciency,  who  had  no 
k-sions  in  the  lungs,  prosonted  a  localized  patch  in  the  pelvis  of  the  kidney, 
involving  a  pyramid,  while  the  ureter,  5  cm.  from  the  bladder  and  at  its 
orifice,  was  thickened  and  tuberculous.  The  prostate  showed  an  area  of 
caseation.  The  process  is  most  common  in  the  middle  period  of  life,  but  it 
may  occur  at  the  extremes  of  age.  It  is  more  frequent  in  men  than  in 
women.  In  the  earliest  stage,  which  may  be  met  with  accidentally,  the  dis- 
ease is  seen  to  begin  in  the  pyramids  and  calyces.  Xecrosis  and  caseation 
proceed  rapidly,  and  the  colonies  of  tubercles  start  throughout  the  pyramids 
and  extend  upon  the  mucous  membrane  of  the  pelvis.  As  a  rule,  from  the 
outset  it  is  a  tuberculous  pyo-nephrosis.    The  disease  may  be  confined  to  one 


TUIJKRCULOSIS. 


826 


tuber- 
n  pul- 
istance 
idneys 
pelvis 
y  lof 
anced 
sides, 
I  pro- 
0,  and 
d,  and 
metres 
ad   no 
idney, 
at  its 
rca  of 
but  it 
lan  in 
he  dis- 
cation 
ramids 
m  tbe 
to  one 


]<idnoy,  or  progress  more  extensively  in  one  than  in  the  other.  At  autopsy 
lioth  orjiiuis  urc  iisimlly  round  enlarged.  One  kichicy  may  lie  cniniiU'ti'ly 
destroyed  and  converted  into  a  series  of  cysts  containing  clieesy  substance — 
a  i'orni  of  kidney  which  the  older  writers  called  scrofulous.  In  the  imtty- 
like  coidcnts  of  these  cysts  lime  salts  may  be  dejwsited.  In  other  instances 
the  walls  of  the  j)elvis  are  thi(kene(l  and  cheesy,  the  jiyramids  eroded, 
and  caseous  nodules  are  scattered  through  the  organ,  even  to  the  capsule, 
which  may  be  thickened  and  adherent.  'JMio  other  organ  is  usually  less 
atfeeted,  and  shows  only  pyelitis  or  a  superficial  necrosis  of  one  or  two  pyra- 
mids. Tiie  ureters  are  usually  thickeiu-d  and  the  mucous  membrane  ulcer- 
ated and  caseous.  Involvement  of  the  l)la(hU'r,  vesicula>  si'niinales,  and 
testes  is  not  uncommon  in  males. 

The  si/Dijitovis  are  those  of  ])yelitis.  The  urine  may  he  ])urulent  for 
years,  and  there  may  be  little  or  no  distress.  J*]ven  before  the  l)ladder  be- 
comes involved  nucturition  is  frecpient,  and  nuuiy  instances  are  mistak(>n 
for  cystitis.  The  condition  is  for  many  years  compatible  with  fair  health. 
The  curability  is  shown  by  the  accidental  discovery  of  the  so-called  scrofu- 
lous kidney,  converted  into  cysts  containing  a  putty-like  substance.  In 
<'ases  in  which  the  disease  beconu^s  advanced  and  both  organs  are  affected, 
•constitutional  sym})toms  are  more  marked.  There  is  irregular  fever,  with 
<?hills,  and  loss  of  weight  and  strength.  General  tuberculosis  is  common. 
In  only  one  of  my  cases  were  the  lungs  uninvolved.  In  a  case  at  the 
Montreal  General  IIos))ital  a  cyst  perforated  and  caused  fatal  i)eritonitis. 

Physical  exanunation  may  detect  special  tenderness  on  one  side,  or  the 
kidney  may  be  i)alpable  in  front  on  deep  pressure;  but  tuberculous  pyelo- 
nephritis seldom  causes  a  large  tumor.  Occasionally  the  jjclvis  be- 
comes enormously  distended;  but  this  is  rare  in  comparison  with  its 
frequency  in  calculous  pyelitis.  The  urine  presents  changes  similar  to 
those  of  ordinary  calculous  pyelitis — pus-cells,  e})itheliuni,  and  occasionally 
definite  caseous  masses.  Albumin  is,  of  course,  present.  Tubercle  bacilli 
may  be  demonstrated  by  the  ordinary  methods.  Tube-casts  are  not  often 
seen. 

To  distinguish  the  condition  from  calculous  pyelitis  is  often  difficult. 
Haemorrhage  may  be  present  in  both,  though  not  nearly  so  frequently  in 
the  tuberculous  disease.  The  diagnosis  rests  on  three  points:  (1)  The  de- 
tection of  some  focus  of  tuberculosis,  as  in  the  testes;  (2)  the  presence  o. 
tubercle  bacilli  in  the  sediment;  and  (3)  the  use  of  tuberculin.  In  woman 
the  kidney  involved  is  now  easily  determined  by  catheterizing  the  ureters 
after  the  plan  of  my  colleague  Kelly. 

The  incidence  of  renal  implication  in  uro-gcnital  tuberculosis  may  be 
gathered  from  Orth's  Gottingen  material,  analyzed  by  Oppenhcim.  Of  GO 
cases  there  were  34  in  which  the  kidneys  were  involved. 

Tuberculosis  of  the  suprarenal  capsules  will  be  considered  under  Ad- 
dison's Disease. 

(h)  Tuberculosis  of  the  Ureter  and  Bladder. — This  rarely  occurs  as 
■a  primary  affection,  but  is  nearly  always  secondary  to  involvement  of  other 
parts,  particularly  the  pelvis  of  the  kidney.  In  the  case  of  uro-gcnital 
.tuberculosis,  above  mentioned,  in  a  patient  who  died  of  heart-disease,  the 


326 


SPKC'IFIC   !NPI<X'TI0rs   DISKASKS. 


/ 


ureter,  jiii^t  wlicru  it  l-uIits  the  bladdiT,  sliuued  a  h'i^Ai  i)aleh  <if  tubcr- 
ciildsis. 

rrotrnctt'd  cystitis,  which  lins  conic  on  withoul  iippiirt'iit  cause,  is 
always  sujr^csiivc  of  (uhcrculosis.  I'lic  renal  re^'ions,  the  testes,  and  tlio 
prostate  should  Ix!  examined  with  care.  It  may  follow  u  i)yelo-ne|thritis, 
or  he  associated  with  primary  disease  of  the  prostate  or  vcsieula-  seiidnalcs. 
Primary  tulforculoKJs  of  the  posterior  wall  n\'  ihe  bladder  may  simulate 
stone. 

(r)  Tuberculosis  of  the  Prostate  and  VesiculsD  Seminales. — The  pros- 
tate is  frecpiently  involved  in  tuherculosis  of  the  uro-i^^enilal  tract.  In 
Krzyincki'a  ca.ses,  of  1.')  males  the  prostate  was  involved  in  11  and  the 
vesicuhc  seminales  in  II.  In  Orth's  cases  the  prostate  wa.s  involved  in  is 
of  the  .'i7  cases  in  males.  These  parts  are  much  more  frcipiently  involved 
than  ordinary  post-mortem  statistics  indicati'.  Per  irrltiin  the  prostatic 
lolx's  are  felt  to  ho  occupied  by  hard  nodules  varyin»?  in  size  from  a  pea  to 
a  hean.  There  is  great  irritahility  of  the  bladder,  and  ajfonizin",'  pain  in 
catheterization.  An  extremely  rai-e  lesion  is  |)rimary  urethral  tuberculosis, 
which  may  simulate  stricture. 

{(/)  Tuberculosis  of  the  Testes. — This  .somewhat  common  alTection 
may  hi!  primary^  oi*,  more  fre(|iiently,  is  secondary  to  tuberculous  disease 
elsewhere,  ^lany  cases  occur  before  the  second  year,  and  it  is  stated  to 
luive  been  nu't  with  in  the  fo'tus.  Jn  inhmts  it  is  serious  and  usually  asso- 
ciated with  tuberculous  disease  in  other  parts.  In  !J  cases  reported  by 
llutincl  and  I )eschani])s,  in  evi-ry  om>  there  was  a  jycnoral  alTection.  In 
yd  cases  reported  by  Jidlien,  (!  were  under  one  year,  and  (!  between  one 
and  two  years  old.  In  5  of  the  cases  both  testicles  were  alTected.  Ko])lilv 
holds  that  most  of  the  instances  of  this  kind  are  con<^enital,  in  J>aum;^arten's 
ponso.  Tn  the  adult  the  tubercles  be^in  within  the  substance  of  the  <;-land, 
but  in  cliildi'en  the  tunica  albuf^inea  is  (irst  alTected.  I'ho  tubercle  does 
not  always  underLjo  caseation,  but  it  may  present  a  nuud)er  of  endjryou'C 
cells,  not  unlike  a  sarcoma. 

Tubercle  of  the  testes  is  most  likely  to  be  confounded  with  sy]ihilis. 
In  the  latter  the  Iiody  of  the  or<ian  is  most  often  all'ected,  there  is  less 
pain,  and  the  outlines  of  the  growth  are  more  nodular  and  irregular.  In 
obscure  ])eritoneal  disease  the  detection  of  tubercle  in  a  testis  has  not  in- 
fre(|uently  led  to  a  correct  diagnosis.  The  assoeiation  of  the  two  condi- 
tions is  not  nncomnion.  The  lesion  in  the  testis  may  heal  completely,  or 
the  d'soasc  may  become  generalized,  (ieneral  infection  has  followed  o])era- 
tion.  Too  much  stress  cannot  he  laid  on  the  importance  of  a  routine 
examination  of  the  testes  in  hospital  patients. 

(i')  Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus.— The 
Fdllnpian  ttihcs  are  by  far  the  most  frocpicnt  seat  of  genital  tubercidosis. 
The  disease  may  he  primary  and  produce  a  most  characteristic  form  of 
sal])ingitis,  in  which  the  tubes  are  enlarged,  the  walls  thickened  and  infd- 
trated,  and  the  contents  cheesy.  Adhesion  takers  place  between  the  fiml)ria' 
atid  the  ovaries,  or  the  uterus  may  be  invaded.  The  condition  is  usually 
bilateral.  It  may  occur  in  yonng  children.  Although,  as  a  rule,  very  evi- 
dent to  the  naked  eye,  there  are  specimens  resembling  ordinary  salpingitis. 


TrUKIll'l'LOSIS. 


327 


whicJi  hIiow  f)ti  niirrnscrtpifiil  oxamiuntion  nnniornus  milinry  tuhcrcli's 
(W'flc'h  1111(1  Williams).  'I'lilK'rtiiiuii.s  i^alpiii^jilis  iiuiy  caurtt'  bcrioiiri  local 
(iisciisu  with  aljsct'ss  ronnatiuu,  and  it  may  be  tlio  blartiiig-poiut  of  pcri- 
loiiitis. 

'i'lilxTciilosis  (tf  ili(>  orori/  is  always  secondary.  Tlicrc  may  be  an  crnp- 
tion  of  tuhcrcics  over  the  siirface  in  an  extensive  involvement  ol'  the  stroma 
with  ahseess  I'ormation. 

'rulierciilosis  of  till'  uterus  is  vcit  rai'c.  Only  tlirct'  examples  have  come 
iinder  my  observation,  all  in  connection  with  pnlnumary  phthisis.  It  may 
Ite  jtrimary.  The  mncosa  of  the  fundns  is  thickened  and  casi'ons,  and  tnber- 
cli's  may  be  seen  in  the  mnscnlar  tissue.  Uceasiunaily  the  ])rucess  e.\tend.s 
to  the  vagiiui. 


;vphilis. 
■  is  less 
lar.  Tn 
not  in- 
condi- 
ely,  or 
o])era- 
routine 

-The 

rcnhjsis. 
orm  of 
d  infd- 
fimbriiC 
usually 
cry  ovi- 
)iiigitis. 


IX.  Ti;ui:iicuLosis  oi'  tin:  ^Fa.mmahy  C.i-and. 

^landry  (lirnns's  ]k'itriige,  viii)  has  collected  -10  cases,  1  of  which  was 
in  a  mall'.  The  disease  is  most  common  between  the  fortieth  and  sixtieth 
years.  The  breast  is  fre(|nently  (istnlous,  nneveidy  indurated,  and  the 
Jiipple  is  retracted.  The  listnhe  and  ulcers  present  a  characteristic  tuber- 
culous asjjcct.  '^riiere  is  also  a  cold  tuberculous  abscess  of  the  breast.  The 
axillary  glands  are  all'ected  in  about  two  thirds  of  the  cases.  The  disease 
runs  a  chronic  course  of  months  or  years.  The  diagnosis  can  be  made  by 
the  general  a])pearance  of  the  listuhe  and  ulcers,  and  by  the  existence  of 
tubercle  bacilli.  The  progiujsis  is  lujt  bad,  if  total  eradication  of  the  dis- 
ease be  ])ossil)le. 

In  18.'^(!  l)edor  descrihed  aii  hypertrophy  of  the  breast  in  the  suhjects 
of  pulmonary  tuberculosis.  As  a  rule,  if  one  gland  is  involved,  usually  on 
the  side  of  the  all'ected  lung,  as  already  nu'utioned,  the  condition  is  one  of 
chronic  interstitial  mammitis,  and  is  not  tuberculous. 

X.  Tuni'^RCULOsis  of  thh  Ci urn. atouy  Systkaf. 

(fl)  Myncarilinm. — Scattered  miliary  tubercles  are  sometimes  met  with 
in  the  acute  disease.  Larger  caseous  tubercles  are  excessively  rare.  Alfred 
Hand,  Jr.,  has  reported  2  cases  and  reviewed  .'?!)  instances  in  the  litera- 
ture. 

{h)  EiuJnrnnli  1(1)1. — Tn  t.'l()  autopsies  in  cases  of  chronic  ]ihthisis  I  found 
endocarditis  in  12.  As  a  rule,  it  is  a  secondary  form,  the  result  of  a  mixed 
infection,  so  common  in  ])ulmonary  tuberculosis.  A  true  t\d)erculoiis  en- 
docarditis does,  however,  occur,  directly  dependent  upon  infection  with 
the  bacillus  of  Koch.  As  a  ride,  it  is  a  vegetative  endocarditis,  not  to  hi; 
distinguished  from  that  caused  l)y  the  strc])tococcus  or  staphylococcus.  In 
rare  cases,  however,  caseous  tubercles  develop. 

(r)  Arfpries. — Primary  tuberculosis  of  the  larger  hlood-vessels  is  un- 
known. The  disease  may,  however,  occur  in  a  largo  artery  and  not  result 
from  external  invasion.  In  a  case  of  chronic  tuherculosis  Flexner  found  a 
fresh  tuberculous  growth  in  the  aorta,  which  had  no  connection  with  cheesy 
masses  outside  the  vessel. 


m 


c:3 


SPECIFIC?  INFKrTIOUS  DISRASKS. 


In  the  hint's  and  otliiT  ()rj,'aiirt  iitta<'kiMl  by  tiiborciiloHirt  the  artcricH  nn* 
involved  in  an  acutu  inlillration  wliidi  usually  InidM  to  throinltoHiH,  or  tulxT- 
clcs  may  develop  in  the  walls  and  proceed  to  caseation  and  soi'ti'iiin;;  I'rc- 
<|iicntly  with  the  result  of  hu'iMorrlia<,'e.  Uy  extension  into  vessels,  particu- 
larly veins,  the  hacilli  are  widely  distrihuteil.  Jn  nieningilib  tuberculoais 
of  the  arteries  playH  an  ini[iortant  rule. 


/ 


XI.    DiAONOHIS    OF    Tl'UKHCULOSIS. 

The  recognition  of  the  diaoaso  usually  rests  upon  the  inacroscopical' 
nnd  nncroseopieal  appearances  of  the  lesions  and  the  pr-sence  of  the  char- 
acteristic Imcilli.  or  late  an  important  additional  dia^fiiostio  agent  has 
heen  introduced  in  tin;  form  of  Koch's  tuberculin.  J"'or  some  years  Tru- 
deau  has  insisted  upon  the  harndessness  of  its  use  in  the  diagnosis  of  ob- 
scure cases.  During  the  |)ast  few  years  it  has  been  employed  extensively 
at  the  Johns  Ilojikins  Hospital,  both  on  the  medical  an<l  surgical  sides, 
with  the  most  satisfactory  results,  and,  so  far  as  I  know,  without  any  harm- 
ful ell'ects.  Jn  obscure!  iidernal  lesions,  in  joint  cases,  and  in  sus[)ected 
tuberculosis  of  the  kidneys  the  nso  of  the  tuberculin  gives  most  valuable 
information.  I  may  mention,  for  example,  an  instance  of  A<ldison's  dis- 
ease in  a  young,  very  muscular  man  without  any  sign  whatever  of  visceral 
tuberculosis.  The  reaction  (as,  indeed,  migiit  have  been  expected)  was 
very  characteristic.  We  have  nsed  the  tuberculin  kindly  furnished  from 
the  Saranac  Laboratory,  which  is  nuide  on  Koch's  origiiuU  plan.  In  adidts^ 
a  milligramme  is  employed,  and  if  this  has  no  reaction  a  Iarg(!r  dose  of  two 
or  three  milligrammes  is  em|)l()ye(l  in  two  or  three  days.  There  is  often 
slight  local  irritation  following  the  injection,  and  within  from  ton  to  twelve 
hours  the  febrde  reaction  begins,  the  temperature  rising  to  from  10!;?° 
to  101°. 

XII.  Thk  Proonosis  in  TunEiicuLosis. 

Not  all  persons  in  whose  bodies  the  bacilli  gain  a  foothold  present 
marked  signs  of  tnbcrcnlosis.  As  will  be  stated  in  the  next  section,  local 
disease  is  found  in  a  considerable  nnmber  of  all  cadavers.  Infection  does 
not  necessarily  mean  the  establishment  of  a  ])rogressivo  and  fatal  disease. 
In  my  antopsies,  excluding  cases  dead  of  pulmonary  ])hthisis,  7,5  per  cent 
presented  tuberculous  lesions  of  the  lungs — a  low  percentage  in  compari- 
son with  other  records,  as  I  carefully  excluded  the  simjde  fil)roid  pucker- 
ing at  the  apex,  and  the  solitary  cheesy  nodules,  imless  surrounded  by  colo- 
nies of  tidjercles. 

In  many  cases  a  natural  or  spontaneous  cure  is  effected,  for  the  condi- 
tions favorable  to  the  development  of  the  disease  are  not  present — in  other 
words,  the  tissue-soil  is  unsuitable.  Apart  from  this  group,  a  majority  of 
which  probably  do  not  show  any  sign  of  disease,  there  may  be  spontaneous 
arrest  after  the  symptoms  have  become  decided.  Many  years  ago  Flint 
called  attention  to  the  self-limitation  and  intrinsic  tendency  to  recovery 
in  well-marked  pulmonary  tuberculosis.  Of  his  G70  cases,  44  recovered, 
and  in  31  the  disease  was  arrested,  spontaneously  in  23  of  the  first  group' 


TUMKUCI'LOSIS. 


829 


rt  nro 
uhcr- 

rlitii- 
uluriis 


lopical! 
I  flmr- 
ut  has 
rt  Tni- 
ol"  ()))- 
iisivi'ly 

I  sides, 
■  luinn- 

SJH'cll'tl 

■aluablo 
n'tf  (li^*- 
viscerai 
lmI)  was 
•d   from 

II  adults 
.'  of  two 
is  often 
1)  twelve 


present 
l)n,  local 
Ion  docs 

disease, 
her  cent 
[ompari- 

pucker- 
|l)y  colo- 

condi- 

im  other 

lority  of 

itaneous 

JO  Flint 

recovery 

|C0V( 


,'ere( 


1, 


and  in  1.'  of  Ihc  second.    This  natural  IciiilfiK y  to  cnrc  is  still  tnoro  strik- 
iiij^dy  shown  in  lymphatic  and  hone  Inhcn  nln>is. 

The  following;  may  l)e  considered  favnndile  circumstances  in  the  pi'oj?- 
nosis  of  pidmonary  tnhereulosis;  A  j;ood  family  history,  previourt  good 
health,  a  strong'  di;;es1ion,  a  suitalde  environment,  and  an  insidions  onsets 
without  hi;^h  fever,  and  without  extensive  pneumonic  consolidation.  Cases 
l)e;;innin;4'  uitli  pleurisy  seem  to  run  a  ni<»re  protraetcil  and  more  favttrahle 
eonrsc.  Repeated  attacks  of  lui'inoptysis  are  unfavorahle.  When  well  estah- 
lishi'd  the  conrso  of  tuhereulosis  in  any  orpin  is  marked  hy  intervals  of 
wcclxs  or  ninntlis  in  which  the  fever  lessens,  the  symptoms  suhside,  and 
there  is  improvement  in  the  fjeneral  health. 

In  iiulmonary  cases  the  duration  is  extremely  variahle.  Tiaennec  placed 
the  avera^^e  duration  at  two  years,  and  for  the  majority  of  eases  this  is 
perhaps  a  correct  estiinatc.  Pollock's  lar^'c  statistics  of  over  !?..'»()()  cnses 
shows  a  mean  duration  of  t  '  disease  of  ovt-r  two  years  and  a  half.  Wil- 
liams's analysis  of  1,000  case,-  in  private  practice  shows  a  much  ni(»re  pro- 
tracted course,  as  the  nveraf,'e  duration  was  over  seven  years. 

Under  the  snhject  of  pro^jnosis  comes  the  (piestion  of  the  niarriajre  of 
persons  who  have  had  tuhereulosis,  or  in  whose  family  the  disease  i)revails.. 
The  followinjf  hrief  statements  may  he  made  with  reference  to  it: 

(n)  Subjects  with  liealed  lymphatic  or  hone  tuhereulosis  marry  witlr 
j)ers()nal  iinimnity  and  may  l)e<ifet  liealthy  children.  It  is  nndeniahle,  how- 
ever, that  in  snch  families,  scrofnla,  caries  of  the  hone,  arthritis,  cerehraV 
and  pulmonary  tuhereulosis  are  more  common.  Which  is  it,  "  hereilite 
de  [jraine  on  heredite  de  terrain,"  as  the  French  have  it,  the  seed  or  the 
soil,  or  l)oth?  We  cannot  yet  say.  The  risks,  liowever,  are  such  as  may 
jiroperly  he  taken. 

{!))  The  (piestion  of  marriajje  of  a  ])erson  who  has  arrested  or  cured 
lun<j^  tuhereulosis  is  more  diillcult  to  decide.  In  a  male,  the  j»ersonal  risk 
is  not  so  great;  and  wlien  the  liealth  and  strength  arc  good,  the  external 
environment  favorable,  and  the  family  history  not  extremely  bad  the  ex- 
periment— for  it  is  such — is  often  successful,  and  many  healthy  and  happy 
families  arc  l)egotten  nndcr  these  circumstances.  In  women  the  (piestion 
is  complicated  with  that  of  child-bearing,  which  increases  the  risks  enor- 
mously. With  a  localized  lesion,  absence  of  hereditary  taint,  good  ])hy- 
si(pie,  and  favorable  environment,  marriage  might  be  ])ermitted.  When 
tul)(^rcnlosis  has  existed,  however,  in  a  girl  whose  family  history  is  l)ad, 
whose  chest  expansion  is  sl'ght,  and  whose  physi(pie  is  below  the  standard,, 
the  physician  shonld,  if  possible,  ]>]ace  his  veto  njwn  marriage. 

(r)  With  existing  disease,  fever,  bacilli,  etc.,  marriage  shonld  be  pro- 
hibited. Pregnancy  nsnally  hastens  tlie  ]irocoss,  though  it  may  be  held 
in  abeyance.  After  parturition  the  disease  advances  rapidly.  There  is 
much  trrth,  indeed,  in  the  remark  of  Dubois:  "  If  a  woman  threatened  with 
phthisis  marries,  she  may  bear  the  first  accouchement  well;  a  second,  witli 
difficulty;  a  third,  never."  Conception  may  occur  in  an  advanced  stagfr 
of  the  disease. 


\ 


ill 


kt  group' 


330 


SPI']CIFIC  INFECTIOUS  DISEASES. 


/ 


XIII.     PliOJ'IIYLAXIS    1\    'rriiKIULLOSIS. 

{(i)  Clnicral — The  sj)iiia  of  ])litliisi(iil  patients  s^lioultl  Ije  carefully  col- 
k'ctod  and  di'stroycd.  I'atit'iits  should  hu  iirycd  not  to  spit  about  caru- 
k'Hsly,  l)ut  always  to  use  n  spit-cup  and  never  to  swallow  the  sputa.  Sev- 
eral forms  of  portal)le  llasks  have  l)een  devised  and  are  now  on  sale.  The 
destruction  of  the  sputa  of  consuni])tives  should  he  a  routine  measure  in 
l)olh  lios])ital  and  private  ]iractice.  Thorou<rh  boiling  or  i)uttinjf  it  into 
the  lire  is  suilicient.  In  hospitals  it  is  well  to  have  printed  directions  as 
to  the  care  of  the  sputa  and  also  ])riutcd  cards  for  out-])atients,  j^iving  the 
most  important  rules.  It  should  be  e.\])lained  to  the  patient  that  the  only 
risk,  ]»ractically,  is  from  this  source.  The  chances  of  infection  are  fireatest 
in  youujf  children.  The  nursin<i^'  and  care  of  consumptives  involve  very 
sli<;lit  risks  indeed  if  jjroper  precautions  are  taken.  The  patient  should 
occupy  a  sin,u'le  bed. 

A  second  im]iortant  <;x'neral  prophylactic  measure  relates  to  the  inspec- 
tion of  dairies  and  sIau<ihter-liouses.  The  ])ossibility  of  the  transmission 
of  tuberculosis  by  infected  milk  has  been  fully  demonstrated,  and  in  the 
interest  of  public  healtli  the  state  should  take  measures  to  stamp  out  tuber- 
culosis in  cattle.  .Systematic  veterinary  inspection  of  dairies,  particularly 
in  the  larj^c  cities,  should  l)e  made,  and  'full  power  trranted  to  confiscate  and 
kill  susi)ected  animals.  The  abattoirs  should  be  under  skilled  veterinary 
control,  and  the  carcasses  of  animals  with  advanced  tuberculosis  confis- 
cated. 

The  advisability  of  jdacing-  ])ulmonary  tuberculosis  on  the  list  of  dis- 
eases of  which  notice  must  be  fi'iveu,  has  been  much  discussed.  I  am 
strongly  in  favor  of  it.  The  hardshi|)s  entailed  upon  individuals  are  trifling 
in  comparison  with  the  ])ul)lie  good  which  would  follow  the  adoption  of 
systematic  measures  of  ins|)ection  and  disinfection. 

(h)  IndivuhtiiJ. — A  nu)ther  with  pulmonary  tulierculosis  should  not 
suckle  her  child.  An  infant  born  of  tr,l)erculous  parents,  or  of  a  family 
in  which  consumption  ])revails,  should  be  Ijrought  up  with  the  greatest 
care  and  gnardvxl  most  ])articularly  against  catarrhal  affections  of  all  kinds. 
Special  attentif)ji  should  be  given  to  the  throat  and  nose,  and  on  the  first 
indication  of  moiith-breathing,  or  any  obstruction  of  the  naso-])harynx, 
a  careful  examination  should  l)e  made  for  adenoid  vegetations.  The  child 
should  be  clad  in  flannel  and  live  in  the  o])en  air  as  much  as  possible,  avoid- 
ing close  rooms.  It  is  a  good  practice  to  sponge  the  throat  and  chest  night 
and  morning  with  cold  water.  Special  attention  should  be  paid  to  diet 
aiul  to  the  mode  of  feeding.  The  meals  should  be  at  regular  hours  and 
the  food  ])lain  and  substantial.  From  tlie  outset  the  child  shoidd  be  en- 
couraged to  drink  freely  of  milk.  I'nfortunately.  in  these  cases  there 
seems  to  be  an  uncontrollable  aversion  to  f'ats  of  all  kinds.  As  the  child 
grows  older,  systematically  regulated  exercise  or  a  course  of  ])ulmonary 
gymnastics  may  be  taken.  In  the  choice  of  an  occ;ipation  ])reference 
should  be  given  to  an  out-of-door  life.  Families  with  a  marked  predisposi- 
tion to  tuherculosis  should,  if  possible,  reside  in  an  ecpiable  climate.  It 
would  1)0  best  for  a  young  man  belonging  to  such  a  family  to  remove  to 


oil 


TUBERCULOSIS. 


331 


Colorado  or  Southern  California,  or  to  some  other  suitable  climate,  before 
trouble  be<;ins. 

The  trilling  ailments  of  children  should  be  carefully  ^vatehed.  In  the 
convalescence  from  the  fevers,  which  so  freciuently  prove  dangerous,  the 
greatest  caution  should  be  exercised  to  prevent  catching  cold.  Cod-liver 
oil,  the  syrup  of  the  iodide  of  iron,  and  arsenic  may  be  given.  As  nu-n- 
tioned,  care  of  the  throat  in  these  children  is  very  important.  Enlarged 
tousils  should  be  removed. 


XIV,  Treatmext  of  Tuberculosis. 

I.  The  Natural  or  Spontaneous  Cure. — The  si)ontaneous  healing  of 
local  tuberculosis  is  an  every-day  alfair.  Many  cases  of  a-"  ^'.itis  and  dis- 
ease of  the  bone  or  of  the  joints  terminate  favorably.  The  sealing  of  pul- 
monary tulierculosis  is  shown  clinically  by  the  recovery  of  patients  in  whose 
sputa  elastic  tissue  and  bacilli  have  been  found;  anatomically,  by  the  pres- 
ence of  lesions  in  all  stages  of  repair.  In  the  granulation  ju-oducts  and 
associated  pneumonia  a  scar-tissue  is  formed,  while  the  smaller  caseous  areas 
become  impregnated  with  lime  salts.  To  such  conditions  alone  should 
the  term  healing  l)e  ap])lied.  When  the  liljroid  change  encapsulates  but 
does  not  involve  the  entire  tuberculous  tissue,  the  tuljcrcle  may  be  termed 
involuted  or  quiescent,  but  is  not  destroyed.  AVIien  cavities  of  any  size 
have  formed,  healing,  in  the  ])roi)er  sense  of  the  term,  does  not  occur. 
I  have  yet  to  see  a  specimen  which  would  indicate  that  a  vomica  had  cica- 
trized. Cavities  may  be  greatly  reduced  in  size — indeed,  an  entire  series 
of  them  may  be  so  contracted  by  sclerosis  of  the  tissue  about  them  that 
an  u])per  lol)e,  in  which  this  process  most  frequently  occurs,  may  be  re- 
of  'I  duced  to  a  third  of  its  ordinary  dimensions.  Laennec  understood  thor- 
oughly this  natural  process  of  cure  in  tuberculosis,  and  recognized  tlie 
id    not  freciuency  with  which  old  tuberculous  lesions  occurred  in  the  lungs.     He 

k'amily  described  cicatrices  completes  and  cicatrices  fstiileuscs,  the  latter  being  the 

[icatest  shrunken  cavities  communicating  with  the  bronchi;  and  remarked  that,  as 

kinds.  tubercles  growing  in  the  glands,  wliich  are  called  scrofula,  often  heal,  why 

lie  first         I      should  not  the  same  take  ])lace  in  the  lungs? 

larynx,        |  There  is  an  old  German  axiom,  "Jedermann  lint  am  Endc  ein  hisclicn 

child  [  TuJjercvlosc"  a  statement  partly  borne  out  by  the  statistics  showing  the 
avoid-  I  proportion  of  cases  in  persons  dying  of  all  diseases  in  whom  quiescent  or 
night  I  tul)erculous  lesions  are  found  in  the  lungs.  We  find  at  the  a])ices  the 
lo  diet  I  following  conditions,  which  have  been  held  to  signify  healed  tuljcrculous 
irs  and  processes:  (1)  Thickening  of  the  pleura,  usually  at  tlie  posterior  surface 

|be  en-  of  the  ap(>x,  witli  subadjacent  induration  for  a  distance  of  a   few  niilli- 

there  metres.     '^Flus  has,  perhaps,  no  great'^r  significance  than  the  milky  jmtch 

child  on  the  pericardium.     (3)  I'uckercd  cicatrices  at  the  apex,  dejiressing  the 

ponary  ])leura,  and  on  section  showing  a  large  ]tigmented,  fil)rous  scar.    The  bron- 

[erence  chioles  in  the  neighborhood  may  be  dilated,  but  ther        e  neither  tubercles 

jsposi-  I  nor  cheesy  masses.  This  may  sometimes,  but  not  alwavs,  iiulicate  a  healed 
:e.  It  I  tuber'^-ulous  lesion.  ('^)  Puckered  cicatrices  witli  cheesy  or  cretaceous 
lOve  to       I    nodules,  and  with  scattered  i.il)ercle3  in  the  vicinity.     (4)  The  cicatrices 

21 


332 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


fislnlcvses  of  Laenncc,  in  whicli  tlio  fibroid  jnicla'ring  has  reduced  the  sizo 
of  one  or  more  cavities  which  conuniinicate  directly  witli  tlie  bronchi. 

In  1, ()()()  autopsies,  exciiidiu^'  tiie  J-'K!  cases  dead  of  ])htiiisis,  tiiere  were 
51)  cases  (T.o  j)er  cent)  wliicii  ])resented  undoubted  tubercidous  k'sions  in 
the  lungs.  I  excluded  the  simple  fibroid  puckering  and  the  solitary  cheesy 
nodules,  unless,  in  the  latter  case,  there  were  colonies  of  tubercles  in  the 
vicinity.  These  ;")!)  cases  died  of  various  diseases  and  at  various  ages.  A 
majority  of  tliem  were  between  forty  and  sixty.  My  experience  tallie:- 
closely  with  the  larger  analysis  made  by  Jfeitler  of  tiie  Vienna  })ost-mortem 
records,  in  which,  of  lG,r)6;;3  eases  in  which  the  death  was  not  directly  caused 
by  phthisis,  there  were  7SU  instances  of  obsolete  tubercle — a  percentage  of 
4.7.  He  excluded,  as  I  have  done,  the  simple  fibroid  induration,  ^'ari- 
ous  oljservations  have  been  made  of  late  in  which  the  ])ercentage  ranges 
from  27  (liollinger)  to  39  (]\lassini).  In  200  autoi)sies,  in  which  this  point 
was  specially  examined,  Harris  found  38.8  ])er  cent  in  which  there  were 
relics  of  former  active  tuberculosis.  The  statement  is  made  l)y  Jjouchard 
that,  of  the  ])ost-mortems  at  the  Paris  morgue — generally  upon  persons 
dying  suddenly — the  jjercentage  found  Avith  some  evidence  of  tuberculous 
lesion,  active  or  obsolete,  is  as  high  as  75.  These  figures  show  the  extraor- 
dinary frequency  of  pulmonary  infection  and  the  encouraging  fact  that  in 
so  large  a  ])ercentage  the  disease  remains  local  and  undergoes  a  process  of 
arrest  or  healing. 

.II.  General  Measures. — The  cure  of  tubercidosis  is  a  question  of  nutri- 
tion; digestion  and  assimilation  control  the  situation;  make  a  patient  grow 
fat  and  the  local  disease  may  be  left  to  take  care  of  itself.  There  are  three 
indications:  First,  to  place  the  })atient  in  surroundings  most  favorable  for 
the  maintenance  of  a  maximum  degree  of  nutrition;  second,  to  take  such 
measures  a.s,  in  a  local  or  general  way,  influence  the  tuberculous  processes; 
third,  to  alleviate  sym]itoms. 

Open-air  Treatment. — The  value  of  fresh  air  and  out-of-door  life 
is  ■well  illustrated  by  an  experiment  of  Trudeau.  Inoculated  raljl)its  con- 
fined in  a  dark,  dam])  place  rapidly  succumbed,  while  others,  allowed  to  run 
wild,  either  recovered  or  showed  slight  lesions.  It  is  the  same  in  human 
tuberculosis.  A  patient  confined  to  the  house — ])artic''larly  in  the  close, 
overheated,  stufTy  dwellings  of  the  poor,  or  treated  in  .  hos])ital  ward — 
is  in  a  j)Osition  analogous  to  that  of  the  rabbit  confined  to  a  hutch  in  the 
cellar;  whereas  a  patient  living  in  the  fresh  air  and  sunshine  for  the  greater 
part  of  the  day  has  chances  comparable  to  those  of  the  rabbit  running  wild. 

The  open-air  treatmeiit  of  tu1)erculosis  may  be  carried  out  at  home, 
by  change  of  residence  to  a  suitable  climate,  or  in  a  sanatorium. 

{a)  At  Home. — In  a  majority  of  all  cases  the  patient  has  to  be  cared  for 
in  his  own  home,  and  if  in  the  city,  lender  very  disadvantageous  circum- 
stances. ]\ruch,  however,  may  be  done  even  in  cities  to  promote  arrest  by 
insisting  upon  ])lenty  of  fresh  air.  It  is  often  impossible  to  attempt  any 
systematic  open-air  treatment  in  city  life,  hut  there  are  many  cases  in  which 
it  can  be  done  if  the  physician  insists  and  if  he  lays  down  ex]ilicit  rules. 
The  patient's  bed  sliould  be  in  the  room  with  most  sunshine.  While  there 
is  fever  he  should  l)e  at  rest  in  bed,  and  for  the  greater  i)art  of  each  day, 


TUBERCULOSIS. 


888 


IP   ?\7.0 

ons  in 
choosy 
ill  the 
es.     A 

tallies 

iiortoin 

CiUisod 

tajio  of 

Vari- 

ranges 
s  point 
ro  wore 
)uchar(l 
persons 
n'culons 
oxtraor- 

that  in 
ocess  of 

)f  nntri- 
!nt  grow 
\Ye  three 
able  for 
ike  snoh 
roeesses; 

floor  life 
)its  con- 
id  to  nin 

human 
10  close, 

ward — 
in  the 

greater 

(T  wild. 

t  home, 

cared  for 
circum- 
irrcst  hy 
|mpt  any 
in  which 
[■it  rules. 
lilo  there 
[ach  day, 


imlops  tlio  weatluT  is  ])histering  and  rainy,  tlic  windows  should  be  open, 
so  that  tlio  ])atioiit  may  l)o  exposed  freely  to  tiio  fresh  air.  Low  tompeia- 
turo  is  not  a  contraindication.  Jf  tiiore  is  a  balcony  or  a  suitable  yard,  ou 
the  brigliter  days  the  patient  may  ho  wrapped  up  and  put  in  a  reclining 
ciiair  or  on  a  sofa.  The  important  tiling  is  for  the  j)iiysician  to  ompliasize 
tlio  fact  that  neither  the  cough,  lover,  night  sweats,  and  not  ovon  luomop- 
tysis  contraindicato  a  full  o.\[)osure  to  the  fresh  air.  In  country  places 
this  can  he  carried  out  much  more  eU'ectivoly.  1  always  advise  to  give 
the  jiationt  an  almanac,  that  he  can  tick  olf  the  number  of  hours  of  sun- 
shine. In  the  summer  ho  should  ho  out  of  doors  for  at  least  eleven  or 
twelve  liours,  and  in  winter  six  or  eight  hours.  At  night  the  room  should 
be  cool  and  thoroughly  well  ventilated.  In  the  early  stages  of  the  disease 
with  much  fever,  it  may  require  several  months  of  this  rest  treatmonl  in 
the  open  air  Ix'fore  the  temperature  falls  to  normal. 

(/')  Trcatineiit  in  Sdnaturia. — rorhajjs  the  most  important  advance  in 
the  treatment  of  tuborcidosis  has  been  in  the  estal)lisliment  in  favorable 
localities  of  institutions  in  which  patients  are  made  to  live  according  to 
strict  rules.  To  Rrohmor,  of  Coborsdorf,  we  owe  the  successful  execution  of 
this  ])lan,  whicli  has  been  followed  in  Oermany  with  most  gratifying  results. 
In  this  country  the  zeal,  energy,  and  scientific  devotion  of  hldward  L. 
Trudoau  have  demonstrated  its  feasibility,  and  the  Saranac  institution 
has  become  a  model  of  its  kind.  "We  need  public  sanatoria  within  easy 
access  of  the  large  cities,  in  which  cases  of  early  tuberculosis  could- be 
treated  at  low  rates  or  at  the  public  cost.  Private  sanatoria  for  the  well- 
to-do  classes  are  urgently  needed.  The  results  at  Gobersdorf,  Falkonstein, 
and  Saranac  demonstrate  the  great  importance  of  system  and  rigid  disci- 
pline in  carrying  out  a  successful  treatment  of  tuberculosis.  The  estab- 
lishment of  Xational  Sanatoria  in  Canada,  the  Sharon  Sanatorium  near 
Boston,  in  charge  of  Dr.  Vincent  Y.  Uowditch,  the  new  Loomis  Sana- 
torium near  New  York,  and  the  establishments  at  Asheville  and  Aiken  indi- 
cate that  l)oth  the  profession  and  the  public  are  beginning  to  ajipreciate  the 
supreme  ini])ortance  of  this  method  of  treatment.  So  far  as  the  profes- 
sion is  concerned,  they  must  have  imi)licit  confidence  in  the  men  in  charge 
of  these  institutions,  in  their  integrity  and  in  their  scientific  ability.  Burton- 
Fanning  has  recently  published  some  interesting  observations  which  show 
that  this  open-air  ]ilan  of  treatment  can  be  carried  out  most  ofTectively  in 
England.  (For  an  interesting  descri]ition  of  the  method  of  life  at  Xordrach 
in  the  Black  Forest  by  a  ])liysician  cured  at  the  sanatorium,  see  pages 
393-39G  of  Fowler  andGodloe's  Diseases  of  the  Lungs.) 

(c)  C^imntic  Trenlmnif. — This,  after  all,  is  only  a  modification  of  the 
open-air  method.  The  first  question  to  be  decided  is  whether  the  patient  is 
fit  to  be  sent  from  home.  Li  many  instances  it  is  a  positive  hardship.  A 
patient  with  well-marked  cavities,  hectic  fever,  night  sweats,  and  emacia- 
tion is  much  better  at  home,  and  the  ])liysician  should  not  be  too  much 
influenced  by  the  imjiortnnities  of  the  sick  man  or  of  his  friends.  The 
requirements  of  a  suitable  climate  are  a  pure  aimnsplicrc,  an  equnhle  fein- 
prrahiir  not  subject  to  rapid  variations,  and  a  ma.rimnm  aivonnt  of  sunshine. 
Given  these  three  factors,  and  it  makes  little  difference  u-herc  a  patient 


r: 


■334 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


goes,  so  long  as  ho  lives  an  avidour  life.  Tlio  purily  of  the  atmosphere  is 
the  first  consideration,  and  it  is  this  requirement  tJiat  is  met  so  well 
in  the  mountains  and  forests.  The  dill'erent  climates  may  l)e  grouped 
into  the  higii  altitudes,  the  dry,  warm  climates,  and  the  moist,  warm 
climates. 

In  this  country  of  high  altitudes,  the  Colorado  resorts  are  the  most 
imi)ortant.  Of  others,  tlu)sc  in  Arizona  and  New  Mexico  have  been  de- 
velo[)ing  ra])idly.  The  rarefaction  of  the  air  in  high  altitudes  is  of  beneiit 
in  increasing  the  res])iratory  movements  in  i)idmonary  disease,  hut  brings 
al)out  in  time  a  condition  of  dilatation  of  the  air-vesicles  and  a  permanent 
increase  in  the  size  of  the  chest  which  is  a  marked  disadvantage  when  such 
persons  attempt  subsequently  to  reside  at  the  sea-level.  The  great  advan- 
tage of  these  western  resorts  is  that  they  are  in  ])r()gressive,  ])rosperous 
countries,  in  which  a  man  may  find  means  of  livelihood  and  live  in  com- 
fort. In  Europe  the  chief  resorts  at  high  altitudes  are  at  Davos,  Les  Avants, 
and  St.  Moritz.  Of  resorts  at  a  moderate  altitude,  Asheville  and  the  Adi- 
rondacks  are  the  best  known  in  this  country.  The  Adirondack  cure  has 
become  of  late  years  quite  famous.  Objections  to  it  are  the  expense,  ex- 
cept in  the  case  of  the  sanitorium,  but  for  well-to-do  ])eo]»le  it  is  by  far 
the  most  satisfactory  place.  One  very  decided  advantage  is  that  after 
arrest  of  the  disease  the  i)atient  can  return  to  the  sea-level  without  any 
special  risk.  The  cases  most  suitable  for  high  altitudes  are  those  in  which 
tlie  disease  is  limited,  without  much  cavity  formation,  and  without  much 
emaciation.  The  thin,  irritable  patients  with  chronic  tuberculosis  and  a 
good  deal  of  emphysema  are  better  at  the  sea-level.  The  cold  winter  cli- 
mate seems  to  be  of  decided  advantage  in  tuberculosis,  and  in  the  Adiron- 
daeks,  where  the  temiierature  falls  sometimes  to  20°  or  even  more  below 
zero,  the  patients  are  able  to  lead  an  out-of-door  life  throughout  the  entire 
"winter. 

Of  the  moist,  warm  climates,  in  this  country  Florida  and  the  Bermudas, 
in  Europe  the  ^Madeira  Islands,  and  in  Great  Britain  Torquay  and  Fal- 
mouth are  the  best  known. 

Of  the  dry,  warm  climates,  Southern  California  in  this  country  is  the 
most  satisfactory.  Many  of  the  health  resorts  in  the  Southern  States,  such 
as  Aiken,  Thomasville,  and  Summcrville,  are  delightfid  winter  climates 
for  tuberculous  cases.  Egypt,  Algiers,  and  the  Kiviera  are  the  most  satis- 
factory resorts  for  patients  from  Europe.  For  additional  information  on 
the  subject  of  climate,  particularly  in  this  country,  the  reader  is  referred 
to  Solly's  recent  work  on  the  subject. 

Other  considerations  which  should  influence  the  choice  of  a  locality 
are  good  accommodations  and  good  food.  Very  much  is  said  concerning 
the  ch  .'"^e  of  locality  in  the  different  stages  of  pulmonary  tuberculosis, 
but  wht.i  the  disease  is  limited  to  an  apex,  in  a  man  of  fairly  good  personal 
and  family  history,  the  chances  are  that  he  may  fight  a  winning  battle  if 
he  lives  out  of  doors  in  any  climate,  whether  high,  dry,  and  cold  or  low. 
moist,  and  warm.  With  bilateral  disease  and  cavity  formation  there  is  but 
little  hope  of  permanent  cure,  and  the  mild  or  warm  climates  are  prefer- 
able. 


TUBERCULOSIS. 


335 


is  the 
les,  siich 
Iclimates 
1st  satis- 
ition  on 
Ireferred 

locality 
icerning 
rcnlosis, 
n^ersonal 
)attle  if 
or  low, 
l-e  is  hx^i 
prefer- 


Ill.  Measures  which,  by  their  Local  or  General  Action,  influence  the 
Tuberculous  Process. — ruder  tlii^  hoadinji:  we  may  consider  the  specitic, 
llic  dictclic,  and  the  general  medicinal  treatment  of  tuberculosis. 

(a)  Specific  T  real  inch  I. — Tlie  use  of  Kocli's  urij,dnal  tul)erculin  has  been 
in  great  part  abandoned.  Some  (  '  servers,  as  Whittaker,  have  liad  good 
success  witii  it.  Jn  April,  18'J7,  .. .ocli  announced  the  discovery  of  new 
tuberculins,  the  most  important  of  which  is  the  so-called  tuberculin  K.  It 
is  still  und(>r  trial.  The  verdict  so  far  has  been  not  at  all  favorable,  ex- 
cept in  lupus. 

A  very  large  numlier  of  antitoxincs  of  various  sorts  have  l)een  intro- 
duced within  the  past  few  years.  ]\Iany  of  them  have  been  submitted  to 
very  searching  tests  in  the  Saranac  Laboratory  by  Trudeau  and  I'jaldwin,. 
whose  careful  work  has  extended  over  a  i)eriod  of  four  years.  They  state 
brietly  that,  while  one  or  two  of  the  serums  have  shown  a  slight  degree  of 
antitoxic  ])ower,  in  all  the  otliers  the  tests  wei'e  negative.  In  none  could 
any  germicidal  or  curative  inlluence  be  demonstrated. 

{h}  Dicfrlic  Trvntmvul. — The  outlook  in  tuberculosis  depends  mueli 
upon  the  digestion.  It  is  rare  to  see  recovery  in  a  case  in  wliich  there  is 
persistent  gastric  trouble,  and  the  ])hysician  should  ever  bear  in  mind  the 
fact  that  in  this  disease  the  prima'  via'  conti'ol  tlu'  ])ositi()ti.  The  early 
nausea  and  loss  of  a]>])etite  in  many  cases  of  plithisis  are  serious  obstacles, 
^lany  patients  loathe  food  of  all  kinds.  A  change  of  air  or  a  sea  voyage 
may  promptly  restore  the  api)etite.  When  cither  of  these  is  imi)ossible, 
and  if,  as  is  almost  always  the  case,  fever  is  present,  the  patient  should  be 
placed  at  rest,  kept  in  the  o])en  air  nearly  all  day,  and  fed  at  stated  inter- 
vals with  small  (pifiutities  cither  of  milk,  butternulk,  or  koumyss,  alternat- 
ing if  necessary  with  meat  juice  and  egg  albumin.  Some  cases  wliich  are 
disturbed  by  eggs  and  milk  do  well  on  koumyss.  It  may  be  necessary  to 
resort  to  Debove's  method  of  over-alimentation  or  forced  feeding.  The 
stomach  is  first  washed  out  with  cold  water,  and  then,  through  the  tube, 
a  mixture  is  given  containing  a  litre  of  milk,  an  egg,  and  lOU  grammes  of 
very  finely  powdered  meat.  This  is  given  three  times  a  day.  Sometimes 
the  patients  will  take  this  mixture  without  the  unpleasant  necessity  of  the 
stomach-tube,  in  wliich  case  a  smaller  amount  may  be  given.  I  can  speak 
of  the  advantage  of  this  plan  in  cases  in  which  the  gastric  symptoms  have 
been  obstinate  and  distressing,  and  the  general  exjiression  of  opinion  is 
very  favorable  to  this  plan  of  treatment  in  such  instances.  In  the  German 
sanatoria  a  very  special  feature  is  this  overfeeding,  even  when  fever  is 
present. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  remarkable  how  rapidly  the  appetite  and  di- 
gestion improve  on  the  fresh-air  treatment,  even  in  cases  which  have  to 
remain  in  the  city.  Care  should  he  taken  that  the  medicines  do  not  dis- 
turb the  stomach.  ISTot  infrequently  the  sweet  syrups  used  in  the  cough 
mixtures,  cold-liver  oil,  creasote,  and  the  hypo])hosphites  produce  irritation, 
and  by  interfering  with  digestion  do  more  harm  than  good.  On  the  other 
hand,  the  bitter  tonics,  witli  acids,  and  the  various  malt  preparations  are 
often  in  these  cases  most  satisfactorv.    The  indications  for  alcohol  in  tuber- 


■\ 


336 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


ciilosis  are  oiil'cchk'd  digt'slioii  with  IVvit,  a  weak  liuart,  and  rai)id  pulse. 
A  routine  administration  is  not  advisable,  and  there  is  no  evidence  that  its 
])er.sistent  use  promotes  libroid  i»rocesses  in  the  tuljereulous  areas,  in  the 
advanced  stages,  jiai'ticidarly  when  the  temperature  is  low  between  eiyht 
and  ten  in  the  m()niini,%  wiiisliy  and  milk,  or  wliisky,  ef,%  and  milk  may 
be  given  with  great  advaiitage.  The  red  wines  are  also  benelicial  in  mod- 
erate quantities. 

{(•)  Ueiieml  Medical  Trcdlmcnt. — Xo  medicinal  agents  have  any  special 
or  i)ccu!iar  action  npon  tubcrcnioiis  processes.  The  inlkience  which  they 
exert  is  n|)()n  tlie  general  nutrition,  increasing  the  physiological  resistance, 
and  rendering  the  tissues  less  suscejjtible  to  invasion.  The  following  are 
the  most  important  remedies  which  seem  to  act  in  this  manner: 

Crcdstilc,  which  may  be  administered  in  ca])sules,  in  increasing  doses, 
beginning  with  1  minim  three  times  a  day  and,  if  well  borne,  increasing 
the  dose  to  8  or  10  minims.  Jt  may  also  be  given  in  solution  with  tincture 
of  cardamoms  and  alcohol.  It  is  an  old  remedy,  strongly  recommended 
by  Addison,  and  the  reports  of  Jaccoud,  Fraentzel,  and  many  others  show 
that  it  has  a  positive  value  in  the  disease.  Ciuaiacol  may  be  given  as  a  sub- 
stitute, either  internally  or  ]iy|)odermically.  In  101  cases  in  which  it  was 
used  at  my  clinic,  by  ]\Iercdith  Ecese,  the  chief  action  Mas  on  the  cough 
and  expectoration,  which  were  much  lessened,  but  the  remedy  had  no  essen- 
tial inlluence  on  the  i)rogress  of  the  disease. 

Cud-Vivcr  Oil. — In  glandular  and  bone  tuberculosis,  this  remedy  is  un- 
doubtedly beneficial  in  improving  the  nutrition.  In  pulmonary  tuber- 
culosis its  action  is  less  certain,  and  it  is  scarcely  wortliy  of  the  unbounded 
confidence  M'liich  it  enjoyed  for  so  many  years.  It  sliould  be  given  in  small 
doses,  not  more  than  a  teaspoonful  three  times  a  day  after  meals.  It  seems 
to  act  better  in  children  than  in  adults.  Fever  and  gastric  irritation  are 
contra-indications  to  its  use.  When  it  is  not  well  borne,  a  dessertspoonful 
of  rich  cream  three  times  a  day  is  an  excellent  substitute.  The  clotted  or 
Devonshire  cream  is  ]U'eferable. 

The  Iltipophospliilcs. — These  in  various  forms  are  useful  tonics,  but  it 
is  doubtful  if  they  have  any  other  action.  They  certainly  exercise  no  spe- 
cific influence  u])on  tubercle.  They  nuiy  be  given  in  the  form  of  the  syrup 
of  the  hy])oph(ts])hitcs  of  calcium,  sodium,  and  potassium  of  the  U.  S.  P. 

Ar^ruic. — There  is  no  general  tonic  more  satisfactory  in  cases  of  tuber- 
culosis of  all  kinds  than  Fowler's  solution.  It  may  be  given  in  3-minim 
doses  three  times  a  day  and  gradually  increased;  stopping  its  use  when- 
ever un]ileasant  sym])toms  arise,  and  in  any  case  intermitting  it  every 
third  or  four  week. 

One  or  two  s]iecial  methods  of  dealing  with  pulmonary  tuberculosis 
may  here  be  mentioned.  The  local  treatment,  by  direct  injection  into  the 
lungs,  has  been  practised  since  its  strong  advocacy  by  Pepper.  It  has, 
however,  not  gained  the  general  sup]iort  of  the  profession,  and  is  occa- 
sionally followed  by  serious  results.  As  a  rule,  it  may  be  practised  with 
impunity,  and  the  injections  may  be  made  with  a  long  hypodermic  needle 
into  any  portion  of  the  lung  which  is  diseased.  Iodine,  carbolic  acid, 
creasotc  (3-per-cent  solution  in  almond  oil),  and  iodoform  have  been  used 


J''' 


TUBERCULOSIS. 


337 


l)ut  it 
Ino  spe- 
|('  svvup 

s.'  r. 

tuber- 
minim 
wlu'ii- 
cvery 

rcnlosis 
iito  the 
lit  has, 
occa- 
1(1  with 
needle 
acid, 
[n  used 


for  the  purpose.  The  remarkaltle  results  whieh  sur^jeons  have  recently 
obtained  in  tlie  treatment  of  joint  tuberculosis  by  inji'i'tions  of  iodol'orni 
point  to  this  as  a  remedy  which  will  [U'obably  i»rove  oi'  service  when  in- 
jected directly  into  the  lungs. 

'treatment  by  compressed  air  is  in  nuiny  cases  beneficial,  and  under 
its  use  the  apjjetite  improves,  there  is  gain  in  weight,  and  reduction  of  the 
fever.     The  air  may  be  saturated  witli  crcasote. 

IV.  Treatment  of  Special  Symptoms  in  Pulmonary  Tuberculosis.— (^0 

The  Fever. — There  is  no  more  (.liilicult  i)roblem  in  practical  therapeutica 
than  the  treatment  of  the  ])yrexia  of  tuberculosis.  The  patient  should  be 
at  rest,  and  iit  the  open  air  fur  a  definite  number  of  hours  daily.  Fever  does 
not  contra-indicate  an  out-of-door  life,  but  it  is  well  for  ])atients  with  a 
temperature  above  1(KI.5°  to  be  at  rest.  For  the  continuous  ])yrexia  or  the 
remittent  type  of  the  early  stages,  quinine,  snmll  doses  of  digitalis,  and 
the  salicylates  may  be  tried;  but  they  are  uncertain  and  rarely  reliable. 
Under  no  circumstances  is  that  priceless  remedy,  (piinine,  so  much  abused 
as  in  the  fever  of  tul)erculosis.  In  large  doses  it  has  a  moderate  antipyretic 
action,  but  it  is  just  in  these  edicient  doses  that  it  is  so  apt  to  disturb  the 
stomach. 

Antii)yrin  and  antifel)rin  may  be  used  cautiously;  but  it  is  better, 
when  the  fever  rises  above  lu;3°,  to  rely  upon  cold  sjjonging  or  the  te[)id 
bath,  gradually  cooled.  "When  softening  has  taken  ])lace  and  the  fever 
assumes  the  characteristic  se])tic  type,  the  ])roblem  becomes  still  more  dilH- 
cult.  As  shown  i.y  Chart  XII  (which  is  not  by  any  means  an  exceptional 
one),  the  ])yrexia,  at  this  stage,  lasts  only  for  twelve  or  fifteen  hours.  xVs 
a  rule  it  is  not  more  than  from  eight  to  ten  hours  in  which  the  fever  is 
high  enough  to  demand  antii)yretic  treatment.  Sometimes  antifebrin, 
given  in  2-grain  doses  every  hour  for  three  or  four  hours  before  the  rise  in 
tem]ierature  takes  ])lace,  cither  prevents  entirely  or  limits  the  ])aroxysm. 
If  the  temperature  begins  to  rise  between  two  and  three  in  the  afternoon, 
the  antifebrin  may  be  given  at  eleven,  twelve,  one,  and,  if  necessary,  at 
two.  It  answers  better  in  this  way  than  given  in  the  single  doses.  Careful 
S])onging  of  the  extremities  for  from  half  an  hour  to  an  hour  during  the 
height  of  the  fever  is  useful.  Quinine  is  of  little  benefit  in  this  type  of 
fever;  the  salicylates  are  of  still  less  use. 

(b)  Sirrdfin;/. — Atropine,  in  doses  of  gr.  y-jTi—Ts'-ij-,  and  the  aromatic  sul- 
phuric acid  in  large  doses,  are  the  best  remedies.  When  there  are  cough 
and  nocturnal  restlessness,  an  eighth  of  a  grain  of  moriihia  may  be  given 
with  the  atro])ine.  ^Muscarin  (TTiv  of  a  1-per-cent  solution),  tincture  of 
nux  vomica  (TTlxxx),  picrotoxin  (gr.  -j.^)  niay  be  tried.  The  patient  should 
use  light  flannel  night-dresses,  as  the  cotton  night-shirts,  when  soaked  with 
perspiration,  have  a  very  unpleasant  cold,  clammy  feeling. 

(r)  The  ci)U(]]i  is  a  troid)lesome,  though  necessary,  feature  in  pulmonary 
tuberculosis.  T'nless  very  worrying  and  disturbing  sleep  at  night,  or  so 
severe  a?  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict  it.  "When 
irritativ(!  and  bronchial  in  character,  inhalations  are  useful,  particularly  the 
tincture  of  benzoin  or  preparations  of  tar,  crcasote,  or  turpentine.  The 
throat  sliould  be  carefully  examined,  as  some  of  the  most  irritable  and 


Ai 


338 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


distressing  forms  of  cou<fh  in  ])litliisis  result  from  laryngeal  erosions.  The 
distressing  nocturnal  e(»iigli,  whieli  begins  just  as  the  patient  gets  into 
bed  and  is  ]»re[)aring  [o  fall  asleep,  reciuires,  as  a  rule,  preparations  of 
opium.  L'odeia,  in  (piarler  or  hall'  gi'ain  d(»ses,  or  the  syrupus  eodeiie  (  3  j) 
may  be  given.  An  excellent  combination  for  tiie  nocturiud  cougli  ot 
l)hthisis  is  morphia  (gr.  J-J^),  dilute  hydrocyanic  acid  (iriij-iij))  aii*l  syrup 
of  Avild  chi'rry  (3]).  Tlie  s])irits  of  chloroform,  i>.  1*.,  or  tlic  mislura 
chloroformi,  l'.  S.  1'.,  or  Jlolfmairs  anodyne,  given  in  whisky  liel'ore  going 
to  slec}),  are  ellicacious.  ]\lild  coUiitcr-irrilalion,  or  the  ap])lication  of  a 
hot  i)oultice,  will  sometimes  jjromptly  relieve  the  cough.  The  morning 
cougli  is  often  much  promoted  Ijy  taking  the  first  thing  in  the  morning  a 
glass  of  hot  milk  or  a  cu[)  of  hot  water,  to  which  1.')  grains  of  bicarbonate 
of  soda  have  been  added.  Jn  the  later  stages  of  the  disease,  wlien  cavities 
have  formed,  tlie  accumulated  secretion  must  be  ex[)ectoratc(l  and  the 
paroxysms  of  coughing  are  now  most  exhausting.  The  sedatives,  such  as 
morphia  and  hydrocyanic  acid,  slioidd  be  given  canliously.  The  anuiuitic 
spirit  of  ammonia  in  full  doses  helps  to  allay  the  ])aroxysm.  AVhcu  the 
expectoration  is  profuse,  creasote  internally,  or  inhalations  of  turpentine 
and  iodine,  or  oil  of  eucalyptus,  are  nsefid.  l-'or  tlie  troul)lcsome  dysphagia 
a  strong  solution  of  cocaine  (gr.  x)  with  boric  acid  (gr.  v.)  in  glycerine  and 
water  (  3  j)  may  l)e  nsed  locally. 

((/)  For  the  dlarrhan  large  doses  of  bismutli,  cond)ined  with  Dover 
powder,  and  small  starch  enemata,  with  or  without  oi)ium,  may  be  given. 
The  acetate  of  lead  and  ojjinm  ])ill  often  acts  promptly,  and  the  acid  diar- 
rh(ea  mixture,  dilnte  acetic  acid  (nix-xv),  morphia  (gr.  i),  and  acetate  of 
lead  (gr.  j-ij),  nuiy  be  tried. 

(e)  The  treatment  of  the  hivmoptysis  will  be  considered  in  the  section 
on  hamiorrhage  from  the  hings.  I)ys])ncoa  is  rarely  a  prominent  symptom 
except  in  the  advanced  stages,  when  it  may  be  very  tronblesome  and  dis- 
tressing.    Ammonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  ])leuritic  ])ains  are  severe,  the  side  may  be  strapped,  or  painted 
with  tincture  of  iodine.  The  dyspei)tic  symptoms  recpiire  careful  treat- 
ment, as  the  outlook  in  individual  cases  dejiends  much  upon  the  coiidition 
of  the  stomach.  Small  doses  of  calomel  and  soda  often  allay  the  distress- 
injx  nausea  of  the  carlv  staue. 


XXXV.    LEPROSY. 

Definition. — A  chronic  infectious  disease  caused  by  the  laciUns  lepra;, 
characterized  by  the  presence  of  tubercular  nodules  in  the  skin  and  mucous 
membranes  (tubercular  leprosy)  or  by  changes  in  the  nerves  (anaesthetic 
le|)rosy).  At  first  these  forms  may  be  separate,  but  ultimately  both  are  com- 
bined, and  in  the  characteristic  tubercular  form  there  are  disturbances  of 
sensation. 

History. — The  disease  appears  to  have  prevailed  in  Egypt  even  so 
far  back  as  three  or  four  thousand  years  before  Christ.  The  Hebrew  writers 
make  many  references  to  it,  but,  as  is  evident  from  the  description  in  Leviti- 
cus, many  different  forms  of  skin  diseases  were  embraced  under  the  term 


LKPUOSY. 


330 


Icprrr, 

jiiuoons 

Isthctic 

|e  coni- 

ices  of 

vcn  po 
Iwritcrs 
Leviti- 
tenn 


leprosy.  I'oth  in  India  nnd  in  Cliina  llic  iilft'ction  wns  nlso  known  many 
tx-nturics  hd'oro  tlic  Christian  era.  Tiif  old  (iroclc  and  ilonian  pliysiciaus 
were  perfectly  familiar  with  ltd  manifestations.  As  evidence  of  a  i)re- 
('ohnnl)inn  existence  of  leprosy  in  America,  Ashmead  refers  to  the  old  ])ieces 
of  Peruvian  ])ottery  represent inp  deforniilios  sufrpfoptivo  of  this  disease. 
'J'hroii;;lioiit  the  middle  a^^cs  leprosy  prevailed  extensively  in  Kurope,  and 
the  nuinhi'r  of  leper  asyhinis  has  heen  estimated  at  at  least  :-M),(JUO.  During 
the  sixteenth  century  it  jiradiially  declined. 

'^I'he  prize  essays  of  the  National  Jie])rosy  Committee  nnd  the  rer(>ntly 
issued  Transactions  of  the  r»erlin  Le|)r()sy  Conference  contain  an  immense 
body  of  valuable  information  relating  to  every  possible  aspect  of  the  dis- 
ease. 

Geographical  Diatribution. — In  ]uiropo  leprosy  prevails  in  Ice- 
land, Norway  and  Sweden,  ])arts  of  liussia,  ])articulai'ly  about  Dorpat,  I{i,i::t, 
and  the  Caucasus,  and  in  certain  ])rovinces  of  Sjiain  and  Tortugal.  In 
(jreat  Jiritain  the  cases  are  now  all  imported. 

In  the  United  States  there  arc  three  important  foci:  Louisiana,  in  wliich 
the  disease  has  been  known  since  ITSo,  and  has  of  late  increased.  The  state- 
ment that  it  was  introduced  by  the  Acadians  does  not  seem  to  me  vciy 
likely,  since  the  records  of  its  existence  in  Xova  Scotia  and  Xew  Uruns- 
Avick  do  not  date  back  to  that  period.  Dr.  Dyer  reports  that  on  January 
13,  1808,  ho  knew  of  124  positive  living  cases,  including  35  in  the  Leper 
Home  in  Iberville  Tarish.  He  adds  that  it  is  justifiable  to  estimate  the 
number  of  lepers  in  the  State  of  Louisiana  as  between  IJOO  and  500.  In 
California,  whither  the  disease  has  been  imported  by  the  Chinese,  cases  are 
not  very  infreqncnt.  I  am  informed  by  D.  W.  ^Montgomery  that  there 
are  (^lay  1,  1S98)  10  cases  in  the  Twenty-sixth  Street  Hospital,  San  Fran- 
cisco. Of  these,  only  2  are  Americans,  10  are  Chinese.  In  ^Minnesota  with 
the  Norwegian  colonists  about  ITO  lejiers  arc  known  to  have  settled.  The 
disease  has  steadily  decreased.  Dr.  Bracken,  the  Secretary  of  the  State 
l)oard  of  Health,  writes  that  all  had  contracted  the  disease  before  com- 
ing to  America.  Four  of  these  are  now  known  to  be  dead.  It  is  rejiorted 
that  two  children  of  one  of  the  le})rous  women  have  shown  symptoms  of 
leprosy. 

The  few  cases  seen  in  the  large  cities  of  the  Atlantic  coast  are  imported. 

In  the  Dominion  of  Canada  there  are  foci  of  leprosy  in  two  or  throe 
counties  of  New  ]>runswick,  settled  by  French  Canadians,  and  in  Capo 
Breton,  Nova  Scotia.  The  disease  apjiears  to  have  been  imported  from 
Normandy  abont  the  end  of  the  last  century.  The  nnnd)er  of  cases  has 
gradually  lessoned.  Dr.  A.  C.  Smith,  the  ])hysician  in  charge  of  the  laza- 
retto, at  Tracadio,  Now  Brunswick,  reports  under  date  of  January  17,  18!JS, 
that  there  are  24  lepers  at  present  under  his  care — 18  males  and  G  females. 
Of  these,  3  are  immigrant  Icelanders  from  iIanitol)a;  1  is  a  netrro  from  the 
"West  India  Islands.  Dr.  Smith  states  that  segregation  is  gradually  stamp- 
ing out  the  disease  in  New  Brunswick.  The  cases  have  dwindled  from  ah.ut 
40  to  half  that  number.  In  Cape  Breton  it  has  almost  disappeared.  A  few 
cases  arc  mot  Avith  among  the  Icelandic  settlors  in  Manitoba,  and  with  the 
Chinese  the  affection  has  been  introduced  into  British  Columbia.    Dr.  Han- 


340 


SIM'XTPIC  INPKCTIorS    DISHASKS. 


/ 


iiin^'toii,  (if  \'i(l(iiiii,  writi'H,  Jnnuary  20,  1S!»S,  tlmt  tlicrc  nre  8  casi's  known 
in  tliis  pruvimc.     Tlicy  arc  Hi';fr('j,'ati'(l  mi  hany  Island. 

Li'jirosy  is  cndt'niic  in  tlie  ^\'l'st  India  Islands.  It  also  nccnrs  in  ^roxicn 
and  tliroii^dioiii  Hit'  Soiiflicni  Slates.  In  the  Sandwich  Islands  it  spread 
rapidly  alter  lS(i(),  and  strenuous  attempts  have  been  nwide  to  stamp  it  out 
hy  .sc<,n'e<iatin^f  all  Icpcrn  on  the  island  of  .Molokai.  In  1S!»4  there  were  1,1  "i".' 
k'pors  in  the  settlement. 

In  I'.ritisii  India,  accordinj^  to  the  TiCprosy  Commission,  there  arc 
1()(),()0()  lepers.  This  is  probably  a  low  estimate.  In  China  lci>rosy  i»revaiU 
extensively.  In  South  Africa,  it  Inis  incri'ased  rapidly.  In  Australia, 
Now  Zealand,  and  the  Australasian  islands  it  also  ])revails,  chi(>ily  among 
the  Chinese.  The  essays  of  Ashburt(»n  Thom|tson  and  James  Cauttic  deal 
fully  with  leprosy  in  China,  Australia,  and  the  Pacific  islands. 

EtiolOg^y. — The  bacillus  lepra',  discovered  by  Hansen,  of  Mergen,  in 
ISTl,  is  universally  recognized  as  tin;  cause  of  the  disease.  It  has  many 
points  of  resemblance  to  the  tubercle  bacillus,  but  can  be  readily  dill'er- 
entiatcd.  It  is  cultivated  with  extreme  ditlii'idty,  and,  in  fact,  there  is 
some  doubt  as  to  whether  it  is  capable  of  growth  on  artificial  media. 

Modes  of  Infection. — {(i)  Inocuhdion. — While  it  is  highly  probable  that 
leprosy  may  be  contracted  by  accidental  inoculation,  the  experimental  evi- 
dence is  as  yet  inconclusive.  "With  one  ])ossible  exception  negative  results 
have  followed  the  attempts  to  reproduce  the  disease  in  num.  The  Ha- 
waiian convict  under  sentence  of  (Icath,  who  Avas  inoculated  on  Scittcnd)cr 
30,  188-i,  by  Arning,  four  weeks  later  had  rheumatoid  pains  and  gradual 
painful  swelling  of  the  ulnar  and  median  nerves.  The  neuritis  gradually 
subsided,  but  tlierc  develo])pd  a  small  lepra  tubercle  at  the  site  of  the  inocu- 
lation. In  IScST  tile  disease  was  quite  manifest,  and  the  man  died  of  it  six 
years  after  inoculation.  The  case  is  not  regarded  as  conclusive,  as  he 
had  Icjjrous  relatives  and  lived  in  a  leprous  country. 

{h)  Hcrcdih/. — For  years  it  was  thought  that  the  disease  was  transmitted 
from  i)arent  to  child,  but  the  general  o])inion,  as  expressed  in  the  recent 
Leprosy  Congress  in  Berlin,  was  decidedly  against  this  view.  Of  course, 
the  possibility  of  its  transmission  cannot  be  denied,  and  in  this  resjject 
le])rosy  and  tuberculosis  occujty  very  nnich  the  same  position,  tliougli  men 
with  very  wide  exiicricnce  have  never  seen  a  new-born  leper.  The  young- 
est cases  are  rarely  under  three  or  four  years  of  age. 

(r)  Bji  Contar/inn. — The  l)acilli  arc  given  olf  from  the  o])cn  sores;  they 
are  found  in  the  saliva  and  expectoration  in  the  cases  with  lc])rous  lesions 
in  the  mouth  and  throat,  and  occur  in  very  largo  nmubers  in  the  nasal 
secretion.  Sticker  fomid  in  1-53  le])crs,  subjects  of  both  forms  of  the  dis- 
ease, bacilli  in  the  nasal  secretion  in  138,  and  herein,  he  thinks,  lies  the  chief 
source  of  danger.  Schaffer  was  able  to  collect  lepra  bacilli  on  clean  slides 
])laccd  on  tables  and  floors  near  to  lepers  whom  ho  had  caused  to  read 
aloud.  The  bacilli  have  also  been  isolated  from  the  urine  and  the  milk  of 
patients.  It  seems  ])robablc  that  they  uiay  enter  the  body  in  many  ways 
through  the  mucous  membranes  and  through  the  skin.  Sticker  believes 
that  the  initial  lesion  is  in  an  ulcer  above  the  cartilaiiinous  part  of  the  nasal 
septum.     One  of  the  most  striking  examples  of  the  contagiousness  of 


Th 


LKPHOSY. 


841 


Imittcil 
recent 
•ouTse, 

VS])C'Ot 
1   HUM! 

K'oung- 

they 
jsion^ 
nasal 
lie  d is- 
le ohief 
sliiles 
1  read 
hilk  of 
ways 
lelicves 
nasal 
kess  of 


l('|»rosy  in  the  fctllmvinff:  "  In  1S(!(),  n  ^'irl  who  had  hitherto  lived  at  Tlolst- 
Icrshdl',  where  no  leprosy  existed,  married  and  went  to  Ww  at  Tarwast  with 
hi'r  niother-in-hiw,  wiio  was  a  K'per.  She  reniaini'd  iieaUhy,  hut  lier  tiireo 
eiiildren  (1,  2,  3)  l)craiiie  k'prous,  as  also  her  youn«,'er  sisti'i'  (1),  who  eanie 
on  a  visit  to  Tarwast  and  sk'pt  with  the  ehihireii.  The  younj,'i'r  histi'r  de- 
veloped leprosy  after  returninj,'  to  I  lolst  fershol'.  At  the  latter  plaee  a 
man  (.■)),  lii'ly-two  years  old,  who  married  one  ol"  the  'youn^'er  sister's' 
children,  ae(piired  leprosy;  also  a  ndative  ((!),  thirty-six  years  old,  a  tailor 
hy  occupation,  who  Iri'ipiented  the  liouse,  and  his  wife  (T),  who  came  from 
a  place  where  no  leprosy  existed.  The  two  men  last  mentioned  are  at 
|»resent  (1(S!»?)  inmates  of  the  lepi'r  asylum  at  l)orpat."  There  is  certain 
I'vidence  to  show  that  the  diseauf  may  he  spread  thi'ou<;h  infi'cted  elotliin<f, 
and  the  liifih  j)ercentajjo  of  washerwomen  anion^'  lepers  is  also  yuf,'j^estive. 

Conditions  influencing  Infection.— 'J'he  disease  attacks  persons  of  all 
aj^es.  We  do  iu)t  yet  understand  all  the  conditions  necessary.  Evidently 
the  closest  and  most  intimate  contact  is  essential.  The  doctors,  nurses, 
and  Sisters  of  Charity  who  care  for  the  ])atients  are  very  rarely  attacked. 
In  the  lazaretto  at  Tracadie  not  one  of  the  Sisters  who  for  more  than  forty 
years  liave  so  faithfully  nursed  the  lepers  has  contracted  the  disease.  Father 
l)amian,  in  the  Sandwich  Islands,  and  Father  Pm^^lioli,  in  Xew  Orleans, 
hoth  fell  victims  in  the  discharfxe  of  their  ])ries!ly  duties,  'i'here  has  lonj^ 
heen  an  idea  that  jjossihly  the  disease  may  he  assoeiated  with  some  special 
kind  of  food,  and  Jonathan  Ilutchinson  helieves  that  n  fish  diet  is  the 
h'rtiiini  quid,  whicli  either  renders  the  ])atient  susceptihlc  or  with  which 
the  |)oison  may  l)e  taken. 

Morbid  Anatomy. — The  le])rosy  tuhercles  consist  of  granuloma- 
tous tissue  made  up  of  cells  of  various  sizes  in  a  connective-tissue  matrix. 
The  hacilli  in  extraordinary  nund)ers  lie  partly  lietween  and  ))artly  in  tl>e 
cells.  Tlie  ])rocess  gradually  involves  the  skin,  giving  rise  to  tuherous  out- 
growths with  intervening  areas  of  ulceration  or  cicati'izatiou,  which  in  the 
face  nuiy  gradually  ])roduee  the  so-called  fncicx  leu  it  I  in  a.  'V\w  mucous 
memhranes,  })articularly  the  conjunctiva,  the  cornea,  and  the  larynx  may 
gradually  he  involved.  In  many  cases  deep  ulcers  foi'ui  whicli  result  in 
extensive  loss  of  suhstance  or  loss  of  fingers  or  toes,  the  so-called  lepra 
iiiiitiJans.  In  anaesthetic  leprosy  there  is  a  pcriidioral  neuritis  due  to  the 
development  of  the  hacilli  in  the  nerve-fd)res.  Indeed,  this  involvement 
of  the  nerves  jdays  a  ]u-imary  ])art  in  the  etiology  of  many  of  the  imjior- 
tant  features,  ])articularly  the  tro])hic  changes  in  th(>  skin  and  the  distui-l)- 
ances  f)f  sensation. 

Clinical  Forms.— (^/)  Tubercular  Leprosy.— Prior  to  the  appear- 
ance of  the  nodules  there  are  areas  of  cutaneous  erythema  which  may  ho 
shar])ly  defined  and  often  hyiiera^sthetic.  This  is  sometimes  known  as 
uiaruhir  leprosy.  The  affected  spots  in  time  hecome  ])igmentod.  In  some 
instances  this  superficial  change  continues  without  the  development  of 
nodules,  the  areas  hocomo  anaesthetic,  the  pigment  gradually  disa])i)ears, 
and  the  skin  gets  perfectly  white — the  Irpra  alha.  Among  the  patients 
at  Tracadie  it  was  particularly  interesting  to  see  three  or  four  in  this  early 
stage  presenting  on  the  face  and  forearms  a  patchy  erythema  with  slight 


I 
I 


i  I 


342 


SPKCinc   IXFKCTIors   DISKASKS. 


/ 


Hwi'lliiij,'  of  till'  t-Uiii.  'I'Ik'  (liii;,Minsi.s  (»f  tlio  cotiilition  is  perfectly  clear, 
tiiHii^'li  it  iiiiiy  l»c  11  lull;,'  time  hefun,'  any  other  than  Henxoiy  chiiii^fes  du- 
veloj).  The  eyelasheH  iiiid  eyehrow^  iiiid  tile  liiiirH  on  the  face  fall  out.  Tlie 
niucoiis  iiieiiihniiies  (iniiliy  lieenme  involved,  |nii'tieuhirly  of  the  nioiitli. 
throat,  and  larynx;  tlu'  voiie  hecomes  liar>h  and  liiiiilly  a|ihnnie.  heath 
results  not  inrrctiiieiitly  Iroin  the  laryn^real  coni|tlications  and  aspiration 
piieiiiiioiiia.  'I'lie  coiijiinetivie  are  l'iv<iiient!y  attacked,  and  the  sight  is  lost 
by  a  leprous  keratitis. 

(^)  Ana38thetic  Leprosy. — This  remaikuMe  form  has,  in  characteristic 
cnsi's,  no  exteniiil  reseinlilaiice  whatever  to  the  other  variety,  it  usually 
begins  with  pains  in  the  limbs  and  areas  of  hypera'sthesia  or  of  numbness. 
A'ery  early  there  may  be  trophic  changes,  seen  in  the  rormiition  of  small 
bullii'  (llillis).  Miiculie  appear  upon  the  trunk  and  extremities,  and  after 
jiersisting  for  a  variable  time  gradually  di.-appcar.  leaving  areas  of  aiues- 
thesia,  but  the  loss  of  sensation  may  come  on  independently  of  the  out- 
break of  macula'.  'J'lu'  nerve-trunks,  whet'e  snperlicial,  may  be  felt  to  be 
large  and  nodular.  The  tro|)liic  di.-turbiinees  are  usually  marked.  Tem- 
lihigus-like  biilhe  develop  in  the  alVected  areas,  which  break  and  leave 
ulcers  which  may  be  very  destructive.  The  lingers  and  toes  arc;  liable  to 
contractures  iind  to  necrosis,  so  that  in  clir(tiiic  cases  the  i)halanges  are 
lost.  The  course  of  amestlietic  leprosy  is  extraordinarily  chronic  and  may 
])ersist  for  years  without  leading  to  mncli  deformity.  One  of  the  most 
prominent  clergymen  on  this  continent  had  amestlietic  leprosy  for  more 
tliaii  thirty  years,  which  did  not  seriously  interfere  with  his  usefulness,  and 
not  in  the  slightest  with  his  career. 

Diagnosis. — Mven  in  the  early  stage  the  dusky  erythematous  macula' 
vitli  hypera'sthesia  or  areas  of  ana'sthcsia  are  very  characteristic.  Jn  an 
advanced  grade  neither  the  tul)ercular  Jior  ana'sthetic  forms  could  jiossibly 
be  mistaken  for  any  other  ad'ection.  In  a  (b)ubtfiil  case  the  microscopical 
examination  of  an  excised  nodule  is  decisive. 

Treatment. — Tiiere  are  7io  specific  remedies  in  the  disease,  and  gen- 
eral tonics  combined  with  local  treatment  meet  the  only  available  indica- 
tions. The  gurjun  and  chaulmoogra  oils  have  been  recommended,  the 
former  in  doses  of  from  5  to  10  minims,  the  latter  in  '^-drachm  doses. 

The  Norwegian  method  of  segregation  should  be  enforced  wherever 
the  disease  prevails,  as  in  Louisiana  and  California.  It  should  be  com- 
])ulsory  in  all  cases  except  where  the  friends  can  show  that  they  have  amjile 
provision  in  their  own  home  for  the  complete  isolation  and  proper  care 
of  the  ]iaticnt. 


th 


XXXVI.    INFECTIOUS  DISEASES  OF   DOUBTFUL  NATURE. 

(1)  FEBIIICULA— EPHEMERAL  FEVER. 

Definition. — Fever  of  slight  duration,  probably  depending  npon  a 
variety  of  canses. 

A  febrile  paroxysm  lasting  for  twenty-fonr  honrs  and  disappearing  com- 
pletely is  spoken  of  as  eidiemeral  fever.  If  it  persists  for  three,  four,  or 
more  davs  without  local  affection  it  is  referred  to  as  febricula. 


nnculiv 

II  an 

ssibly 

pical 


•rcn- 
idica- 
,   the 

'S, 

crevor 
coin- 
am  i»lo 
r  care 


URE. 


ipon  a 

rr  com- 
)ur,  or 


IN'FMCTKH'S   DISKASKS  OP  DorMTKl'L  NATL'UK. 


343 


The  cnsosi  may  l>»'  dividcil  into  several  ^ToniH; 

{(i)  Tliofo  wliicli  repic-i'Mt  mild  or  ahoitive  ty|K's  ol'  tlie  iiilVitious  dis- 
onsc'tf.  It  is  not  very  iiirretiiunt,  during'  an  epidemic  ol"  typhoid,  Kcarlot 
fever,  or  nieash'H,  to  aeu  C'H«e8  with  some  of  the  prodromal  symptoms  and 
sii^dit  I'ever,  which  persist  for  two  or  tiiree  days  without  any  distinetivo 
features.  I  have  already  spoken  of  these  in  connection  witli  the  aljortivo 
type  of  tyi»hoid  fever.  I'ossibly,  as  Kahler  biiggehts,  bumu  of  the  tabes  of 
transient  fever  are  due  to  the  rheumatic  pois(»n. 

(I>)  In  n  lar^'er  and  jterhaps  more  im|»ortant  <,'roMp  of  cases  tlie  symp- 
toms develop  with  dyspepsia,  in  children  indi;rcstion  and  jiastro-iiites- 
tinal  catarrh  are  (d'len  aicompanieil  l»y  fever.  I'ossihly  some  instances  of 
jon^'er  duration  may  Ijc  due  to  the  alisorptittn  of  certain  toxic  substances. 
Slight  fever  has  been  known  to  follow  the  eating  ol  decomposing  sul)- 
stanccs  or  the  drinking  of  stale  beer;  but  the  gastric  juice  has  remarkable 
antiseptic  jiroperties,  and  the  fre(piency  with  which  jtersons  take  from 
choice  articles  which  are  '*  liigli,"  shows  that  itoisonmg  is  not  likely  to 
occur  iinless  there  is  existing  gastro-intestinal  disturbance. 

{(■)  Cases  which  follow  exposure  to  foul  odors  or  sewer-gas.  That  a 
febrile  paroxysm  nuiy  follow  a  jirolonged  exposure  to  noxious  odors  has 
long  been  recognized.  'I'he  cases  which  havi'  been  desci'ibed  under  this 
heading  are  of  two  kinds:  an  acute  severe  form  with  nausea,  vomiting, 
colic,  and  fever,  followed  ]ierhap8  by  a  condition  (d'  collnpse  or  conui; 
secondly,  a  form  of  low  fever  with  or  without  chills.  .V  good  (\vi\\  of  doidit 
still  exists  in  the  minds  of  the  profession  about  these  case,-)  of  so-called 
sewer-gas  ])oisoning.  It  is  a  notorious  fact  that  workers  iii  sewers  nro 
remarkably  free  from  disease,  and  in  uiiiiiy  of  the  cases  which  have 
been  reported  the  illness  may  have  i)een  oidy  a  coincidence.  'I'liere  are 
instances  in  which  jtcrsons  have  been  taken  ill  with  vomiting  and  slight 
fever  after  exposure  to  the  odor  of  a  very  olTensivc  ])ost  mortem. 
Whether  true  or  not,  the  idea  is  firmly  imphinfcMl  in  the  mimls  of  the 
laity  that  very  ])owerful  odors  from  decomposing  nuittcrs  nuiy  produce 
sickness. 

{(1)  ]\rany  cases  doubtless  dei)end  upon  sliglit  unrecognized  lesions,  such 
as  tonsillitis  or  occasionally  an  abortive  or  larval  ]meumonia.  Children 
are  mncli  more  fre((uently  affected  than  adults. 

The  fti/niphiws  set  in,  as  a  rule,  abruptly,  though  in  some  instances 
there  may  have  been  ])relinunary  mahiise  and  indisposition.  Headache, 
loss  of  aiipetite,  and  furred  tongue  are  present.  The  urine  is  scanty  and 
high-colored,  the  fever  ranges  from  101°  to  10:3°,  sometimes  in  children  it 
rises  higher.  The  cheeks  may  be  flushed  and  the  patient  has  the  outwai'd 
manifestations  of  fi'ver.  In  children  there  may  be  bronchial  catarrh  with 
sliglit  congh.  Herpes  on  the  lips  is  a  common  s3-mptom.  Occasionally 
in  children  the  cerebral  symptoms  are  marked  at  the  outset,  and  there  may 
be  irritation,  restlessness,  and  nocturnal  delirium.  The  fever  terminates 
abrnjitly  by  crisis  from  the  second  to  the  fourth  day;  in  some  instances 
it  may  continue  for  a  week. 

The  (l!a/]tiosi.<<  generally  rests  npon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and  most 


■ 


344 


SPECIFIC  INFECTIOUS  DISEASES. 


important  (jf  all  tliL'  rai)i<l  disappcnrnnce  of  the  jtyrcxia.     The  cases    aost 
readily  reco^niized  are  those  with  acute  gastro-intestinal  distiirhauce. 

The  Ircatnieiit  is  that  of  mild  })yrexia — rest  in  bed,  a  laxative,  and  a 
fever  mixture  containing  nitrate  of  [lotassium  and  sweet  spirits  of  nitre. 


/ 


(2)  WEIL'S   DISEASE. 

AcUtB  Febrile  Icterus. — In  188G  Weil  described  an  acute  infectious  dis- 
ease, characterized  by  fever  and  jaujuliee.  ^iuch  discussion  has  taken  place 
concerning  the  true  nature  of  this  aU'ection,  but  it  has  not  been  delinitely 
determined  whether  it  is  a  specilic  disease  or  only  a  jaundice  which  nuiy 
be  due  to  various  causes.  The  majority  of  the  cases  have  occurred  during 
the  summer  nu)nths.  '^^IMie  cases  have  occurred  in  groups  in  diU'erent  cities. 
A  :*';w  cases  have  been  rej)ort(.'d  in  this  country  (Lanphear).  Males  are 
most  frequently  affected.  .Many  of  the  cases  have  been  in  butchers.  The 
age  of  the  patients  has  been  from  twenty-live  to  forty. 

The  disease  sets  in  abrujjtly,  usually  without  ])rodromes  and  often 
with  a  chill.  There  are  headache,  i)ains  in  the  back,  and  sometimes  in- 
tense i)ains  in  the  legs  and  muscles,  particularly  of  the  cheeks.  The  fever 
is  characterized  by  marked  remissions.  Jaundice  ai)pears  early.  The  liver 
and  spleen  are  usually  swollen;  the  former  may  be  tender.  The  jaundice 
nuiy  be  light,  but  in  many  of  the  cases  described  it  has  been  of  the  ob- 
structive form,  and  the  stools  have  been  clay-colored.  Gastro-intestinal 
symptoms  are  rarely  ])resent.  The  fever  lasts  from  ten  to  fourteen  days; 
sometimes  there  are  slight  recurrences,  but  a  deiinite  relapse  is  rare. 

Albumin  is  usually  present  in  the  uri  le;  luematuria  has  occurred  in 
some  cases. 

Cerebral  symptoms,  delirium  and  coma,  may  be  present. 

In  the  few  post-uu)rtenis  which  have  been  made  nothing  distinctive 
has  been  found.  The  investigations  of  Jaeger  render  it  not  imi)ossible 
that  this  epidemic  form  of  jaundice  depends  upon  infection  with  a  proteus 
— hacUJus  proteus  jluorcscens. 

(3)  MILK-SICKXESS. 

This  remarkable  disease  prevails  in  certain  districts  of  the  United 
States,  west  of  the  Alleghany  ^Mountains,  and  is  connected  with  the  affec- 
tion in  cattle  known  as  the  Ircnihlrs.  It  prevailed  extensively  in  the  early 
settlements  in  certain  of  the  Western  States  and  proved  very  fatal.  The 
general  opinion  is  that  it  is  communicated  to  man  only  by  eating  the  flesh 
or  drinking  the  milk  of  diseased  animals.  The  butter  and  cheese  are  also 
poisonous.  In  animals,  cattle  and  the  young  of  horses  and  sheep  are  most 
susceptible.  It  is  stated  that  cows  giving  milk  do  not  themselves  show 
marked  symptoms  unless  driven  rapidly,  and,  according  to  Graff,  the  secre- 
tion may  be  infective  when  the  disease  is  latent.  When  a  cow  is  very  ill, 
food  is  refused,  the  eyes  are  injected,  the  animal  staggers,  the  entire  mus- 
cular system  trembles,  and  death  occurs  in  convulsions,  sometimes  with 
great  suddenness.  Nothing  definite  is  known  as  to  the  cause  of  the  dis- 
ease.   It  is  most  frequent  in  new  settlements. 


INFECTIOUS   DISEASES  OP   DOL'IJTFUL  NATL'UE. 


845 


'iiitcfl 
affoc- 
b  carlv 
The 
le  floi^h 
ire  al^o 
'  most 
slioM' 
secro- 
?vy  ill. 
mup- 
is  with 
lie  dis- 


In  man  thu  sym])toms  are  those  of  a  more  or  less  acute  intoxication. 
After  a  few  days  of  iiiicasiiU'ss  and  distress  tiie  ]>aticnt  is  seized  with  pains 
in  the  stomach,  nausea  and  vomiting,  fever  and  intense  thirst.  There  is 
usually  o])stinate  constipation.  The  tongue  is  swollen  and  tremulous,  the 
breath  is  extremely  foul  and,  according  to  Crralf,  is  as  characteristic  of  the 
disease  as  is  tlie  odor  in  snudl-pox.  Cerebral  symptoms — restlessness,  irri- 
tability, coma,  and  convulsions — are  sometimes  marked,  and  there  may 
gradually  be  j)roduced  a  tyi)hoid  state  in  which  tlie  patient  dies. 

The  duration  of  the  disease  is  variable.  In  the  most  acute  forms  death 
occurs  Avithin  two  or  three  days.  It  nu\y  hi^t  for  ten  days,  or  even  for 
three  or  four  weeks.  Gralf  states  that  insanity  occurred  in  one  case.  The 
poisonous  nature  of  the  llesh  and  of  the  milk  has  been  demonstrated  ex- 
perimentally. xVn  ounce  of  butter  or  cheese,  or  four  ounces  of  the  beef, 
raw  or  boiled,  given  three  times  a  day,  will  kill  a  dog  within  six  days.  Xo 
definite  })athologieal  lesions  are  known.  Fortunately,  the  disease  has  be- 
come rare,  and  the  observation  of  Drake,  Yandell,  and  others,  that  it 
gradually  disa])|)ears  'vitli  the  clearing  of  the  forests  and  im])roved 
tillage,  lias  been  amply  substantiated.  It  still  prevails  in  i)arts  of  Xorth 
Carolina. 

(4)  GLANDULAR  FEVER. 

Definition. — An  infectious  disease  of  children,  develoi)ing,  as  a  rule, 
without  ])renionitory  signs,  and  characterized  by  slight  redness  of  the 
throat,  high  fever,  swelling  and  tendei'ness  of  the  lymph-glands  of  the  neck, 
particularly  those  behind  the  sterno-cleido-niastoid  muscles.  Thj  fever  is 
of  short  duration,  bu^"  the  enlargement  of  the  glands  })ersists  for  from 
ten  days  to  three  weeks. 

In  children  acute  adenitis  of  the  cervical  and  other  glands  with  fever 
has  been  noted  by  many  observers,  l)ut  I'feitfer  in  1889  called  special 
attention  to  it  under  the  name  of  Dniesen-Fieher.  He  described  it  as  an 
infectious  disease  of  young  children  between  the  ages  of  five  and  eight 
years,  characterized  by  the  above-mentioned  symptoms.  Since  PfeiU'er's 
paper  a  good  deal  of  work  has  been  done  in  connection  with  the  subject, 
and  in  this  conntry  West  and  Ilamill,  and  in  England  Dawson  "Williams, 
have  more  particularly  emphasized  the  condition. 

Etiology. — It  may  occur  in  e]ndemic  form.  West,  of  Bellaire,  Ohio, 
describes  an  epidemic  of  9C  cases  in  children  Ijctween  the  ages  of  seven 
months  and  thirteen  years.  r>ilateral  swelling  of  the  carotid  lymph-glands 
was  a  most  marked  feature.  In  three  fourt's  of  the  cases  the  post-cervical, 
inguinal,  and  axillary  glands  were  involved.  The  mesenteric  glands  were 
felt  in  37  cases,  the  s]deen  was  enlargi'd  in  57,  and  the  liver  in  87  cases. 
Coryza  was  not  present,  and  there  were  no  bronchial  or  pulmonary  symp- 
toms. Cases  occurred  between  the  months  of  October  and  June.  The 
nature  of  the  infection  has  not  been  determined. 

Symptoms. — The  onset  is  sudden  and  the  first  complaint  i?  of  pain 
on  niovimr  the  head  and  neck.  There  may  be  nausea  and  vomitinff  and 
abdominal  pain.  The  temperature  ranges  from  101°  to  103°.  The  tonsils 
may  be  a  little  red  and  the  lymphatic  tissues  swollen,  but  the  throat  symj)- 


it 


346 


SPECIFIC  INFECTIOUS  DISEASES. 


/ 


toms  are  quite  transient  and  unimportant.  On  the  second  or  tliird  day 
the  enlarged  ghuids  ajjpear^  and  durijig  tlie  couriie  tliey  vary  in  size  from  a 
])('a  to  a  goose-egg.  ^J'hey  are  ])aii)ful  to  tlie  touch,  but  tliere  is  rarely  any 
redness  or  swelling  oi'  the  skin,  though  at  times  there  is  some  i)uHiness  of 
the  subcutaneous  tissues  of  the  neck,  and  there  may  be  a  little  dilliculty  in 
swallowing.  In  some  instances  there  has  been  discomfort  in  the  chest  and 
a  ])aro.\ysmal  cough,  indicating  involvement  of  the  tracheal  and  bronchial 
glands.  The  swelling  of  the  glands  ])ersists  for  from  two  to  three  weeks. 
Among  the  serious  features  of  the  disea.se  are  the  termination  of  the 
adenitis  in  suppuration,  which  seems  rare  (though  Neumann  has  met  with 
it  in  13  cases),  and  ha-morrhagic  nephritis.  Acute  otitis  media  and  retro- 
pharyngeal al)sccss  have  also  been  rci)orted. 

The  outlook  is  favoral)le.  West  suggests  the  use  of  small  doses  of  calo- 
mel during  the  height  of  the  trouble. 

(5)  MOUNTAIN  FEVER— MOUNTAIN  SICKNESS. 

Several  distinct  diseases  have  been  described  as  mountain  fever.  An 
important  grou]),  the  mounluin  uvwinia,  is  associated  with  the  ancliijhjstoina, 
which  has  not  yet  been  met  with  in  this  country.  A  second  group  of  cases 
belongs  to  tyi)hoid  fever;  and  instances  of  this  disease  occurring  in  moun- 
tainous regions  in  the  Western  States  are  referred  to  as  mountain  fever. 
The  observations  of  irolf  and  Smart,  and  more  recently  of  Woodrulf  and  of 
liaymond,  show  that  the  disease  is  ty])hoid  fever. 

Recently  C.  E.  Woodruff,  of  the  army,  has  reported  a  group  of  35  cases 
at  Fort  Custer,  which,  as  he  says,  would  certainly  have  been  described  as 
mountain  fever,  but  in  which  the  clinical  features  and  the  Widal  faction 
showed  there  was  no  question  that  they  were  typhoid.  Ivaymond,  too,  re- 
cently called  attention  to  the  existence  of  ty])hoid  fever  in  Wyoming  among 
the  Indians  in  the  reservation  and  the  soldiers  at  the  post.  It  would  be 
well,  I  think,  for  the  use  of  the  term  mountain  fever  to  be  discontinued. 

2Iounfaiii  sicl-iicss  comprises  the  remarkable  group  of  phenomena  which 
develop  in  very  high  altitudes.  The  condition  has  been  very  accurately  de- 
scribed by  ;Mr.  "\\'hymper.  In  tlio  ascent  of  Chimborazo  they  were  first 
affected  at  a  height  of  Kl.nni  feet.  The  symptoms  were  severe  headache, 
gasping  for  breath,  evidently  urgent  hcsoin  dc  ra^pirer.  The  throat  was 
parched,  and  there  was  intense  tiiirst,  loss  of  appetite,  and  of  general 
mahiise.  Mr.  Whymper's  temperature  was  100.4°.  The  symptoms  in  his 
case  lasted  for  nearly  three  days.  In  a  less  aggravated  form  such  symp- 
toms may  present  themselves  at  much  lower  levels,  and  in  the  ascent  of  the 
railroad  at  Pike's  Peak  many  persons  siilfcr  from  distress  in  breathing.  The 
original  cases  described  by  Cieneral  Fremont  were  of  this  nature.  xV  very 
full  description  is  given  by  Allbutt  in  vol.  iii  of  his  System. 


aiid 


(G,  .MILIARY  FEVER— SWEATING  SICKNESS. 

The  disease  is  characterized  by  fever,  profuse  sweats,  and  an  eruption 
of  miliary  vesicles.  It  prevailed  and  was  very  fatal  in  England  in  the 
fifteenth   and   sixteenth   centuries,   but   of   late   years   it   has   been    con- 


INFECTIOUS  DISEASES  OP  DOUBTFUL  IS^VTUIIE. 


3i; 


fined  entirely  to  certain  distriets  in  France  (Picardy)  and  Italy.  An  epi- 
deniie  of  ^onio  extent  occurred  in  France  in  LSST.  liirsch  gives  a  chrono- 
logical account  of  VJA  epidemics  between  1718  and  ISTD,  many  of  -which 
Avere  limited  to  a  single  village  or  to  a  few  localities.  Occasionally  the  dis- 
ease has  become  Avidi'ly  sjiread.  Slight  ei)idemics  Iiavo  occurred  in  Uor- 
many  and  Switzerland.  Within  the  ])ast  few  years  there  have  been  several 
small  outbreaks  in  Austria.  They  are  usually  of  sliort  duration,  lasting  only 
for  three  or  four  weeks — sometimes  not  more  than  seven  or  eight  days. 
As  in  influenza,  a  very  large  number  of  persons  are  attacked  in  rapid  suc- 
ccssidii.  In  tlie  mild  cases  there  is  only  slight  fever,  with  loss  of  ap])etite, 
an  er}-tliematons  eru[)tion,  ])r()fuse  ])erspiration,  and  an  outbreak  of  miliary 
vesicles.  The  severe  eases  ])resent  the  symptoms  of  intense  infection — de- 
lirium, high  fever,  profound  ])rostration,  and  hamiorrhage.  The  death- 
rate  at  the  outset  of  the  disease  is  usually  high,  and,  as  is  so  graphically 
described  in  the  account  of  some  of  the  e[)idemics  of  the  middle  ages,  death 
may  occur  in  a  few  hours.  The  most  rect'ut  and  the  fullest  account  of  the 
disease  is  given  in  XothnageFs  Ilandbuch  by  Immermann. 


I 


15  cases 
ihed  as 
■action 
00,  re- 
among 
l)uld  be 
ued. 
which 
v]y  de- 
rc  first 
ad  ache, 
at  was 
general 
in  lii^ 
svnip- 
of  the 
.    The 
A  very 


ruptinn 

in  the 

In    con- 


(7)   FOOT   AND   MOUTH   DISEASE— EPIDEMIC  STO:\rATITIS— 

AIMITIIOUS   FEVER. 

Foot  and  mouth  disease  is  an  acute  infectious  disorder  mot  Avith  chiefly 
in  cattle,  sheep,  and  ])igs,  but  attacking  other  domestic  animals.  It  is  of 
extraordinary  activity,  and  spi'cads  with  "lightning  ra])idity ''  over  vast 
territories,  causing  very  serious  losses.  In  cattle,  after  a  ])eriod  of  incuba- 
tion of  three  or  five  clays,  tlic  'uimal  gets  feverish,  the  mucous  membrane 
of  the  mouth  swells,  and  little  grayish  vesicles  the  size  of  a  hemp  seed 
Ijegin  to  develop  on  the  edges  and  lower  portion  of  the  tongue,  on  the 
gums,  and  on  the  mucous  membrane  of  the  lips.  They  contain  at  first  a 
clear  fluid,  which  b(>comos  turbid,  and  then  they  enlarge  and  gradually 
become  converted  into  superficial  ulcers.  There  is  ptyalism,  and  the  ani- 
mals lose  flesh  rapidly.  In  the  cow  the  disease  is  also  frccpiently  seen 
about  the  udder  and  teats,  and  the  milk  becomes  yellowish-white  in  color 
and  of  a  mucoid  consistency. 

The  transmission  to  man  is  by  iio  moans  uncommon,  and  of  lato  sev- 
eral important  epidemics  have  boon  studied  in  the  neighborhood  of  llerlin. 
F)r.  Salmon  informs  mo  that  in  the  United  States  foot  and  mouth  dis- 
ease has  very  rarely  occurred,  but  in  -1870,  as  well  as  in  1811,  it  was 
communicated  in  a  few  instances  to  man.  Iti  ZuilTs  translation  of  Fried- 
borgor  and  Friihnor's  Fathology  and  Therapeutics  of  Domestic  Animals 
(rhilndel]>hia,  181)."))  the  disease  is  tints  described:  "Transmission  of 
a])hthous  fever  to  man  is  not  rare.  The  veterinarian  has  oftener  occasion 
to  observe  it  than  the  ])hysician.  The  use  of  milk  from  aphthous  cows 
cmtaminatos  children  (luite  frotpiontly  and  is  fatal  to  them.  This  may 
also  hn]ipen  throngh  ingestion  of  butter  or  choose  made  of  milk  coming 
from  a]ihthous  animi.ls.  or  also  directly  through  wounds  of  the  arms,  hands, 
or  bv  intermediary  agents.     In   man   the  svmiitoms  arc:  fever,  digestive 

troubles,  and  A'esicnlar  eruption  npon  the  lips,  the  Intccal  and  pharyngeal 
22 


!'■;■ 


348 


SPECIFIC  INFECTIOUS  DISEASES. 


mucous  membranes  (angina).  The  disease  does  not  seem  to  be  trans- 
missible through  the  meat  of  diseased  animals.  Perhaps  the  serious  afrec- 
tions  of  the  skin  which  were  observed  to  develop  in  children  after  vaccina- 
tion (especially  in  1883-'84)  may  have  been  determined  by  mistaking  the 
mammary  eruption  of  aphthous  fever  for  cow-pox." 

In  widespread  epidemics  there  has  been  sometimes  a  marked  tendency 
to  ha}morrhages.  The  disease  runs,  as  a  rule,  a  favorable  course,  but  in 
Siegel's  report  of  a  recent  epidemic  the  mortality  was  8  per  cent. 

Several  forms  of  micro-organisms  have  been  described  in  connection 
with  it.    Klein  has  described  a  micrococcus. 

When  epidemics  are  prevailing  in  cattle  the  milk  should  be  boiled, 
and  the  proper  prophylactic  measures  taken  to  isolate  both  the  cattle  and 
the  individuals  who  come  in  contact  with  them. 


/ 


SECTION  11. 


DISEASES  DUE  TO  AI^IMAL  PARASITES. 


f 


I.    PSOROSPERMIASIS. 

Under  this  term  are  embraced  several  affections  produced  by  the  spo- 
rozoa.  These  parasites,  belonging  to  the  protozoa,  are  also  known  as  psoro- 
sperms  and  gregarinida?.  They  are  extraordinarily  abundant  in  the  in- 
vertebrates, and  are  not  uncommon  in  the  higher  mammals.  The  entire 
group  of  blood  parasites,  hf.'matozoa,  which  live  within  the  corpuscles,  are 
closely  related  to  them.  Psorosperms  are,  as  a  rule,  parasites  of  the  cells 
— Cytozoa.  The  commonest  and  most  suitable  variety  for  study  is  the 
Coccidium  oviforvie  of  the  rabbit,  which  produces  a  disease  of  the  liver  in 
which  the  organ  is  studded  throughout  with  whitish  nodules,  ranging  in 
size  from  a  pin's  head  to  a  split  pea.  On  section  each  nodule  is  seen  to  be 
a  dilated  portion  of  a  bile-duct;  the  walls  are  lined  with  epithelium  in  the 
interior  of  which  are  multitudes  of  ovoid  bodies — the  coccidia.  Anotlier 
very  common  form  occurs  in  the  muscles  of  the  pig,  the  so-called  Kainey's 
tube,  which  is  an  ovoid  body  w  ithin  the  sarcolemma  containing  a  number 
of  small, sickle-shaped, unicellular  organisms,  the  Sarcocystis  Mieschcri.  An- 
other species,  the  S.  Iiominis,  has  been  described  in  man. 

These  bodies  probably  play  a  more  important  7vle  in  human  pathology 
than  has  hitherto  been  thought.  The  cases  reported  may  be  grouped  under 
the  following  divisions:  internal  and  external. 

(1)  Internal  Psorospermiasis. — In  a  majority  of  the  cases  of  this  group 
the  psorosperms  have  been  found  in  the  liver,  producing  a  disease  similar 
to  that  which  occurs  in  rabbits.  In  Guebler's  case  there  were  tumors 
which  could  be  felt  in  the  liver  during  life,  and  they  were  determined  by 
Leuckart  to  be  due  to  coccidia.  In  W.  B.  ITaddon's  case  the  patient  was 
admitted  to  St.  Thomas's  Hospital  with  slight  fever  and  drowsiness;  he 
gradually  became  unconscious;  death  occurred  on  the  fourteenth  day  of 
observation.  Whitish  neoplasms  were  found  upon  the  peritonanim,  omen- 
tum, and  on  the  layers  of  the  pericardium;  and  a  few  were  found  in  the 
liver,  spleen,  and  kidneys.  A  somewhat  similar  case,  though  more  remark- 
able, as  it  ran  a  very  acute  course,  is  reported  by  Silcott.  A  woman,  aged 
fifty-three,  admitted  to  St.  Mary's  Hospital,  was  thought  to  be  suffering  ""rom 
typhoid  fever.    She  had  had  a  chill  six  weeks  before  admission.    There  were 

849 


350 


DlSKASivS   DUH   TO  ANLMAIi   PAUASITIOS. 


/ 


ffvcr  of  ail  iiitcriiiittciit  ly|i(',  slight  diiirrhd'a,  ii;ui.-rii,  t('ii(l('nK'.>-s  nvor  llic 
livLT  uiul  !?iiIltii,  and  a  dry  lujiyuc;  dcalh  occMUTL'd  Iroiu  liuail-railurc.  Tlio 
li\cr  was  enlarged,  \vi'i<,du'd  83  ounces,  and  in  its  substance  there  were  ease- 
cdis  loci,  around  each  ol'  winch  was  a  rinji;  of  congestion.  The  s|ileeu 
wci^^hed  1(!  ounces  and  cont;;incd  siiuilar  liodics.  '!'he  ileum  i)reseiitcd  six 
])aiiule-like  eJevatiuns.  The  nuisses  resend)led  tubercles,  but  un  examina- 
tion coccidia  were  I'ound. 

'i'lie  ])arasiles  are  also  found  in  the  kidneys  and  ureters.  Cases  of  this 
kind  have  Ix^en  recorded  by  lUand  Sutton  and  Paul  i'^ve.  In  love's  case 
the  symptoms  Mere  luenuituria  and  fre(|uent  nucturition,  and  di'ath  took 
pliU'c  on  the  se\entcenth  day.  The  nodules  throughout  the  pelvis  and 
ureters  June  been  re^nirdod  as  mucous  cysts,  hi  a  (;ase  rci)orted  Ly  Joseph 
(li'iniths  the  tumors  in  the  ureter  caused  hydronei)hr()sis. 

(2)  Cutaneous  Psorospermiasis.' — The  parasitic  nature  of  the  l-cnitosis 
fdlliruldris  of  White,  and  oi'  I'a^a't's  disease  ol'  the  nipple,  which  seemed 
to  have  been  established,  has  been  called  in  question,  and  the  bodies  tic- 
scribed  as  psorosjjerms  are  believed  to  be  the  result  of  epithelial  degenera- 
tion. So,  too,  in  niolluscuin  c(mta<;'iosum  and  in  epithelionui,  the  nature 
of  the  structures  wliich  lie  in  and  ))clAvecn  the  epithelial  cells,  and  which 
have  some  resemblance  to  j)Sorospernis,  is  still  unsettled;  some  claiming 
that  they  are  truly  parasitic,  others  afTinning  that  they  are  nothing  but 
altered  protoplasm  of  the  ej)ithclial  cells. 

There  are  several  undoubted  instances,  however,  of  parasitic  si)orozoa 
])roduciiig  extensive  disease  of  the  skin.  In  Wernicke's  case  (from  lUienos 
Ayres)  the  lesions  Avere  scattered  over  the  face,  trunk,  and  left  thigh.  The 
sporozoa  -were  found  in  numbers  in  the  ]uis  of  the  skin  lesions,  and  also 
in  the  inguinal  glands,  which  were  excised. 

Kixford  and  (iilchrist  describe  two  cases  (Johns  no])kins  Ilosjjital  Re- 
ports, vol.  i).  In  the  first  case,  which  was  regarded  as  tuberculosis  of  the 
skin,  the  lesioji  remained  local  for  nearly  eight  years.  The  lymphatic  glands 
then  became  involved.  The  all'ection  gradually  attacked  the  nose,  checks, 
and  other  ])arts  of  the  licad,  the  left  hand,  the  leg,  and  the  left  testicle. 
For  seven  or  eight  years  the  |)atient  had  no  constitutional  sym])tonis,  but 
after  the  glands  became  involved  an  intermittent  fever  develo])ed.  In  the 
later  stages  he  had  a  cough  with  purulent  expectoration.  The  antopsy 
revealed  what  a])]H'ared  to  l)e  tuberculosis  of  the  lungs,  adrenals,  and  testis. 
There  were  numerous  tubercnlons-looking  nodules  in  the  spleen,  on  the 
surface  of  the  liver,  and  the  pleura?.  In  all  of  the  lesions  enormous  nninbers 
of  sporozoa  were  found,  csjiecially  in  the  caseous  masses.  Successfnl  inocu- 
lations Avere  made  into  rabbits  and  dogs.  The  second  case  was  similar,  but 
much  more  acute.  There  were  thirty  skin  lesions  distributed  over  the 
body.  Tlie  i)atient  died  within  tlirce  months  after  the  a])pearance  of  the 
initial  lesion.  In  an  excised  lymph-gland  enormous  numbers  of  sporozoa 
Avere  fonnd.  The  cycle  of  development  was  readily  followed.  I'liese  l)odi(>s 
differ  in  all  ])oints  from  those  dt'scribcd  as  jirotozoa  in  cancer  and  in  mol- 
luscum  contagiosum. 

Two  of  the  most  important  profozoon  diseases — namciy,  amoebic  dys- 
cnterv  and  malaria — have  been  described. 


form 
call, 
in  Jc 

lllef 
the  ii 
inces 
Dishn 
Accor 
are  ai 
conn  I 
J^ilxu'i; 
Th 
in  test i 
ease  o 


DISTOMFASIS. 


3.".  I 


iitiil  Ke- 
of  the 

choc'lv^, 
testicle, 
iins,  but 

In  the 
aiitopsy 
(1  testis. 

on  tlie 
Ininnhers 
il  inoc\i- 
ilar,  1>"t 
(YCT  the 
;e  of  tlie 

s])oro7.0ii 

;0  1)0(VU'S 

in  niol- 
ehic  dys- 


II.    PARASITIC    INFUSORIA. 

Several  flafrclliito  liavo  \h'vu  round  parasitic  in  Tuan.  Anion;i;  the  most 
common  are  tlie  Ti iilionnuias  n((/iiialis,  wliich  measures  J.")  to  25  fi  in 
leii^^tli,  and  lias  I'our  lla^clla,  whieli  are  as  lon^'  a.s  or  hui-^er  than  tlie  body, 
it  is  by  no  means  an  uncommim  parasite  in  the  aeid  vaj^iiial  iiiiieus. 

The  Tvi('hi)monax  or  Ceironwuds  lioniiiiis  lives  in  the  intestines,  and 
is  met  with  in  the  stools  nnder  all  sorts  ol"  conditions.  Il  is  probably  not 
pathogenic.  1  have  seen  it  also  in  the  vomit  in  a  case  of  ehnmic;  gastric 
catarrh.  Triehomonads  have  been  met  with  also  in  the  urine  in  sevi'ial 
cases,  and  may  be  li'uly  pathogi'iiic.  In  hock's*  case  the  imrasites  wero 
associated  with  a  lueinorrhagie  cystitis  without  bacteria. 

The  Lainhlla  iiilrslinalis  is  another  intestinal  moiiail,  larger  than  the 
common  Triclioiiioinis.  Flagellates  have  also  been  found  in  the  expec- 
toration in  eases  of  gangrene  of  the  lung  and  of  bronchiectasis,  and  in 
jileurisy. 

Among  the  ]iarasitie  Cillala  may  be  mentioned  the  ]>(ilaiili<linin  culi, 
which  lias  been  found  occasionally  in  the  lai'ge  intestine  in  forms  of  dys- 
entery. The  parasite  is  oval  in  form,  70  to  IUO/a  long  and  50  to  70 /*  broad. 
It  is  donbtfnl  whether  it  is  i)athogenic. 

III.    DISTOMIASIS. 

Several  forms  of  trcmaiodcs  or  flukes  are  parasitic  in  man,  and  when 
in  numl)ers  may  cause  serious  disease. 

(1)  Liver  J'lul'cs. — The  following  species  of  llukes  Iiave  been  fonnd: 
The  Fasriold  hcpalira,  a  very  comnum  ])arasite  in  ruminants,  which  has  a 
length  of  from  2S  to  ',Vi  mm.  ^riie  Distininini  hnircuhtlinii,  a  much  smaller 
form,  fi'om  (S  to  Kt  mm.  in  length,  which  is  also  very  common  in  sheep  and 
cattle.  The  Dlslonui  hiisl'i,  llu'  largest  form,  measuring  fi'om  I  to  S  cm. 
in  length.  One  or  two  other  less  important  foniis  have  occasionally  Ih'cii 
met  with,  ^riie  studies  of  the  Japanese  ]ihysicians  have  brought  to  light 
the  interesting  fact  that  ihere  is  a  distoma  widely  endemic  in  certain  ])rov- 
inces  in  that  counti'y.  The  two  forms  described  as  DislmiKi  riKJcmi'diin  and 
Dl^loiiin  prniiriosuni  are  identical,  and  are  known  now  as  Dixhiinn  sineiisc. 
According  to  Baelz,  fnlly  20  ])er  cent  of  the  inhabitants  of  certain  provinces 
are  alTected.  The  Dhhnna  frliiirinii,  which  has  been  found  recently  in  this 
coimtiy  by  Ward,  of  Nebraska,  \n  cats,  is  a  common  human  jiarasite  in 
Siljcria. 

The  flukes  oecnpy  the  bilo-])assagos  and  the  npper  jiortion  of  the  small 
intestine.  "When  in  large  nnmbers  tliey  may  cause  serious  and  fatal  dis- 
ease of  the  liver,  nsnally  with  ascites  and  janndice.  Tli(>  li\-cr  may  be  enor- 
monsly  enlarged;  in  Kichner's  cfi^^o  it  McigluMl  If  pounds.  The  flukes  may 
canse  a  chronic  cholangitis,  leading  to  great  thickening  or  even  calcifica- 
tion of  the  walls  of  the  liile-dnct.  The  ova  have  been  fonnd  in  the  stools. 
Occasionally  the  distomes  are  fonnd  under  the  skin. 


*  American  Journal  of  the  Medical  Sciences,  January,  1896. 


352 


DISEASES  DUE  TO  ANIMAL  TARASITES. 


.  \ 
/ 


The  oikU  nic  fluke  discasu  of  .Tapiiii  is  c-liaraclcri/cd  l»y  enlargement  of 
the  liver,  emaciation,  (liarrluea,  and  i'rtMHicntly  ascites. 

(2)  The  Jllood  Fluke;  Srliislnsoma  hiiwalnbinm  [HUhnrzia  hvmalohia). 
— This  treniatodc  is  i'onnd  in  Kfi/pt,  soiitliern  Africa,  and  Arabia,  and  is 
the  cause  in  these  countries  of  the  endemic  luematuria.  The  female  ia 
about  2  cm.  in  length,  cylindrical,  lilil'orm,  and  al)out  ().U7  mm.  in  diame- 
ter. The  i)arasite  lives  in  the  venous  system,  particularly  in  the  portal 
vein,  and  in  the  veins  of  the  8i)leen,  bladder,  kidneys,  and  mesentery.  Ac- 
cording to  ]5ilharz,  at  least  50  per  cent  of  the  lower  classes  in  Kgypt  are 
infected  witli  it.  It  is  not  yet  known  how  the  ])arasite  gains  entrance  to 
the  body.  In  all  i)robability  it  is  by  drinking  impure  water  containing  the 
embryos. 

The  symptoms  are  due  to  ihanges  in  the  mucous  membrane  of  the 
urinary  organs  cau.sed  by  the  ])resence  of  the  ova  in  the  blood-vessels  of 
these  ])arts.  Iliematuria  is  the  first  and  most  constant  symptom,  leading 
gradually  to  aniemia.  There  is  generally  i)ain  during  micturition.  The 
blood  is  not  constant  in  the  urine.  The  ova  of  the  Bilharzia  are  readily 
seen  under  a  microscope  with  a  low  power.  They  are  ovoid  in  shai)e, 
translucent,  with  a  small  s])ike  at  one  end.  They  may  be  widely  distributed 
in  the  body — in  the  sul)mucosa  of  the  bowel,  in  polypoid  excrescences  in 
the  rectum,  in  the  lungs  and  elsewhere. 

The  disease  is  rarely  fatal;  a  great  majority  of  the  cases  recover.  Chil- 
dren are  more  commonly  attacked  than  grown  persons,  and  the  disease 
often  disa])pears  by  the  time  of  ])uberty. 

(3)  lirunchial  Fhtl-c ;  Dislomum  Wcstermanni;  Parasitic  Ilamophjsis. — 
In  parts  of  China,  Japan,  and  Formosa  there  is  an  epidemic  disease,  de- 
scribed by  Einger  and  Manson,  characterized  by  attacks  of  cough  and 
lurmoptysis  associated  with  the  i)resence  of  a  snuUl  fluke  in  the  bronchial 
tubes. 

IV.    DISEASES   CAUSED    BY   NEMATODES. 

I.    ASCARIASIS. 

(a)  Asraris  himhricoides,  the  most  common  human  parasite,  is  found 
chiefly  in  children.  The  female  is  from  ?  to  1'-^  inches  in  length,  the  male 
from  4  to  8  inches.  In  form  it  is  cylindrical,  being  pointed  at  both  ends;  it 
has  a  yellowish-brown,  sometimes  a  slightly  reddish  color.  Four  longitudinal 
1  lands  can  be  seen,  and  it  is  striated  transversely.  The  ova,  which  are 
sometimes  found  in  large  numl)ers  in  the  fneces,  are  small,  brownish-reel 
in  color,  elli]itical,  and  have  a  very  thick  covering.  They  measure  0.075 
mm.  in  length  and  0.0,58  mm.  in  width.  The  life  history  has  been  demon- 
strated to  be  ''  direct  " — i.  e.,  without  intermediate  host.  The  ])arasite 
occupies  the  upper  portion  of  the  small  intestine.  Usually  not  more  than 
one  or  two  are  present,  luit  occasionally  they  occur  in  enormous  numbers. 
The  migrations  are  ])eeuliar.  They  may  pass  into  the  stomach,  whence 
they  may  be  ejected  by  vomiting,  or  they  may  crawl  up  the  oesophagus 
and  enter  the  pharynx,  from  Mhich  they  may  be  withdrawn.  A  child  under 
my  care  in  the  small-pox  department  of  the  General  Hospital,  during  con- 


eh  are 
ish-rcd 
c  0.0T5 
(Iciiinn- 
larasite 
)re  than 
umbers^, 
whence 
opha.irns 
d  under 
ng  con- 


DISEASKS  CAUSED  BY  NEMATODES. 


3:>3 


valosccnrp,  villidrew  in  this  way  ninro  tlian  thirty  round  worms  within  a 
Tew  weeks,  in  other  instances  the  worm  rcachi's  the  larynx,  and  lias  lieeii 
known  to  prodnce  fatal  aspiiyxia,  or,  [tassin^'  into  tht'  tracliea,  to  cause 
pm^M'ene  of  the  lunj;.  Tlieymay  ^'o  throii<,di  the  Kustaeliian  tulic  and  appear 
at  the  external  meatus.  The  most  serious  mi^n'ation  is  into  the  hile-duct. 
There  is  a  specimen  in  the  Wistar-ilorner  Museum  of  th(>  Tniversity  of 
rennsylvania  in  which  not  oidy  the  common  duct,  hut  also  the  nuiin 
branches  throu^diout  the  liver,  are  enormously  distended  and  packed  with 
luimcrous  round  worms.  'JMie  howel  may  he  blocked,  or  in  rare  instances  an 
ulcer  may  be  jieri'orated.  Kven  the  healthy  bowel  wall  may  be  penetrated 
(A])ostolides). 

A  peculiarly  irritating  substance,  often  evident  to  the  sense  of  smell  ia 
handling  s])ecimens,  is  formed  by  the  round  worms.  I'cipcr  aiul  others 
suggest  that  the  nervous  sym])toms,  sometimes  resembling  those  of  menin- 
gitis, are  due  to  this  jjoison.  ('hauH'ard,  Marie,  and  Tauchon  have  gone  still 
fui'thcr,  and  report  a  remarkable  condition  of  fever,  intestinal  symptoms, 
foul  hreath,  and  intermittent  diarrham  in  connection  with  the  ])resenee  of 
lumhrieoides.  They  call  it  typho-lumbricosis.  The  febrile  condition  may 
continue  for  a  month  or  more.  The  symptoms  are  sujiposed  to  be  excited 
reilexly,  or  to  be  due  to  the  virulence  of  the  ascarides  themselves.  It  does 
not  seem  to  nic  a  very  clearly  detined  condition,  and  when  one  considers 
the  extraordinary  frecpiency  of  lumbricoid  worms  and  the  remarkable  num- 
ber which  may  be  harbored  without  causing  any  sjjccial  trouble,  I  think  we 
recpiire  more  evidence  before  we  accept  the  conclusions  of  these  authors. 

The  sym])toms  are  not  definite.  When  a  few  parasites  are  present  they 
may  be  passed  withont  causing  disturbance.  In  cliildren  there  are  irritative 
symptoms  usually  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  grinding  of  the  teeth,  twitchings,  or  convulsions.  These 
sym]>toms  uiay  be  marked  in  very  nervous  children. 

Treatment. — Santonin  can  bo  given,  mixed  with  sugar,  in  doses  of 
from  one  half  to  one  grain  for  a  child  and  two  to  three  grains  for  an  adult, 
followed  by  a  calomel  or  a  saline  purge.  The  dose  nuiy  be  given  for  three 
or  four  days.  An  unjtleasant  consecpience  which  sometimes  follows  the 
administration  of  this  drug  is  xantho])sia  or  yellow  vision. 

(b)  Oxyuris  vermicnlnris  {Thread-worm;  Fin-worm). — This  common 
imrasite  occupies  the  rectum  and  colon.  The  male  measures  about  -i  mm. 
in  length,  the  female  about  10  mm.  They  produce  great  irritation  and 
itching,  particularly  at  night,  symptoms  which  become  intensely  aggravated 
by  the  nocturnal  migration  of  the  parasites.  Occasionally  peri-rectal  ab- 
scesses are  formed,  containing  numbers  of  the  M'orms. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  there  may  be  loss  of  appetite  and  anirmia.  Though  most 
common  in  children,  the  parasite  occurs  at  all  ages. 

The  worm  is  readily  detected  in  the  fa}ces.  Infection  probably  takes 
]»lace  through  the  water  or  possibly  through  salads,  such  as  lettuce  and 
cresses.  A  person  the  subject  of  the  worms  passes  ova  in  large  numbers 
in   the  fn?ces,   and  the   possibility   of   reinfection   must   be   scrupulously 


guarded  against. 


354 


DISKASES  DUE  TO  ANIMAL  PARASITKS. 


/ 


Tlio  trcutiiH'iit  is  siiii|ili',  tli()ii;^li  occiisioiiiilly  tlicrc  arc  instances  in 
wliicii  all  t'i)rnis  nf  iiiiMJication  luv  ri'sihtcd.  A  cusc  is  iiu'iitioticcl  of  a  ^'cu- 
tlciiiaii,  u'^c'l  lorlv.  wlici  iiiul  siill'iTt'd  rroiii  cliildlioncl  ami  liad  I'ailfd  to 
obtain  any  l)L'nt'lit  I'roni  prolon{,'c'd  trcatinont  liy  many  liclniintliolo^^'ists. 
I  have  r('|iort('d  a  case  of  st'vcnd  years'  dnratioii.  Santonin  niiiy  he  used 
in  small  dost-s,  and  mild  pnr^^ativi's,  part icnlarly  rliuharli.  l^ar;,^.'  injiH!- 
tions  containinjx  carbolic;  acid,  vincpir,  (|nassiu,  ulocs,  or  tni'iK'ntinc'  may 
be  I'luployi'd.  in  children  the  nsi'  ol'  cold  injections  of  stronj;  salt  and 
wati'f  is  usually  cllicacious.  Tlicy  should  be  repfjitcd  t'or  at  least  ten  days. 
In  friviii;;  the  injection  care  shoidd  be  taken  to  have  the  hips  well  elevated, 
m  that  the  fluid  can  be  retained  as  Ion;:  us  possible.  For  the  intense  iteli- 
in<,'  and  irritation  at  Jiight  vus-eiine  may  be  freely  nsou,  or  bcdladouna  oint- 
ment. 

TT.  TincitiNrASis, 

The  Trichina  sph-alis  in  its  adult  condition  lives  in  the  small  intes- 
tine. The  disease  is  ])roduced  by  the  embryos,  wliich  ])ass  from  the  ijites- 
tines  and  reach  the  voluntary  lunscles,  where  they  finally  become  encap- 
sulated lai'Vic — muscle  tricbiiue.  Jt  is  in  the  mi;^ration  of  the  endiryos 
(possibly  from  poisons  produced  by  them)  that  the  grou[)  of  symptoms 
known  as  triehinasis  is  produced. 

Dvscription  of  IJic  Piirosilcs. — ()i)  Adult  or  intestinal  form.  The  feinali; 
measures  from  '.]  to  1  mm.;  the  male,  1.5  mm.,  and  has  two  little  projections 
from  the  hinder  end. 

(h)  The  larva  or  muscle  trichina  is  from  O.n  to  1  mm.  in  length  and  lies 
coiled  in  an  ovoid  capsule,  which  is  at  lirst  translnceut,  but  subse(|ncntly 
o])a(iue  and  infiltrated  with  lime  salts.  The  worm  presents  a  ])ointcd  head 
and  a  somewhat  rounded  tail. 

When  flesh  containirg  the  trichina;  is  eaten  hy  man  or  by  any  ani- 
mal in  which  tlie  development  can  take  place,  the  capsides  are  digested 
and  the  trichina'  set  free.  They  ])ass  into  the  small  iidcstine,  and  about 
the  third  day  attain  their  full  growth  and  become  sexually  mature.  A'ir- 
chow's  e.\])eriments  have  shown  that  on  the  sixth  or  seventh  day  the  em- 
bryos are  fully  developed.  The  young  ])roduced  by  each  female  trichina 
have  been  estimated  at  several  hnndred.  Lenckart  thinks  that  varions 
broods  are  develo])cd  in  snccession,  and  that  as  many  as  a  thousand  em- 
bryos may  be  ])r()duced  by  a  single  worm.  The  time  from  the  ingestion 
of  the  iK'sh  containing  the  muscle  trichinie  to  the  develo]nnent  of  the 
brood  of  embryos  in  the  intestines  is  from  seven  to  nine  days.  Tin; 
female  worm  ])en(,'ti'ates  the  int(>stinal  wall  and  the  embryos  are  probably 
discharged  directly  into  the  lymph  spaces  (Askanazy),  thence  into  the 
venons  system,  and  by  the  blood  stream  to  the  mnscles,  which  constitute 
tlu'ir  seat  of  election.  Dr.  J.  Y.  Ciraham,  of  the  I'niversity  of  Alabama, 
has  recently  reviewed  the  (piestion  of  the  mode  of  transmission  in  an  ex- 
haustive monograiih,  and  he  gives  strong  arguments  in  favor  of  the  trans- 
mission througii  the  blood  stream.  After  a  ])reliminary  nugration  in  the 
intermuscular  connective  tissue  they  penetrate  the  primitive  muscle-fibres, 
and  in  about  two  weeks  develop  into  the  full-grown  muscle  form.     In  this 


tlu 


"'SKASKS  OAL'SKD   DY   NKMATODKS. 


355 


lo 


1  em- 

■siion 
r  the 
The 
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tituti; 
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HI  ex- 
tra ns- 
n  the 
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;n  this 


u 


proffSH  (in  inters! ili.il  nivusiliH  is  cxeilcd  ami  ^radiiallv  an  ovoid  fn])ft\ile 
(K.'M'lops  ahoiil  the  parasite,  'i'wo,  (iccasionally  three  ur  I'oiir,  wornid  may 
1)0  sot'ii  within  a  niii^h'  capsule.  This  process  ol'  ciitapsiilatioii  lias  hoeii 
estimated  lo  take  aiiciit  six  wei'ks  Within  the  niiisrlcs  the  parusiti'S  do 
not  iiiiderj:o  t'lirlher  development.  (Jrailiially  the  capsnie  In'conies  thicker, 
and  nitinialely  lime  salts  are  deposited  within  it.  'I'liis  ehanire  may  take 
place  in  man  within  I'onr  or  li\e  months.  In  the  h<>j,'  it  may  he  did'crred 
for  many  years.  The  ealiiliealioii  I'enders  (he  cyst  visihie,  ami  since  lirst 
seen  by  Tie<lemann,  in  lS2'i,  and  Jlilton,  in  lH3'i,  tliesc  small.  opa<pie,  oat- 
sha|»ed  bodies  havi>  been  familiar  objects  tr)  demonstrators  (tf  normal  and 
morbid  anatomy.  The  trichitiie  may  live  within  thi'  mu.scles  for  an  indeli- 
nite  period.  They  have  been  found  alive  and  cajjuble  of  dev(dopin<^  as  lato 
as  twenty  or  even  twenty-fivo  years  after  their  entrance  into  the  system. 
In  many  instances,  however,  the  worms  are  coni|ilelely  calcilled.  T\ui 
trichina  has  been  fonnd  or  **  raised  "  in  twenty-six  diU'erent  s|)ecies  of  ani- 
mals (Stik's).  .Medical  literatnre  abonnds  in  references  to  it.s  presence  in 
lisli,  earthworms,  etc.,  but  these  |)arasites  belon<;  to  other  p'ncra.  In 
fa'cal  exannnations  for  the  parasite  it  is  well  to  remember  that  the  "'cell 
biidy  "  of  the  anterior  ))ortion  of  the  intestine  is  a  diagnostic  criterion  ot! 
the  7'.  spiralis.  Jt  was  lirst  found  in  the  \\o'^  by  the  late  .Joseph  Leidy. 
Mxperimcntally,  ^niinea-pips  and  rabbits  are  readily  infeeti'd  by  fi'edinj; 
them  with  muscle  containin;j:  the  larval  form.  Do^'s  are  iufei-ted  with 
dilliculty;  cals  more  readily,  ivxperimentally,  ainmals  sometimes  die  of 
the  disease  if  lar<ie  nund)ers  of  the  parasites  have  been  eaten.  In  the  hoj^ 
the  trichina',  like  the  cysticcrci,  cause  few  if  any  symptoms.  An  animal 
the  muscles  of  which  are  swarming  with  living'  trichina'  may  be  well  nour- 
ished ami  healthy-lookin^i'.  An  iin|»ortaiit  ]»oint  also  is  the  fact  that  in 
the  lio<i-  the  capside  (b)es  not  readily  become  calcified,  so  that  the  ])arasites 
are  not  visible  as  in  the  human  muscles.  For  a  lon<x  time  the  trichina  was 
looked  upon  as  a  patholo>iical  curiosity,  but  in  lS(i()  Zenker  discovered  in 
a  j^ii'l  in  the  Hresden  Hospital,  who  had  symptoms  of  typhoid  fever,  both 
the  inlestinal  and  the  muscle  forms  of  the  tricliina\  since  which  time  the 
disease  has  been  thoroughly  studied. 

^lan  is  infected  by  eatiu'r  the  llesh  of  trichinous  lioy-s.  The'  incidence 
of  the  disease  in  swine  varies  much  in  dill'ei'cnt  countries.  Jn  Oermany, 
where  a  thorou,i,di  and  systenuitic  micros(o]»ic  examination  of  all  swine 
llesh  is  made,  the  ])rop(u1ion  of  trichinous  hojxs  is  about  I  in  l,S."')"i.  At 
the  IJerlin  abattoii',  where  the  nncroscopic  examination  is  ct)mluctcd  by  a 
staflf  of  over  ei.iihty  nien  and  wonu'U,  I  wo  ])ortions  are  taken  from  the  ab- 
dominal muscles,  from  the  diaphra^^m.  and  from  the  intercostal  muscles, 
and  one  ])iece  from  the  muscles  of  the  larynx  and  tonLTue.  .\  special  coni- 
]tressor  is  used  to  llatten  the  frairments  of  (he  muscle,  and  the  examination 
is  nuule  with  a  mairnifyintr  ])ower  of  from  T<>  to  !()(»  diameters.  Durincf 
the  three  years  ending-  in  ISS.")  there  were  ()03  trichinous  hosrs  detected,  a 
ratio  of  1  to  1.292.  Statistics  aiv  not  available  in  Knizland.  In  the  United 
States  systematic  inspection  is  unl\iu)wn,  and  the  statistics  are  by  no  nu'ans 
extensive  enoujjfh.  "Taking  all  the  examinations  of  American  pork  thus 
far  made,  both  at  home  and  abroad,  and  we  have  a  total  of  298,782,  in  which 


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356 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


/ 


tricliina.^  were  found  0,280  times,  being  2.1  per  cent,  or  1  to  48  "  (Salmon, 
1884). 

In  1883,  in  conjunction  with  A.  W.  Clement,  I  examined  1,000  hogs 
at  the  Montreal  abattoir,  and  found  only  4  infected. 

Modes  of  Infection. — The  danger  of  infection  depends  entirely  nipon 
the  mode  of  preparation  of  the  flesii.  Thorough  cooking,  so  that  all  parts 
of  the  meat  reach  the  boiling  point,  destroys  the  parasites;  but  in  large 
joints  the  central  portions  are  often  not  raised  to  this  temperature.  The 
frequency  of  the  disease  in  dilferent  countries  depends  largely  upon  the 
habits  of  the  })e()])le  in  the  pre})aration  of  pork.  In  North  (rermany,  wlicre 
raw  ham  and  irnrst  are  freely  eaten,  the  greatest  number  of  instances  have 
occurred.  In  South  Germany,  France,  and  England  cases  are  rare.  In 
this  country  the  greatest  number  of  persons  attacked  have  been  Germans. 
Salting  and  smoking  the  flesh  are  not  always  sufficient,  and  the  Havre 
experiments  showed  that  animals  are  readily  infected  when  fed  with  por- 
tions of  the  pickled  or  the  smoked  meat  as  prepared  in  this  country.  Carl 
Fraenkel,  however,  states  that  the  experiments  on  this  point  have  been 
negative,  and  that  it  is  very  doubtful  if  any  cases  of  trichiniasis  in  Germany 
have  been  caused  by  American  pork.  Germany  has  yet  to  show  a  single 
case  of  trichiniasis  due  to  pork  of  unquestioned  American  origin. 

Frequency  of  Infection. — The  dissecting-room  and  post-mortem  statis- 
tics show  that  from  one  half  to  two  per  cent  of  all  bodies  contain  trichinae. 
Of  1,000  consecutive  autopsies,  of  which  I  have  notes,  trichina?  were  present 
in  ()  instances.  I  have,  in  addition,  seen  them  in  two  dissecting-room  cases 
and  in  two  bodies  at  the  Philadel])hia  nosj)ital. 

The  disease  often  occurs  in  epidemics,  a  large  number  of  persons  being 
infected  from  a  single  source.  Among  tlie  best  known  of  these,  one  occurred 
at  Iledersleben,  in  which  there  were  337  persons  affected,  and  another  at 
Kmersleben,  in  which  there  were  250  persons  attacked.  The  extensive  out- 
breaks of  this  sort  have  been,  with  few  exceptions,  in  North  Germany,  and 
they  are  a  comment  on  the  inefficiency  of  the  inspection.  The  statistics  on 
the  sidjject  in  this  country  have  been  collected  for  me  by  Alfred  Mann, 
by  F.  A.  Packard,  of  Philadelphia,  and  more  exhaustively  by  C.  W.  Stiles, 
who  states  that  up  to  1893  there  was  a  total  of  709  cases,  since  which  he 
says,  in  a  letter  of  February  7,  1898,  there  have  been  40  or  50  cases  re- 
ported. He  thinks  that  900  would  cover  the  total  number  thus  far  re- 
jtorted  for  this  country.  According  to  States,  New  York  heads  the  list 
with  129  cases;  Illinois  shows  119;  Massachusetts,  115;  I)wa,  108.  Only 
rarely  are  cases  diagnosed  in  hospital  ])ractice.  With  the  exccjition  of  a 
typical  case  in  one  of  Traube's  wards,  I  never  recognized  an  instance  of  the 
disease  until  the  past  eighteen  months,  during  which  time  3  cases  have 
occurred  in  my  service  at  the  Johns  Hopkins  Hospital. 

Symptoms. — The  ingestion  of  trichinnus  flesh  is  not  necessarily  fol- 
lowed by  the  disease.  When  a  limited  number  are  eaten  only  a  few  em- 
bryos pass  to  the  muscles  and  may  cause  no  symptoms.  Well-characterized 
cases  present  a  gastro-intestinal  period  and  a  period  of  general  infection. 

In  the  course  of  a  few  days  after  eating  the  infected  moat  there  are 
signs  of  gastro-intestinal  disturbance — pain  in  the  abdomen,  loss  of  appe- 


DISEASES  CACSED  BY  NEMATODES. 


357 


tite,  vomiting,  and  sometimes  diarrhoea.  Tlie  preliminary  symptoms,  how- 
ever, are  by  no  means  constant,  and  in  some  of  the  large  epidemics  eases 
have  been  observed  in  which  they  have  been  absent.  In  other  instances 
the  gastro-intestinal  features  have  been  marked  from  the  outset,  and  the 
attack  luis  resembled  cholera  nostras.  I'ain  in  dilferent  ])arts  of  the 
body,  general  debility,  and  weakness  have  been  noted  in  some  of  tlie 
e])i(lemics. 

The  invasion  synii)tonis  develop  between  the  seventh  and  the  tenth  day, 
sometimes  not  until  the  end  of  the  second  week.  There  is  fever,  cxcei)t  in 
very  mild  cases.  Chills  are  not  common.  The  thermometer  may  register 
102°  or  10-1°,  and  the  fever  is  usually  remittent  or  intermittent.  The  mi- 
gration of  the  parasites  into  the  muscles  excites  a  more  or  less  intense  myo- 
sitis, which  is  characterized  by  pain  on  pressure  and  movement,  and  by 
swelling  and  tension  of  the  muscles,  over  which  the  skin  may  be  oedema- 
tous.  The  limbs  are  placed  in  the  positions  in  which  the  muscles  are  in 
least  tension.  The  involvement  of  the  muscles  of  mastication  and  of  the 
larynx  may  cause  difhcu^jy  in  chewing  and  swallowing.  In  severe  cases 
the  involvement  of  the  diaphragm  and  intercostal  mubclfs  may  lead  to 
intense  dyspnffia,  which  sometimes  proves  fatal.  Oedema,  a  feature  of  great 
importance,  may  be  early  in  the  face,  particularly  about  the  eyes.  Later 
it  develops  in  the  extremities  when  the  swelling  and  stiffness  of  the  mus- 
cles are  at  their  height.  Profuse  sweats,  tingling  and  itching  of  the  skin, 
and  in  some  instances  urticaria,  have  been  described. 

Blood. — A  marked  leucocytosis,  which  may  reach  above  30,000,  is  pres- 
ent. A  special  feature  is  the  extraordinary  increase  in  the  number  of 
eosinophilic  cells,  which  may  comprise  more  than  50  per  cent  of  all  the 
leucocytes.  There  have  been  in  my  wards  within  the  past  two  years  5 
cases  in  which  this  eosinophilia  Avas  most  pronounced.  In  4  of  the  cases 
the  diagnosis  was  actually  suggested  by  the  great  increase  in  the  eosino- 
l)hiles;  in  1  case  they  reached  G8  per  cent  of  the  total  number  of  leuco- 
cytes. 

The  general  nutrition  is  much  disturbed  and  the  patient  becomes 
emaciated  and  often  ana}mic,  particularly  in  the  protracted  cases.  The 
patellar  tendon  reflex  may  be  absent.  The  jiatients  are  usually  conscious, 
except  in  cases  of  very  intense  infection,  in  which  the  delirium,  dry  tongue, 
and  tremor  give  a  picture  suggesting  ty])hoid  fever.  In  addition  to  the 
dyspna}a,  present  in  the  severer  infections,  there  may  be  bronchitis,  and  in 
the  fatal  cases  pneumonia  or  ])leurisy.  In  some  epidemics  polyuria  has  been 
a  common  symptom.    Albuminuria  is  frequent. 

The  intensity  and  duration  of  the  symptoms  depend  entirely  upon  the 
grade  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.  In  the  severe  forms  convalescence  is  not  established  for 
six  or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the 
muscular  strength.  One  case  in  the  Hedersleben  epidemic  was  weak  eight 
years  after  the  attack. 

Of  72  fatal  cases  in  the  Hedersleben  epidemic,  the  greatest  mortality 
occurred  in  the  fourth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two 
(lied  in  the  second  week  with  severe  choleraic  symptoms. 


358 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


/ 


The  mortality  luis  ranged  in  (liU'eiviit  outbreaks  from  1  or  2  per  cent 
to  30  i)er  cent.  In  the  lledersleben  epidemic  lOl  persons  died.  Among 
the  4.jG  cases  rejiorted  in  this  country  there  were  1'12  deaths. 

The  andloniiral  cluiiii/c.s  are  ehielly  in  the  voluntary  muscles.  The 
trichinie  enter  the  primitive  muscle  l)un(lles,  which  undergo  granular  de- 
generation with  marked  nuclear  proliferation.  There  is  a  local  myositis, 
and  gradually  about  the  parasite  a  cyst  wall  is  formed.  These  changes,  as 
Avell  as  the  reniarkalde  alterations  in  the  blood,  have  been  described  in  full 
by  Dr.  Thomas  K.  Urown.'''  Cohnheim  has  described  a  fatty  degeneration 
of  the  liver  and  enlargement  of  the  mesenteric  glands.  At  the  time  of  death 
in  the  fourth  or  fifth  week  or  later  the  adult  trichinae  are  still  found  in  the 
intestines. 

The  prognosis  depends  much  upon  the  quantity  of  infected  meat  which 
has  been  eaten  and  tlic  nundjer  of  trichiuiB  which  mature  in  the  intestines. 
In  children  the  outlook  is  more  favorable.  Early  diarrhoea  and  moder- 
ately intense  gastro-intestinal  symptoms  are,  as  a  rule,  more  favorable  than 
constipation. 

Diagnosis. — The  disease  should  always  be  «ns])ected  when  a  large 
birthday  party  or  Fcst  among  Germans  is  followed  by  cases  of  apparent 
typhoid  fever.  The  parasites  may  be  found  in  the  remnants  of  the  ham 
or  sausages  used  on  the  occasion.  The  worms  may  be  discovered  in  tlu; 
stools.  The  stools  should  be  spread  on  a  glass  plate  or  black  background 
and  examined  with  a  -low-power  lens,  wlien  the  trichince  are  seen  as  small, 
glistening,  silvery  threads.  In  doubtful  cases  the  diagnosis  may  be  made 
by  the  removal  of  a  small  fragment  of  muscle.  A  special  harpoon  has 
been  devised  for  this  purjiose  by  means  of  which  a  small  portion  of  the 
biceps  or  of  the  ])ectoral  muscle  may  be  readily  removed.  Under  cocaine 
ana'sthesia  nn  incision  may  be  made  and  a  small  fragment  removed.  The 
disease  may  be  mistaken  for  acute  rheumatism,  particularly  as  the  pains 
are  so  severe  on  movement,  but  tluTo  is  no  s]ieoial  swelling  of  the  j(nnts. 
The  great  increase  in  the  cosinophiles  in  the  blood  is,  as  mentioned  above, 
a  most  suggestive  point  in  diagnosis.  The  tenderness  is  in  the  muscles 
both  on  pressure  and  on  movement.  The  intensity  of  the  gastro-  intestinal 
symptoms  in  some  cases  has  led  to  the  diagnosis  of  cholera.  !Many  of  the 
former  epidemics  were  doubtless  described  as  typhoid  fever,  which  the 
severer  cases,  owing  to  the  prolonged  fever,  the  sweats,  the  delirium,  dry 
tongue,  and  gastro-intestinal  sym]3toms,  somewhat  resemble.  The  pains 
in  the  muscles,  Avith  tension  and  swelling,  oedema,  particularly  about  the 
eyes,  and  shortness  of  breath  are  the  most  important  diagnostic  point<. 
Under  acute  myositis  reference  has  already  been  made  to  the  cases  which 
closely  resemble  trichiniasis.  The  e]iidemic  in  1S79  on  board  the  training 
slii])  Cornwall  presented  symptoms  similar  to  those  of  trichiniasis.  One 
patient  died.  Two  months  after  burial  the  body  was  examined,  and  living 
and  dead  nematode  worms  were  found  which,  as  r)astian  sho-wed,  were  not 
the  tricliim,  but  a  rhabditis.  They  were  probably  not  parasitic,  but  en- 
tered the  bodv  of  the  cadet  after  Imrial. 


*  Journal  of  Experimental  Medicine,  vol.  iii. 


.'  i       ^SES  CAUSED  BY  NEMATODES. 


359 


The 
)ains 
)ints. 
)OYe, 
1  soles 
tinal 
i:  the 
the 
dry 
)ains 
the 

hich 
iniinsr 
One 
ivinir 
-G  not 
it  cn- 


Prophylaxib. — it  is  not  (Idiuilcly  known  how  swiiic'  hecome  dis- 
■casetl.  It  has  hccii  Ihon^Hit  that  they  are  intVeteil  iroiu  rats  about  shiiijili- 
tcr-hoiisL's,  hill  it  is  just  as  ri'asoiiahlf  to  hi'lievc  that  the  rats  are  inlY'eled 
hy  eating'  portions  o!'  tlie  trichinoiis  ilesh  of  swiiie.  'i'he  swine  shouhl,  as 
tar  as  jtossihlc,  he  grain-i'ed,  and  not,  as  it.  so  eoniuion,  aUowud  to  eat  oll'al. 
The  most  salisJ'actory  jtrophyhixis  is  the  complete  cooking  of  i)ork  and 
fiausaj^a-s,  and  to  this  custom  in  EngUuid,  France,  South  CJermany,  and 
l)articidariy  in  this  country,  immunity  is  largely  due. 

Treatment. — If  it  has  been  discovered  within  twenty-four  or  thirty- 
six  hours  that  a  large  number  of  ])ersons  have  eaten  infected  meat,  the 
indications  are  to  thoroughly  evacuate  the  gastro-intestinal  canal.  I'urga- 
tives  of  rhul)arb  and  senna  nuiy  be  given,  or  an  occasional  dose  of  calomel. 
(Jlycerin  has  heen  recomniendod  in  large  doses  in  order  that  by  ]iassing 
into  the  intestines  it  may  Ijy  its  hygroscoj)ic  pro])erties  destroy  the  worm. 
^Jak'-i'ern,  kamala,  santonin,  and  tliymol  have  all  been  recommended  in 
this  stage.  Turj»entine  may  be  tried  in  full  doses.  There  is  no  doubt  that 
diarrlui'a  in  the  first  week  or  ten  days  of  the  infection  is  distinctly  favor- 
able. The  indications  in  the  stage  of  invasion  are  to  relieve  the  i)ains, 
to  secure  slecj),  and  to  su])port  the  patient's  strength.  Tnere  arc  no  medi- 
cines which   have   any   inlluence   upon   tlie   embryos   in   their   migration 


through  the  muscles. 


III.    AXCIIYLOSTOMIASIS. 


The  Uncinaria  (Dachmius,  Sfrongiihis)  dvodenaUs,  also  known  as  the 
SclerostoDi'um  or  Anchi/lostontum  duodcnale,  is  the  only  strongyle  harmful  to 
man.  It  belongs  to  the  same  family  as  the  Sdcrodomum  cquinnm,  which 
causes  the  verminous  aiu'urism  in  tlie  horse.  The  parasites  live  in  the 
ui)])er  ])ortion  of  the  small  intestint',  cliielly  in  the  jejunum.  ^Fhey  are 
easily  seen,  the  mak'  being  from  (i  to  10  mm.  long,  and  the  IV'inale  from 
10  to  18  mm.  The  moiith  is  provided  with  a  series  of  tooth-like  hooks, 
by  means  of  which  the  parasite  attaches  itself  to  the  mucous  membrane. 
Tlie  male  has  a  ])rominent  expansion  or  Inirsa  at  the  tail  end.  The  exist- 
ence of  the  parasite  has  long  been  known,  but  it  was  not  thought  to  be 
])athogenic  until  (Jriesinger  demonstrated  its  association  with  the  l^gy])- 
tion  clilorosis.  It  has  also  been  sliown  to  be  the  cause  of  the  aufvinia 
to  wliicli  miners  and  brick-makers  are  subject.  Throughout  Europe  the 
disease  has  been  widely  spread  by  the  em])loyment  of  Italian  and  Polish 
laborers.  In  certain  Italian  provinces  it  is  extremely  ]»revalent  and  serious. 
It  occurs  in  the  Indies,  in  Brazil,  and  the  "West  Indies,  and  has  been  de- 
scribed in  Jamaica  (Strachan).  Dobson  has  shown  that  there  is  an  extraor- 
dinary prevalence  of  the  worm  even  among  healthy  coolies  in  India  and 
Assam,  amounting  to  80  per  cent.  Dolley  states  that  the  parasite  was 
described  many  years  ago  by  ])hysicians  in  the  Southern  States,  but  no 
recent  observations  upon  the  disease  have  Tieen  made  in  this  country. 

Symptoms. — The  parasites  withdraw  blood  by  suction,  and  the  symp- 
toms result  from  this  slow  depletion.  That  the  parasites  produce  a  toxic 
substance  has  also  been  suggested.  In  the  early  stage  there  may  only  be 
gastric  or  gastro-intestinal  disturbance,  but  if  the  parasites  are  present  in 


3G0 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


/ 


large  niiinl)C'rs  anwinia  is  gradually  produced  and  constitutes  the  charac- 
teristic feature  of  tlie  disease,  Tiic  l^gyptian  chlorosis,  brick-maker's  ana?- 
mia,  tunnel  anannia,  miner's  cachexia,  and  moxintain  ana>mia  are  due  to 
this  cause.  The  clinical  course  is  varial)le.  In  some  instances  the  ana-mia 
develops  acutely  and  reaches  a  high  grade  within  a  short  time,  causing  great 
shortness  of  hreath  and  cudema.  There  is  serious  disturbance  of  nutrition, 
sometimes  diarrha>a  and  colicky  pains;  but  the  most  pronounced  symptom 
is  the  })allor  and  the  associated  ])]ienomena  of  chronic  anivmia,  with  debility 
and  wasting.  The  lesions  of  the  intestines  are  those  of  chronic  catarrh, 
and  small  luemorrhages  occur  in  the  mucosa.  The  worms  are  found  within 
5i  metres  of  the  pylorus,  often  with  their  heads  buried  in  the  mucosa.  Dila- 
tation and  hypertro])]iy  of  the  heart  have  been  found  in  many  cases.  Sand- 
with  states  that  in  Kgypt  the  disease  is  most  common  in  peasants  who  work 
in  the  damp  earth,  many  of  whom  are  earth-caters. 

The  diagnosis  is  not  ditlicult.  The  eggs,  which  are  abundant  in  the 
stools,  are  oval,  about  '62  fi  long  by  'i'Z  fi  broad,  and  possess  a  thin,  trans- 
parent shell.  There  is  no  oi)erculum,  as  in  the  ovum  of  the  oxyuris,  and 
eggs  found  in  the  faeces  arc  in  various  stages  of  segmentation.  The  larvae 
develop  in  moist  earth  and  readily  get  into  the  drinking-water,  througa 
which  infection  occurs. 

The  systematic  emjjloyment  of  latrines  and  the  boiling  of  all  v/ater 
used  for  drinking  ])ur])oses  are  the  important  prophylactic  measures. 
Thymol,  recommerded  by  IJozzolo,  is  a  specific,  and  should  be  given  in 
large  doses,  2  grammes  (in  wafers)  at  8  A.  M.  and  2  grammes  at  10  A.  M. 
(Sandwith).  The  diet  should  be  milk  and  soup.  Two  hours  after  the 
second  dose  of  thymol  a  ])urge  of  castor  oil  or  magnesia  is  given.  If  neces- 
sary, the  treatment  may  be  repeated  in  a  week. 


IV.    FiLAEIASIS. 

Zoologically  the  FUaria  sanguinis  nominis  is  as  yet  suh  jiidice.  Man- 
son's  views  are  as  follows: 

Under  the  general  term  Filaria  sanguinis  liominis  three  species  of 
nematodes  are  included: 

1.  Filaria  hnncrofti,  Cobold,  1877.  This  is  the  ordinary  blood  filaria. 
The  embryos  are  found  in  the  peripheral  circidation  only  during  sleep  or 
at  night.  The  mosquito  is  the  intermediate  host.  The  embryos  measure 
270  to  340  /i.  long  by  7  to  11  ft  broad;  tail  pointed.  The  adult  male  meas- 
ures 83  mm.  long  by  0.407  mm.  broad;  the  tail  forms  two  turns  of  a  spiral. 
The  adult  female  measures  155  mm.  long  by  0.715  mm.  broad;  vulva  2.5() 
mm.  from  anterior  extremity;  eggs  38  /a  by  14  /x.  This  is  the  species  to 
which  the  hiTmatochyluria  and  elephantiasis  are  attributed. 

2.  Filaria  divrna,  Manson,  1891.  The  larvre  agree  with  the  preceding, 
except  that  Manson  indicates  the  absence  of  granules  in  the  axis  of  the 
body.  The  worms  occur  in  the  peripheral  circulation  only  during  the 
day,  or  when  the  patient  stays  awake.  Manson  suspects  that  the  Filaria  loa 
represents  the  adult  stage. 

3.  Filaria  perstans,  Manson,  1891.   Only  the  embryos  are  known.  These 


DISEASES  CAUSED  BY  NEMATODES, 


361 


(ling, 


These 


are  much  f^niallor  than  the  piret'diiig — ^00  /*  long,  posterior  extremity  oh- 
tuse,  anterior  extremity  with  a  sort  of  retractile  roritellum. 

This  is  the  species  to  which  ^[anson  would  attribute  the  sleeping- 
sickness  of  the  negroes.  Hq  is  also  inclined  to  regard  thi-  Filaria  /htsIiuis 
as  the  cause  of  cniw-craiv,  a  ))apillo-pustular  skin  eru})tion  of  the  west 
coast  of  Africa,  which  is  probably  the  same  as  Nielly's  dermatoae  parasilaire, 
the  parasite  of  which  was  called  by  JManchard  lihaJxLiis  Xii-lh/i.  ^lanson 
has  shown  that  in  the  ))l()od  of  tlie  aboriginal  Indians  in  JJritish  (luiana 
there  are  two  forms  of  filarial  end)ry()s,  whicli  dilfer  sonu^what  from  the 
ordinary  ty])es.  Daniels  and  Ozzard  have  shown  the  extraordinary  i)reva- 
lenee  of  these  ])arasites  in  the  a])originals — fully  58  i)er  cent.  Recently 
Daniels  lias  found  the  mature  filaria'  in  two  sul)jects  in  the  upper  i)art  of 
tiie  mesentery,  near  tlu?  paiu'reas  and  in  the  subpericardial  fat. 

The  most  important  of  tliese  is  the  Filaria  bancrofli,  which  produces 
the  hivmatochyluria  and  the  lymph-scrotum. 

The  fenude  produces  an  extraordinary  numher  of  embryos,  which  enter 
the  blood  current  through  tlie  lymi)hatics.  Each  eml)ryo  is  within  its 
shell,  which  is  elongated,  scarcely  perceptible,  and  in  no  way  impedes  the 
movements.  They  are  about  the  ninetieth  part  of  an  inch  in  leiigth  and 
the  diameter  of  a  red  blood-corpuscle  in  thickness,  so  that  they  readily 
pass  through  the  capillaries.  They  move  with  the  greatest  activity,  and 
form  very  striking  and  readily  recognized  objects  in  a  blood-drop  under 
the  microscope.  A  remarkable  feature  is  the  peric'dic'ty  in  the  occurrence 
of  the  embryos  in  the  blood.  In  the  daytime  they  a\  j  almost  or  entirely 
absent,  whereas  at  night,  in  typical  cases,  they  are  present  in  large  num- 
bers. If,  however,  as  Stephen  Mackenzie  has  shown,  the  patient,  reversing 
his  habits,  sleeps  during  the  day,  the  ])eriodicity  is  reversed.  The  further 
develoi)ment  of  the  embryos  appears  to  be  associated  with  the  mosquito, 
which  at  night  sucks  the  blood  and  in  this  way  frees  them  from  the  body. 
Some  slight  development  takes  place  within  the  body  of  the  mosquito, 
and  it  is  probable  that  the  embryos  are  set  free  in  the  water  after  the  death 
of  the  host.  The  further  development  is  not  known,  but  it  probably  occurs 
in  drinking-water.  The  filaria?  may  be  present  in  the  body  without  causing 
any  symptoms.  In  animals  blood  filaria^  are  very  common  and  rarely  cause 
inconvenience.  It  is  only  when  the  adult  worms  or  the  ova  block  the  lymph 
channels  that  certain  definite  sym]itoms  occur.  ]\[anson  suggests  that  it 
is  the  ova  (prematurely  discharged),  which  are  considerably  shorter  and 
thicker  than  the  full-grown  embryos,  which  block  the  lym])h  channels  and 
produce  the  conditions  of  hffmatochyluria,  elephantiasis,  and  lymph- 
scrotum. 

The  parasite  is  widely  distributed,  particularly  in  tropical  and  sub- 
tropical countries.  Guiteras  has  shown  that  the  disease  prevails  extensively 
in  the  Southern  States,  and  since  his  ])aper  appeared  contributions  have 
been  made  by  ]\ratas,  of  Xew  Orleans,  Mastin,  of  ]\robile,  and  De  Saussure, 
of  Charleston. 

Tlie  efTects  produced  may  be  described  under  the  following  conditions: 

(a)  JTn'mntnrldjluria. — Without  any  external  manifestations,  and  in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time 


302 


DISEASES  DUI']  TO   ANL^IAL  PAUASITEH. 


/ 


to  time  passes  urine  of  iiii  opiUiiK!  wliiti',  milky  apiH-'arnnco,  or  ])loo(ly,  or 
a  chylous  lliiid  whicli  on  siltlin^f  shows  a  slij-htly  reddish  iddt.  'J'hc  iiriiio 
iiiny  he  iioi'iiuil  in  (itinntity  or  incTciiscd.  Tlit'  condition  is  nsnally  intcr- 
niiltcnt,  and  the  palit'nt  jnay  [)ass  normal  urine  i'or  weeks  or  months  at  a 
time.  Micn)seo|tically,  the  chylous  urine  contains  minuh.'  molecular  iat 
granules,  usually  icd  hlood-corpuscles  in  various  amounts.  The  end)ryos 
uere  iirst  discovered  hy  l)eman|uay,  at  I'aris  (JS(i;i),  uiul  in  the  urine  hy 
^\'uche^er,  at  liahia,  in  ]!S(i(i.  It  is  rt'uiarkalile  for  how  long  the  condition 
may  persist  without  serious  impairment  ol"  the  health.  A  j)atient,  sent  to 
me  by  Dawson,  of  Charleston,  has  liad  ha.'matochyluria  intermittently  for 
eighteen  years.  The  only  inconvenience  has  been  in  the  passage  of  the 
hlood-clots  wliioli  collect  in  the  Madder.  At  times  he  has  also  uneasy  sensa- 
tions in  the  lumbar  region.  'J'he  embryos  are  present  in  his  blood  at  night 
in  largo  numbers.  Chyluria  is  not  always  due  to  the  fllaria.  The  non- 
l)arasitic  form  of  the  disease  has  already  been  considered. 

()p])ortunitie8  for  studying  the  anatomical  condition  of  tliese  cases 
rarely  occur.  In  the  case  described  by  Ste})hen  .Mackenzie  the  renal  and 
jieritoncal  lyrajjli  plexuses  were  enornujusly  enlarged,  extending  from  the 
diaphragm  to  the  pelvis.  The  thoracic  diict  above  the  diai)liragm  was  im- 
])ervious. 

{!>)  Ljimph-scrdhim  and  certain  forms  of  cJrphantinsis  are  also  caused 
by  the  filaua.  In  the  former  the  tissues  of  the  scrotum  are  enormously 
thickened  and  the  distended  lymph-vessels  may  be  plainly  seen.  A  clear, 
sometimes  a  turbid,  fin  id  follows  puncture  of  the  skin.  The  parasites  are 
not  ahvays  to  be  found.  T  have  oxauuned  two  typical  cases  without  find- 
ing lilaria  in  the  exuded  lluids  or  in  the  blood  at  night.  So  also  the  major- 
ity of  cases  of  elephantiasis  which  occur  in  this  country  are  non-i)arasitic. 
In  China  it  is  stated  that  the  ])arasites  occur  in  all  these  cases.* 

Treatment. — ^o  far  as  I  know,  no  drug  destroys  the  embryos  in  the 
blood.  In  infected  districts  the  driiiking-water  should  be  boiled  or  til- 
lered. In  cases  of  chylnria  the  y)atients  should  use  a  dry  diet  and  avoid 
all  excess  of  fat.  The  chyle  may  disappear  quite  rapidly  from  the  urine 
under  those  measures,  but  it  does  not  necessarily  indicate  that  the  case  is 
cured.  So  long  as  clots  and  albnmin  are  present  the  leak  in  the  lymphoid 
•varix  is  not  healed,  although  the  fat,  not  1)eing  supplied  to  the  chyle,  may 
not  be  present.  A  single  tumblerful  of  milk  will  at  once  give  ocular  proof 
of  the  patency  or  otherwise  of  the  rnptnre  in  the  varix  (Manson). 

'^riie  surgical  treatnu>nt  of  some  of  these  cases  is  most  successful,  par- 
tiicularly  in  the  removal  of  the  adult  fllaria:'  from  the  enlarged  lym])h-glands, 
cp))ecially  in  the  groin.  ^laitland  states  that  during  the  past  seven  years 
25  ODorations  of  this  kind  have  been  performed  without  serious  symptoms. 

Y.  Dt^acoxttasts  (fluinca-n-nrm  Disease). 

The  F'llnnn  or  Drantiiruhis  niedineiisis  is  a  widely  spread  parasite  in 
parts  of  Africa  and  the  P'ast  Indies.    In  the  United  States  instances  occa- 

*  For  full  coiisidpriition  of  t"^e  subipft  of  ooiiffonital  ooclusion    ami    dilntatioii  of 
lymph  channels,  sec  the  work  on  t.ns  siil)ject  by  Samuel  C.  Biisey,  New  York,  1878. 


sion 


Miritio 
out  a 

Ml    tlll> 

the  en 
to  pre 
low, 

Th 
of  niei 
iniiarjK 
said  (( 

In 
a  recei 
be  allic 
•iated 
fever  1; 
ing.     ] 
•  ysted 
cysts,  t 
to  the 
tion. 


DISEASES  CAUSED  BY  NEMATODES. 


8G3 


in  tho 

or  iil- 

avoid 

urine 

case  is 

mithciil 

0,  mny 

r  proof 


tation  of 

■(78. 


sionally  occur.  .Jiirvis  reports  a  fiisc  in  a  [lost  cliaiiliiin  who  had  livid  at. 
Fortress  Monroe,  \'a.,  I'or  thirty  ycar.s.  \'aii  JlarliMjiCn'.s  patii-iit,  a  man 
ajrcd  lorty-sevcn,  had  never  lived  out  of  I'liihuleliihia,  .-^o  that  the  wuiiu 
iiiiLst  i)e  inehided  anion<;-  the  parasites  of  this  eoiiiitry.  A  majority  of  the 
eases  re|iorted  in  Anierieaii  journals  have  heen  imported. 

Only  the  female  is  known.  It  develops  in  the  sulicutaiiiMtus  and  inter- 
muscular connective  ti>sues  and  produces  vesi(des  and  ahscesses.  In  the 
larii'c  majority  of  the  cases  tlu;  )»arasitc  is  found  in  tlu'  U'^'.  Of  ISI  cases, 
in  Jvi  the  worm  was  found  in  the  feet,  oo  times  in  the  ley',  and  1  1  times  in 
I  lie  thij^h.  it  is  usually  solitary,  thoui^di  there  are  cases  on  record  in  which 
six  or  more  have  lieeii  present.  It  is  cylindrical  in  foini,  uhont  ".'  mm.  in 
diameter,  and  from  ."»()  to  SO  em.  in  len>:,th. 

The  worm  ^ains  entrance  to  the  system  throu<ili  the  stonuuh,  not 
throu<,di  the  skin,  as  was  formerly  supi)osed.  It  is  proliahle  that  both  male 
and  female  are  in^a'sted;  but  tlu'  former  dies  and  is  dischar^'ed,  while  the 
hitter  after  impre^niation  penetrates  the  intestine  and  attains  its  f-dl  de- 
\('lopment  in  the  subcnlane<)us  tissues,  v  lu're  it  may  remain  ((uiescent  for 
a  lon^'  time  and  can  be  felt  beneath  the  skin  like  a  Inindle  (d'  strinj;.  The 
worm  contains  an  I'nornious  nnndier  of  livinj^'  (Mubryos,  and  to  enable  them 
to  escai)e  she  travels  slowly  downward  head  lirst,  and.  as  mentioiieil,  usually 
leaches  the  foot  oi'  ankle.  'I'he  head  then  ])em't  rates  the  skin  ami  the  epi- 
dermis forms  a  little  vesicle,  which  ruptures,  ami  a  small  idcer  is  left,  at  the 
bottom  oi'  which  the  head  often  ])rotru(les.  'Vhc  distendi'd  uterus  ru|)tures 
and  the  embryos  are  diiK'harged  in  a  whitish  lluid.  After  getting  rid  (jf 
them  the  worm  will  sjjontaneously  leave  her  host.  Jn  the  water  the  em- 
bryos develo])  in  the  cyclops — a  small  crustacean — and  it  seems  likely  that 
man  is  infected  by  driidving  the  water  containing  tliese  developed  larvic. 

When  the  worm  first  ajijiears  it  should  noi  be  disturlu'd,  as  after  par- 
turition she  may  leave  spontaneously.  When  the  worm  begins  to  come 
out  a  common  procedure  is  to  roll  it  round  a  jiortion  of  smooth  wood  and 
in  this  way  i)revent  the  retraction,  and  each  day  wind  a  little  more  until 
the  entire  worm  is  withdrawn.  It  is  stated  that  s])ecial  care  must  l)e  taken 
to  prevent  tearing  of  the  worm,  as  disastrous  consequences  sometimes  fol- 
low, ])r()hably  from  tlie  irritation  caused  by  the  migration  of  the  embryos. 

The  ])arasite  nuiy  he  excised  entire,  or  killed  by  injections  of  bichloride 
of  mercury  (1  to  1,000).  It  is  stated  that  the  leaves  of  the  plant  called 
(ininrpaltce  are  almost  a  si)ecific  in  the  disease.  Asafietida  in  full  doses  is 
said  to  kill  the  worm. 

In  East  Africa  Kolh  states  that  he  found  in  the  ahd(uninal  cavity  of 
a  recently  killed  native  ^Massai  several  large  nematode  worms  belii'ved  to 
be  allied  to  the  filaria  medinensis.  He  thinks  +"iis  parasite  is  possibly  asso- 
ciated witli  what  is  known  as  the  ^lassai  disear j,  characterized  by  attacks  of 
fever  lasting  some  three  days,  with  tendern(>ss  of  the  abdomen  and  vomit- 
ing. Koll)  thinks  that  in  these  cases  the  filariiv  which  have  become  en- 
cysted al3ont  the  liver  "as  a  normal  event  in  their  life  history  burst  their 
cysts,  the  contents  escaping  into  the  peritoneal  cavity,  therehy  giving  rise 
to  the  symptoms."  The  subject  is  one  which  requires  further  investiga- 
tion. 

23 


304 


DISKASKS  DL'K  TO  ANIMAL  PAUASITE.S. 


.  \ 
/ 


VI.  Other  NKM.vTODiis. 

(a)  Among  loss  iniportimt  fllariiin  worms  parasitic  in  man  the  follow- 
in",'  may  bo  niontioncd:  Fihiria  hxt,  which  is  a  cyliiKlrical  worm  of  aljoiit 

3  cm.  in  loii<,'th  and  wiioso  habitat  is  boncath  tlio  conjunctiva.  It  luis 
boon  found  on  tho  West  African  coast,  in  lirazil,  and  in  tlio  Wost  Indies. 
Filaria  Iciitis,  which  has  boon  found  in  a  cataract.  'J'iiroe  8|)ocimons  havo 
boon  found  togothor.  I  ilaria  hihiiiUft,  which  has  boon  found  in  a  pustule 
in  the  iippor  lip.  Filaria  hotninis  oris,  which  was  (U'scril)C(l  by  I^oidy, 
from  tho  moulii  of  a  child.  Filaria  broiicliiallH,  which  has  boon  found 
occasioiudly  in  the  trachea  and  bronchi.  This  jmrasito  has  been  soon  in  a 
few  cases  in  tho  bronchioles  and  in  the  kings.  There  is  no  evidence  that 
it  over  produces  an  extensive  verminous  bronchitis  similar  to  that  which 
J  havo  described  in  dogs.  Filaia  iininil.is — the  common  Filaria  saiKjuiiiis 
of  tho  dog — of  which  liowlljy  has  described  two  cases  in  man.  In  one  case 
with  litTmaturia  female  worms  were  found  in  the  i)ortal  vein,  and  the  ova 
wore  ])rosent  in  tho  thickened  bladder  wall  and  in  tho  ureters. 

(b)  Trichorephaliis  dispar  (Whip-wortii). — This  ])arasite  is  not  infre- 
quently found  in  tho  ciecnni  and  large  intestine  of  man.    It  moasuios  from 

4  to  5  cm.  in  length,  the  male  being  somewhat  shorter  than  the  female. 
The  worm  is  readily  recognized  by  the  remarkable  diU'eronce  between  the 
anterior  and  ])osterior  ])ortions.  Tho  former,  which  forms  at  least  three 
fifths  of  tho  body,  is  extremely  thin  and  hair-like  in  contrast  to  the  thick 
hinder  portion  of  the  body,  which  in  the  female  is  conical  and  pointed,  and 
in  the  male  more  obtnse  and  usually  rolled  like  a  spring.  The  eggs  are 
oval,  lemon-shaped,  0.05  mm.  in  length,  and  each  is  proviuvd  with  a  button- 
like i)rojection. 

Tho  numl)er  of  the  worms  found  is  varial)lo,  as  many  as  a  thousand 
having  boon  counted.  It  is  a  widely  spread  parasite.  In  parts  of  Europe 
it  occurs  in  from  10  to  30  per  cent  of  all  bodies  examined,  but  in  this  coun- 
try it  is  not  so  common.  Tho  trichocoi)lialus  rarely  causes  symptoms. 
It  has  boon  thought  by  certain  physicians  in  the  East  to  be  the  cause  of 
beri-beri.  Several  cases  have  been  reported  recently  in  which  profound 
ananuia  has  occurred  in  connection  with  this  ])arasite,  usually  with  diar- 
rhcoa.  Enormous  numbers  may  be  present,  as  in  Rudolphi's  case,  without 
producing  any  symptoms. 

The  diagnosis  is  readily  made  by  t'ue  examination  of  the  ffcces,  which 
contain,  sometimes  in  great  abundance,  the  characteristic  lemon-shaped, 
hard,  dark-brown  eggs. 

(r)  Dioctoplu/me  gigas  (Eiistrongi/his  gigas). — This  enormous  nematode, 
the  male  of  which  measures  about  a  foot  in  length  and  the  female  about 
three  feet,  occurs  in  very  many  animals  and  has  occasionally  been  met  with 
in  man.  It  is  usually  found  in  the  renal  region  and  may  entirely  destroy 
the  kidney. 

(d)  Slrongyhidcs  iutesiinalis. — lender  this  name  are  now  included  the 
email  nematode  worms  found  in  the  fa?ces  and  formerly  described  as^ 
Angnilhila  sfercoralis,  Angvilliila  inlestinalis,  and  Ehabdonema  i  ^estinale. 
This  parasite  occurs  abundantly  in  the  stools  of  the  endemic  diairhoea  of 


f^srg-sliol] 


or  eye). 


DISKASKS  CAUSKD   BY  CKSTODKS. 


305 


hot  countries,  mid  lias  lu'cn  spcciiilly  (Icscrilicd  by  llic  I''rt'iU'li  in  tlie  diar- 
rlio'n  of  C'ociiin-Cliina.  It  occurs  also  in  I5razil,  and  has  lioon  found  in 
Jtaly  in  connt'ction  with  the  aiuhylii>tonia  in  casi's  of  miners'  anicniia.  It 
is  stated  that  tho  worms  occupy  all  parts  of  the  intestines,  nnd  iuivo  even 
been  found  in  the  biliary  and  [)am'reatic'  ducts.  It  is  only  when  they  are 
in  very  lar^'e  numbers  that  they  pnxluce  severe  diarrluea  and  auieuiia. 

AcANTii()ii;i'iiAi-.v  {Tlioni-licaded  l!'((/v//,s). 

'^Fhe  (lliianfdrln/nrhits  or  I'Jrliimirln/nrlius  (/ii/iis  is  a  eoniuion  parasite  in 
the  intestine  of  the  hoi,'  and  attains  a  lar^a'  size.  The  larvie  develop  in 
cockchafer  ^rubs.  The  American  internu'diati'  host  is  tho  June  bu<,' 
(Stiles).  Jiaud)l  found  a  snudl  Ecliiiiorln/nrlnis  in  the  intestine  of  a  boy. 
Welch's  specimen,  which  was  found  encysted  in  the  intestine  of  a  soldier 
at  Xetley.  is  stated  by  ('obbold  ])robably  not  *o  have  been  an  f'Jchinorhi/n- 
cliiis.  Kccently  a  case  of  Ecliinorliynrltiis  iiionilifuniti.s  iuis  been  described 
in  Italy  by  Grassi  and  C'alandruceio. 


V.    DISEASES   CAUSED    BY  CESTODES 

{Tiipe-tvormn ;  Hydatid  Disease). 

]\ran  harbors  tho  adidt  parasites  in  the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 


ousand 
urope 
conn- 
)toms. 
\ise  of 
found 
diar- 
Ihoul 


1 


matode. 

e  about 
ct  with 
destroy 

dod  the 
ibed  a> 
estinak. 
rhoea  of 


I.  IxTESTiXAL  Ckstodks;  Tate-wokms. 

(n)  Ta'nxa  snJivm,  or  pork  ta])c-worm.  This  is  not  a  common  form  in 
this  country.  It  is  much  more  frequent  in  parts  of  Europe  and  Asia. 
When  mature  it  is  from  G  to  18  feet  in  len<fth.  The  head  is  small,  round, 
not  so  lar<io  as  tho  head  of  a  pin,  and  provided  with  four  suckinj;  disks  and 
a  double  row  of  booklets;  hence  it  is  called,  in  contradistinction  to  the 
other  form  in  man,  the  armed  tapo-worm.  To  the  hci  I  succeeds  a  narrow, 
thread-like  neck,  then  tho  segments,  or  ])ro<rlottides,  as  they  are  called. 
The  segments  possess  both  male  and  fenuile  generative  organs,  and  about 
every  four  hundred  and  fiftieth  becomes  mature  and  contains  ripe  c:^.  Thfi 
worm  attains  its  full  growth  in  from  three  to  three  and  a  half  months, 
after  which  time  the  segments  arc  continuously  shed  and  ai)pear  in  tlie 
stools.  The  segments  arc  about  1  cm.  in  length  and  from  7  to  8  mm.  in 
l)readth.  Pressed  botwoer  glass  plates  the  uterus  is  seen  as  a  median  stem 
with  about  eight  to  fourteen  lateral  branches.  There  are  many  thousands  of 
ova  in  each  ripe  segment,  and  each  ovum  consists  of  a  firm  shell,  inside  of 
which  is  a  little  embryo,  provided  with  six  booklets.  The  segments  are 
continuously  passed,  and  if  the  ova  are  to  attain  further  development  they 
must  be  taken  into  the  stomach,  cither  of  a  pig,  or  of  man  himself.  The 
egg-shells  arc  digested,  the  six-hooked  embryos  become  free,  and  jiassing 
from  tho  stomach  roach  various  parts  of  the  body  (the  liver,  muscles,  brain, 
or  eye),  where  they  develop  into  the  larva:-  or  cysticerci.    A  hog  under  these 


.3r,n 


DISKASKS   DUE  TO  ANTMAT.   PARASITES. 


/ 


(  iri'iiiiisliiMccs  irt  siiiil  to  he  nirdslnl,  ami  llif  ('\>tii-"i'rci  iirc  spokni  ol'  art 
iiH'iisU'H  (»r  Itlinldcr  worms. 

Tlic  liiniii  siiliinn  rt'ccivctl  its  mime  licciiiisc  it  win  tliouirlit  In  exist  as 
a  HtlitHi'y  iMirasitc  in  the  linwcl,  Iml  tun  or  three  nv  »  veil  more  worms  in;iy 
occur. 

(//)  Tdiiin  8(if/in('l(i  or  nicilincinirlhihi — tlie  iiiiiiniiril  oi'  liccf  ta|te-\vorm. 
This  is  a  lonnror  aii<l  iar;::er  |tarasite  than  the  Tanid  snliinn.  It  is  certainly 
the  eoiiiiiion  tape-wdini  of  this  country.  Of  ncort'S  of  Bpt'cimens  which  I 
ha\e  c\amine(l  almost  all  were  of  this  variety.  Acconlin^f  to  I'eren^'ep- 
l-'erand  it  has  spi'ead  rajiidly  in  western  l''nro|ie,  owiii^-'  proltahly  to  the 
im|Mirtafion  of  Iteef  and  live-stock  fiom  the  .Mediterranean  hasin.  It  may 
attain  a  len;jlh  of  I,")  or  '.Ml  feet,  or  nioie.  The  head  is  larf,'c  in  comparison 
with  that  of  the  Tiiiiid  snliinn,  and  measures  over  '4  mm.  in  Itreadth.  It  is 
sipiarc-shaped  and  providecl  with  f(ti.r  lar;;e  suckin<;  disks,  hut  there  are  no 
hooklets.  The  ripe  scLrments  arc  from  17  to  IS  mm.  in  len^'th,  and  from 
S  to  1(»  mm.  in  lireadlli.  The  uterus  consists  of  a  median  stem  with  from 
fifteen  to  thirty-live  lateral  hranches,  which  are  ^iven  olV  more  dichoto- 
mously  than  in  the  Taiiid  solidin.  The  ova  are  somewhat  lar^^cr,  and  the 
shell  is  thicker,  hut  the  two  forms  can  scarcely  he  distin^iiislieil  hy  their  ova. 
The  ripe  se<nnents  arc  pa.<sed  as  in  the  l/riiid  suliiiin,  and  are  inj^cstcd  by 
callle,  in  the  flesh  or  or^MUis  (d'  wliicli  the  e^gs  Uovelop  into  the  hladder 
woims  or  cysticerci.  Xo  instance  of  the  cysticercus  u\'  tin,'  Inn  in  xdijiudlii 
has,  so  far  as  I  know,  heen  reported  in  man. 

Of  (tther  forms  of  tape-W(uin  may  l)e  mentioni'd: 

{(■)  DiixjJidiiiiii  nidininti  (Tdiiid  rlliplicn ,  Tiviiid  rdriiiiierind).  A  small 
]iarasite  vcit  common  in  the  do>;' and  occasionally  I'ound  in  man;  the  larvio 
develop  in  the  lice  and   (leas  of  the  do^'. 

(il)  // i/iiininli'iisis  iliniiinild  ('[\v}iid  /Idrd-pinirlala).  A  small  ceslode  was 
found  in  the  intestine  of  a  child  in  lioston,  and  has  since  been  met  with  in 
one  or  two  casis.  It  is  common  in  rats.  The  larvie  develop  in  Li'iiidoph'ra 
and  in  beetles. 

((')  Jf;/iiicd(>h'/isif<  iiddd  {TiVdin  iiaiid)  occnrs  not  infri'qucntly  in  Italy; 
the  Ddrdincd  Mdildi/dscdrii'iisis  {7\rnia  Mdddf/dsrniicnsis)  is  a  rare  form. 

(/")  Ta'iila  coiifiisd,  a  new  species  described  by  Ward. 

((/)  Bolhriorc/ilidhis  hihis.  A  cestode  worm  fonnd  only  in  certain  dis- 
tricts borderin<;  on  the  TJaltic  Sea,  in  jiarts  of  Switzerland,  and  in  Japan. 
So  far  as  T  know,  it  has  not  been  fonnd  in  this  country  e.\cej)t  in  a  few 
im]>orted  cases.  The  ])arasite  is  larfre  and  long,  measnring  from  25  to  30 
feet  or  more.  Its  head  is  dilTerent  from  that  of  the  taenia,  as  it  possesses 
two  hderal  <rrooves  or  ])its  and  has  no  booklets.  The  larva'  develop  in  th<> 
})eriton:eum  and  nniscles  of  the  ])ike  and  otlu'r  fish,  and  it  has  been  shown 
e.\]»erimentally  that  they  grow  into  the  adult  worm  when  eaten  by  man. 

Symptoms. — These  ])arasitcs  are  fonnd  at  all  ages.  They  are  not 
nnoommon  in  children  and  are  occasionally  fonnd  in  sncklings.  AV.  T. 
riant  refers  to  a  nnmber  of  cases  in  children  nnder  two  years,  and  there  is 
one  in  the  literatnre  in  which  it  is  stated  that  the  tape-worm  was  found 
in  an  infant  five  days  old. 

The  parasites  may  cause  no  disturbance  and  are  rarely  dangerous.     A 


DISK  ASKS  CACSKI)  nV   CKSTOPKS. 


307 


lIH 


Italy; 

I'dI'III. 

in  (lis- 
iipiin. 
ii  IVw 
to  3lt 

iSSt'SSt'S 

in  thf 
sl\()\vn 

hum. 

ire  11' it 

here  i^ 
foiintl 

us.     A 


kijowlt'dji;*'  (•!'  tilt'  c.Ni.'-tt'iK't'  (•[  the  worm  i,x  jifiicrally  ii  Miiircf  nl'  worry  uuil 
iin.vii'ty;  tlu'  imticiit  imiy  liiivc  cuMsidiTiihlt'  distress  an<l  coinplaiti  of  alj- 
ilniiiinal  |)iiii)r<,  nniix'ti,  diarrliu'ii,  aiul  soiiictitiic''  aiiii>nui).  <>c('a.>«iiiiially  tin; 
ii|i|it'tit<'  is  ravt'iiDii.s.  In  wniiifii  aiwl  in  iicrvoiis  imticiits  llu'  coiistitutioniil 
di^tnrllall(,•e  may  Ijo  con.-idi'rahlt',  and  wc  not  inlrcincntly  sec  ;;;ri'at  mental 
de|ir('S).ion  .uid  I'ven  liy|Hieliondria.  N'ai'ions  nervons  plieiioinena,  sneli  as 
iliorca,  eonvid.xions,  or  epilepsy,  are  helieveil  to  lie  eause(|  by  tlie  [•anidKort. 
Siicli  ell'eets,  however,  are  very  rare.  'I'lie  lUilhrioci-jilutlHs  may  eauso  a 
severe  and  even  fatal  form  of  anaMiiiti,  wliicli  has  lieen  desciilu'd  fidly  in 
a  recent  nioiio;,fra|ili  liy  Schaumann,  of  l|e|sin;i;fors. 

'The  (litif/iiosis  is  ncNcr  donhtful.  The  presence  of  the  -r;:mcMts  is  dis- 
linctive.  Tiie  ova,  too,  may  he  reeo<.Mii'/ed  in  the  stools.  It  makes  l»nt  liltlu 
diil'crenee  as  to  the  form  of  tape-worm,  hut  the  ripe  se;:ments  of  the  Ttciiid 
siKjiiuilii  are  hir^^fr  and  hroader,  and  show  dilVerenees  in  the  <;i'nerativo 
system  as  already  iiKMitioni'd. 

The  prn/tlt  1/1(1. ii.'<  is  most  important.  Careful  altciition  vlioidd  ho  ;:ivon 
to  thre(^  points.  First,  all  tape-worm  sej-iiients  should  he  burned.  They 
slio'.dd  never  he  thrown  into  the  water-closet  or  outside;  secondly,  careful 
inspection  of  meat  at  the  abattoirs;  and  thirdly,  cooking  the  meat  sulli- 
ciently  to  kill  the  parasites. 

In  the  ca.so  of  the  beef  mensleis,  the  distiihiition  o\'  the  jiarasitos,  na 
'/wm  by  ()sterta;.^  shows  that  tlu'  muscles  (d'  the  jaw  ai'e  much  more  I'ro- 
ipiently  alVecled  than  other  ]»arts — ;W!U  times,  while  other  or^ians  wero 
infected  hut  ")')  time!?.  Sometimes  there  are  instances  of  fjeneral  infec- 
tion. Stiles  states  that  no  exact  statistics  have  been  published  for  this 
country.  In  lierlin  the  ]iroportion  of  cattle  infectcil  in  iSii-^-'ii;!  was  al)out 
1  to  (>T"3.  Cold  stora;;-e  kills  the  cysticercus  usually  within  thi'ce  weeks. 
The  measles  are  more  readily  overh«d\ed  in  beef  than  in  |»ork,  as  they  do 
not    pi'escut  such  an  opaipie  white  color. 

In  the  examination  (d'  ho^s  for  cysticerei  '^  particular  stress  slu)uld  ho 
laid  upon  the  t(Ui;iue,  tlu'  muscles  of  masticati')!),  and  the  muscles  of  the 
>lioulder,  lU'cdv,  and  diaphra,um  "  (Stiles).  Accudin;;  to  Stiles,  statistics  Tor 
I  he  T'nited  States  are  not  availaitle.  American  ]io;;s  arc  comi)ai'atively  free. 
In  I'russiii  one  ho<i-  is  infected  in  about  every  i'l'-l'i.  Specimens  have  been 
lound  alive  twent\-nine  days  after  slaiiiihtci'inir.  In  the  cxandnation  of 
1.(10(1  ho,i;s  in  ^loidval,  l^r.  CU'iueut  and  J  found  "(I  instances  oH  cysticerei, 
I'or  full  details  with  rid'erenco  to  the  ins))ection  of  meat  for  animal  ])ara- 
sites.  the  pi'actitioner  is  I'cfcrrcil  to  the  work  (d'  l>r.  Stiles  in  JUiUetin  Xo. 
1!),  t'nilc(l  States  T'Jepartment  of  A.uricullure.  1S!)S. 

Treatment. — For  two  days  prior  to  llie  administration  of  the  rcnu'- 
dies  the  patient  sluiuld  take  a  very  li.irht  diet  and  have  the  bow  is  moved 
occasionally  by  a  saline  cathartic.  The  practitioner  has  the  choice  td'  a 
laroo  numher  of  drufrs.  As  a  rule,  llie  male  fern  acts  promptly  and  well. 
Tlie  ethereal  extract,  in  '?-(lrachm  doses,  may  be  ^dven  fastin;jf.  and  fol- 
lowed in  the  course  of  a  ct)U])le  of  hours  by  a  brisk  ])ur<i-ative.  This  usually 
succeeds  in  hi'iufrin^''  away  a  larire  jtortio,!,  but  not  always  the  entire  woi'in. 

A  coinhination  of  the  remedies  is  sometimes  very  efrective.  An  in- 
fusion is  made  of  pomegranate  root,  half  an   ounce;  pumpkin   seeds,   1 


308 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


/ 


ounce;  powdered  ergot,  a  draelini;  and  boiling  water,  10  ounces.  To  an 
emulsion  of  the  male  fern  (a  drachm  of  ethereal  extract),  made  with  acacia 
powder,  2  minima  of  croton  oil  are  added.  The  patient  should  have  had 
a  low  diet  the  jirevious  day  and  have  taken  a  dose  of  silts  in  the  evening. 
The  emulsion  and  infusion  are  mixed  and  taken  fasting  at  nine  in  the 
morning. 

The  ])omegranatc  root  is  a  very  elTicient  remedy,  and  may  be  given  as 
an  infusion  of  the  bark,  3  ounces  of  which  may  be  macerated  in  10  ounces 
of  water  and  then  reduced  to  one  half  by  evaporation.  The  entire  quan- 
tity is  then  taken  in  divided  doses.  It  occasionally  produces  colic,  but  is 
a  very  elfective  remedy.  The  acti/e  principle  of  the  root,  pelletierine,  is 
now  much  employed.  It  is  given  in  doses  of  G  to  8  or  even  10  grains,  with 
a  little  tannin  (grs.  v)  in  sweetened  water,  and  is  followed  in  an  hour  by  a 
purge. 

Pumpkin  seeds  are  sometimes  very  efficient.  Three  or  4  ounces  should 
be  carefully  bruised  and  then  macerated  for  tw'elve  or  fourteen  hours  and 
the  entire  quantity  taken  and  followed  in  an  hour  by  a  purge.  Of  other 
remedies,  koosso,  turpentine  in  ounce  doses  in  honey,  and  kamala  may  be 
mentioned. 

Unless  the  head  is  brought  away,  the  parasite  continues  to  grow,  and 
within  a  few  months  the  segments  again  appear.  Some  instances  are 
extraordinarily  obstinate.  Doidjtless  almost  everything  depends  upon  the 
exposure  of  the  worm.  The  head  and  neck  may  be  thoroughly  protected 
beneath  the  valvule  conniventes,  in  which  case  the  remedies  may  not  act. 
Owing  to  its  armature  tho  ta'iiia  solium  is  more  difficult  to  expel.  It  is 
probable  that  no  degree  of  peristalsis  could  dislodge  the  head,  and  unless 
the  worm  is  killed  it  does  not  let  go  its  extraordinarily  firm  hold  on  the 
mucous  membrane.  If  warm  water  be  jDut  in  the  commode  the  worm  is  less 
likely  to  contract  and  be  broken. 


II.  Visceral  Cestodes. 

Whereas  adult  tfonia?  may  give  rise  to  little  or  no  disturbance,  and  rarely, 
if  ever,  prove  directly  fatal,  the  affections  caused  by  the  larva>  or  immature 
forms  in  the  solid  organs  are  serious  and  important.  There  are  two  chief 
cestode  larva?  known  to  frequent  man  (a)  the  Cijsticcrciis  ceUuloscc,  the 
larva  of  the  Ta'nia  solium,  and  (b)  the  Echinococcus,  the  larva  of  the  Tmnia 
echiiwcoccns.  The  Cysticernis  tanice  saginatce  has  been  found  only  two  or 
three  times  in  man. 

I.  Cysticercus  cellulosae. — "When  man  accidentally  takes  into  his  stom- 
ach the  ripe  ova  of  Tcnnia  solium  he  is  liable  to  become  the  intermediate 
host,  a  part  usually  played  for  this  tape-worm  by  the  pig.  This  accident 
may  occur  in  an  individual  the  subject  of  Ta'nia  solium,  in  which  case  the 
mature  proglottides  either  themselves  wander  into  the  stomach  or,  what 
is  more  likelj',  are  forced  into  the  organ  in  attacks  of  prolonged  vomiting. 
Of  course  the  accidental  ingestion  from  the  outside  of  a  few  ova  is  quite 
possible,  and  the  liability  of  infection  should  always  be  borne  in  mind  in 
handling  the  segments  of  the  worm. 


DISEASES  CAUSED  BY  CESTODES. 


309 


stom- 
icdiato 
ciclcnt 
ise  the 

-what 
niting. 

quite 
ind  in 


The  pymptoms  dcpeml  ciitircly  upon  the  mimbor  of  ova  ingested  and 
the  lucahties  reached.  Jii  the  hog  the  cystieerei  produce  very  little  dis- 
turbance. The  muscles,  the  connective  tissue,  and  the  hrain  nu\y  be  swarm- 
ing with  the  measles,  as  they  are  called,  and  yet  the  nutrition  is  nuiintained 
and  the  animal  does  not  a])pfar  to  be  seriously  iuMmimoded.  In  the  in- 
vasion ])eriod,  if  large  numbers  of  the  ])arasites  are  taken,  tliere  is,  in  all 
probability,  constitutional  disturbance;  certainly  this  is  seen  in  the  calf, 
when  fed  with  the  ripe  segments  of  Tcenia  saginala. 

In  man  a  few  eysticerci  lodged  beneath  the  skin  or  in  the  muscles  may 
rause  no  damage,  and  in  time  the  larviu  die  and  become  calcified.  Tliey 
are  occasionally  found  in  dissection  subjects  or  in  post  mortems  as  ovoid 
white  bodies  in  the  muscles  or  sul)cutaneous  tissue.  Jn  this  country  they 
are  very  rare.  I  have  seen  but  one  instance  vy  my  post-mortem  experience. 
Depending  on  the  number  and  the  locality  specially  ail'ected,  tlie  symptoms 
may  be  grouped  into  general,  cerebro-spinal,  and  ocular.  In  155  cases  com- 
piled by  Stiles,  the  i)arasite  in  11?  was  found  in  the  brain,  in  32  in  the 
muscles,  in  9  in  the  heart,  in  3  in  the  Inngs,  subcutaneously  in  5,  in  the  liver 
in  2. 

(1)  General. — x\s  a  rule  the  invasion  of  the  larva?  in  man,  unless  in  very 
large  numl)ers,  does  not  cause  very  definite  symptoms.  It  occasionally 
happens,  however,  that  a  striking  picture  is  produced.  For  i'nstance, 
a  patient  was  admitted  to  my  wards  very  stiff  and  helpless,  so  much  so 
that  he  had  to  be  assisted  upstairs  and  into  bed.  lie  complained  of  numb- 
ness and  tingling  in  the  extremities  and  general  weakness,  so  that  at  first 
he  was  thought  to  have  a  peripheral  neuritis.  At  the  examination,  how- 
ever, a  number  of  painful  subcutaneous  nodides  were  discovered,  which 
proved  on  excision  to  be  the  eysticerci.  Altogether  75  could  be  felt  sub- 
cutaneously, and  from  the  soreness  and  stilfness  they  probably  existed  in 
large  numbers  in  the  muscles.  There  were  none  in  his  eyes,  and  he  had 
no  symptoms  pointing  to  brain  lesions. 

(2)  Cerebro-spinal. — Remarkable  symptoms  may  result  from  the  pres- 
ence of  the  eysticerci  in  the  brain  and  cord.  In  the  silent  region  they  may 
be  abundant  without  producing  any  symptoms.  I  have  in  my  ])ossession 
the  brain  of  a  pig  containing  scores  of  "  measles,"  yet  the  animal  in  the 
few  moments  in  which  I  saw  it  just  prior  to  death  did  not  present  any 
symptoms  to  attract  attention.  In  the  ventricles  of  tlie  brain  the  eysti- 
cerci may  attain  a  considerable  size,  owing  to  the  fact  that  in  regions  in 
which  they  are  unrestrained  in  their  growth,  as  in  the  ]ieritonieum,  the 
bladder-like  body  grows  freely.  When  in  the  fourth  ventricle,  remarkal)le 
irritative  symptoms  may  be  produced.  In  1884  I  saw  with  Friedliinder  in 
Berlin  a  case  from  Riess's  wards  in  which  during  life  there  had  been  symp- 
toms of  diabetes  and  anomalous  nervous  symptoms.  Post  mortem,  the 
cysticercus  was  found  beneath  the  valve  of  Vieussens,  pressing  upon  the 
floor  of  the  fourth  ventricle. 

(3)  Ocular. — Since  von  Graefe  demonstrated  the  presence  of  the  cysti- 
cercus in  the  vitreous  humor  many  cases  have  been  placed  on  record,  and 
it  is  a  condition  easily  recognized  by  oculists. 

Except  in  the  eye,  the  diagnosis  can  rarely  be  made;  when  the  cysti- 


370 


DISEASES  DUE  TO  ANIMAL   PARASITES. 


/' 


ci'ix'i  arc  siibcutimcoii^,  onv  iiuiy  l)0  cxci.^cd.  It  is  possible  that  wlicn 
munt'roii.s  lliroii^^iiout  tliu  imiscle.s  they  may  be  seen  under  tlie  tongue,  in 
which  situation  they  may  exist  in  tlie  pi;^'  in  numbers. 

ir.  Echlnococcus  Disease. — The  liydatid  worms  or  ochinocoeci  arc  tlic 
larMe  oi'  the  Tania  echiiKirucciis  of  tlie  (h)g.  'J'his  is  a  tiny  cestode  not 
more  than  4  or  5  mm.  in  lengtli,  consisting  of  oidy  three  or  four  segments, 
of  wliicli  tlie  terminal  one  alone  is  mature,  and  lias  a  length  of  about  2  mm. 
and  a  breadth  of  O.G  mm.  The  head  is  small  and  provided  with  four  suck- 
ing disks  and  a  rostellum  with  a  double  row  of  booklets.  'V\ns  is  an  exceed- 
ingly rare  i)arasite  in  the  dog.  C'obbold  states  that  he  has  never  met  with 
a  natural  specimen  in  England.  Leidy  had  not  one  in  his  large  collection. 
I  have  not  met  with  an  instance  in  this  country,  nor  do  I  know  of  its  ever 
having  been  described.  The  only  si)ecimens  in  my  cabinet  I  procured 
experimentally  Ijy  feeding  a  dog  with  echinococcus  cysts  from  an  ox.  The 
worms  are  so  snudl  that  they  may  be  ri'adily  overlooked,  since  they  form 
small  white,  thread-like  bodies  closely  adherent  among  the  villi  of  the 
small  intestines.  The  ripe  segment  contains  about  5,000  eggs,  which  at- 
tain their  develo])i""nt  in  the  solid  organs  of  various  aiiinuds,  particularly 
the  hog  and  ox,  more  rarely  the  horse  and  the  sheep.  In  soiue  countries 
man  is  a  common  intermediate  host,  owing  to  the  accidental  ingestion  of 
the  ova. 

Di'i'dupmc'itt. — The  little  six-hooked  embryo,  freed  from  the  eggshell 
by  digestion,  burrows  through  the  intestinal  wall  and  reaches  the  perito- 
neal cavity  or  the  muscles;  it  may  enter  the  portal  vessels  and  be  <:arried  to 
the  liver.  It  may  enter  the  systemic  A'cssels,  and,  passing  the  pulmonary 
capillaries,  as  it  is  protoplasmic  and  elastic,  may  reach  the  brain  or  other 
])arts.  Once  having  reached  its  destination,  it  undergoes  tlie  folloM'ing 
changes:  The  booklets  disajipear  and  the  little  embryo  is  gradually  con- 
verted into  a  snuill  cyst  Avhicli  presents  two  distinct  layers — an  external, 
laminated,  cuticular  membrane  or  cajisule,  and  an  internal,  granular,  par- 
enchymatous layer,  the  endocyst.  The  little  cyst  or  vesicle  contains  a 
clear  fluid.  There  is  more  or  less  reaction  in  the  neighboring  tissues,  and 
the  cyst  in  time  has  a  fibrous  investment.  When  this  primary  cyst  or 
vesicle  has  attained  a  certain  size,  buds  develop  from  the  parenchymatous 
layer,  which  are  gradually  converted  into  cysts,  presenting  a  structure  iden- 
tical with  that  of  the  original  cyst,  namely,  an  elastic  chitinous  memhrane 
lined  with  a  granular  parenchymatous  layer.  These  secondary  or  daughter 
cysts  are  at  first  connected,  with  the  lining  membrane  of  the  primary 
cyst,  hut  are  soon  set  free.  In  this  way  the  parent  cyst  as  it  grows  may 
contain  a  dozen  or  more  daughter  cysts.  Inside  these  daughter  cysts  a  simi- 
lar process  may  occur,  and  from  buds  in  the  walls  grancklaughter  cysts  are 
developed.  From  the  granidar  layer  of  the  parent  and  daughter  cysts  buds 
arise  which  develop  into  brood  capsules.  From  the  lining  membrane  the 
little  outgroAvths  arise  and  gradually  develoj.  into  bodies  known  as  scolices, 
which  re])reseut  in  reality  the  head  of  the  Ta'iiia  cchiiwcocciis  and  present 
four  sucking  disks  and  a  circle  of  hooklets.  Each  scolex  is  capable  when 
transferred  to  the  intestines  of  a  dog  of  developing  into  an  adult  tape-worm. 
The  difference  between  the  ovum  of  an  ordinary  tape-worm,  such  as  the 


DISEASES  CAUSED  BY  CESTODES. 


371 


Tlu 


Tfcnia  solium,  and  tlio  Tirnin  cchiiiorocciis  is  in  this  way  very  striking.  In 
the  I'unner  easo  tiie  ovum  (luvcl()|)s  into  a  single  lai'va — tliu  Ci/slirrrcus  celhi- 
hsa — whereas  the  egg  of  the  Tirnia  echiiidcucciis  tlevelo})S  into  a  cyst  which 
is  capable  of  multiplying  enormously  and  fi'oni  the  lining  nicnihrane  of 
which  millions  of  larval  tape-worms  develoi*.  Ordinarily  in  man  the  de- 
veloi)mcnt  of  the  cchinococcus  takes  ])lace  as  i.hove  mentioned  and  by 
an  endogenous  form  in  which  the  secondary  and  tertiary  cysts  are  con- 
tained within  the  primary;  but  in  animals  the  formation  may  be  dilferent, 
as  the  buds  from  the  primary  cyst  penetrate  between  the  layers  and  develop 
externally,  fornung  the  ex(>genous  variety.  A  third  form  is  the  multilocular 
cchinococcus,  in  which  from  the  jjrimary  cysts  buds  deveIo|)  wliich  are  cut 
off  comi)letely  and  are  surrounded  Ijy  thick  capsules  of  a  connective  tissue, 
which  join  together  and  idtinuUely  form  a  hard  mass  represented  by 
strands  of  connective  tissue  enclosing  alveolar  spaces  aitout  the  size  of 
peas  or  a  little  larger.  In  these  s])aces  are  found  the  remnants  of  the 
cchinococcus  cyst,  occasionally  the  scolices  or  booklets,  but  tlu  y  are  often 
sterile. 

The  fluid  of  the  echinococcus  cysts  is  clear  and  lim|)id,  and  has  a  spe- 
cific gravity  from  1.005  to  1.00!).  It  does  not  c  ntain  all)Uinin,  but  may 
contain  traces  of  sngar.  As  .ule,  the  cysts,  when  not  degenerated,  con- 
tain the  hydatid  heads  or  scolices  or  the  characteristic  booklets. 

Changes  in  the  Cyst. — It  is  not  known  delinitely  bow  long  the  echino- 
coccus remains  alive,  but  it  i)rol)al)ly  lives  many  years — according  to  some 
authors  as  long  as  twenty  years.  The  most  common  change  is  death  and 
the  gradual  insj)issation  of  the  contents  and  conversion  of  the  cyst  into  a 
mass  containing  putty-like  or  granular  material  which  may  be  partially 
calcified.  Iienmants  of  the  chitinous  cyst  wall  or  booklets  may  be  found. 
These  obsolete  hydatid  cysts  are  not  infrecpu'utly  found  in  the  liver.  A 
more  serious  termination  is  rupture,  which  may  take  ])lace  into  a  serous 
sac,  or  perforation  may  take  ])lace  externally,  when  the  cysts  are  discharged, 
as  into  the  bronchi  or  alimentary  canal  or  urinary  ])assages.  More  un- 
favorable are  the  instances  in  which  ru]>ture  occurs  into  the  bile-passages 
or  into  the  inferior  cava.  Recovery  may  follow  tlie  ru]»ture  and  discharge 
of  the  hvdatids  externallv.     Sudden  death  has  been  known  to  follow  the 

t.'  *■' 

ru])ture.  A  third  and  very  serious  mode  of  tci'uiination  is  suppuration, 
which  may  occur  si)ontaneously  or  follow  rupture  and  is  found  most  fre- 
quently in  the  liver.  Large  abscesses  may  be  formed  which  contain  the 
hydatid  mend)ranes. 

Geographical  Distribution  of  tho  Krhiiinnirrus. — The  disease  prevails 
most  extensively  in  those  countries  in  which  nuin  is  l)rought  into  close 
contact  with  the  dog,  ]iarticularly  when,  as  in  Australia,  the  dogs  are  used 
extensively  for  herding  sheep,  the  animal  in  which  the  larval  form  of  the 
Taniia  ecliinococcns  is  most  frequently  found.  In  Iceland  the  cases  are 
very  numerous.  In  Europe  tlie  disease  is  not  uncommon.  In  this  country 
it  is  extremely  rare  and  a  great  majority  of  all  cases  are  in  foreigners. 
Tp  to  July.  ISni,  I  have  been  able  to  find  in  the  literature  (and  in  the 
museums)  only  85  eases  in  the  United  States  and  Canada.  In  the  Ice- 
landic settlements  of  Manitoba  many  instances  occur.    A.  II.  Ferguson,  who 


♦ 


i 


372 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


/ 


has  operated  on  a  munbur  of  cases  at  tlie  Winnipeg  (jleneral  Hospital,  states 
tliat  between  rorty-iive  and  lii'ty  })ersons  with  echinococcus  disease  have 
been  treated  iji  Winnijjeg  since  1874,  tlic  date  of  tlie  Icelandic  immigra- 
tion. 

Lfislrihuliun  in  the  Body. — Of  the  1,803  cases  comprised  in  the  statis- 
tics of  Uavaine,  Cobbold,  Finsen,  and  Neisser,  the  parasites  existed  in  the 
liver  in  953,  in  the  intestinal  canal  in  1G3,  in  the  lung  or  ])leura  in  lo3,  in 
the  kidneys,  l)ladder,  and  genitals  in  18(!,  in  the  brain  and  si)inal  canal  in 
l'^7,  bone  01,  heart  and  blood-vessels  01,  other  orgaiib  158.  Of  the  85 
cases  in  liiis  country,  the  liver  was  the  seat  of  the  disease  in  50.  Of  50 
consecutive  cases  treated  by  Hosier  at  the  (ireii'swald  clinic,  30  involved 
the  li\er,  10  the  lungs,  3  the  right  kidney,  and  1  the  spleen. 

Symptoms. — {a)  Ilydalkls  of  the  Liver. — Small  cysts  may  cause  no 
disturbance;  large  and  growing  cysts  produce  signs  of  tumor  of  the  liver 
with  great  increase  in  the  size  of  the  organ.  Naturally  the  physical  signs 
depend  much  upon  the  situation  of  the  growth.  Near  the  anterior  sur- 
face in  the  epigastric  region  the  tumor  nuiy  form  a  distinct  prominence 
and  have  a  tense,  firm  feeling,  sometimes  with  lluctuation.  A  not  infre- 
quent situation  is  to  the  left  of  the  suspensory  ligament,  forming  a  tumor 
M'hich  ])ushos  up  the  heart  and  causes  an  extensive  area  of  dulness  in  the 
lower  sternal  and  left  hypochondriac  regions.  In  the  right  lobe,  if  the 
tumor  is  on  the  posterior  surface,  the  enlargement  of  the  organ  is  chiefly 
upAvard  into  the  pleura  and  the  vertical  area  of  dulness  in  the  posterior 
axillary  line  is  increased.  Superficial  cysts  may  give  what  is  known  as  the 
hydatid  fremitus.  If  the  tumor  is  palpated  lightly  with  the  fingers  of  the 
left  hand  and  percussed  at  the  same  time  with  those  of  the  right,  there  is 
felt  a  vibration  or  trembling  movement  which  persists  for  a  certain  time. 
It  is  not  always  present,  and  it  is  doubtful  whether  it  is  peculiar  to  the 
hydatid  tumors  or  is  due,  as  Triangon  held,  to  the  collision  of  the  daugh- 
ter cysts.  Very  large  cysts  iw"  accompanied  by  feelings  of  pressure  or 
dragging  in  the  hepatic  region,  nietimes  actual  pain.  The  general  con- 
dition of  the  patient  is  at  first  good  and  +lie  nutrition  little,  if  at  all,  in- 
terfered with.  Unless  some  of  the  acci  .its  already  referred  to  occur,  the 
symptoms  indeed  may  be  trifling  and  due  only  to  the  pressure  or  weight 
of  the  tumor. 

Suppuration  of  the  cyst  changes  the  clinical  picture  into  one  of  pyamiia. 
There  are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of  weight. 
Perforation  may  occur  into  the  stomach,  colon,  pleura,  bronchi,  or  exter- 
nally, and  in  some  instances  r'^^overy  has  taken  place.  Perforation  into 
the  ])ericardiuni  and  inferior  vena  cava  is  fatal.  In  tlie  latter  case  the 
daughter  cysts  have  been  found  in  the  heart,  plugging 'the  tricuspid  ori- 
fice and  the  pulmonary  artery.  Perforation  of  the  bile-passages  causes 
intense  jaundice,  and  may  lead  to  suppurative  cholangitis. 

An  interesting  symptcmi  connected  with  the  ru])ture  of  hydatid  cysts 
is  the  development  of  urticaria,  which  may  also  follow  aspiration  of  the 
cysts.  Bricger  has  separated  a  highly  toxic  material  from  the  fluid,  and  to 
it  the  symptoms  of  ]>oisoning  may  be  due. 

Diagnosis. — Cysts  of  moderate  size  may  exis    .vithout  producing  symp- 


re  or 
con- 
,  in- 
,  the 


ight. 
exter- 
into 
the 
ori- 
■auses 


DISEASES  CAUSED  BY  CESTODES. 


3T3 


3ymp- 


tonis.  Large  imiltij)l(.;  ctliiiiucocui  may  cause  gruat  eiihirgeiiiciit  with 
irregularity  of  the  outline,  and  such  a  eonililion  persisting  lor  any  time 
with  retention  of  the  health  and  strength  suggests  hydatid  disease.  An 
irregular,  ])ainless  eidargenient,  i)artieularly  in  the  left  lol)e,  or  the  i)res- 
enee  of  a  large,  smooth,  lluetuatiiig  tumor  of  the  ei)igastric  region  is  also 
very  suggestive,  and  in  this  situation,  when  accessible  to  jtalpation,  it 
gives  a  sensation  of  a  smooth  elastic  growth  and  possibly  also  the  hydatid 
tremor.  A\'hen  suppuration  occurs  the  clinical  picture  is  really  that  of 
abscess,  and  only  the  existence  of  previous  enlargement  of  the  liver  with 
good  health  would  point  to  the  fact  that  the  suppuration  was  associated 
with  hydatids.  Syphilis  may  produce  irregular  enlargement  without  much 
disturbance  in  the  health,  sometimes  also  a  very  definite  tumor  in  the 
epigastric  region,  but  this  is  usually  iirm  and  not  lluctuating.  The  clinical 
features  nuiy  simulate  cancer  very  closely.  In  a  case  which  I  reported  the 
liver  was  greatly  enlarged  and  there  were  many  nodular  tumors  in  the 
abdomen.  The  i)ost  mortem  showed  enormous  suppurating  hydatid  cysts 
in  the  left  lohe  of  the  liver  which  had  perforated  the  stomach  in  two 
l)laces  and  also  the  duodenum.  The  omentum,  mesentery,  and  ])elvis  also 
•contained  numerous  cysts.  As  a  rule,  the  clinical  course  of  the  disease 
uould  suffice  to  separate  it  clearly  from  cancer.  Dilatation  of  the  gall- 
bladder and  hydronephrosis  have  both  been  mistaken  for  hydatid  disease. 
In  the  former  the  mobility  of  the  tumor,  its  shape,  and  the  mucoid  char- 
acter of  the  contents  suffice  for  the  diagnosis.  \n  some  instances  of  hydro- 
nephrosis only  the  exploratory  puncture  could  distinguish  between  the 
conditions.  More  frequent  is  the  mistake  of  confounding  a  hydatid  cyst 
■of  the  right  lobe  pushing  up  the  pleura  with  pleural  effusion  of  the  right 
;side.  The  heart  may  be  dislocated,  the  liver  de[)ressed,  and  dulness,  feeble 
breathing,  and  diminished  fremitus  are  i)rcsent  in  both  conditions.  Fre- 
richs  lays  stress  upon  the  different  character  of  the  line  of  dulness;  in  the 
echinococcus  cyst  the  upper  limit  presents  a  curved  line,  the  maximum 
of  which  is  usually  in  the  scajjular  region.  Suppurative  pleurisy  may  be 
caused  by  the  perforation  of  the  cyst.  If  adhesions  result,  the  perforation 
takes  place  into  the  lung,  and  fragments  of  the  cysts  or  small  daughter 
■cysts  may  be  coughed  up.  For  diagnostic  purposes  the  exploratory  punc- 
ture should  be  used.  As  stated,  the  fluid  is  usually  perfectly  clear  or  slightly 
•opalescent,  the  reaction  is  neutral,  and  the  specific  gravity  varies  from  1.005 
to  1.009.  It  is  non-albuminous,  but  contains  chlorides  and  sometimes  traces 
of  sugar.  Hooklets  may  be  found  either  in  the  clear  fluid  or  in  the  sup- 
purating cysts.  They  are  sometimes  absent,  however,  as  the  cyst  may  be 
sterile. 

(b)  Echinococcus  of  the  Txespiraiory  System. — Of  809  cases  of  single 
hydatid  cyst  collected  by  Thomas  in  Australia,  the  lung  was  affected  in 
134  cases.  The  larva?  may  develop  primarily  in  the  pleura  and  attain  a 
large  size.  The  symptoms  are  at  first  those  of  compression  of  the  lung 
flnd  dislocation  of  the  heart.  The  physical  signs  are  those  of  fluid  in  the 
]ileura  and  the  condition  could  scarcely  be  distinguished  from  ordinary 
efTusion.  The  line  of  dvdness  may  be  quite  irregular.  As  in  the  echino- 
coccus of  the  liver,  the  general  condition  of  the  patient  may  be  excellent 


374 


DISEASES  DUE  TO  ANIMAIi  PARASITES. 


.  \ 
/ 


in  spite  of  the  existence  of  extensive  disease.  I'leiirisy  is  rarely  excited, 
'i'lie  cysts  may  liecoiiie  iiillaiiietl  and  jierforatc  the  cliest  wall.  In  a  cn.so 
of  J).  1*'.  SiMilh's,  of  W'alkcrlow  II,  Ontario,  a  ;iirl,  a^cd  twi'iily,  iiad  a  run- 
ning' sore  in  the  ci;^litli  left  intercostal  space.  Tliis  was  fri'ely  opened, 
and  in  the  pns  which  llowed  out  were  >i  nnnilier  oi'  well-eharaeterixed  echino- 
coccns  cysta  of  varioii.' sizes.    The  pjiient  recovered. 

Kchinocoeci  occur  r.iore  freciuently  in  the  hin<,'  than  in  the  ))leura.  If 
small,  they  nuiy  exist  for  some  time  without  causin<f  serious  symptoms. 
In  their  gi'owth  they  compress  the  lun<f  and  sooner  or  later  lead  to  inllam- 
matory  ])rocesses,  often  to  pnigrene,  and  the  formation  of  cavities  which 
connect  with  the  bronchi.  Fragments  of  membrane  or  small  cysts  may  be 
expectorated.  Ihemorrhafie  is  not  infreijueut.  Perforation  into  the  jileura 
witl'i  empyema  is  common.  A  majority  of  the  cases  are  regarded  during 
life  as  either  phthisis  or  gangrene,  and  it  is  only  the  detection  of  the  char- 
acteristic meml)ranes  or  the  booklets  which  leads  to  the  diagnosis.  The 
condition  is  nsnally  fatal;  oidy  a  few  cases  have  recoveivd.  Of  the  S") 
American  cases,  in  G  the  cysts  occnrred  in  the  lung  or  pleura. 

((■)  I'jrhiitocticriis  of  the  Kithiei/s. — In  the  collected  statistics  referred 
to  above  the  gen ito-m'i nary  system  comes  second  as  the  seat  of  hydatid 
disease,  though  here  the  alt'ection  is  rare  in  comparison  with  that  of  the 
liver.  Of  the  8r)  American  cases,  there  were  only  3  in  which  the  kidneys 
or  bladder  were  involved.  '^^Flie  kidney  may  be  converted  into  an  eu(jrmous 
cyst  resend)ling  a  hydronej)hrosis. 

The  diagnosis  is  only  possible  by  i)nncturo  and  examination  of  the 
fluid.  The  cyst  may  ])erforate  into  the  ])elvis  of  the  kidney,  and  portions 
of  the  memlirane  or  cysts  may  be  discharged  with  the  nriie,  sometimes 
])ronucing  renal  colic.  I  have  reported  a  case  in  which  for  many  months 
the  ])atieid  passed  at  intervals  nnnd)ers  of  small  cysts  with  the  ui'ine.  The 
general  health  was  little  if  at  all  distnrbed,  exee])t  by  the  attacks  of  colic 
during  the  ])assage  of  the  parasites. 

((/)  Echiiiociiccvs  of  ill.  Nrrrovs  Si/sfciit. — In  this  conutry  vei'y  few  in- 
stances have  occurred  in  the  biain.  One  or  two  reports  indicate  clearly 
that  the  common  cystic  disease  of  the  choroidal  plexnses  has  been  mistaken 
for  hydatids.  Davies  Thomas,  of  Anstralia,  has  tabulated  !)T  cases,  includ- 
ing some  of  the  Cystirercini  rdhihistv.  According  to  his  statistics,  the  cyst 
is  more  common  on  the  right  than  on  the  left  side,  and  is  most  frequent 
in  the  cerebrum. 

The  sym])toms  are  very  indefinite,  as  a  rule,  being  those  of  tumor. 
Persistent  headache,  convulsions,  either  limited  or  general,  and  gradually 
develo])ing  blindness  have  been  prouiiuent  features  in  manj'  cases. 

Multilocular  Echinococcus. — This  form  merits  a  brief  separate  descrip- 
tion, as  it  dilfei's  so  renuirkably  from  the  usual  type  of  the  disease.  It  has 
been  met  Avith  only  in  Bavaria,  'WTirtendierg,  the  adjacent  districts  of 
Switzerland,  and  in  the  Tyrol.  Possett  has  reported  13  cases  from  von 
Rokitansky's  clinic  at  Innsbruck.  In  the  United  States  cases  are  occasion- 
ally seen.  The  patient  of  Delafield  and  Prudden  Avas  a  German,  who  had 
been  in  the  country  five  years.  F(n'  a  year  previous  to  his  death  he  was 
out  of  health,  jaundiced,  and  somewhat  emaciated.     A  lluctuating  tumor 


adult 
seldoiu 
mon,  1 


PAiaSlTir  AKACIINIDA. 


375 


was  found  in  tlic  ri^dit  luniliiir  and  unihilical  ri'jrions,  apparcnlly  ronncctcd 
with  tlic  liver.  'This  was  (ipcncil.  and  dcalli  i'oiliiwcd  from  lui'morrhago. 
About  a  I'linitli  of  the  li^lit  lolic  nf  ihc  liver  was  oceii[iie([  by  an  invgulai" 
cavity  with  r(itii;li,  ragged  widls,  wliicb  in  |)lace.s  were  I'roni  one  to  two 
inclies  in  thickness  and  enclosed  irregular  small  cavitic.'..  Th"  lainellatud 
cuticnhi  characteristic  of  the  echinococcus  cvst  was  I'ound  lining  these  cavi- 
tics.  In  some  instances  the  tumor  bears  n  striking  likeness  to  colloid  can- 
cer, as  on  section  it  presents  u  fil)rous  stroma  with  cavities  containing 
gelatinous  material.  They  are  often  sterile — that  is,  without  the  hydatid 
heads  or  larva'.  This  form  is  almost  exclusively  confined  to  the  liver,  antl 
the  symptoms  resembh'  more  tlmse  of  tumor  or  cirrhosis.  The  Hver  is,  as 
a  lule,  eidai'ged  and  smontli,  not  irregular  as  in  preseiu'c  of  tlie  ordinary 
echinococcus.  Jaunilice  is  a  common  symptom.  The  spleen  is  usually  I'li- 
larged,  there  is  pi'ogressive  emaciation,  and  toward  tlie  close  Ini'inorrhages 
are  common. 

Treatment  of  Echinococcus  Disease. — Medicine^  are  of  no 
avail.  I'ost-morteni  reports  show  that  in  a  considerable  nund)er  of  eases 
the  ])arasite  dies  and  tlie  cyst  becomes  harndcss.  Operative  measures  should 
be  resorted  to  when  the  cyst  is  large  or  troublesome.  The  siinjtle  aspira- 
tion of  the  contents  has  l)een  successful  in  a  large  nundicr  of  cases,  and  as 
it  is  not  in  any  way  dangerous,  it  may  he  tried  before  tin;  more  radical 
procedure  of  incision  and  evacuation  of  the  cysts.  Supjturation  has  oc- 
casi(uially  followed  the  |)uncture.  Injections  into  the  sac  should  not  be 
])ractised.  With  modern  methods  surgeons  now  open  and  evacuate  ihe 
echinococcus  cysts  with  great  boldness,  and  the  Australian  records,  Mliich 
arc  the  most  numerous  and  important  on  this  suliject,  show  that  recovery 
is  the  nde  in  a  large  proportion  of  the  cases.  Snpi»urative  cysts  in  the 
liver  should  be  treated  as  abscess.  Xaturally  the  outlook  is  less  favorable. 
The  ])ractical  treatment  of  hydatid  disease  has  been  greatly  advanced 
by  Australian  surgeons.  The  works  of  the  Australian  ])hysicians  James 
(Jraham  and  Thomas  may  be  consulted  for  interesting  details  in  diagnosis 
and  treatment. 


VI.    PARASITIC    ARACHNIDA. 


■:CVip- 

t  has 
ts  of 
I  von 
asion- 
o  had 
e  was 
:umin' 


(1)  Pentastomes. — (a)  Liiifiuatula  rhhxiria  (Pcnloslonia  taninidcs)  has 
a  somewhat  lancet-shaped  body,  the  female  being  from  3  to  4  inches  in 
length,  the  male  about  an  inch  in  length.  The  body  is  tapering  and  marked 
by  numerous  rings.  The  adult  worm  infests  the  frontal  sinuses  and  nostrils 
of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  which  is  known  as 
the  LiiKjualuhi  srrrafa  (Penfaxfnnuon  (lenliculahim),  is  seen  in  the  internal 
organs,  particularly  the  liver,  but  has  also  been  found  in  the  kidney.  The 
adult  worm  has  been  found  in  the  nostril  of  man,  but  is  very  rare  and 
seldom  occasions  any  inconvenience.  The  larva;  are  by  no  means  uncom- 
mon, particularly  in  parts  of  fiermany. 

(h)  The  PnrncepJiohifi  cntistrictiis  {Peniasiomum  consfridiim),  which  is 
about  the  length  of  half  an  inch,  with  twenty-three  rings  on  the  abdomen, 


i;!;' 


m 


370 


DISKASKS  DUE  TO  ANIMAL   PAIIASITES. 


/ 


was  found  by  Aitkcii  in  the  liver  and  lungh  of  a  yoldior  of  a  West  Indian 
rt'ginicnt. 

Tiio  jJurnKite  is  very  rare  in  this  country.  Flint  refers  to  a  ^lis.souri 
case  in  wliicli  {'roni  75  to  KM)  of  tio  parasites  were  ex|)e('t()rate(l.  The 
liver  was  enlari-ed  and  the  parasites  ])rohably  occupied  tliis  region.  In 
18GI)  I  saw  a  specimen  wliich  luid  been  passed  with  the  urine  by  a  patient 
of  James  II.  Richardson,  of  Toronto. 

(2)  Deraodex  (Acarus)  folliculorum  (var.  hominis).— A  minute  pam- 
site,  from  ().;5  mm.  to  0.1  mm.  in  Iciigtii,  wliicii  lives  in  the  sebaceous  folli- 
cles, i)articularly  of  the  face.  It  is  doubtful  wlicther  it  ])roduces  any  syni])- 
toms.  I'ossibly  M'hen  in  large  nundjcrs  they  may  e.xcite  inllammation  of 
the  follicles,  leading  to  aciu'. 

(3)  Sarcoptes  (Acarus)  scabiei  (llch  Insecl). — This  is  the  most  imjwr- 
tant  of  tlie  arachnid  ])arasitcs,  as  it  produces  troublesome  aiul  distressing 
skin  eruptions.  The  nude  is  0.23  mm.  in  length  and  O.IS)  mm.  in  breadth; 
the  fenude  is  0.45  mm.  in  length  and  0.35  mm.  in  width.  The  female  can 
be  seen  readily  with  the  naked  eye  and  has  a  ])early-whitc  color.  It  is  not 
so  common  a  parasite  in  the  United  States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  1  cm.  in  length,  which  it  makes 
for  itself  in  the  epidernus.  At  the  end  of  this  burrow  the  female  lives. 
The  nuile  is  seldom  found.  The  chief  seat  of  the  parasite  is  in  the  folds 
where  the  skin  is  most  delicate,  as  in  the  web  between  the  fingers  and  toes, 
the  backs  of  the  hands,  the  axilla,  and  the  front  of  the  abdomen.  The  head 
and  face  are  rarely  involved.  The  lesions  wliich  result  from  the  presence 
of  the  itch  insect  are  very  numerous  and  result  largely  from  the  irritation' 
of  the  scratching.  The  commonest  is  a  papular  and  vesicular  rash,  or,  in 
children,  an  ecthymatous  eruption.  The  irritation  and  pustulation  which 
follow  the  scratching  may  completely  destroy  the  burrows,  but  in  typical! 
cases  there  is  rarely  doubt  as  to  the  diagnosis. 

The  treatment  is  simide.  It  should  consist  of  warm  baths  with  a  thor- 
ough use  of  a  soft  soap,  after  which  the  skin  should  be  anointed  with  sul- 
phur ointment,  which  in  the  case  of  children  should  be  diluted.  An  oint- 
ment of  naidithol  (drachm  to  the  ounce)  is  very  efficacious. 

(4)  Leptus  autumnalis  {Harvest  Bur/). — This  reddish -colored  parasite, 
about  half  a  millimetre  in  size,  is  often  found  in  large  numbers  in  fields 
and  in  gardens.  They  attach  themselves  to  animals  and  man  with  their 
sharp  proboscides,  and  the  booklets  of  their  legs  produce  a  great  deal  of 
irritation.  They  are  most  frequently  found  on  the  legs.  They  are  readily 
destroyed  by  sulphur  ointment  or  corrosive-sublimate  lotions. 

Several  varieties  of  ticks  are  occasionally  found  on  man — the  Ixodes 
ricinvs  and  the  Dermacentor  amcricaniis,  which  are  met  with  in  horses 
and  oxen. 


VII.    PARASITIC    INSECTS. 

(1)  Pediculi  {Phili'iriasis ;  Pedicnhsis). — There  are  three  varieties  of  the 
body  louse,  which  are  found  only  in  persons  of  uncleanly  habits. 

Pediculiis  capitis. — The  male  is  from  1  to  1.5  mm.  in  length  and  the- 


PARASITIC   IXSKCTS. 


377 


I  i- 


thor- 


oint- 


irasitc, 

their 
leal  of 
readily 

\lxod('>( 
horses 


I  of  the' 


female  nearly  I'  mm.  The  c  .Inr  varies  somewhat  with  the  dilTerent  rnoes 
of  men.  It  is  lij^ht  f^my  with  a  Mack  mar^Mii  in  the  Muroitcan,  and  very 
much  (iiirkor  in  the  negro  and  Chinese.  'J'hey  arc  oviparous,  and  tlio  female 
lays  aliout  sixty  eggs,  which  mature  in  a  week.  The  ova  are  attached  to 
the  hairs,  nnd  can  he  readily  seen  as  wiiite  specks,  known  |)opuiarly  as  nits. 
The  symptoms  are  irritati<in  and  itching  of  the  scalp.  When  numerouti 
the  insects  may  e.vcite  an  eczema  or  a  pustular  dermatitis,  which  cau.>ie.s 
crusts  and  scab.^,  particularly  at  the  hack  of  the  head,  in  the  most  i'\tremi> 
cases  the  hair  l)ecomes  tangled  in  these  crusts  and  nuitted  together,  form- 
ing at  the  occiput  a  tirm  'iiass  which  is  known  as  plini  jnilauira^  as  it  was* 
not  infrecpiont  among  the  Jewish  inhal)itants  of  Poland. 

Pediculus  corporis  (vestimenlurum). — This  is  considerably  larger  than 
the  head  louse.  It  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  liaMiiorrhagic  specks,  which  are  viry  common  about  the  neck,  back, 
and  abdomen.  'J'he  irritation  of  the  bites  may  cause  urticaria,  and  the 
scratching  is  usually  in  linear  lines.  In  long-standing  cases,  ])articularly 
in  old  dissipated  characters,  the  skin  becomes  rough  and  grc.itly  ])igmented, 
a  condition  which  has  been  termed  the  vagabond's  disease — inorhiis  rrnirinn 
— and  which  nuiy  be  mistaken  for  the  bronzing  of  Addison's  disease. 

I'hthirius  ptihis  dilfers  somewhat  from  the  other  forms,  and  is  found 
in  the  ])arts  of  the  body  covered  with  short  hairs,  as  the  pubes;  more  rarely 
the  axilla  and  eyebrows. 

The  laches  hhnatrcs  are  stated  by  French  writers  to  bo  excited  by  t'le 
irritation  of  jK'diculi. 

Treatment. — For  the  redicuhts  capitis,  when  the  condition  is  very 
bad,  the  hair  should  be  cut  short,  as  it  is  very  ditficult  to  destroy  thor- 
oughly all  the  nits.  Kejieated  saturations  of  the  hair  in  coal-oil  or  in  tur- 
])entine  arc  usually  ethcacious,  or  with  lotions  of  carbolic  acid,  1  to  50. 
Scru])ulous  cleanliness  and  care  are  sufRcient  to  prevent  recurrence.  In 
the  case  of  the  Pcdicuhis  corporis  the  clothing  should,  be  placed  for  sev- 
eral hours  in  a  disinfecting  oven.  To  allay  the  itching  a  warm  bath  con- 
taining 4  or  5  ounces  of  bicarbonate  of  soda  is  useful.  The  skin  may  be 
rubbed  with  a  lotion  of  carbolic  acid,  2  drachms  to  the  ])int,  with  'i  ounces 
of  glycerin.  For  the  Phthirivs  pubis  white  precijntatc  or  v  ".inary  mer- 
curial ointment  should  be  used,  and  the  parts  should  be  thoroughly  washed 
two  or  three  times  a  day  with  soft  soap  and  water. 

(2)  Cimex  lectularius  {Common  Bed-hug). — ?"'his  parasite  is  from  3  to 
4  mm.  in  length  and  has  a  reddish-brown  color.  It  lives  in  the  crevices  of 
the  bedstead  and  in  the  cracks  in  the  iloor  and  in  the  walls.  It  is  noc- 
turnal in  its  habits.  The  peculiar  odor  of  the  insect  is  caused  by  the  secre- 
tion of  a  special  gland.  The  parasite  possesses  a  long  proboscis,  with  whicli 
it  sucks  the  blood.  Individuals  differ  remarkably  in  the  reaction  to  the 
bite  of  this  insect;  some  are  not  disturbed  in  the  slightest  by  them,  in 
others  the  irritation  causes  hypora?mia  and  often  intense  urticaria.  Fumi- 
gation with  sulphur  or  scouring  with  corrosive-sublimate  solution  or  kero- 
sene destroys  them.    Iron  bedsteads  should  be  used. 

(3)  Pulex  irritans  (The  Common  Flea). — The  male  is  from  2  to  2.5 
mm.  in  length,  the  female  from  3  to  4  mm.    The  flea  is  a  transient  para- 


378 


DISKASKS  DUK  TO   ANIMAL   PAUASITKS. 


Bite  oil  man.  'riic  liitc  caii.'^cs  n  circiilur  red  spnt  of  li_v|ii'rii'iiiiii  in  the  centre 
of  which  is  11  liltli'  s|u'(k  uiiiTt'  tlio  horin^;  iip|ianUiis  has  cnteriMl.  Tho 
anioiint  ol'  initnlion  iniiscd  lt_v  lh<'  hitc  is  varialilc.  .Many  persons  snU'cr 
intensely  and  a  dill'iisL'  (.M^yliK'nia  or  an  irrilalilc  urtiiariu  dt-vt'lnps;  ollicrs 
buH'cr  nn  inconviMiicncc  wliati'Vcr. 

'i'hc  I'lilr.!-  iinirlniiiM  (siiiiil-flcd ;  jiiif/ir)  is  found  in  tropical  coiintrii'H, 
paitiiidarly  in  tlic  West  Indies  and  South  America.  It  is  mucii  smaller 
llian  the  common  Ilea,  and  not  only  penetrates  tho  skin,  hut  hurrows  and 
protluces  an  inllammal ion  with  puslidar  or  vesicular  s\velIin^^  It  most 
i'reiiuently  attacks  the  feet.  It  is  readily  removed  wilh  a  needle.  Where 
they  e.\i.-t  in  lar^'e  numhers  the  essential  oils  are  used  on  the  feet  as  a 
preventive. 


/ 


VIII.    MYIASIS. 

Of  these,  the  most  important  are  the  larva'  of  certain  diptera,  i)articii- 
larly  the  llesh  Hies — ('rmjiliild.     The  condition  is  called  myiasis. 

'JMie  most  common  form  is  that  in  which  an  external  wound  bocomos 
lirinij,  as  it  is  called.  This  myiasis  vulnerum  is  cau.se(l  hy  the  lurvit'  of 
either  the  hlue-hottle  or  the  common  llesh  Hy.  The  larviu  of  the  LiiclJia 
niiucJIrriti,  the  so-called  screw-w(U-m,  have  heen  found  in  the  nose,  in 
wounds,  and  in  the  va<:ina  after  delivery.  'J'hey  can  he  removed  readily 
with  the  forceps;  if  there  is  any  dilliculty,  thorou«,di  cleansin^j;  and  the 
application  of  an  antiseptic  l»anda;,a'  is  sullicieiit  to  kill  them.  The  ova 
of  these  Hies  may  he  deposited  in  the  nostrils,  the  ears,  or  the  conjunctiva — 
the  myiasis  narium,  aurium,  conjunctiva'.  'J'his  ijivasion  rarely  takes  place 
unless  these  re^dons  are  the  seat  of  disease.  In  the  nose  and  in  the  ear  the 
lar\ie  may  cause  serious  inilammation. 

The  cutaneous  myiasis  may  he  caused  hy  tho  larvio  of  tho  Musca  vnmi- 
laria,  hut  more  commonly  hy  the  hot-ilies  of  the  ox  and  sheep,  which 
occasionally  attiick  man.  This  condition  is  rare  in  temperate  climates. 
^latas  has  descrihed  a  case  in  which  a^strus  larva}  were  found  in  the  glu- 
teal region.  In  parts  of  Central  America  the  eggs  of  another  hot-fly,  the 
Drrnialohia,  are  not  infre(piently  de])()sited  in  the  skin  and  produce  a 
swelling  very  like  the  ordimiry  boil. 

A  s])ecinien  of  the  irnnidlomi/in  scalaris.  one  of  the  privy  flies,  was  sent 
to  me  by  Dr.  llartin,  of  Kaslo  City,  British  Columbia,  the  larva}  of  which 
were  ])assed  in  large  numbers  in  the  stools  of  a  man  aged  twenty-four, 
a  native  of  Louisiana.  They  were  presojit  in  the  stools  from  ]\Iay  1  to  Julv 
15,  1897. 

Myiasis  interna  may  result  from  the  swalloAving  of  the  larvte  of  the 
common  house  fly  or  of  species  of  the  genus  Anthomyia.  There  are  many 
c'ises  on  record  in  Avhich  the  larvre  of  the  Mii!<cn  fhnnrslica  have  boon  dis- 
charged by  vomiting.  Instances  in  Avliich  dipterous  larvte  have  been  pa'ssed 
in  the  fseces  are  less  common.  Finlayson,  of  Glasgow,  has  recently  re- 
ported an  interesting  case  in  a  phvsiciau,  who,  after  protracted  constipa- 
tiou  and  ])ain  in  the  back  and  sides,  passed  largo  numbers  of  the  larva} 
of  the  flower  fly — Anilwrnijia  canicuhris.     Among  other  forms  of  larvoe 


MYIASIS. 


379 


:,  the 
lice   ii 


or  f/nillcs,  ns  they  nro  Honictimos  oalli'tl,  which  havo  hcen  found  in  tlio 
t'lrri'n,  nro  thoHo  of  the  ('(ttmiion  houHo  lly,  the  hlue-hottlo  lly,  anil  tho 
'I'vrtiinin/zii  fnxrn.  Tlu'  liirvii'  of  dllicr  iiisfcts  arc  extremely  rare.  It  is 
.stated  that  t!ie  eatcr|iillar  of  the  tal)l)y  moth  has  hcen  found  in  tiiu  fiuceri. 
Here  may  l)e  mentioned  amoiij,'  the;  elTeets  cd"  insects  the  remarkahio 
urticaria  epiilrmira,  which  in  caused  in  some  districtH  hy  tlie  procession 
cateritilhirs,  part ieidarly  tlie  Hpecies  CtivlhiwaDipa.  'IMicri!  are  distri(.'ts  in 
the  Kaiillier;;er  Sciiwei/,  which  have  liccn  rendered  ahiiost  uninhahitahlo 
liy  tile  irritative  sl\in  eruptions  caused  l)y  tiie  presence  vX  tiieso  insc^ets,  tho 
action  of  which  is  not  necessarily  in  conseciuence  of  actual  contact  with 

tlieui. 

in  Africa  tlie  Inrvnp  of  the  Cnyor  fly  are  not  uncommonly  found  be- 
neath tile  skin,  in  little  boilij. 


of  the 
many 
n  dis- 
pa'ssed 
tly  ro- 
nstipa- 
larvpc 
larvJB 


24 


/ 


SECTION  III. 
THE  INTOXICATIONS 

AND  HUN-STROKK. 


I.   ALCOHOLISM. 

(1)  Acute  Alcoholism. — Wlicn  u  liir^'c  (itmntily  of  alcohol  is  tiikon,  its- 
iniluc'iuc  on  tlu!  nervous  system  is  niiiiiii'cstcd  in  niiisciilnr  incoiirdina- 
tion,  mcntiil  distiirhniu'c,  and,  linnlly,  narcosis.  'I'iic  individual  ])i('sonts 
a  Hushed,  sometinius  slightly  cyanoscd  face,  a  I'ldl  pulse,  with  det'i)  hut  raroly 
stertorous  rcsi)irations.  The  pupils  are  dilated.  The  tempi  rature  is  fre- 
quently helow  normal,  ])articularly  if  the  patient  has  heen  exposed  to  cold. 
I'erhaps  the  lowest  rei)orted  temperatures  have  heen  in  cases  of  this  sort. 
An  instance  is  on  record  in  whicii  the  i)ationt  on  admission  to  hospital  had 
a  teni])eraturc  of  24°  C.  (ea.  75°  F.),  and  ten  hours  hiter  the  temperature 
had  not  risen  to  1)1°.  The  unconsciousness  is  rarely  so  deep  that  the  pa- 
tient cannot  he  roused  to  .some  extent,  and  in  reply  to  (piestions  he  mutters 
incoherently.  Muscular  twitehings  nuiy  occur,  but  rarely  convulsion 
The  breath  has  a  heavy  j'lcoholic  odor. 

The  diagnosis  is  not  dillicult,  yet  mistakes  are  fre([uently  made.  Per- 
f  ns  are  sometimes  brought  to  hospital  by  the  police  su])))osed  to  be  drunk 
wlien  in  reality  they  are  dying  from  ajjoplexy.  Too  great  care  cannot  be 
exercised,  and  the  patient  should  receive  the  benefit  of  the  doubt.  In 
some  ir.3tances  the  mistake  has  ariseii  '-om  the  fact  that  a  person  who  has 
been  drinking  heavily  has  been  stricken  with  a)io])lexy.  In  this  condition 
the  coma  is  usually  dee])er,  stcrtor  is  j)resent,  and  there  may  be  evidence  of 
hemiplegia  in  the  greater  flaccid ity  of  the  limbs  on  one  side.  The  subject 
will  be  considered  in  the  section  u])on  ura^nic  coma. 

Dipsomnnin  is  a  form  of  ncute  alcoholism  seen  in  pcrsoits  with  a  strong 
hereditary  tendency  to  drink.  IVriodically  the  victims  go  "on  a  sjiree," 
but  in  the  intervals  they  are  entirely  free  from  any  craving  for  alcohol. 

(2)  Chronic  Alcoholism. — Tn  moderation,  wine,  beer,  and  spirits  may 
be  taken  throughout  a  long  life  without  impairing  'he  general  health. 

According  to  Payne,  the  poisonous  effects  of  alcohol  are  manifested  (1) 
B"  a  functional  poison,  as  in  acute  narcosis;  (2)  as  a  tissue  poison,  in  which 
its  effects  are  seen  on  the  parenchymatous  elements,  particularly  epithe- 
380 


ALrollOMSM. 


881 


its' 


IVr- 
unk 

lot  1)t' 
In 

o  has 
ition 
CO  of 

lllljC'Ct 

4ronjj: 
iree," 
1. 
mny 

■a  (1) 

which 
spithe- 


liuni  niid  iKT'-  pnidiirinf,'  n  hIow  (h'p'ncrntion,  and  on  tlw  Mood-vonaelri, 
niiiHin^'  thick  .n^'  mid  idtiinatcly  liltroid  cliaii^'cs;  and  (il)  as  a  clieckor 
of  ttHHiu'  oxidation,  nince  tlit>  alcohol  ix  conHunicd  in  place  of  the  fat.  Tliiti 
leads  to  fatty  chan^i    and  Honictinicri  to  a  condition  of  general  stcatoHJd. 

The  chief  eirt'cta  of  chronic  alcohol  poiHonin^  may  he  thus  Huninui- 
rizcd. 

Nftroiis  > /.v/t-m. — Functional  disturhancc  is  common,  rnstcadincs!* 
of  the  musclea  in  performing'  any  aition  is  u  constant  feature.  The  tremor 
is  Itest  si'cn  in  the  hands  and  in  the  lon<,'ue.  The  mental  processes  may 
he  dull,  particularly  in  the  early  morning'  hours,  and  the  patient  is  unahle 
to  transact  any  husiness  until  he  has  had  his  accutitomed  8timulanl.  Irri- 
tahility  of  temper,  for<;etfulness,  ami  a  chanj^e  in  the  moral  character  of 
till!  individual  ^^radually  come  on.  The  jud;,Mncnt  is  seriously  impairetl, 
the  will  eiifeehled,  and  ill  the  dual  stages  dementia  may  supervene.  The 
relation  of  chronic  alcoholism  to  insanity  has  hccn  much  discussed.  Ac- 
cording to  Savage,  of  4,000  patients  admitted  to  the  IJethlehem  Hospital, 
i;{;{  gave  drink  as  the  cause  of  their  insanity.  Chronic  alcoholism  la  he- 
Iiev<'d  hy  many  to  he  one  of  the  special  causes  of  dementia  paralytica,  hut 
the  opinions  of  experts  on  this  (picstion  arc  still  discordant.  Savage  states 
that  not  more  that  7  per  cent  are  causi'd  hy  alcohol  alone.  In  many  cases 
it  is  certainly  one  of  the  important  elements  in  the  strain  which  leads  to 
this  hreakdown.  Mpilepsy  may  result  directly  from  chronic  drinking.  It 
is  n  hope""l  form,  timl  may  disappear  entirely  with  a  return  to  liahits  of 
temperaii' 

No  characteristic  changes  arc  found  in  the  nervous  system.  Ila'inor- 
rhagic  pachymeningitis  is  not  very  uncommon.  Opacity  and  thickening 
of  the  pia-arachiioid  ineinliranes,  with  more  or  less  wasting  of  the  convo- 
lutions, generally  occur.  IMiese  are  in  no  way  peculiar  to  c'M'onic  alcoli(d- 
isin,  but  are  found  in  old  jiersons  an<l  in  chronic  wasting  diseases.  In  the 
very  protracted  cases  there  may  he  chronic  encephalo-meningitis  v\ith  ad- 
hesions of  the  niemhranes.  Finer  changes  in  the  nerve-cells,  their  pro- 
cesses, and  the  neuroglia  have  heeii  described  by  Berkley,  lloch,  and  others. 
liy  far  the  most  striking  eil'ect  of  alcohol  on  the  nervous  system  is  the  pro- 
duction of  the  alcoholic  neuritis,  which  will  be  considered  later. 

Difjpstive  Si/strni. — Catarrh  of  the  stomach  is  the  most  common  symp- 
tom. The  to])er  has  a  furred  tongue,  heavy  l)reath.  and  in  the  morning  a 
sensation  of  sinking  at  the  stomach  until  he  has  had  his  dram.  'IMie  appe- 
tite is  usually  impaired  and  the  bowels  are  constipated.  In  beer-di-inkers 
dilatation  of  the  stomach  is  common. 

Alcoh(d  ])r()duccs  definite  changes  in  the  liver,  leading  ultimately  to 
the  various  forms  of  cirrhosis,  'o  be  descril)ed.  In  Welch's  laboratory  J. 
Friedenwald  has  canscd  typical  cirrhosis  in  rabbits  by  the  administration 
of  alcohol.  The  effect  is  probably  a  jirimary  degenerative  change  in  the 
liver-cells,  although  many  good  observers  still  hold  i'lat  the  poison  acts 
first  n]ion  the  connective-tissue  elements.  It  is  probable  that  a  special 
vulncral)ility  of  the  liver-cells  is  necessary  in  the  etiology  of  alcoholic 
cirrhosis.  There  are  cases  in  which  comparatively  moderate  drinking  for 
a  few  years  has  been  followed  by  cirrhosis;  on  the  other  hand,  the  livers 


382 


THE   INTOXICATIONS  AND  SUN-STKOKE. 


/ 


of  j)t'rs())is  who  liiive  been  steady  drinkers  i'or  thirty  or  forty  years  may 
show  only  a  nioderute  grade  of  sclerosis.  For  years  before  cirrhosis  develops 
heavy  drinkers  may  ])resent  an  enlarged  and  tender  liver,  with  at  times 
swelling  of  tiie  spleen.  With  tlie  gastric  and  liepatic  disorders  the  facie.s 
often  !)ec<)mes  very  characteristic.  The  venules  of  the  cheeks  and  nose  are 
dilated;  the  hitter  becomes  enlarged,  red,  and  uiay  })resent  the  condition 
known  as  acne  rosacea.  The  eyes  are  watery,  the  conjunctiviu  hyperffimic 
and  sometimes  bile-tinged. 

The  heart  and  arteries  in  chronic  tojjcrs  show  important  degenerative 
changes.  Alcoholism  is  one  of  the  si)ecial  factors  in  causing  arterio- 
sclerosis. Steell  lias  i)ointed  out  the  frecjuency  of  cardiac  dilatation  in 
these  cases. 

Kidnei/s. — The  influence  of  chronic  alcoholism  upon  these  organs  is 
by  no  means  so  marked.  According  to  Dickinson  the  total  of  renal  disease 
is  not  greater  in  the  drinking  class,  and  lie  holds  that  the  effect  of  alcohol 
on  the  kidneys  has  been  much  overrated.  Fonnad  has  directed  attention 
to  the  fact  that  in  a  large  })roportion  of  chronic  alcoholics  the  kidneys  are 
increased  in  size.  The  Guy's  Hospital  statistics  support  this  statement, 
and  Pitt  notes  that  in  43  per  cent  of  the  bodies  of  hard  drinkers  the  kidneys 
were  hypertrophied  without  showing  morbid  change.  The  typical  granu- 
lar kidney  seems  to  result  indirectly  from  alcohol  through  the  arterial 
changes. 

It  was  formerly  thought  that  alcohol  was  in  some  way  antagonistic  to 
tuberculous  disease,  but  the  observations  of  late  years  indicate  clearly  that 
the  reverse  is  the  case  and  that  chronic  drinkers  are  much  more  liable  to 
both  acute  and  pulmonary  tuberculosis.  It  is  probably  altogether  a  c^ues- 
tion  of  altered  tissue-soil,  the  alcohol  lowering  the  vitality  and  enabling  the 
bacilli  more  readily  to  develop  and  grow. 

(3)  Delirium  Tremens  {mania  a  potu)  is  really  only  an  incident  in  the 
history  of  chronic  alcoholism,  and  results  from  the  long-continued  action 
of  the  poison  on  the  brain.  The  condition  was  first  accurately  described 
early  in  this  century  by  Sutton,  of  Greenwich,  who  had  numerous  oppor- 
tunities for  studying  the  different  forms  among  the  sailors.  One  of  the 
most  thorough  and  carefal  studies  of  the  disease  was  made  by  Ware,  of 
Boston.  A  spree  in  a  temperate  person,  no  matter  how  prolonged,  is  rarely 
if  ever  followed  by  delirium  tremens;  but  in  the  case  of  an  hal)itual 
drinker  a  tcmp:>rar\-  excess  is  apt  to  bring  on  an  attack.  It  sometimes 
develops  in  consequence  of  the  sudden  withdrawal  of  the  alcohol.  There 
are  circumstances  which  in  a  heavy  drinker  determine,  sometimes  with 
abrTi])tness,  the  onset  of  delirium.  Such  are  an  accident,  a  sudden  fright 
or  shock,  {\nd  an  acute  inflammation,  particularly  jmeumonia.  At  the 
outset  of  the  attack  the  patient  is  restless  and  depressed  and  sleeps  badly, 
symptoms  which  cause  him  to  take  alcohol  more  freely.  After  a  day  or 
two  the  characteristic  delirium  sets  in.  The  patient  talks  constantly  and 
incoherently;  he  is  incessantly  in  motion,  and  desires  to  go  out  and  attend 
to  some  imaginary  business.  Hallucina^''>ns  of  sight  and  hearing  develop. 
He  sees  objects  in  the  room,  such  as  rats,  mice,  or  snakes,  and  fancies  that 
they  are  crawling  over  his  body.    The  terror  inspired  by  these  imaginary 


ALCOnOTilSM. 


383 


agmary 


objects  is  great,  and  has  given  the  popular  name  "  horrors"  to  the  disease. 
The  patients  need  to  be  wateiied  constantly,  for  in  their  delusions  they 
may  jump  out  of  the  window  or  escape.  Auditory  lialiucinations  are  not 
so  common,  but  the  patient  may  C()m[)lain  of  hearing  the  roar  of  animals 
or  the  threats  of  imaginary  enemies.  There  is  much  muscular  tremor; 
the  tongue  is  covered  with  a  thick  white  fur,  and  when  protruded  is  tremu- 
lous. The  ])ulse  is  soft,  rapid,  and  readily  compressed.  There  is  usually 
fever,  but  tlie  temperature  rarely  registers  above  103°  or  103°.  In  fatal 
cases  it  may  be  higher.  Insomnia  is  a  constant  feature.  On  the  third  or 
fourth  day  in  favorable  cases  the  restlessness  abates,  the  i)atient  sleeps, 
and  improvement  gradually  sets  in.  The  tremor  persists  for  some  days, 
the  hallucinations  gradually  disa])pear,  and  the  appetite  returns.  In  more 
serious  cases  the  insomnia  ])ersists,  the  delirium  is  iiu-essant,  the  pulse  be- 
comes more  frequent  and  feeble,  the  tongue  dry,  the  prostration  extreme, 
and  death  takes  j)lace  from  gradiuil  heart-failure. 

Diagnosis. — The  clinical  picture  of  the  disease  can  scarcely  be  con- 
founded wim  any  other.  Cases  with  fever,  liowever,  may  be  mistaken  ior 
meningitis.  By  far  the  most  common  error  is  to  overlook  some  local  dis- 
ease, such  as  pneumonia  or  erysipelas,  or  an  accident,  as  a  fractured  rib, 
which  in  a  chronic  driiiker  may  precipitate  an  attack  of  delirinm  tremens. 
In  every  instance  a  careful  examination  should  be  made,  particularly  of 
the  lungs.  It  is  to  be  remend)ercd  that  in  the  severer  forms,  particularly 
the  febrile  cases,  congestion  of  the  l)ases  of  the  lungs  is  by  no  means  un- 
common. Another  point  to  be  borne  in  mind  is  the  fact  that  pneumonia 
of  the  apex  is  apt  to  be  accompanied  by  delirium  similar  to  mania  a  pohc. 

Prognosis. — Eecovery  takes  place  in  a  large  ])roportion  of  the  cases 
in  private  practice.  In  hos])ital  practice,  })articnlarly  in  the  large  city 
hospitals  to  which  the  debilitated  patients  are  taken,  the  death-rate  is 
higher.  Gerhard  states  that  of  1,241  cases  admitted  to  the  Philadeli)hia 
IIos])ital  121  proved  fatal.  Recurrence  is  freqnent,  almost  indeed  the  rule, 
if  the  drinking  is  kept  up. 

Treatment. — Acute  alcoholism  rarely  requires  any  special  measures, 
as  the  patient  sleeps  off  the  effects  of  the  debauch.  In  the  ease  of  pro- 
found alcoholic  coma  it  may  be  advisable  to  wash  out  the  stomach,  and  if 
collapse  sym])toms  occur  the  limbs  should  be  rubbed  and  hot  a])])lications 
made  to  the  body.  Should  convulsions  supervene,  chloroform  may  be 
carefully  administered.  In  the  acute,  violent  alcoholic  mania  the  hypo- 
dermic injection  of  apomor])hia,  one  eighth  or  one  sixth  of  a  grain,  is 
usually  very  effectual,  causing  nausea  and  vomiting,  and  rapid  disappear- 
ance of  the  maniacal  symptoms. 

Chronic  alcoholism  is  a  condition  very  difficidt  to  treat,  and  once  fully 
established  the  habit  is  rarely  abandoned.  The  most  obstinate  cases  are 
those  with  marked  hereditary  tendency.  Withdrawal  of  the  alcohol  is  the 
first  essential.  This  is  most  effectually  accomjdished  by  ])lacing  the  pa- 
tient in  an  institution,  in  Avhich  he  can  be  carefully  watched  during  the 
trying  period  of  the  first  week  or  ten  days  of  abstention.  The  absence  of 
temptation  in  institution  life  is  of  special  advantage.  For  the  sleepless- 
ness the  bromides  or  hyoscine  may  be  employed.     Quinine  and  strychnine 


384 


THE  INTOXICATIONS  AND  SUN-STROKE. 


in  tonic  doses  may  be  given.  Cocaine  or  the  fluid  extract  of  coca  has  been 
rt'fonunended  as  a  substitute  for  alcohol,  but  it  is  not  of  much  service. 
I'rolonged  seclusion  in  a  suitable  institution  is  in  reality  the  only  effectual 
means  of  cure.  "When  the  hereditary  tendency  is  strongly  developed  a  lapse 
into  the  drinking  hal)it  is  almost  inevitable. 

In  delirium  tremens  the  patient  should  be  confined  to  bed  and  care- 
fully watched  night  and  day.  The  danger  of  escape  in  these  cases  is  very 
great,  as  the  ])atient  imagines  himself  pursued  by  enemies  or  demons. 
Flint  mentions  the  case  of  a  man  who  escaped  in  his  night-clothes  and  ran 
barefooted  for  fifteen  miles  on  the  frozen  ground  before  he  was  over- 
taken. The  patient  should  not  be  strapped  in  bed,  as  this  aggravates  the 
delirium;  sometimes,  however,  it  may  be  necessary,  in  which  case  a  sheet 
tied  across  the  bed  may  be  sufficient,  and  this  is  certainly  better  than  vio- 
lent restraint  by  three  or  four  men.  Alcohol  should  be  withdrawn  at  once 
unless  the  pulse  is  feeble. 

Delirium  tremens  is  a  disease  which,  in  a  large  majority  of  cases,  runs 
a  course  very  slightly  influenced  by  medicine.  The  indications  for  treat- 
ment are  to  procure  sleep  and  to  support  the  strength.  In  mild  cases  half 
a  drachm  of  bromide  of  potassium  combined  with  tincture  of  capsicum 
may  be  given  every  three  hours.  Chloral  is  often  of  great  service,  and  may 
be  given  without  hesitation  unless  the  heart's  action  is  feeble.  Good  re- 
sults sometimes  follow  the  hypodermic  use  of  hyoscine,  one  one-hundredth 
of  a  grain.  Opium  must  be  used  cautiously.  A  special  merit  of  Ware's 
work  was  the  demonstration  that  on  a  rational  or  expectant  plan  of  treat- 
ment the  percentage  of  recoveries  was  greater  than  with  the  indiscriminate 
use  of  sedatives,  which  had  been  in  vogue  for  many  years.  When  opium  is 
indicated  it  should  be  given  as  morphia,  hypodermically.  The  effect  should 
be  carefully  watched,  and  if  after  three  or  four  quarter-grain  doses  have 
been  given  the  patient  is  still  restless  and  excited,  it  is  best  not  to  push  it 
farther.  When  fever  is  present  the  tranquillizing  effects  of  a  cold  douche 
or  cold  bath  may  be  tried,  or  the  cold  pack.  The  large  doses  of  digitalis 
formerly  employed  are  not  advisable. 

Careful  feeding  is  the  most  important  element  in  the  treatment  of 
these  cases.  Milk  and  concentrated  broths  shoiild  be  given  at  stated  inter- 
vals. If  the  pulse  becomes  rapid  and  shows  signs  of  flagging  alcohol  may 
be  given  in  combination  with  the  aromatic  spirits  of  ammonia. 


II.    MORPHIA    HABIT   {Morphinomnnia ;  Morphinism). 

This  habit  arises  from  the  constant  use  of  morphia — taken  at  first,  as  a 
rule,  for  the  purpose  of  allaying  pain.  The  craving  is  gradually  engen- 
dered, and  the  habit  in  this  way  acquired.  The  injurious  effects  vary 
very  much,  and  in  the  East,  where  opium-smoking  is  as  common  as  tobacco- 
smoking  with  us,  the  ill  effects  are,  according  to  good  observers,  not  so 
striking. 

The  habit  is  particularly  prevalent  among  women  and  physicians  who 
use  the  hypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or 


MORPHIA  HABIT. 


3S5 


have 


as  a 
ngen- 

vary 
lacco- 

lot  so 

!  who 
ria  or 


sciatica.     The  acquisition  of  the  linhit  as  a  pure  luxury  is  rare  in  this 
country. 

The  symptoms  at  first  are  sliglit,  and  moderate  doses  may  be  taken  for 
months  without  serious  injury  aiul  without  disturbance  of  health.  There 
are  exceptional  instances  in  which  for  a  period  of  yer.rs  excessive  doses 
Juive  been  taken  without  deterioration  of  the  mental  or  bodily  functions. 
As  a  rule,  the  dose  necessary  to  obtain  the  desired  sensations  has  grad- 
ually to  be  increased.  As  the  eifects  wear  off  the  victim  exi)eriences  sensa- 
tions of  lassitude  and  mental  depression,  accompanied  often  with  slight 
aiausca  and  epigastric  distress,  symptoms  which  are  relieved  by  another 
dose  of  the  drug.  The  confirmed  opium-eater  often  presents  a  very  char- 
acteristic appearance.  There  is  a  sallowness  of  the  comi)lexiou  which  is 
almost  pathognomonic,  and  he  becomes  emaciated,  gray,  and  ])rematurely 
aged.  lie  is  restless,  irritable,  and  unable  to  remain  quiet  for  any  time. 
Itching  is  a  common  symptom.  The  sleep  is  disturbed,  the  appetite  and 
digestion  are  deranged,  and  except  when  directly  under  the  influence  of 
the  drug  the  mental  condition  is  one  of  depression.  Occasionally  there 
are  profuse  sweats,  which  may  be  preceded  by  chills.  The  pupils,  except 
when  imder  the  direct  influence  of  the  drug,  are  dilated,  sometimes  un- 
equal. P  .  ms  addicted  to  morphia  are  inveterate  liars,  and  no  reliance 
whatever  •  i  be  placed  u])on  their  statements.  In  many  instances  this  is 
not  confineu  to  matters  relating  to  the  vice.  In  women  the  symptoms  may 
be  associated  with  those  of  pronounced  hysteria  or  neurasthenia.  The 
practice  may  be  continued  for  an  indefinite  time,  usually  requiring  increase 
in  the  dose  until  ultimately  enormous  quantities  may  be  needed  to  obtain 
the  desired  efl'ect.  Finally  a  condition  of  asthenia  is  induced,  in  which 
the  victim  takes  little  or  no  food  and  dies  from  the  extreme  bodily  de- 
1)ility.  An  increase  in  the  dose  is  not  always  necessary,  and  there  are 
liahitues  who  reach  the  point  of  satisfaction  with  a  daily  amount  of  2  or 
3  grains  of  morphia,  and  who  are  able  to  carry  on  successfully  for  many 
years  the  ordinary  business  of  life. 

The  treatment  of  the  morphia  habit  is  extremely  difficult,  and  can  rarely 
be  successfully  carried  out  by  the  general  practitioner.  Isolation,  sys- 
tematic feeding,  and  gradual  withdrawal  of  the  drug  are  the  essential 
elements.  As  a  rule,  the  patients  must  be  under  control  in  an  institution 
and  should  be  in  bed  for  the  first  ten  days.  It  is  best  in  a  majority  of 
cases  to  reduce  the  morphia  gradually.  The  diet  should  consist  of  beef- 
juice,  milk,  and  egg-white,  which  should  be  given  at  short  intervals.  The 
sufferings  of  the  patients  are  usually  very  great,  more  particularly  the  ab- 
dominal pains,  sometimes  nausea  and  vomiting,  and  the  distressing  rest- 
lessness. Usually  within  a  week  or  ten  days  the  opium  may  be  entirely 
withdrawn.  In  all  cases  the  pulse  should  be  carefully  watched  and,  if 
feeble,  stimulants  should  be  given,  with  the  aromatic  spirits  of  ammonia 
nnd  digitalis.  For  the  extreme  restlessness  a  hot  bath  is  serviceable.  The 
>leeplessness  is  the  most  distressing  symptom,  and  various  drugs  may  have 
to  be  resorted  to,  particularly  hyoscine  and  sulphonal  and  sometimes,  if 
the  insomnia  persist,  morphia  itself. 

It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient 


386 


THE  INTOXICATIONS  AND  SUN-STROKE. 


has  no  moans  of  obtaining  morphia.  Even  iindcr  tlie  I'avorahlo  circum- 
stances of  seclusion  in  an  institution,  and  constant  watching  l)y  a  night  and 
H  day  nurse,  I  liave  known  a  patient  to  i)ractice  deception  for  a  period  of 
three  niontlis.  After  an  apparent  cure  tiie  patients  are  only  too  apt  to 
lapse  into  the  liahit. 

The  condition  is  one  which  has  become  so  common,  and  is  so  much  on 
the  increase,  that  physicians  should  exercise  the  utmost  caution  in  pre- 
scribing mor])hia,  })articularly  to  female  patients.  Under  no  circumstances 
whatever  should  a  jjatient  with  neuralgia  or  sciatica  be  allowed  to  use  the 
hy})odermic  syringe,  and  it  is  even  safer  not  to  intrust  this  dangerous 
instrument  to  the  hands  of  the  nurse. 


/ 


III.    LEAD-POISONING  (Plumbism;  Saturnism). 

Etiology. — The  disease  is  widespread,  particularly  in  lead-workers 
and  among  plumbers,  painters,  and  glaziers.  The  metal  is  introduced  into 
the  system  in  many  forms.  Miners  usually  escape,  but  those  engaged  in 
the  smelting  of  lead-ores  are  often  attacked.  Animals  in  the  neighbor- 
hood of  smelting  furnaces  have  suffered  with  the  disease,  and  even  the 
birds  that  feed  on  the  berries  in  the  neighborhood  may  be  alfectcd.  Men 
engaged  in  the  white-lead  factories  arc  particularly  prone  to  plumbism. 
Accidental  poisoning  may  come  in  many  ways;  most  commonly  by  drink- 
ing water  which  has  passed  throiigh  lead  pijjcs  or  been  stored  in  lead- 
lined  cisterns.  Wines  and  cider  which  contain  acids  quickly  becv/me  con- 
taminated in  contact  with  lead.  It  was  the  frequency  of  colic  in  certain 
of  the  cider  districts  of  Devonshire  which  gave  the  name  of  Devonshire  colic, 
as  the  frequency  of  it  in  Poitou  gave  the  name  colic^  Pictoninn.  Among 
the  innumerable  sources  of  accidental  poisoning  may  be  mentioned  milk, 
various  sorts  of  beverages,  hair  dyes,  false  teeth,  and  thread.  xV  serious 
outbreak  of  lead-poisoning,  which  was  investigated  by  David  D.  Stewart, 
occurred  recently  in  Philadelphia,  owing  to  the  disgraceful  adulteration 
of  a  baking-powder  with  chromate  of  lead,  which  was  used  to  give 
a  yellow  tint  to  the  cakes.  Lead  given  medicinally  rarely  produces  poi- 
soning. 

All  ages  are  attacked,  but  J.  J.  Putnam  states  that  children  are  rela- 
tively less  liable.  The  largest  number  of  cases  occur  between  thirty  and 
forty.  According  to  Oliver,  from  whose  recent  Gulstonian  lectures  I  here 
quote,  females  are  more  susceptible  than  males.  He  states  that  they  are 
much  more  quickly  brought  under  its  influence,  and  in  a  recent  epidemic 
in  which  a  thousand  cases  were  involved  the  proportion  of  females  to  males 
was  four  to  one. 

The  lead  gains  entrance  to  the  S3'stem  through  the  lungs,  the  digestive 
organs,  or  the  skin.  Poisoning  may  follow  the  use  of  cosmetics  contain- 
ing load.  Through  the  lungs  it  is  freely  absorbed.  The  chief  channel, 
according  to  Oliver,  is  the  digestive  system.  It  is  rapidly  eliminated  by 
the  kidneys  and  skin,  and  is  present  in  the  urine  of  lead-workers.  The 
susceptibility  is  remarkably  varied.    The  symptoms  may  be  manifest  within 


LEAD-POISONING. 


887 


rela- 
ty  and 


a  month  of  exposure.  On  tlio  other  hand,  Taiuiuerel  (des  rhinchcs)  met 
with  a  case  in  a  man  who  had  heen  a  lead-worker  I'or  illty-two  years. 

Morbid  Anatomy. — Small  quantities  of  lead  oecur  iu  the  hody  in 
health.  J.  J.  i'ntnani's  rejjorts  show  that  of  150  ])ersons  not  presenting 
symptoms  of  lead-poisoning  traees  of  lead  oeeiirred  in  the  urine  of  '2o  jier 
cent. 

In  ehronic  jjoisoning  lead  is  found  in  the  various  organs.  The  all'eeted 
muscles  are  yellow,  fatty,  and  fiijroid.  The  nerves  present  the  features  of 
a  i)eri])heral  degenerative  neuritis.  The  cord  and  the  nerve-roots  are,  as  a 
rule,  uninvolved.  Jn  the  })rimary  atrophic  form  the  ganglion  cells  of  the 
anterior  horns  are  prohahly  implicated.  In  the  acute  fatal  eases  there  may 
he  the  most  intense  entero-colitis. 

Clinical  Forms. — Acute  Poisoning. — We  do  not  refer  here  to  tlie 
accidental  or  suicidal  cases,  which  present  vomiting,  pain  in  the  abdomen, 
and  collapse  symptoms.  In  workers  in  lead  there  are  several  manifesta- 
tions which  follow  a  short  time  after  exposure  and  set  in  acutely.  There 
may  be,  in  the  first  place,  a  rapidly  developing  anaunia.  Acute  neuritis  has 
been  described,  and  convulsions,  ei)ile])sy,  ami  a  delirium,  which  may  be, 
as  Stephen  Mackenzie  has  noted,  not  unlike  that  produced  by  alcohol. 
There  are  also  cases  in  which  the  gastro-intestinal  symptoms  are  most 
intense  and  rai)idly  ])rove  fatal.  There  was  admitted  under  my  care  in  the 
riiiladel))hia  Hospital  a  ])ainter,  aged  fifty,  suffering  with  anannia  and 
severe  abdominal  pain,  which  had  lasted  about  a  week.  He  had  vomiting, 
constipation  at  first,  afterward  severe  diarrhoea  and  melaina,  with  distention 
and  tenderness  of  the  abdomen.  There  were  albumin  and  tube-casts  in  the 
urine.  The  temi)erature  was  usually  subnormal.  Death  occuiTed  at  the 
end  of  the  second  week.  There  was  found  the  most  intense  entero-colitis 
with  hamiorrhages  and  exudation.  These  acute  forms  develop  more  fre- 
quently in  persons  recently  exposed,  and,  according  to  Mackenzie,  are  more 
frequent  in  winter  than  in  summer.  Da  Costa  has  reported  a  case  of  hemi- 
plegia developing  after  three  days'  exposure  to  the  poison. 

Chronic  poisoning  presents  the  following  symptoms: 

(a)  Anaemia,  the  so-called  saturnine  cachexia,  which  may  be  profoimd. 
As  a  rule,  however,  the  corpuscles  do  not  sink  below  50  per  cent.  In  some 
of  the  chronic  cases  there  may  be  a  persistent  pallor  of  the  face  with  a  tol- 
erably high  blood-count. 

(b)  Blue  line  on  the  gums,  which  is  a  valuable  indication,  but  not  invari- 
ably present.  Two  lines  must  be  distinguished:  one,  at  the  margin  be- 
tween the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed  by 
rinsing  the  mouth  and  cleansing  the  teeth.  The  other  is  the  well-known 
characteristic  blue-black  line  at  the  margin  of  the  gum.  The  color  is  not 
uniform,  but  being  in  the  papilla;  of  the  gums  the  line  is,  as  seen  with  a 
magnifying-glass,  interrupted.  The  lead  is  absorbed  and  converted  in  the 
tissues  into  a  black  sulphide  by  the  action  of  sidphuretted  hydrogen  from 
the  tartar  of  the  teeth.  The  line  may  form  in  a  few  days  after  exposure 
(Oliver)  and  disappear  wifbin  a  few  weeks,  or  may  persist  for  many  months. 
Phili])son  has  noted  the  u  eurrence  of  a  black  line  in  miners,  due  to  the 
deposition  of  carbon. 


388 


THE  INTOXICATIONS  AND  SUN-STROKE. 


/ 


Tliu  most  ini})c)rttint  symptoms  of  chronic  lead-poisoning  are  colic, 
lead-palsy,  and  tlie  cncei)lial()i)athy.  Of  these,  the  colic  is  the  most  tvn- 
^pient.  Of  Tanquerel's  cases,  there  were  1,^17  of  colic,  101  of  paraly  is, 
and  72  of  enccphalopiitliy. 

{(•)  Colic  is  the  most  common  symptom  of  clironic  lead-poisoning.  It 
is  often  preceded  by  gastric  or  intestinal  sym})toms,  particularly  constipa- 
tion. The  pain  is  over  the  whole  abdomen.  The  colic  is  usually  parox- 
ysmal, like  true  colic,  and  is  relieved  by  i)ressiire.  There  is  often,  in  addi- 
tion, between  the  ])aroxysnis  a  didl,  heavy  ])ain.  There  may  be  vomiting. 
During  the  attack,  as  Kiegel  noted,  the  pulse  is  increased  in  tension  and 
the  heart's  action  is  retarded.  Attacks  of  pain  with  acute  diarrhoea  may 
rec'tr  for  weeks  or  even  for  three  or  four  years. 

'   Lcad-palsi/. — This  is  rarely  a  primary  manifestation.     The  onset 
mil  acute,  subacute,  or  chronic.     It  usually  develops  without  fever. 

In  its  distribxition  it  may  Ijc  partial,  limited  to  a  muscle  or  to  certain  mus- 
cle grou])s,  or  generalized,  involving  in  a  short  time  the  muscles  of  the 
■extremities  and  the   trunk.      Madame  Dejerine-Khimi)kG   recognizes   the 
following  localized  forms: 

(1)  Anti-l)rachial  tyi)e,  paralysis  of  the  extensors  of  the  fingers  and  of 
the  wrist.  In  this  the  musculo-spiral  nerve  is  involved,  causing  the  char- 
acteristic wrist-drop.  The  supinator  longus  usually  escapes.  In  the  long- 
continued  flexion  of  the  car])us  there  may  be  slight  disidacement  back- 
ward of  the  bones,  with  distention  of  the  synovial  sheaths,  so  that  there 
is  a  prominent  swelling  over  the  wrist.  This,  which  is  sometimes  known 
as  Gruebler's  tumor,  though  not  of  any  moment,  is  often  very  annoying  to 
the  patient. 

(2)  Brachial  type,  which  im^olves  the  deltoid,  the  biceps,  the  brachi- 
alis  anticup,  and  the  supinator  longus,  rarely  the  ]iectorals.  The  atrophy 
is  of  the  scapulo-humeral  form.  It  is  bilateral,  and  sometimes  follows  the 
first  form,  but  it  may  he  primary. 

(3)  The  Aran-Duchenne  type,  in  wliich  the  small  muscles  of  the  hand 
and  of  the  thenar  and  hypothenar  eminences  are  involved,  so  that  we  have  a 
paralysis  closely  resembling  that  of  the  early  stage  of  polio-mj/elitis  anterior 
chronica.  The  atrophy  is  marked,  and  may  be  the  first  manifestation  of 
the  lead-palsy.  Mohius  has  shown  that  this  form  is  particularly  developed 
in  tailors. 

(4)  The  peroneal  type.  According  to  Tanquerel,  the  lower  limbs  are 
involved  in  the  proportion  of  13  to  100  of  the  upper  limbs.  The  lateral 
peroneal  muscles,  the  extensor  communis  of  the  toes,  and  the  extensor 
])roprius  of  the  big  too  are  involved,  producing  the  steppage  gait. 

(ri)  liaryngeal  form.  Adductor  paralysis  has  been  noted  by  Morell 
Mackenzie  and  others  in  lead-palsy. 

Generalized  Palsies. — There  may  be  a  slow,  chronic  paralysis,  gradually 
involving  the  extremities,  beginning  with  the  classical  picture  of  wrist- 
drop. ]\[ore  frequently  there  is  a  rapid  generalization,  producing  complete 
paralysis  in  all  the  muscles  of  the  parts  in  a  few  days.  It  may  pursue  a 
course  like  an  ascending  paralysis,  associated  with  rapid  Avasting  of  all 
four  limbs.     Such  cases,  however,  are  very  rare.     Death  has  occurred  by 


LEAD-POISONINO. 


389 


It 


Irnor 
m  of 
oped 


loroU 

Inally 
wrist- 
II  plete 
pne  a 
of  all 
ed  by 


involvt'int'iit  of  tho  dinplirn^'in.  Oliver  reports  a  cns^c  of  riiilii)son's  in 
wliicli  coniplc'to  i»araly.<is  yui)erveni;d.  Dejcriiui-Klimipko  alsi)  recognizes 
a  febrile  fonn  of  general  paralysis  in  leud-poisoning,  which  may  closely 
resemble  the  sul)acute  fcipinal  i)aralysis  of  Duchenne. 

There  is  also  a  primary  saturnine  muscular  atrophy  in  which  the  weak- 
ness and  wasting  come  on  togetlier  ami  clevelo|)  proportionately.  It  is  this 
form,  according  to  (Jowers,  which  most  fretiuently  assumes  the  Aran- 
Duchenne  type. 

The  electrical  reactions  arc  those  of  lesions  of  the  lower  motor  seg- 
ment, and  will  l)e  described  under  diseases  of  the  nerves.  The  degener- 
ative reaction  in  its  dill'erent  grades  may  be  present,  dei)ending  upon  the 
severity  of  the  disease. 

Usually  with  the  onset  of  the  paralysis  there  are  pains  in  the  legs  and 
joints,  the  so-called  saturnine  arthralgias.  Sensation  may,  however,  he 
imalfected. 

(e)  The  cerebral  symptoms  are  numerous.  Optic  neuritis  or  neuro- 
retinitis  may  develop.  Hysterical  symptoms  occasionally  occur  in  girls. 
Convulsions  are  not  uncommon,  and  in  fits  developing  in  the  adult  the 
possibility  of  lead-poisoning  should  always  be  considered.  True  oi)ile])sy 
may  follow  the  convulsions.  An  acute  delirium  may  occur  with  liallucina- 
tions.  The  patients  may  have  trance-like  attacks,  wliich  follow  or  alternate 
•with  convulsions.  A  few  cases  of  lead  encephalopathy  finally  drift  into 
lunatic  asylums.  Tremor  is  one  of  the  commonest  manifestations  of  lead- 
poisoning. 

(/)  Arteriosclerosis. — T^rcad-workers  are  notoriously  subject  to  arterio- 
■eclerosis  with  contracted  kidneys  and  hypertrophy  of  the  heart.  The  cases 
visually  show  distinct  gouty  de])osits,  particularly  in  the  big-toe  joint;  but 
in  this  country  acute  gout  in  lead-workers  is  rare.  According  to  Sir  "Wil- 
liam Roberts,  the  lead  favors  the  precipitation  of  the  crystalline  urates  of 
the  tissues.  Ealfe  has  shc,;n  that  lead  diminishes  the  alkalinity  of  the 
hlood,  and  so  lessens  the    jlubility  of  the  uric  acid. 

Prognosis. — Tn  the  minor  manifestations  of  lcad-])oisoning  this  is 
good.  According  to  Gowers,  the  outlook  is  bad  in  the  primary  atrophic 
form  of  paralysis.  Convulsions  are,  as  a  rule,  serious,  and  the  mental 
symptoms  which  succeed  may  be  permanent.  Occasionally  the  wrist-drop 
persists. 

Treatment. — Prophylactic  measures  should  be  taken  at  all  lead-works, 
bnt,  unless  employes  are  careful,  poisoning  is  apt  to  occur  even  under  the 
most  favorable  conditions.  Cleanliness  of  the  hands  and  of  the  finger-nails, 
frequent  bathing,  and  the  use  of  respirators  when  necessary,  should  be  in- 
sisted upon.  When  the  lead  is  in  the  system,  the  iodide  of  potassium 
should  be  given  in  from  5-  to  10-grain  doses  three  times  a  day.  For  the 
colic,  local  applications  and,  if  severe,  morphia  may  be  nsed.  An  occa- 
sional morning  purge  of  sulphate  of  magnesia  may  be  given.  For  the  anna- 
mia  iron  should  be  used.  In  the  very  acute  cases  it  is  well  not  to  give  the 
iodide,  as,  according  to  some  writers,  the  liberation  of  the  lead  which  has 
been  deposited  in  the  tissues  may  increase  the  severity  of  the  symptoms. 
For  the  local  palsies  massage  and  the  constant  current  should  be  used. 


1 1 


390 


Till":   INTOXICATIONS  AND  SUN-STROKE. 


/ 


IV.    ARSENICAL    POISONING. 

Acute  paiftoiiliii/  by  ar.«c)iic  is  coiiiiiion,  pnrticuliiily  by  Paris  green  and 
Kucli  mixtures  us  "  Jfoiigli  on  Hats,"  w  hicli  are  used  to  destroy  vermin  and 
iuBcets.  The  chief  symptoms  are  intense  ])ain  in  the  stomach,  vomiting, 
and,  hiter,  eolic,  with  diarrhoea  and  tenesmus;  occasionally  the  syiuploms 
are  those  of  collapse.  If  recovery  lakes  place,  paralysis  may  follow.  The 
treatment  should  be  similar  to  that  of  other  irritant  |»oisons — rapid  re- 
moval M'itli  the  stomach  [jiimp,  the  ])romotiou  of  vomiting,  and  the  use 
of  milk  and  eggs.  If  the  poison  has  been  taken  in  solution,  dialyzed  iron 
may  be  used  in  large  doses  of  from  (5  to  S  drachms. 

('lirt)iiic  Arsenical  I'uixuniiig. — Arsenic  is  used  extensively  in  the  arts, 
particularly  in  the  manufacture  of  colored  [tapers,  artificial  llowers,  and 
in  many  of  the  fabrics  employed  as  clothing.  The  ghized  green  and  red 
l)ai)ers  used  in  kindergartens  also  contain  arsenic.  It  is  present,  too,  in 
many  wall-papers  and  cari)ets.  j\Iuch  attention  has  been  ])aid  to  this  (jucs- 
tion  of  late  years,  us  instances  of  i)oisoaing  have  been  thought  to  depend 
\x\)0\\  wall-papers  and  other  household  fabrics.  The  arsenic  compounds 
may  be  either  in  the  form  of  solid  i)articles  detached  from  the  paper  or  as 
a  gaseous  volatile  body.  The  investigations  of  Gosio,  confirmed  by  Sanger, 
have  shown  that  a  volatile  compound  is  formed  by  the  action  on  arsenical 
organic  matter  in  wall-])apers  of  several  moulds,  notably  i)enicillum  brevi- 
caule,  mucor  mucedo,  etc.  In  moisture,  and  at  a  temperature  of  from  60° 
to  95°  F.,  a  volatile  compound  is  set  free,  probably  "  an  organic  deriva- 
tive of  arsenic  pcntoxide"  (Sanger).  The  chronic  poisoning  from  fabrics 
and  wall-papers  may  be  due,  according  to  this  author,  to  the  ingestion  of 
minute  continued  doses  of  this  derivative,  "  which  from  its  state  of  oxida- 
tion is  likely  to  be  accumidatcd  in  the  system,  from  which  it  is  slowly 
eliminated."  Arsenic  is  eliminated  in  all  the  secretions,  and  has  been 
found  in  the  milk.  J.  J.  Putnam,  it  should  be  remembered,  has  shown 
that  it  is  not  uncommon  to  find  traces  of  arsenic  in  the  urine  of  many 
persons  in  apparent  health  (30  per  cent).  The  effects  of  moderate  quanti- 
ties of  arsenic  are  not  infrequently  seen  in  medical  practice.  In  chorea 
and  in  pernicious  anemia,  steadily  increasing  doses  are  often  given  until 
the  patient  takes  from  15  to  20  drops  of  Fowler's  solution  three  times  a 
day.  Flushing  and  hypera}mia  of  the  skin,  puffiness  of  the  eyelids  or  above 
the  eyebrows,  nausea,  vomiting,  and  diarrhoea  are  the  most  common  symp- 
toms. Redness  and  sometimes  bleeding  of  the  gums  and  salivation  occur. 
In  the  protracted  administration  of  arsenic  ])aticnts  may  complain  of 
numbness  and  tingling  in  the  fingers.  Pigmentation  of  the  skin  I  have 
seen  on  several  occasions.  In  chorea  neuritis  has  occurred,  and  a  patient 
of  mine  with  ITodgkin's  disease  developed  multi]ile  neuritis  after  taking 
1  iv  3  j  of  Fowler's  solution  in  seventy-five  days,  during  which  time  there 
were  fourteen  days  on  which  the  drug  was  omitted. 

In  the  slow  poisoning  by  the  absorption  of  arsenic  in  minute  doses,  as 
from  wall-paper  and  fabrics,  the  symptoms  are  varied.  J.  J.  Putnam  grou])? 
them  into  the  cases  in  which  the  symptoms  mainly  concern  the  general 


gone  ( 


F(Mjr)   POISONING. 


SOI 


'h' 


nutrition  without  tij^ma  of  local  irritation;  those  in  which  the  syniptonw 
are  due  to  irritation  of  the  conjuiietiva',  nioutii,  or  pliarynx;  tlioso  with 
symptoms  ixjinlin;,'  to  the  (li«,H'slive  tract;  cases  with  marlicd  nervous  \)\\q- 
noiiicna;  and  tliose  in  whicli  the  nutrition  of  some  spcciiil  part  of  the  l)(»dy 
is  involved.  The  most  (■omiiion  symjitoms  are  those  of  anicmia  and  dchility, 
pcrlia[)s  with  sli«,dit  irritation  of  the  mucous  mend)rane,  and  numlmcss  and 
tinj,din<,',  and  ^astral<ria.  How  far  these  symptoms  nro  to  be  attrihuted  to 
the  small  (plant itics  of  arsenic  absorbed  from  wall-papei"s  and  fabrics  is  by 
some  considered  iloubtful.  That  children  and  adults  may  take  with  im- 
punity lar},^'  doses  for  nu)nlhs  without  un|)leasant  ell'ects,  and  the  fact  of 
the  jiradual  establishment  of  a  toleration  which  enables  Styrian  peasants 
to  take  as  much  as  8  grains  of  arsenious  acid  in  a  day,  speak  stronfj;ly 
a<,'ainst  it.  On  the  other  hand,  as  San^'cr  states,  we  do  not  know  accurately 
the  ell'ects  of  many  of  the  compounds  in  nunute  and  long-continued  doses, 
notably  the  arsemites. 

Arsenical  paraU/sis  has  the  same  characteristics  as  lead-i)alsy,  but  the 
legs  are  more  all'ected  than  the  arms,  particularly  the  extensors  aiul  i)ero- 
neal  group,  so  that  the  j)atient  has  the  chameteristic  steppage  gait  of 
peripheral  neuritis. 

The  electrical  reaction  in  the  muscles  may  be  disturbed  before  there  is 
any  loss  of  ]K)wer,  and  when  the  j)atient  is  asked  to  extend  the  wrist  fully 
and  to  si)read  the  fingers  slight  weakness  may  be  detected  early. 


grou])? 
reneral 


V.    FOOD    POISONING.     (Bromniotoxiamua ;  Vimg/tan). 

There  may  be  "  death  in  the  i)ot "  from  many  causes.  Food  may  con- 
tain the  specific  organisms  of  disease,  as  of  tuberculosis  or  trichinosis;  milk 
and  other  foods  may  become  infected  with  typhoid  bacilli,  and  so  convey 
the  disease. 

Animals  (or  insects,  as  bees)  may  feed  on  substances  which  cause  their 
flesh  or  jjroducts  to  be  poisonous  to  man. 

The  grains  used  as  food  may  be  infected  with  fungi  and  cause  the  epi- 
demics of  ergotism,  etc. 

Foods  of  all  sorts  may  become  contaminated  with  the  bacteria  of  putre- 
faction, the  products  of  which  may  be  highly  poisonous. 

For  a  full  description  of  food  poisoning  see  Yaughan's  section  on  the 
subject  in  vol.  xiii  of  the  Twentieth  Century  Practice. 

Among  the  more  common  forms  are  the  following: 

(1)  Meat  Poisoning  (Krenfoxismiis). — Cases  have  usually  followed  the 
eating  of  sausages  or  pork-])ie  or  hcad-checse,  and  also  occasionally  beef, veal, 
and  mutton.  Sausage  poisoning,  which  is  known  by  the  name  of  hotuUsm 
or  allantiasis,  has  long  been  recognized,  and  there  have  been  numerous 
outbreaks,  particularly  in  parts  of  Crcrmany.  Similar  attacks  have  been 
produced  by  ham  and  by  head-cheese.  The  precise  nature  of  the  kreotoxi- 
cons  has  not  yet  been  determined.  Other  outbreaks  have  followed  the 
eating  of  beef  and  veal.  In  the  majority  of  these  cases  the  meat  has  under- 
gone decomposition,  though  the  change  may  not  have  been  evident  to  the 


3S)2 


THE  INTOXICATIONS  AND  SUN-STIIOKK. 


/ 


tiiHte.  The  syiujitoiiis  of  meat  ixtisoiiiiip  nre  tlioHo  of  lU'uto  gnstro-iiitcHtinall 
irritation.  Jiallanl'H  (k'scriptioii  (»f  tlic  Wt'llhcfk  cusos,  (juoti'il  by  Vauglum,. 
holds  good  for  n  inajotity  of  tlinii: 

"A  period  of  iiiciiltalioii  lucccdcd  (he  ilhicHS.  In  51  canes  where  this 
coiiUl  he  accurately  determined,  it  waa  twelve  hour«  or  less  in  5  cases;  Ite- 
tween  twelve  and  thirty-six  hours  in  3\  cases;  hetwceu  thirty-six  and 
forty-eight  hours  in  H  cases;  and  later  thai,  this  in  only  4  cases.  In  numy 
cases  the  first  definite  syniptoins  occurred  suddenly,  and  evidi'iitly  uiu'.x- 
pectedly,  hut  in  some  casi-s  there  were  observed  during  the  in(ul)ation 
more  or  less  feeling  of  languor  and  ill-health,  loss  of  appetite,  nausea,  or 
fugitive,  griping  pairs  in  the  helly.  In  about  a  third  of  the  cases  the  first 
definite  symptom  was  a  sense  of  chilliness,  usually  with  rigors,  or  trem- 
bling, in  one  case  accompanied  by  dyspncea;  in  a  few  cases  it  was  giddi- 
ness with  faintne.^s,  sometimes  accompanied  Ijy  a  cold  sweat  and  tottering; 
in  others  the  first  symptom  was  headache  or  }iain  somewhere  in  the  trunk 
of  the  body — c.  g.,  in  the  chest,  back,  Itetween  the  shoulders,  or  in  the  ab- 
donu'ii,  to  which  part  the  pain,  win  rever  it  might  have  commenced,  subse- 
quently extended.  In  oiu'  case  the  first  symptom  noticed  was  a  dilliculty 
in  swallowing.  Jii  two  cases  it  was  intense  thirst.  lUit  however  the  attack 
nuiy  have  commenced,  it  was  usually  not  long  before  pain  in  the  abdomen, 
diarrluea,  and  vomiting  came  on,  diarrluea  being  of  more  certain  occur- 
rence than  vomiting.  The  ])ain  in  several  cases  commenced  in  the  chest 
or  between  the  shoulders,  and  extended  first  to  the  upper  and  then  to  the 
\.\ver  i)art  of  the  .ibdomen.  It  was  usually  very  severe  indeed,  (piickly 
])roducing  i)rostration  or  faintness,  with  cold  sweats.  It  was  variously  de- 
scribed as  cram])y,  burning,  tearing,  etc.  'fhe  diarrlueal  discharges  were 
in  some  cases  (piitc  unrestrainable,  and  (where  a  description  of  them  could 
be  obtained)  were  said  to  have  been  excee(lingly  oll'ensive  and  usually  of  a 
dark  color.  Muscular  weakness  was  an  early  and  very  remarkable  symp- 
tom in  nearly  all  the  cases,  and  in  many  it  was  so  great  that  the  ]iaticnt 
could  only  stand  by  holding  on  to  something.  Headache,  sometimes  severe, 
was  a  cominon  and  early  symptom;  and  in  most  cases  there  was  thirst,  often 
intense  and  most  distressing.  The  tongue,  when  o'  .-lerved,  was  described 
\isually  as  thickly  coated  with  a  brown,  velvety  fur,  1,  it  red  at  the  ti])  nn(\ 
edges.  In  the  early  stage  the  skin  was  often  cold  to  ti.e  touch,  but  after- 
ward fever  set  in,  the  tcnijierature  rising  in  some  cases  to  101°,  103°,  and 
10-4°  F.  In  a  few  severe  cases,  where  the  skin  was  actually  cold,  the  patient 
complained  of  heat,  insisted  on  throwing  off  the  bedclothes,  and  was  very 
restless.  The  pulse  in  the  height  of  the  illness  became  quick,  counting 
in  some  cases  100  to  12S.  The  above  were  the  symptoms  most  frequently 
noted.  Other  symptoms  occurred,  however,  some  in  a  few  cases,  and  some 
only  in  solitary  cases.  These  I  now  proceed  to  enumerate.  Excessive 
sweating,  cramps  in  the  legs,  or  in  both  legs  and  arms,  convulsive  flexion 
of  the  hands  or  fingers,  muscular  twitchings  of  the  face,  shoulders,  or 
hands,  aching  pain  in  the  shoulders,  joints,  or  extremities,  a  sense  of  stiff- 
ness of  the  joints,  prickling  or  tingling  or  numbness  of  the  hands  lasting 
far  into  convalescence  in  some  cases,  a  sense  of  general  com.pression  of  the 
skin,  drowsiness,  hallucinations,  imperfection  of  vision,  and  intolerance 


FOOD   POISONING. 


303 


astinp- 
of  the 
erance 


of  light.  Ill  tlirct'  r-HHCH  (ono  timt  of  u  medical  man)  tiioro  was  ohsorvt'd 
yellowness  of  tho  skin,  cifiiiT  gi'iieral  or  conllni'd  to  the  faco  and  eyes.  In 
one  ease,  at  a  late  staj^e  of  the  iMness,  there  was  some  pulmonary  congestion 
and  an  attack  of  what  was  i't>gar(h'i|  as  ^nmt.  In  tiie  fatal  cases  death  was 
precciU'd  hy  coliapsi'  like  that  of  cholera,  coldm-ss  of  tlu'  surface,  pinched 
features,  aiul  lilueness  of  the  lingers  and  toes  and  arouiul  the  sunken  eyes. 
The  (lehility  of  convalcsci'nce  was  in  nearly  all  cases  ])rotracted  to  several 
weeks. 

"The  mildest  cases  were  cliaracteri/ed  usM;dly  hy  Utile  reinarkiilile  lie- 
yond  tlie  following  synii'toms,  vi/.,  alxlominal  pains,  voiuiting,  diarrlio'a, 
thirst,  headache,  and  muscular  weakiu'ss,  any  one  or  two  of  which  might 
he  ahsent." 

Many  instances  arc  on  record  of  poisoning  hy  canned  goods,  particu- 
larly meat.  Some  of  these,  according  to  John  (.J.  Johnson,  have  hcen  cases 
of  corrosive  ])oisoning  from  muriate  of  zinc  and  muriate  of  tin  used  as  an 
iimalgam,  hut  poisonous  ell'ects  identical  with  those  just  descrihed  have 
followed  the  use  of  camu'd  meats. 

t'l'rtain  game  hirds,  particularly  the  grouse,  are  stated  to  be  poisonous, 
in  special  districts  and  at  certain  seasons  of  the  year. 

(2)  Poisoning  by  Milk  Products. — (n)  (Idldrlotn.rismiis,  indicating  the 
poisoiu)Us  ell'ects  which  follow  the  driid<ing  of  milk  infcct(M|  with  sapro- 
phytic hacteria,  is  considered  in  the  section  on  the  diarrlnea  of  infants. 

{h)  Clicrsc  I'oisoiiiiKj  (Tyrotoxismus). — \'arious  milk  products,  ice  cream, 
custard,  and  cheese  nuiy  prove  highly  poi.^onous.  Anu)ng  the  poisons 
\'aughan  now  states  that  the  tyrotoxicon  "is  not  the  one  most  frc(piently 
l)rcsent,  nor  is  it  the  most  active  one."  Tn  one  epidemic  he  and  Novy  have 
isolated  from  cheese  a  suhstance  helonging  to  the  poisonous  albumins, 
and  in  an  extensive  ice-cream  e])idemic  \^iughan  and  Perkins  found 
in  the  ice  cream  a  highly  ])athogenic  bacillus,  but  its  toxine  has  not  been 
separated. 

The  symptoms  are  those  of  acute  gastro-intestinal  irritation,  and  are 
similar  to  those  already  detailed  by  Hallard. 

(3)  Poisoning-  by  Shell-flsh  and  Fish. — (a)  ^fiissd  Poisoninfj  (Mytilo- 
toxismus).— Hrieger  has  seimrated  a  ])tomaine — mytilotoxin — which  exists 
chiefly  in  the  liver  of  the  mussel.  The  obsi>rvations  of  Schmidt mann  and 
Cameron  have  shown  that  the  mussel  from  the  o|)en  sea  only  becomes 
poisonous  when  placed  in  filthy  waters,  as  at  Wilhelmshafen. 

The  symptoms  of  mussel  jjoisoning  follow  the  eating  of  either  raw  or 
cooked  mussels.  The  sym])toms  are  those  of  an  acute  poisoning  with  pro- 
found action  on  the  nervous  system,  and  without  gastro-intestinal  numifes- 
tations.  There  are  numl)ncss  and  coldness,  no  fever,  dilated  pu[)ils,  and 
rajiid  pulse;  death  occurs  sometimes  within  two  hours  with  collapse  symp- 
toms. Poisoning  occasionally  follows  the  eating  of  oysters  which  are  stale 
or  decomposed.    The  sym])toms  are  usually  gastro-intestinal. 

(h)  Fish  Poisoning  (Ichthyotoxismus). — There  are  two  distinct  varie- 
ties; in  one  the  poison  is  a  physiological  ])roduct  of  certain  glands  of  the 
fisli.  in  tlie  other  it  is  a  product  of  bacterial  growth.  The  salted  sturgeon 
used  in  parts  of  Pussia  has  sometimes  proved  fatal  to  large  numbers  of 


;H= 


394 


THE  IN'ToXICATIoyS  AVT*  SUK-STHOKK. 


/ 


ptTtfotiH.  Ill  tlic  iiiiilillr  jtartK  of  Kiiropc  tlu<  barb  Ih  Htatotl  to  bo  Honu'tiinoH 
|M)i^*om)UH,  i»r«»(liu'iii>,'  tlu;  «o-call('<l  "' Ixtrhen  cluili'i'n."  In  China  end  ilapan 
variourt  .x[t«'ci»'H  of  tbf  ti'lrndnti  arc  also  toxic,  HornctimcH  causing'  (U-aih  with  n 
an  lioiir.  with  symptoms  of  intense  distiirhaiicc  of  liic  niTvciis  system. 
lU-ri-bi'n  if*  thought  by  some  to  bt*  due  to  tiie  consumption  of  certain  kimU 
of  iUh. 

(1)  Grain  Poisoning  iSlfolinlnms). 

(I)  iifiji)lisiii.-  ''V\\v  pidlon^'cd  use  of  nicnl  made  from  j^rains  contam- 
inated with  the  erpit  liin^'iis  (riavirvptf  puijturrn)  causes  a  series  of  symp- 
t«»nis  known  an  er^'otism,  epidemics  <d'  which  have  [uevailed  in  dill'ereut 
partH  of  Miirope.  Two  forms  of  thin  chronic  ergotism  are  descril>cd — tiie 
one,  pm^'rcnous,  is  believed  to  be  due  to  the  sphacelinic  acid,  th«'  other, 
Convulsive,  or  spasmodic,  is  diu'  to  the  cornutin.  In  the  former,  mortilica- 
tion  alfects  the  extremities- — ^usually  the  toes  and  liu;iers,  h'ss  commoidy 
the  ears  and  nose.  Preceding?  the  onset  of  the  ^an;,'rene  there  are  usually 
nna'sthesia,  tin^din^',  pains,  spasmodic  movementH  of  the  muscles,  and  jirad- 
ual  l)lood  stasis  in  certain  vascular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  prodiomal 
stap'  of  ten  to  fourteen  days,  in  which  the  patient  complains  of  weakness, 
headache,  and  tin<,'linj]j  nensation.s  in  dilTerent  i>ttitj  of  the  body,  perhaps 
accompanied  with  sli^dit  fever,  symptoms  of  spasm  d"veIo|),  prodiKMU^' 
cramps  in  the  muscles  and  contractures.  The  arms  are  Hexed  and  the 
lcf,'s  and  toes  extcnd«'d.  These  spasms  nuty  last  from  a  few  hours  to  many 
days  and  rela|»ses  are  frequent,  'n  severer  cases  epile[)sy  deveh)p8  and  the 
})atient  nuiy  die  in  convuisi  >ns.  Mental  symjitoms  are  common,  nianifeste<l 
sometimes  in  n  ])reliminary  delirium,  l)ut  riuM-e  commonly,  in  the  chronic 
poisoninff,  as  melanclndia  or  dementia.  Posterior  spinal  sclerosis  occurs 
in  chronic  erfi;otism.  In  the  interesting  group  of  29  cases  studied  by 
Tuczek  and  Siemens,  !)  died  at  various  f)eriods  after  the  infection,  and 
four  post  mortems  showed  dc;,fenera(ion  of  the  posterior  columns.  A  con- 
dition similar  to  tal)es  dorsalis  is  gradually  produced  by  this  slow  degenera- 
tion in  the  spinal  cord. 

(?)  Lathfirixw  (iiUpinosis). — An  afTection  ])roduced  by  the  u.se  of  meal 
from  varieties  of  vetclics,  chiefly  the  Lathjfriis  stitinis  and  Fj.  cirern.  The 
grain  is  po|)ularly  known  as  the  cliick-jjea.  The  grains  ».re  usually  pow- 
dered and  mixed  with  the  meal  from  other  cereals  in  the  ])reparaiion  of 
l)read.  As  early  as  the  seventeenth  century  it  was  noticed  that  tlic  nse 
of  flour  with  which  the  seeds  of  the  Laf?n/rvs  were  mixed  caused  stiffness 
of  the  legs.  The  subject  did  not,  liowever,  attract  much  attention  before 
the  studies  of  James  Irving,  in  India,  who  between  185!)  and  ISHS  pid*- 
lished  several  important  communications,  describing  a  form  of  spastic 
paraplegia  affecting  large  numbers  of  the  inhabitants  in  certain  regions  of 
India  and  due  to  the  u.«e  of  meal  made  from  the  Lnfhijnis  seeds.  It  also 
])roduces  a  spastic  paraftlegia  in  animals.  The  Italian  observers  describe 
a  similar  form  of  paraplegia,  and  it  has  been  observed  in  Algiers  by  tlic 
French  physicians.  The  condition  is  that  of  a  spastic  paralysis,  involving 
chiefly  the  legs,  which  may  proceed  to  complete  ^laraplegia.  The  arm> 
are  rarely,  if  ever  affected.    It  is  evidently  a  slow  sclerosis  induced  under 


81TX-.STFI()KR. 


:m 


ilif  iiilliit'iici'  III'  tliir*  tovic  M;;t'rit.  'I'lic  ]ir(>ciHo  iiimtoiuii'til  condition^  ho 
liii  iM  1  Clin  iisccrliiiii,  liiiH  not  vet  lircii  ili'trrniitu'tl. 

(A)  J'flhii/ni  (.MiiHlihiiiiif*). — 'I'liirt  in  ii  niilrilioiinl  (li.xfiirliiintt;  diic  to 
the  ii.-c  fif  iillcitil  iiiiii/i'.  Tlic  dij-ciist'  occiiis  rxlcii.-iv fly  in  juirls  of  Itiily, 
in  tilt'  (iiiiitli  of  l''ranr«',  hihI  in  Spiiin.  It  lins  not  Imtii  uK-crvt'ij  in  thirt 
country.  Ii  incvnilM  oxti'iisivcly  iinioii;;  the  poorer  cIii.''m's,  |tiirticnlarly  in 
tlic  country  districts,  and  nppcars  to  lie  ai-tHoi'iatcd  in  sninc  way  with  the 
ii-«c  of  niai/c  which  (accordiii;r  to  iiior'l  authorities)  is  t'enneiitcd  of  diseased. 
In  the  early  slajit'  the  syni|»t<nns  ar«'  inilclinite,  characteri/cd  hy  deliility, 
{laiiiv  in  the  H|iine,  insoninia,  di^'cstive  distiirhances,  nioi'(  rarely  diarrtnea. 
The  liist  clear  manifestation  of  the  diseaso  is  the  pellajiral  erylliemn,  which 
almost  iinarialily  np|ieai'H  in  the  sprin^r.  Thi,'  is  followed  hy  dcsiccatimi 
iind  exfoliation  of  the  epidermis,  which  hcconH's  very  ron;.di  and  dry,  and 
occasionally  criistn  form,  licnenth  which  there  is  siip|MiralioM.  With  these 
ciitaneons  manifestations  there  arc  di;:estivc  tnmltlcs — salivation,  dyspepsin, 
iiiid  diarrlnca — which  may  he  (d'  a  dysenteric  nature,  .\fter  lasting,'  for  a 
lew  months  impro\cmerit  occurs  in  the  milder  cases  and  convalescence  is 
;;radnally  cstiililishcd.  In  the  inoi'c  seviTc  and  chronic  forms  there  arc 
proiioniiccd  nervous  symptoms — hcatlache,  hacknchc,  spasms,  and  finally 
paralysis  and  mental  distnrhance.  The  |)aralyfic  condition  alTccts  the  Ic«,'!< 
and  leads  ^^radnally  to  paraplc^na.  The  mental  manifestations,  which 
are  rarely  met  with  until  the  third  or  I'onrth  attack,  arc  melancholia  or 
suicidal  mania.  Finally,  there  may  he  a  condition  of  the  most  jiroiiounced 
cachexia. 

The  anatomical  fnidln<rs  nro  indefinite.  Chronic  dejjenorativc  chancres 
liave  ln'cri  found,  particularly  fatty  dc^ciieration  and  a  peculiar  pi^rmcnta- 
tion  in  the  viscera,  'i'he  measures  to  he  employed  arc  clian<,'c  in  diet,  re- 
moval from  tiic  infected  district,  and,  as  u  prophylaxis,  proper  i»re.serva- 
lion  of  the  maize. 


if  meal 

The 

pow- 

lion  of 

he  use 

itilTness 

Ijpforo 
;S  puh- 

spastic 
rions  of 

It  nl^n 
It'scrihe 

l)y  the 
volvin.ii 
10  arm> 
fl  under 


VI.    SUN-STROKE  (Sirinitia). 
(ITeat  Exhditxfion  ;  Jnsuhition  ;   Thirmir  Fviwr ;  Jleat-strokf. ;  Coup  de  Solfil.) 

Definition.— A  condition  produced  hy  exposure  to  excessive  lient. 

It  is  one  of  the  oldest  of  reco^niized  diseases;  two  instances  are  men- 
tioneil  in  the  liihie.  It  was  lon^'  confounded  with  apoplexy.  The  An<rIo- 
[ndiaii  suTjreons  jjnve  adniirnhle  '  'scri|»tions  of  it.  In  this  country  the 
most  important  contriI)utions  have  conu'  from  the  Xew  York  Ifospital  and 
the  Pennsylvania  TIos|)ital:  from  the  former.  th(>  studies  of  Swift  and 
Dnrrach,  from  the  latter,  the  i)apers  of  (Jerlinrd,  (Jeor^'c  IJ.  Wood,  the 
elder  Pepper,  and  TiOvick.  Tn  Xew  Oi-Ieans,  IJenuett  Dowler  studied  the 
ilisease  and  rcco<juized  the  dillerence  hetween  heat  exhaustion  ami  sun- 
stroke.    Two  forms  are  reco^mized,  heat  exhaustion  and  lu'at-stroke. 

Heat  Exhaustion. — Prolon^rcd  exposure  to  hiirh  temperatures,  jiarticu- 
liirly  when  coudiined  with  ])hysical  exertion,  is  liahle  to  l)e  followed  by 
extreme  prostration,  collapse,  restlessness,  and  in  severe  cases  by  delirium. 
The  surface  is  usually  cool,  the  ])ulse  small  and  rapid,  atid  the  tempcrnturo 
tnav  be  subnormal — as  low  as  95°  or  9G°.     The  individual  need  not  neces- 


396 


TIIK   INTOXICATIONS  AND  SUN-STROKK. 


/ 


Sillily  be  exposed  lo  (lit'  direct  rays  of  lluj  sun,  Itiit  llie  eonditioii  may 
eoine  on  at  iii^lit  or  when  \vorkiii<,'  in  close,  eoiiliiied  rooms.  It  may  also 
follow  exposure  to  great  artilieial  heat,  as  in  the  enyine  rooms  of  the  Atlan- 
(if  st('amshi|)s. 

Sun-Stroke  or  Thermic  Fever. — The  eases  are  ehielly  found  in  jx-rsons 
who,  while  workinji;  very  hard,  are  exposed  to  the  sun.  Soldiers  on  the 
mareh  with  (heir  heavy  uecoutremeiits  are  particularly  liiihle  to  attack. 
In  the  lar<;i'r  cities  of  this  country  the  cases  are  almost  exclusively  con- 
lined  to  workmen  \\\\o  are  much  exijosed  and,  at  the  same  time,  iuivo  been 
drinkinj;  beer  and  whisky. 

Morbid  Anatomy  and  Pathology.— //(>/•  nKirlls  occurs  eaily. 
I'utrefai'tive  chanji'es  (levelo|t  with  great  rapidity.  'L'lie  venous  engorge- 
ment is  extreme,  jtarticularly  in  (he  cerebrum.  The  left  veidricle  is  con- 
tr."  (ed  (Wood),  and  (he  rigid  chamber  dilaled.  The  blood  is  usually  tluid; 
(he  lungs  are  iidensely  conges(ed.  I'arenchymatous  changes  occur  in  the 
liver  and  kidneys. 

According  (o  Wood,  "heat  exhauslion  wi(h  lowered  temperature  repre- 
sents a  sudden  vaso-motor  palsy,  i.e.,  a  condition  in  which  the  existing 
elVect  of  the  heat  ])aralyzes  the  centre  in  the  medulla."  On  the  other  hand, 
thornuc  fever  is  held  to  be  due  to  ])aralysi.s  nnder  the  inlhu'nce  of  the  ex- 
tiome  external  heat  of  the  centre  in  the  medulla  which  regulates  the  dis- 
])osition  of  the  bodily  heat.  Owing  to  this  disturbance,  more  heat  is  })ro- 
duced  and  less  given  oil'  than  normally. 

8and)ron  has  recently  (15.  j\r.  .7.,  ISDiS,  i)  advanced  the  view  that  siriasis^ 
is  an  infectious  disease,  lie  argues  that  heat  alone  cannot  cause  it,  that 
it  occurs  in  certain  localities  and  in  epidemic  outbursts,  and  ])ersons  ac- 
climatized have  a  relative  immunity,  etc.  The  question  is  one  worthy  of 
most  careful  study. 

Symptoms. — The  ])atient  may  be  struck  down  and  die  Avithin  an 
hour  with  syni[)toms  of  heart-failure,  dyspno'a,  and  coma.  This  form, 
sometimes  known  as  the  asphyxial,  occurs  chiefly  in  soldiers  and  is  graphic- 
ally described  by  Parkes.  Death  indeed  may  be  almost  instantaneous,  the 
victims  falling  as  if  struck  upon  the  head.  The  usual  ^orm  in  this  lati- 
tude comes  on  during  exposure,  with  ])ain  in  the  head,-  dizziness,  a  feel- 
ing of  opjjression,  and  sometimes  nausea  and  vomiting.  Visual  disturb- 
ances are  common,  and  a  ])atient  may  have  colored  vision.  Diarrhoea  or 
frequent  micturition  may  su])ervene.  Tnsensibii'ty  follows,  which  may 
be  transient  or  which  deepens  into  a  profound  conia.  The  patients  are 
usually  admitted  to  hos])ital  in  an  unconscious  state,  with  the  face  flushed, 
the  skin  ],;ingent,  the  pulse  rapid  and  full,  and  the  temperature  ranging 
from  107°  to  110°,  or  even  higher,  as  shown  in  the  accompanying  chart. 
F.  A.  Packard  states  that  of  the  31  cases  admitted  to  the  PennsylvaniiT 
ITos])itnl  in  the  summer  of  18S7,  in  a  majority  of  them  the  temi)crature 
was  between  110°  and  111°.  In  one  case  the  temperature  was  112°.  The 
breathing  is  labored  and  deep,  sometimes  stertorous.  T"^sually  there  is 
com]detc  relaxation  of  the  muscles,  but  twitchings,  jactitation,  or  very 
rarely  convulsions  may  occur.  The  pujiils  may  at  first  be  dilated,  hut  by 
the  time  the  cases  are  admitted  to  hospital  they  are  (in  a  majoritj')  ex- 


srN-.sTU()Ki':. 


397 


trciiu'ly  colli rnctcd.  I'clccliiii'  iiiny  bo  itrcscnt  upon  llic  skin.  In  the  fatal 
cases  (he  coma  deepens,  llic  cardiac  pulsations  beconu!  more  rapid  und 
fcel)le,  the  lireatliinj,'  heeonu's  hurried  and  sliallow  and  ol'  the  Cheyno- 
Stoke.s  type.  'I"h«'  I'atal  ternunation  may  occur  within  twenty-rour  or 
thirty-six  liours.  l-avorahlc;  indications  are  the  return  of  consciousness 
and  a  Tail  in  the  I'evt'r.  The  I'ccovery  in  these  cases  may  he  comph'te.  In 
other  instances  there  are  reniarkahle  arter-ell'ei'ts.the  most  ('onstant  ol'  which 
is  a  i)ernuinent  inahility  to  hear  hif,di  temperatures.  SiU'h  patients  hucomo 
very  uiu'asy  when  the  thermometer  reaches  Sd"  1-'.  in  tiie  shade.  Loss  of 
the  power  of  mental  concentration  and  failure  of  memory  are  more  con- 
Htant  and  very  trouhlesome  .se(|ueia'.    Such  patients  are  always  woise  iu  the 


a>a  or 
may 
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The 
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Chart  XIII, — Case  of  sun-stroke  treated  with  the  ice-bath  ;   recovery. 

(Rectal  temperatures), 

hot  weather.  Oocasiorially  convulsions  and  lunrked  mental  disturbance 
may  develop.  Dercum  has  described  peri])lieral  neuritis  as  a  sequence,  and 
the  patient  whose  cliart  is  here  ^nven  develojied  an  acnto  neuritis  in 
the  legs.  This  is  a  point  in  favor  of  the  infectious  nature  of  the  dis- 
ease. 

Oniteras  has  called  attention  to  a  form  of  fever  occurring  in  the  South, 
known  in  Florida  as  "  Florida  fever,"  in  the  Carolinas  as  "  country  fever," 
and  in  tropical  countries  as  fvvrc,  infJnmmatoire.  The  cases  last  for  a  vari- 
able time,  and  are  mistaken  for  malaria  or  typhoid;  but  he  believes  them 


:}' 


398 


THE  INTOXICATIONS  AND  SUN-STROKE. 


/ 


to  be  entirely  distinct  luul  due  to  a  ])rolonn:('d  action  of  the  high  tempera- 
tures.    He  has  called  the  condition  a  "continiic<l  thermic  fever." 

The  diagnosis  of  heat  e.\han.stion  from  thermic  fever  is  readily  made, 
as  the  ditVerence  Itetwecn  tiie  two  conditions  is  striking.  "Jn  solar  ex- 
haustion the  skin  is  moist,  i)ale,  and  cool;  the  breathing  is  easy  thongh 
hnrried;  the  i»uL<o  is  small  and  soft;  the  vital  forces  fall  into  a  temporary 
collajjse;  the  senses  remain  entire "  (Dowler);  whereas  in  sun-stroke  or 
heat  a])()])le.\y  there  is  usually  nnconsciousness  and  y)yre-\ia. 

The  mode  of  onset,  together  with  the  circumstances  under  which  it 
occurs  and  the  high  temi)erature,  ])ermits  th'jrmic  fever  to  be  readily  dif- 
ferentiated from  apoplexy  and  coma  from  other  conditions. 

Treatment. — In  heat  exhaustion  stimulants  slu)uld  be  given  freely, 
and  if  the  temperature  is  below  normal  the  hot  bath  should  be  used. 
Ammonia  may  be  given  if  necessary.  In  thermic  fever  the  indications 
are  to  reduce  the  temperature  as  rapidly  as  possible.  This  may  be  done 
by  packing  the  patient  in  a  bath  with  ice.  liubbing  the  body  with  ice  was 
])ractised  at  the  New  York  Hospital  by  Parrach  in  1857,  and  is  an  excel- 
lent ])rocedure  to  lower  the  temperature  rapidly.  Ice-water  enemata  may 
also  be  employed.  At  the  Pennsylvania  Hospital  in  the  summer  of  1S87 
the  ice-pack  was  used  with  great  advantage.  Of  31  cases  only  l'^  died, 
results  probably  as  satisfactory  as  can  be  obtained,  considering  that  many 
of  the  })aticnt3  are  almost  moribund  when  brought  to  hospital.  They  should 
be  com[)ared  with  Swift's  statistics,  in  which  of  150  cases  78  died.  In  the 
cases  in  which  the  symptoms  are  those  of  intense  asphyxia,  and  in  which 
death  may  take  place  in  a  few  minutes,  free  bleeding  should  be  practised, 
a  procedure  Avhich  saved  "Weir  ^Mitchell  when  a  young  man.  For  the  con- 
vulsions chloroform  should  be  given  at  once.  Of  other  remedies,  the  anti- 
pyretics have  l)een  employed,  and  may  be  given  when  there  is  any  special 
objection  to  hydrotherapy,  for  which,  however,  they  cannot  be  substituted. 


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SECTIOX  IV. 


CONSTITUTIONAL  DISEASES. 


I.    ARTHRITIS    DEFORMANS. 

• 

Definition. — A  chronic  disease  of  the  joints  of  doubtful  etiology, 
characterized  by  clumges  in  the  cartilages  and  synovial  membranes,  with 
l)eri-articular  formation  of  bone  and  great  deformity. 

Long  believed  to  be  intimately  associated  with  gout  and  rlieumatism 
(whence  the  names  rheumatic  gout  and  rheumatoid  arthritis),  this  close 
relationship  seems  now  A'cry  doubtful,  since  in  a  majority  of  the  cases  no 
history  of  either  affection  can  l)c  determined. 

Etiology. — Age. — A  majority  of  tlie  cases  are  ])etween  the  ages  of 
thirty  and  fifty.  In  A.  E.  Garrod's  analysis  of  500  cases  there  were  only  25 
under  twenty  years  of  age. 

Sex. — Among  Garrod's  500  cases  there  wore  411  in  women.  In  James 
Stewart's  recent  report  of  40  cases  from  the  Royixl  Victoria  Hospital  only 
20  were  in  females.  In  women  its  close  association  with  the  menopause 
has  been  noted.  It  seems  to  be  more  frequent,  too,  in  tlujse  who  have  had 
ovarian  or  uterine  trouble  or  Avho  are  sterile. 

Hereditary  Predisposition. — In  21G  cases  in  Garrod's  series  there  was  a 
family  history  of  joint  troubles.  Two  or  three  children  in  a  family  may 
be  affected.  It  is  stated  also  that  the  disease  is  more  common  in  families 
with  a  ])ht]iisical  history. 

liheiimatism  and  Govt. — In  nearly  a  third  of  Garrod's  cases  there  was 
a  history  of  gout  in  the  family;  of  rheunuitism  in  only  ()4  eases. 

Exposure  to  cold,  wet  and  damp,  errors  in  diet,  worry  and  care,  and 
local  injuries  are  all  spoken  of  as  possible  exciting  causes. 

At  present  there  are  two  chief  views  prevailing  as  to  the  etiology  of 
arthritis  deformans — one  that  it  is  of  nervous  origin,  the  other  that  it  is  a 
chronic  infection. 

The  Relation  of  Arthritis  Deformans  to  Diseases  of  the  Nervous  Sys- 
tem.— Our  accurate  knoAvledge  of  arthropathies  of  nervous  origin  dates 
from  the  papers  of  J.  K.  Mitchell,  of  Philadelphia,  in  1831  and  1833,  in 
which  he  reported  cases  of  inflammation  of  the  joints  in  connection  with 
caries  of  the  spine  and  concussion  of  the  cord.  Acute  and  chronic  forms 
of  arthritis  may  occur  with  gross  lesions  of  the  cord;  the  former  are  found 

399 


f: 


400 


CONSTITUTIONAL  DISEAtS-.S. 


/ 


in  jvcuto  myelitis,  the  latter  with  sclerosis  of  the  jmstcrior  columns.  The 
acute  spinal  arthritis  presents  anatomically  inllanimation  of  the  synovial 
sheaths  and  of  the  fibrous  investment  of  the  articulations.  The  chronic 
artiiritis  Avliich  we  see  in  syrin<,''()myelia,  tabes,  and  hemi])le<iia  i)resents  a 
combination  of  atrophy  and  liyperplasia  of  tiic  bones,  with  thickening  of 
tbe  ligaments  and  more  or  less  elfusion.  Again,there  are  joint  lesions  which 
follow  injuries  of  the  nerve  trunks  themselves,  cases  of  which  have  been 
reported  by  S.  Weir  ]\litchell.  The  following  are  the  main  jjoints  urged  in 
favor  of  the  nervous  origin  of  the  disease:  First,  the  articular  changes  are 
similar  to,  if  not  identical  with,  those  of  the  chronic  spinal  arthroi)- 
athies.  Secondly,  tlie  frequent  association  in  arthritis  deformans  of  dys- 
trophies of  the  skin  (glossy  skin),  nails,  bones,  and  muscles — changes  which 
are  evidently  of  neurotic  origin.  In  certain  cases  there  is  marked  and  early 
atrophy  of  the  muscles.  Ord,  indeed,  thinks  that  this  atrophy  with  the 
articular  lesions  forms  a  dystrophy  analogous  to  progressive  muscular  atro- 
l)hy.  Thirdly,  the  symmetrical  onset  and  progress  of  the  disease.  Fourthly, 
the  imi)lication  of  nerve  trunks.  There  may  he  not  only  numbness  and 
tingling,  but  in  certain  cases  excruciating  pains.  Post  mortem,  neuritis 
has  been  found  in  several  cases,  but  whether  prinuiry  or  secondary  is  doubt- 
ful. The  reflexes  are  not  infrequently  increased,  in  32  of  50  of  Garrod's 
eases.  We  need  information  as  to  the  condition  of  the  spinal  cord  in  these 
cases  of  arthritis  deformans.  Triboulet  and  Thomas  have  rei)orted  from 
Dejerine's  service  a  case  of  a  wonuin  with  chronic  arthritis,  in  whom  the 
autopsy  showed  a  sclerosis  of  the  posterior  columns  of  the  cord  in  the  dorsal 
region  and  of  the  columns  of  Goll  in  the  cervical  region,  with  degeneration 
of  the  posterior  roots.  The  history  indicated  that  the  arthritis  developed 
after  a  puer])cral  infection. 

Arthritis  Deformans  as  a  Chic^ic  Infection. — During  the  past  few 
years  the  idea  has  been  gaining  ground  that  the  disease  is  of  microbic  origin. 
Satisfactory  evidence  for  this  view  is  not  yet  fortl  .coming.  Schiiller,  Ban- 
natvne  and  Blaxall,  and  several  Fvcnch  observers  have  found  micro-organ- 
isms  in  the  fluid  of  the  joints.  ]\Iore  valuable  really  is  the  frequent  asso- 
ciation of  arthritis  deformans  with  previous  acute  infections;  thus  in  James 
Stewart's  cases  there  was  a  history  of  gonorrhoea  in  30  per  cent  of  the  males, 
and  in  his  series  of  40  case?  50  ])er  cent  had  had  previously  some  infectious 
troul)le.  Of  late  years  we  have  learned  to  recognize  cases  which  have  fol- 
lowed directly  upon  a  severe  attack  of  influenza. 

The  acute  mode  of  onset  in  some  instances  is  suggestive  of  an  infection. 
The  joints  may  be  red  and  swollen  and  painful,  and  present  the  clinical 
picture  of  an  acute  infective  process. 

And,  lastly,  a  consideration  of  the  form  in  children  described  by  Still 
lends  weight  to  this  vicAV,  particularly  in  the  wides])read  enlargement  of 
the  lymi)h-glands  and  the  swelling  of  the  spleen.  A  number  of  the  very 
best  students  of  the  disease,  as  Biiumler,  of  Freiberg,  have  accepted  the 
infective  theory  of  the  disease,  but  at  present  I  think  the  evidence  is  quite 
as  much  in  favor  of  the  older  neurotic  view. 

Morbid  Anatomy. — The  changes  in  the  joints  differ  essentially 
from  those  of  gout  in  the  absence  of  deposits  of  urate  of  soda,  and  from 


ARTHRITIS  DEFORMANS. 


401 


olironic  rliciiniatism  in  the  existence  of  extensive  sinictural  alterations, 
particularly  in  the  cartila<j;es.  W'r  are  largely  indehted  to  the  niagniiicent 
work  of  Adams  for  our  knowledge  of  the  aiuUomy  of  this  disease.  The 
changes  l)egin  in  the  cartilages  and  synovial  nuMuhranes,  the  cells  of  which 
jirolii'erate.  The  cartilage  covering  the  joint  undergoes  a  peculiar  fihrilla- 
lion,  heconies  soft,  and  is  either  al)sorljed  or  gradually  thinned  hy  attri- 
tion, thus  laying  bare  the  ends  of  the  bone,  which  become  smooth,  polished, 
and  eburnated.  At  the  margins,  where  the  pressure  is  less,  the  proliferating 
elements  may  develop  into  irregular  nodules,  which  ossify  and  enlarge  the 
li'jads  of  the  bones,  forming  osteophytes  which  eomi)letely  lock  the  joint. 
The  periosteum  may  also  form  new  bone.  There  is  usually  great  thicken- 
ing of  the  ligaments,  and  finally  comi)lete  anchylosis  results.  This  is  rarely, 
however,  a  true  anchylosis,  but  is  caused  by  the  osteophytes  and  thickened 
ligaments.  There  are  often  hyperostosis  and  increase  in  the  articular  ends 
of  the  bone  in  length  and  thickness.  In  long-standing  cases  and  in  old 
persons  there  may,  on  the  other  hand,  be  great  atro])hy  of  the  heads  of  the 
aifected  bones.  The  spongy  substance  becomes  friable,  and  in  the  hip-joint 
the  wasting  may  reach  such  an  extreme  grade  that  the  articulating  surface 
lies  between  the  trochanters.  This  is  sometimes  called  morbus  cuxce  senilis. 
The  anatomical  changes  may  lead  to  great  deformity.  The  metacarpal 
joints  are  enlarged  and  thickened,  and  the  fingers  are  deflected  toward  the 
ulnar  side.  The  toes  often  show  a  similar  deflection.  The  exostoses  at  the 
joints  are  known  as  Ilaygarth's  nodosities. 

The  radiographs  of  arthritis  deformans  are  very  instructive.  The  clear 
interosseous  spaces  at  the  level  of  the  joints  disapi)ear  early,  the  hyper- 
trophy and  deformity  of  the  articular  extremities,  and  more  particularly 
the  exostoses  at  the  margins,  give  a  very  distinctive  picture  of  the  dis- 
ease. 

The  muscles  become  atrophied,  and  in  some  cases  the  wasting  reaches 
a  hi<jfh  grade.  Xeiiritis  has  been  demonstrated  in  the  nerves  about  the 
joints. 

Symptoms. — Charcot  makes  a  convenient  division  of  the  cases  into 
those  with  Heberden's  nodes,  the  general  progressive  form,  and  the  partial 
or  mono-articular  form. 

Heberden's  Nodes. — In  this  form  the  fingers  are  affected,  and  "little 
hard  knobs"  develop  gradually  at  the  sides  of  the  distal  phalanges.  They 
are  much  more  common  in  women  than  in  men.  They  begin  usually  be- 
tween the  thirtieth  and  fortieth  year.  The  sul)jects  may  have  had  digestive 
troubles  or  gout.  Heberden,  however,  says  "  they  have  no  connection  with 
gout,  being  found  in  persons  who  never  had  it."  In  the  early  stage  the 
joints  may  be  swollen,  tender,  and  slightly  red,  particularly  when  knocked. 
The  attacks  of  pain  and  swelling  may  come  on  in  the  joints  at  long  inter- 
vals or  follow  indiscretion  in  diet.  The  little  tubercles  at  the  sides  of  the 
florsal  surface  of  the  second  phalanx  increase  in  size,  and  give  the  charac- 
teristic appearance  to  the  affection.  The  cartilages  also  become  soft, 
and  the  ends  of  the  bones  eburnated.  Frate  of  soda  is  never  deposited 
(Charcot).  The  condition  is  not  curable;  but  there  is  this  hopeful 
feature — the  subjects  of  these  nodosities  rarely  have  involvement  of  the 


402 


CONSTITUTIONAL  DISEASES. 


/ 


larger  joints.  They  liave  l)een  rcgaided,  too,  as  an  indication  oC  longevity. 
C'liarcot  states  tliat  in  women  willi  tlieso  nodes  cancer  seems  more  fre- 
qiicnl. 

General  Progressive  Form. — Thir;  occurs  in  two  varieties,  acute  and 
chronic.  Tlie  iicule  I'oiin  juay  resenil)le,  at  its  outset,  ordinary  articular 
rheunuitisni.  There  is  involvement  of  many  joints;  swelling,  particularly 
of  the  synovial  siicatlis  and  bursa';  not  often  redness;  but  there  is  nu)d- 
erate  fever.  Jioward  describes  this  condition  as  most  frc(|uent  in  young 
women  fi'oni  twenty  to  thirty  years  of  age,  often  in  connection  with  recent 
delivery,  lactation,  or  rapid  child-bearing.  Acute  cases  may  develop  at 
the  inen()i)ause.  It  may  also  come  on  in  children.  "  These  patients  suffer 
in  their  general  health,  become  weak,  pale,  dejjressed  in  spirits,  and  lose 
flesh.  In  several  cases  of  this  form  nuirked  intervals  of  improvement  have 
occurred;  the  local  disease  has  ceased  to  progress,  and  tolerable  comfort 
has  been  exi)erienccd  perhaps  until  pregnancy,  delivery,  or  lactation  again 
determines  a  fresii  ()utl)reak  of  the  disease.'' 

The  clirunic  form  is  by  far  the  most  common.  The  joints  are  usually 
involved  symmetrically.  The  lirst  symptojus  are  }>ain  on  movement  and 
slight  swelling,  which  may  be  in  the  joint  itself  or  in  the  i)eri-articular 
sheaths.  In  some  cases  the  ell'usion  is  marked,  in  others  slight.  The  local 
conditions  vary  greatly,  and  ])eri(Kls  of  imitrovement  alternate  with  attacks 
of  swelling,  redjiess,  and  pain.  At  first  only  one  or  two  joints  are  affected; 
usually  the  joints  of  the  hands,  then  the  knees  and  feet;  gradually  other 
articulations  are  involved,  and  in  extreme  cases  every  joint  in  the  body 
is  affected.  Pain  is  an  extremely  variable  symptom.  Some  cases  i)ro- 
cced  to  the  most  extreme  deformity  without  it;  in  others  the  suffering  is 
very  great,  particularly  at  night  and  during  exacerbations  of  the  disease. 
There  are  cases  in  which  pain  of  an  agonizing  character  is  an  almost  con- 
stant symi)tom,  requiring  for  years  the  use  of  morphia. 

Gradually  the  sha])e  of  the  joints  is  greatly  altered,  partly  by  the  pres- 
ence of  osteophytes,  ])artly  by  tlie  great  thickening  of  the  capsular  liga- 
ments, and  still  more  by  the  retraction  of  the  muscles.  In  moving  the 
alfected  joint  cre])itation  can  be  felt,  due  to  the  eburnation  of  the  articular 
surfaces.  Ultimately  tlie  joints  become  com])letely  locked,  not  by  a  true 
bony  anchylosis,  but  by  the  osteo])hytes  which  form  around  the  articular 
surfaces,  like  ring-bone  in  horses.  There  is  also  a  spurious  anchylosis, 
caused  by  the  thickening  of  the  capsular  ligaments  and  fibrous  adhesions. 
The  muscles  about  the  joints  undergo  important  changes.  Atrophy  from 
disuse  gradually  su])ervenes,  and  contractures  tend  to  flex  the  thigh  ui)on 
the  abdomen  and  the  leg  upon  the  thigh.  There  are  cases  with  rapid 
muscular  Avasting,  symmetrical  involvement  of  the  joints,  increased  reflexes, 
and  trophic  changes,  which  strongly  suggest  a  central  origin.  Xumbness, 
tingling,  ])igmcntation  or  glossiness  of  the  skin,  and  onychia  may  be  pres- 
ent. In  extreme  cases  the  patient  is  com])letely  hel])less,  and  lies  on  one 
side  with  the  legs  drawn  up,  the  arms  fixed,  and  all  the  articulations  of  the 
extremities  locked.  Fortunately,  it  often  happens  in  these  severe  general 
cases  that  the  joints  of  the  hand  are  not  so  much  affected,  and  the  patient 
may  be  able  to  knit  or  to  write,  though  unable  to  walk  or  to  use  the  arms. 


ARTriRITIS   DEFORMANS. 


403 


\)X0- 


pros- 
litra- 


rlosis, 
sions. 
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of  tlio 
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lationt 

arms. 


It  is  sllrpri!^in<|;  iiidood  how  iiiiich  lortuin  patients  with  advanced  arthritis 
(k'l'ornians  can  accomplish.  So  one  who  luid  seen  the  Iteautifid  models 
iiiid  microscopic  pre])arations  oi.  the  late  11.  D.  Sclunidt,  of  ^.'ew  Orleans, 
could  iniajiine  that  he  had  been  alllicted  for  years  witli  a  most  extreme 
^rade  of  this  terrible  disease.  In  many  cases,  after  involvin<f  two  or  three 
joints,  the  disease  becomes  arrested,  and  no  further  development  occurs. 
It  may  be  limited  to  tlie  m  rists,  or  to  the  knees  and  wrists,  or  to  the  knees 
aud  ankles.  A  majority  of  tlie  patients  linally  reach  a  quiescent  staj^as  in 
which  they  are  free  from  ])ain  and  enjoy  excellent  liealth,  sull'erin;,'  only 
fiom  the  inconvenience  and  crippling  necessarily  associated  with  the  dis- 
ease. 

Coincident  afi'ections  arc  not  uncommon.  In  the  active  sta<:;c  the  pa- 
tients are  often  amvmic  and  siill'er  from  dyspepsia,  which  may  recur  at 
intervals,    'i'here  is  no  tendency  to  involvement  of  the  heart. 

The  partial  or  mono-articular  form  atfeets  chietly  old  persons,  and  is 
seen  jjarticularly  in  tlie  hip,  the  knee,  the  spinal  column,  or  shoulder.  It 
is,  in  its  anatomical  features,  identical  Mith  the  ficneral  disease.  In  the 
hi|)  and  shoulder  the  muscles  early  show  wastiu<r,  and  in  the  hip  the  con- 
dition ultimately  becomes  that  already  described  as  murbus  coxa'  senilis. 
These  cases  seem  not  infrequently  to  follow  an  injury.  They  dill'er  from 
Ihe  polyarticular  form  in  occurrin<;  chieiiy  in  men  and  at  a  later  period  of 
life.  One  of  the  most  interestinjjf  forms  aifects  the  verteln'a%  completely 
locking  the  articulations,  and  ])roducing  the  condition  known  as  xpoitdi/lilis 
(leformans.  When  the  cervical  spine  is  involved,  the  head  cannot  be  moved 
u[)  and  down,  l)ut  is  carried  stiiUy.  Usually  rotation  can  be  eifected.  The 
dorsal  and  lumbar  spines  may  also  be  involved,  and  the  body  cannot  be 
flexed  in  the  slightest  degree.  Other  joints  may  not  l)e  alTectcd,  or  with  the 
s])ine  the  hip  and  shoulder  joints  may  be  anchyloscd.  Marie  has  described 
tills  condition  as  spondyhse  rliizomelique.  The  smaller  joints  are  not  af- 
fected. There  is  a  remarkable  specimen  of  it  in  the  museum  of  the  Uni- 
versity of  Buffalo. 

Arthritis  Deformans  in  Children. — A.  E.  fJarrod  remarks  that  all  the 
cases  which,  on  account  of  their  clinical  features,  are  classed  as  examples 
of  arthritis  deformans  in  children  are  not  truly  of  that  nature.  Some 
cxam])les  certainly  resemble  closely  the  disease  in  adults.  In  others  there 
are  very  striking  differences.  A  very  interesting  variety  has  lieen  dilfcr- 
entiated  by  George  F.  Still,  in  which  the  general  enlargement  of  the  Joints 
is  associated  with  swelling  of  the  lymph-glands  and  of  the  spleen.  lie  has 
studied  23  cases  of  this  character.  The  following  are  among  the  more 
striking  peculiarities.  The  onset  is  almost  always  before  the  second  denti- 
tion. Girls  are  more  frequently  affected  than  boys.  The  sym])toms  com- 
]ilainod  of  are  usually  slight  stiffness  in  one  or  two  joints;  gradually  others 
become  involved.  The  onset  may  be  more  acute  with  fever,  or  even  with 
chills.  The  enlargement  of  the  joints  is  due  rather  to  a  general  thickening 
of  the  soft  tissues  than  to  a  bony  enlargement.  There  is  no  bony  grating. 
The  limitation  of  movement  may  lie  oxtrome,  owing  to  the  fixation  of  the 
joints,  and  there  may  be  much  muscular  Avasting.  The  enlargement  of  the 
lymph-glands  is  most  striking.    In  a  case  at  present  under  my  observation 


404 


CONSTITUTIONAL   DISKASES. 


/ 


llio  yiipnitroclilciir  ^flands  arc  as  lar;^'c;  as  liazd-mits.  The  onlargomoiit  is 
•ffnt'ral.  The  cd^a'  ol'  the  h])1c'L'1i  can  usually  be  felt  hclow  the  costal  margin. 
Sweating  is  often  profuse  and  there  may  he  anieniia,  but  heart  complications 
arc  rare.    The  childri'ii  look  puny  and  gent  rally  show  arrest  of  development. 

Diagnosis. — Arthritis  deformans  in  an  advanced  stage  can  rarely  bo 
mistaken  for  either  rheumatism  or  gout.  Marly  cases  are  dillicull  or  impos- 
sible to  distinguish  from  chronic  rheunuitism.  Jt  is  important  to  distin- 
guish from  the  mono-articular  form  the  local  arthritis  of  the  shoulder-joint 
which  is  characterized  by  jiain,  thickening  of  the  capsule  and  of  the  liga- 
ments, wasting  of  the  shoulder-girdle  muscles,  and  sometimes  by  neuritis. 
This  is  an  alfection  which  is  quite  distinct  from  arthritis  deformans,  and  is, 
moreover,  in  a  majority  of  cases  curable. 

Treatment. — Arthritis  deformans  is  an  incurable  disease.  In  many 
cases,  after  involvement  of  two  or  three  joints,  the  jjrogress  is  arrested. 
Too  often  it  invades  successively  all  the  articulations,  and  in  ten,  fifteen, 
or  twenty  years  the  cri|)pling  becomes  general  and  permanent. 

The  best  that  can  be  hoped  for  is  a  gradual  arrest.  It  is  useless  to 
saturate  the  ])aticnts  with  iodide  of  ])otassium,  salicylates,  or  (piinine. 
Arsenic  seems  to  do  good  as  a  general  tonic.  The  improvement  may  be 
nuirked  if  large  doses  of  it  are  given.  Iron  should  be  used  freely,  if  there 
is  ana-mia.  An  old  recipe,  called  the  "  Chelsea  Pensioner,"  containing  sul- 
]»hur  ,",  j,  cream  of  tartar  ,",  j,  rhul)ar])  i^  iv,  gum  guaiacum  iij,  honey  f)  xvj 
i^^i^-'-  ,")  j  night  and  morning  in  warm  wine),  was  formerly  much  used. 
Careful  attention  to  the  digestion,  ])lenty  of  good  food,  and  fresh  air  are 
important  measures.  IIydrothera])y,  with  carefully  performed  massage, 
is  best  for  the  alleviation  of  the  ])ain.  and  may  possibly  restrain  the  progress 
of  the  affection.  In  early  cases  local  im])rovement  and  often  great  gain  in 
the  general  strength  follow  a  prolonged  treatment  at  the  hot  mineral  baths; 
l)ut  the  ])ractitioner  should  exercise  care  in  recommending  this  mode  of 
treatment,  which  is  of  very  doubtful  value  when  the  disease  is  well  estab- 
lislied.  I  have  repeatedly  known  cases  to  be  rendered  much  worse  by  resi- 
dence at  these  institutions.  AVhen  good  results,  it  is  largely  from  change 
of  scene  and  climate,  and  the  careful  regulation  of  the  diet.  The  local 
treatment  is  of  benefit  in  arresting  the  progress.  "When  there  are  much 
heat  and  pain  the  limb  should  be  at  rest,  cold  compresses  applied  at  night, 
the  joints  wrapped  in  oiled  silk,  and  in  the  morning  thoroughly  massaged. 
It  is  surprising  how  much  can  be  done  by  carefully  ap])lied  friction  to  re- 
duce the  thickening,  to  promote  absorption  of  effusion,  and  to  restore 
mobility.  ^lassage  is  also  of  special  benefit  in  maintaining  the  nutrition  of 
the  muscles,  which  early  tend  to  atro])hy.  In  the  case  of  the  knees  this 
mode  of  treatment  ■will  sometimes  prevent  the  retraction  of  the  muscles 
and  the  gradual  flexion  of  the  legs  on  the  thighs.  Xo  benefit  can  be  ex- 
pected from  electricity.  The  hot  air  treatment,  recently  introduced,  should 
be  given  a  thorough  trial,  as  it  has  produced  good  results  in  some  cases. 

I  iiildren  much  may  be  done  surgically  in  the  way  of  breaking  up  the 
fibrous  adhesions. 


iiths; 
of 
cstab- 
rcsi- 
ange 
local 
niieh 
light, 
aged. 
0  re- 
cstorc 
ion  of 
this 
uscles 
)e  ex- 
lonld 

OS. 

ip  the 


CHIIONIC   HIIKUMATISM.  405 


II.    CHRONIC    RHEUMATISM. 

Etiology. — This  aHVt'ti(Hi  may  follow  an  acuto  or  sulmcuto  nttnck,  but 
more  coiniiioiily  (•(tiiics  on  insidiously  in  persons  who  liavc  passed  tlio 
middle  period  of  life.  In  my  experienee  it  is  extremely  rare  as  a  seipieneo 
III'  acute  rheumatism.  It  is  most  common  among  the  })0()r,  jtarticularly 
washer-women,  day-laborers,  and  those  whose  oceu[)ation  exposes  them  to 
cold  and  damp. 

Morbid  Anatomy. — The  synovial  membranes  are  injected,  ])ut  there 
is  usually  not  much  ciVusion.  'I'he  capsule  and  liganu'uts  of  the  joints  are 
thickened,  and  the  sheaths  of  the  tendons  in  the  neighborhood  undergo 
similar  alterations,  so  that  the  free  play  of  the  joint  is  greatly  impaired, 
in  long-standing  cases  the  cartilages  also  undergo  changes,  and  may  show 
erosions.  lOven  in  cases  with  the  severest  symptoms,  the  j(unt  nuiy  be 
very  slightly  altered  in  ai)pearance.  Imi)ortant  changes  take  place  in  the 
Miuscles  and  nerves  adjacent  to  chronically  inlhuncd  joints,  particularly 
in  the  mono-articular  lesions  of  the  shoulder  or  hi[).  Muscular  atrophy 
supervenes  ])artly  from  disuse,  partly  through  nervous  influences,  either 
centric  or  reflex  (Vul[)ian),  or  as  a  residt  of  peripheral  neuritis.  Jn  some 
cases  when  the  joint  is  much  distended  the  wasting  may  be  due  to  pressure, 
either  on  the  muscles  themselves  or  on  the  vessels  sup|)lying  them. 

Symptoms. — Stiffness  and  i)ain  are  the  chief  features  of  chronic 
rheumatism.  The  latter  is  very  liable  to  exacerbations,  especially  dur- 
ing changes  in  the  weather.  The  joints  may  be  tender  to  the  touch  and  a 
little  swollen,  l)nt  are  seldom  reddened.  As  a  rule,  many  joints  are  affected; 
hut  there  are  instances  in  which  the  disease  is  confined  to  one  shoulder, 
knee,  or  hip.  The  stiffness  and  i)ain  are  more  marked  after  rest,  and  as  the 
(lay  advances  the  joints  may,  with  exertion,  become  much  nuire  supple. 
The  general  health  may  not  be  seriously  impaired.  The  disease  is  not  im- 
mediately dangerous.  Anchylosis  may  occur,  and  ultimately  the  joints 
may  become  much  distorted.  In  many  instances,  particularly  those  in 
which  the  i)ain  is  severe,  the  general  health  may  be  seriously  involved  and 
the  subjects  become  anaunic  and  very  apt  to  suffer  with  neuralgia  and  dys- 
]iepsia.  Valvular  lesions,  due  to  slow  sclerotic  changes,  are  not  uncommon. 
They  are  associated  with,  not  dependent  upon,  the  articular  disease. 

The  prognosis  is  not  favorable,  as  a  majority  of  the  cases  resist  all  meth- 
ods of  treatment.  It  is,  however,  a  disease  which  persists  indefinitely,  and 
docs  not  necessarily  shorten  life. 

Treatment. — Internal  remedies  are  of  little  service.  It  is  important 
to  maintain  the  digestive  functions  and  to  keep  the  general  health  at  a 
liigh  standard.  Iodide  of  potassium,  sarsaparilla,  and  guaiacum  are  some- 
times beneficial.    The  salicylates  are  useless. 

Local  treatment  is  very  beneficial.  "  Firing  "  with  the  Paquelin  cautery 
relievos  the  pain,  and  it  is  perhaps  the  best  form  of  counter-irritation, 
brassage,  with  passive  motion,  helps  to  reduce  swelling,  and  prevents  anchy- 
losis. It  is  particularly  useful  in  cases  which  are  associated  with  atrophy 
nf  the  muscles.     Electricity  is  not  of  much  benefit.     Climatic  treatment 


400 


CoNSTITlfTIoNAL  DISKASKS. 


is  scrv  inlvniiliip'iMis.  Miinv  cuhch  nic  ^^rcnllv  liil|ict|  Ity  iimloiip'd  rcsi- 
(li'iicc  ill  sdiillici'ii  Kiirn|i<'  nr  Soiillicni  Ciililoriiiti.  Kicli  imliciitH  slioiilil 
iilwiivs  wiiiU'i'  ill  llic  Siiiitli,  tiiid  ill  lliirt  wtiv  avoid  llic  cnM,  (Iiiiii|i  VMHtlitT. 
II V(lr(itli('ni|K'iiti('  niciisiircs  iirc  s|)<'riiilly  iM'iit'licinl  in  chniiiic  rliciiiiiii- 
tisiii.  (iiTiil  rclit'l'  IS  iiirt»i(l('(|  liy  u  iii|t|»iii^'  llu'  iiircrlcd  juinl.s  in  cnld  cldilis, 
(•<»vi'rrd  willi  ii  lliiii  l.iycr  <d'  Idniikcl,  and  itiolcclcd  svilli  oiled  hilk.  'I'lii' 
Ttirkisli  balli  in  iiscl'iil,  hiil  the  lull  hcticlit  td'  this  tifaliiiciit  is  nircly  sci'ii 
I'Mcpl  at  liatliiiijr  fslaldislimciits.  'I'lic  iiot  iilkaliin'  wmIits  nrc  |Miili(iilaily 
iisrlul.  aiitl  11  rcsidfiiic  at  llu'  Hot  Spriii^^s  of  Nir^iiiin  or  Arkaiisns,  or  nt 
JlaiilV,  in  llic  Uoiky  Moiinlnins,  on  tlii'  Canadian  I'ai'ilie  Kailway,  will  hoiiu'- 
tinies  curt'  evt'ii  ohstinaU'  i-asos. 


/ 


III.    MUSCULAR    RHEUMATISM   (.V//<//7'<'). 

Definition. — A  painriil  aircctioii  of  tlic  voliinlnry  niiisclcs  and  of  the 
fascia'  and  |u'ritistcimi  to  wliicli  llicy  arc  atlaclicd.  Tlic  alTcclioii  lias  re- 
ceived various  naiiics,  aceordin<;  lo  its  seal,  as  torticollis,  liiiiilia^io,  [ilciiro- 
dynia.  etc. 

Etiology. — 'The  attacks  follow  cold  and  cx]>osiirc.  the  usual  conditions 
favoraldc  to  the  di'velo|iiiient  of  rlieiimatisni.  It  is  l»y  no  means  certain 
that  till'  niiisciilar  tissues  are  the  si'at  of  the  disease.  Many  writers  claim. 
]>i'rha|ts  correctly,  that  it  is  a  lU'iiral^ia  of  the  sensory  nerves  of  the  niii> 
cles.  Intil  our  know  led  <,'e  is  more  accurate,  however,  it  may  he  considered 
under  the  rheumatic  alTectious. 

It  is  most  commonly  met  with  in  men,  iiarticiilarly  those  ex])osed  lo 
C(dd  and  whose  oi'cnpatious  are  lahorioiis.  It  is  apt  to  follow  I'xposnre  to 
a  draujiht  of  air,  as  from  an  opeu  window  in  n  railway  carria^'c.  A  sudden 
ciiillinjr  after  heavy  exertion  may  also  hrinj;  on  an  attack  of  lninha<ro. 
I'ersons  of  a  rheumatic  or  f^outy  liahit  arc  certainly  more  prone  to  tliif= 
nlTcctiou.  One  attack  renders  an  individual  uiore  liahle  to  another.  Jt  is 
usuallv  acute,  hut  may  hecome  suhacute  or  even  chronic. 

Ssnnptoms. — The  alTection  is  entirely  local.  The  constitutional  dis- 
turbance is  slight,  and,  even  in  severe  cases,  there  may  be  no  fever,  rain 
is  a  prominent  synii>tom.  It  may  be  constant,  or  may  occur  only  when 
the  muscles  are  drawn  into  certain  positions.  It  may  be  a  dull  ache,  like 
the  pain  of  a  bruise,  or  sharp,  severe,  and  enim])-like.  It  is  often  sulliciently 
intense  to  cause  the  jiaticnt  to  cry  out.  Pressure  on  the  alVected  ]>art  usually 
•rives  relief.  As  a  rule,  myalgia  is  a  transient  alTection,  lasting  from  a  few 
hours  to  a  few  days.  Occasionally  it  is  i)rolonged  for  several  weeks.  It  i^ 
very  a])t  to  recur. 

The  following  are  the  principal  varieties: 

(1)  Lunbago,  one  (d"  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.  It  occurs  chiefly  in 
workingmen.  It  conies  on  suddenly,  and  m  very  severe  cases  completely 
incapacitates  the  patient,  who  may  be  unable  to  tiirn  in  bed  or  to  rise  from 
the  sitting  posture. 

(5)  Stiff  neck  or  torticollis  affects  the  muscles  of  the  antero-latcral 


flOUT. 


4()7 


liil  (lis- 
I'ain 

I  when 
\(\  liki' 
ii-icntly 
\isuiilly 
III  a  few 
It  i^ 


rc;,'iMii  of  llii'  iici  K.     II    is  very  ciiiiiiiuiii,  ami  ncciirs  most    rr(>(|iiciilly  in 

I  111-  yoiiii^'.    'I'lic  |iMli('iil  iin|il,-4  ihf  liciiil  ill  a  iicculiar  nninin'r,  ami  ndnlfs 

ihc  wliolt'  ImhIv  ill  iilt('||i|i|iiiH  to  tiiiii  il.  i'siiiilly  tlii>  nltnck  is  (■(iiilitli'il  Id 
iiiM'  .'^i'li'.     'I'Ih'  iiiiiscli's  III   llir  Imck  of  IJif  iit'ck  imiy  also  lie  aH'cflcd. 

(3)  Ploiirodynia  iiivnivcs  (Ik-  iiilcicDsltil  |||||^('|(•s  mi  otu;  sidr,  innj  in 
Millie  iiislaiiccs  III)'  |itrlunils  timl  h-iihIiis  ma^'iiiis.  'I'liis  is,  |iit1iii|is,  tin- 
liinsi  |iiiiiiriil  i'unii  III'  I  III-  (lisciisc,  as  llic  clii'sl  ciiiimmI  he  nt  rest.  Il  is  liioM! 
rniiiiiinii   (III    llic    li'l't    llniii   MM    IJii'    ri;>:llt    sitlf.      A    (|t'('|)   hrcillll,  or  colliiiiill;,', 

(jiiiscs  very  iiilciisc  jiiiiii,  iiml  llic  it's|iiiiilory  iiiovcinciils  iiif  icslnclcd  on 
llic  alVcclcd  siilc.  'riici'c  limy  he  |i:iiii  on  |ircssiirc,  s<niicliiiics  ovor  a  very 
liniiletl  area.  Il  niny  lie  (lillieiill  |o  distiii^riiish  froiii  iiilcrctistal  tieiiral;ria. 
Ml  wliieli  all'iMjinii,  lio\sc\er,  Ihe  jiiiin  is  iisiiiilly  more  cireiiinsiTilted  and 
|i;iro\ysnial,  and   lliere  nre  lender   jioinls  iiloii;,'  llie  e(nirse  ol'  the  nerves. 

II  is  soiiH'tinies  mistaken  Tor  pleurisy,  Inil  ciirernl  physieal  examinalion 
leiidily  (lislin;,Miislies  helweeii  the  two  aU'eel  ions. 

(I)  Ainon;;  other  loiins  whieh  may  he  nieiilioned  art'  cophalodynia, 
;iileelin;,'  the  i  inseles  of  the  head;  scapulodynia,  oniodynia,  and  dorsodynia, 
idl'eeliiij,'  the  (iins<-les  ahoni  the  shouhler  and  ii|i|ier  |iji!t  of  ||ie  hiick.  My- 
id^ia  niiy  also  occur  in  the  ahdominal  nuiselcs  anri  in  \\\y\  miiHcles  of  the 
v\\  remit  ics. 

Treatment. --lies t  of  the  alVcclcd  mnsclcs  is  of  the  lirsl  imporlancc. 
Slrappiii;;  the  siih;  will  somctiines  coni|dclely  relieve  |)lciirodynia.  No 
licliel'  is  mor(!  widespread  amon^'  Ihc  pnhlic  than  in  tlu;  ollicacy  ol'  porous 
plasters  I'or  muscular  pains  of  all  sorts,  particularly  tliosti  ahout  ilie  triiiik. 
If  the  pain  is  severe  and  aJ,'olliziIl^^  a  hypodciini(!  of  morphiii  j,mvcs  im- 
niediiite  relief.  For  luniha;^:*)  aciipnncliire  is,  in  acute  cases,  IIk;  most  elli- 
(  ieni  treatnienl.  .Needles  of  from  Ihri'c  to  four  inches  in  leii^dh  (ordinary 
honnct-necdies,  sterilized,  will  do)  an;  thrust  into  the  himhar  muscles  at 
the  scat  of  the  pain,  and  withdrawn  after  live  or  ten  minutes.  In  many 
instances  the  relief  is  iminediale,  and  I  can  corrohorate  fully  Ihe  slale- 
iiicnls  of  I{in<ier,  who  taught  me  this  practice,  as  to  its  extraordinary  and 
prompt  elVicacy  in  many  instances.  The  eor.stanl  current  is  sometimes 
very  liencficial.  In  many  forms  of  myalgia  tl'<e  themio-cautery  gives  great 
iclief.  In  ohstinale  cases  l)listers  may  be  tried.  Hot  fomentations  are 
soothing,  and  at  the  outset  a  'I'urkisli  hath  may  cut  short  the  attack.  In 
chronic  cases  iodide  of  polassiuin  may  he  used,  and  both  guaiacum  and 
sulpluir  have  been  strongly  recommended.  Persons  suliject  to  this  alfec- 
liou  sljould  be  warmly  clothed,  and  avoid,  if  j)ossible,  ex])osure  to  C(>1(1 
and  damp.  In  gouty  ])ersons  the  diet  should  be  restricted  and  th(!  alkaline 
nineral  waters  taken  freely.  Large  doses  of  nux  vomica  are  sometimes 
beneficial. 


IV.    GOUT   {Podagra). 

Definition. — A  nutritional  disorder,  one  factor  of  whicb  is  an  ex- 
cessive formation  of  nric  acid,  characterized  clinically  by  attacks  of  acute 
nrthritis,  by  the  gradual  deposition  of  urate  of  soda  in  and  about  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 


408 


CONSTITUTION  A  li   DISKASKS. 


/ 


Etiology. — 'I'Ih'  pri'ciHc  iiiiliiri'  dl'  llic  (listiiiliiiiiic  in  inctaltoliHin  U 
not  kiiitwii.  'I'Imti'  Ik  pndml)!)'  ili-lVt'tivo  oxidation  «»l'  llif  rooiUtiilTrt,  com- 
liiiU'il  with  iiii|KM'l'('ct  cliiiiiniitinii  of  the  \vaHtt>  prodiictti  of  Mic  hody. 

Aiiioii^'  iiii|>ortjiiit  cliolo^jiciil  rncluis  in  j,'oiil  arc  (he  follow  in;;:: 

((()  llvivililiini  I ii/liinins. — StatisticH  show  that  in  from  r>(l  to  (iO  |)(r 
cent  of  all  faxi's  the  discaHc^  t'xihtcd  in  the  parciitH  or  ^'randparcnts.  Tlu' 
traiiHnMHHioii  in  Hiipponcd  to  he  more  marked  from  the  nialu  mU\  Canes 
villi  n  Hlrong  hereditary  taint  have  heeii  known  to  devidop  l>efore  puherty. 
'I'lie  disease  has  heen  seen  even  in  infants  at  the  hreast.  Males  are  more 
n.liji'et  to  the  disease  than  females.  It  rarely  develops  hefore  the  lliirlietli 
year,  and  in  a  iarj^'e  majority  of  the  easen  the  first  manifestations  appear 
Ix'fore  the  ap'  (d"  lifty.  {!>)  Mco/ml  is  the  most  potent  factor  in  the  etiidoj^y 
of  tlie  disease.  I'eiinenled  liipiors  favor  its  development  much  more  tli:iii 
distilled  spirits,  and  it  prevails  most  extensively  in  countries  like  l';ii;,dand 
nnd  (iermaiiy,  which  consnme  the  nutst  heer  and  ah'.  Tlu!  li^diter  heers 
used  in  this  country  are  much  les8  liahle  to  produce  j;out  than  the  heavier 
]']n^dish  and  Scotch  ales,  (r)  Fuud  plays  a  rule  eipial  in  importance  to  that 
of  alcohol.  Overeating;  without  active  hodily  excrci.^e  is  rc;,nirdcd  as  a  very 
Hpecial  predisp(>siu<(  cause.  A  form  (d'  ^^oiity  dyspepsia  has  heen  descril»e(|. 
A  rohnst  and  active  dij,'estion  is,  however,  often  uu'l  in  j^outy  jtersons. 
(iout  is  hy  no  means  confined  to  the  rich.  In  l-!n;,dand  the  comhinatiou 
of  |ioor  food,  defective  liy;,nenc,  and  an  cxci'.ssive  consumption  of  malt 
liipiors  makes  the  "  poor  man's  ^'out  "  a  common  aU'ection.  (il)  Lend. 
(larrod  has  shown  that  workers  in  lead  are  8|>ecially  prone  to  pout.  In  IM 
])er  cent  of  the  hos])ital  cases  the  patients  had  heen  ])ainters  or  workers  in 
lead.  The  as.sociation  is  prohahly  to  he  sou<,dit  in  the  ]irodiU'tion  hy  this 
])oisou  of  artcrio-scli'rosis  and  chronic  nephritis.  Chronic  lead-poisoninn' 
is  here  frecpu'utly  associated  with  artcrio-sclcrosis  and  contractc(l  kidneys. 
Lut  lead-<,M)ut  is  comparatively  rare.  (Jouty  de])osit.s  are,  however,  to  he 
found  in  the  l)ip-t()e  joint  and  in  the  kidneys  in  eases  of  chronic  ])lund)isni. 

The  nature  of  <,'out  is  unknown.  That  there  is  faulty  metabolism,  asso- 
ciatetl  in  some  very  special  way  with  the  clu'mistry  of  uric  acid,  we  know. 
but  nothinj;  more.  The  remainder  is  theory,  awaiting;  refutation  or  con- 
firmation. '^I'he  conditions  of  life  favorable  to  the  develo])ment  of  gout  arc 
])rescnt  in  too  mauy  of  us  after  the  middle  period  of  life — more  fuel  in  the 
form  of  meat  and  drink  than  the  machine  needs.  (J.  H.  Balfour  ))ut  it  well 
vhen  he  says:  '*  The  gouty  diathesis  is  only  a  comprehensive  term  for  all 
those  changes  in  the  character  and  com])ositio)i  of  the  blood  induced  by 
the  evils  of  civilization — deficient  exercise  nnd  excess  of  nutriment.  .  .  . 
(iout,  on  the  other  baiul,  is  the  name  given  to  all  those  modifications  of  our 
metabolism  canscd  by  the  gonty  diathesis,  as  well  as  to  all  the  sym])tom.- 
to  which  those  modifications  give  rise." 

The  views  regarding  uric  acid  and  its  relation  to  gout  are  very  nu- 
merous. 

C         ''  holds  that  with  lessened  alkalinity  of  the  blood  there  is  an  in- 

cv  Jie  uric  acid,  due  chiefly  to  diminished  elimination.     TTc  attrib- 

..  deposition  of  the  urate  of  soda  to  the  diminished  alkalinity  of  the 

.ma,  which  is  unable  to  hold  it  in  solution.    In  an  acute  paroxysm  there 


Tlu 


GOUT. 


4i'U 


U  nn  nrriiniiilii.tion  of  the  iiratcH  in  the  hlnod,  nml  tlic  iiilliiiiiiuation  U 
ciuiHcil  liy  their  HiKhh'ii  (h'|i))Hit  in  crvHtulliiic  ronii  ahoiit  the  joint. 

Iliii;;  thinlss  tliat  thiTc  in  no  in('r«'a>nl  I'oniiatioii  of  uric  acid  in  ^oiit, 
liiit  tliat  till-  lilood  is  U'SH  alkahnc  than  normal,  and  h>s  aide  to  hold  tlit> 
uric  acid  or  its  salts  in  solution. 

Acfonlin^  to  Sir  William  Uoiicrts,  the  chalk-like  deposits  are  I'oiined 
of  the  crystalline  hiurate  of  sodinm,  and  "  the  arthritic  inci<lents  of  gout 
may  he  said,  not  im|»ro|i<'rly,  to  he  siMi|ily  incidents  iiv-rlaininj;  to  the  pre- 
cipitation of  these  crystals  in  the  structures  of  the  joints." 

Lovisoi)  (Die  llarnsiiurediathese,  iierlin,  ISD.'i)  adopts  iliiri)ac/e\vski'.<( 
views  that  the  uric  acid  is  related  especially  to  the  niicleius  (d'  the  liody, 
and  is  deriviwl  in  great  part  from  the  destruction  of  the  white  Idond-cor- 
pusidcs,  the  excretion  increasing  jkuI  /kissu  with  the  intensity  of  the  leuco- 
cytosis.  While  this  is  tru(  in  many  diseases,  as  in  pneumonia,  Hichter,  in  a 
(ar(d'ul  stiuly,  has  shown  llml  there  are  important  exci'ptions. 

I'lhstein   thinks  that   the  lirst  change  is  a  nutritive-tissue  disturhance, 

which  leads  to  necrosis,  and  in  the  necrotic  areas  the  urates  are  dep(»sitc(J 

-a  view  which  has  heen  modilied  hy  von  Xoordcn,  who  holds  that  a  spe- 

t  ial  ferment  leads  to  the  tissue  change,  to  which  the  deposit  of  the  urale.H 

is  secondary. 

Koliscli  believes  that  the  kidneys  not  oidy  have  the  function  of  excret- 
ing hut  also  that  of  forming  uric  acid,  lie  holils  that  the  graver  iiumi- 
i't'stalions  of  gout  only  make  their  a|)pcarance  when  the  functions  of  the 
kidiu'y  heeome  impaired  from  sonu;  cause.  Jn  his  studies  on  metaholism 
in  gout,  he  finds  that  the  total  alloxuric  bodies  (uric  acid  and  xanthin  hasesji 
are  increased  in  the  urine.  'I'his  is  due  to  an  increase  of  the  alloxuric  or 
xanthin  liases  and  not  of  the  uric  acid,  which  in  reality  is  diminislu'd.  In 
nephritis,  Koliscli  found  that  although  the  total  alloxuric  bodies  were  elim- 
inated in  normal  amount,  yet  the  xanthin  bases  were  markedly  increased 
at  the  expense  of  the  uric  acid  excreted.  With  the  kidneys  healthy,  the 
greater  part  of  the  alloxuric  bodies  is  eliminated  as  uric  acid,  but,  when  dis- 
eased, Koliscli  holds  that  the  uric  acid  becomes  diminished  and  the  xanthin 
bases  are  relatively  increased.  This  leads  him  to  believe  that  the  kidney 
normally  jirodiices  uric  acid,  lie  demonstrated  the  toxic  elTccts  of  the 
xanthin  bases  on  the  kidneys  by  injecting  rabbits  and  guinea-pigs  subcu- 
taneonsly  with  hypoxanthin  for  ])eriods  of  one  to  two  months.  Jn  this  way 
dednite  ])arenchyniatons  degeneration  was  produced.  Having  shown  that 
(he  xanthin  bases  were  also  increased  in  gout,  he  believes  that  they  are  con- 
cerned in  the  jirodiiction  of  the  kidney  aflVction  which  jirecedes  the  develop- 
iiiont  of  gout,  (hirrod  now  holds  that  uric  acid  is  normally  formed  in  the 
kidneys,  and  that  when  it  ap])ears  in  the  blood  this  results  from  its  reabsorp- 
lion  after  having  l)ecn  formed  in  these  organs.  Luff  claims  that  uric  acid 
under  normal  conditions  is  ])roduced  only  in  the  kidneys.  Latham  also  is 
of  the  opinion  that  the  final  fornintion  of  uric  acid  takes  ])lace  in  the 
kidneys,  where  it  is  produced  by  the  union  of  substances  formed  in  th'; 
liver  and  conveyed  to  them  by  the  blood  current. 

C'ullen  held  that  gout  was  ])rimarily  an  affection  of  the  nervous  system. 
On  this  nervous  theory  of  gout  there  is  a  basic,  arthritic  stock — a  diathetic 


I 
I 


i'.'V 


410 


CONST  IT  U  T  ION  AL   DLS  K  ASES. 


/ 


liiiljit,  of  wlikli  <,'out  and  rlicmnatisin  are  two  distinct  branchos.  Tlio 
gouty  diatlu'sis  is  t'.\i)i'i's>ii.'d  in  {a)  a  nc'uro(?is  of  tliu  norvo-centrt'.s,  whieli 
may  bt'  iidK'rit('(l  or  a'(|iiir('d;  and  (h)  "a  pccidiar  incapacity  I'or  normal 
elaboration  within  tiic  whole  body,  not  merely  in  the  liver  or  in  one  or  two 
organs,  ol'  I'ood,  whereby  uric  acid  is  Toi'mt'cl  at  times  in  excess,  or  is  in- 
cai)able  of  being  didy  transformed  into  more  soluble  and  less  noxious 
l)roducts  "  (Duckworth).  The  explosive  neuroses  and  the  iniluence  of  de- 
jtressing  circumstances,  |)liysical  or  mental,  point  strongly  to  the  part 
played  by  the  nervous  system  in  the  disease.  The  rocents  works  of  Duck- 
worth and  William  i'lwart  may  be  consulted  for  a  full  discussion  of  the  vari- 
ous theories  on  the  nature  of  gout. 

Morbid  Anatomy. — 'i'he  hloixl  is  stated  to  have  an  excess  of  uric 
acid.  It  may  be  obtained  from  the  blood-serum  by  the  method  known  as 
(iarrod's  nric-acid  thread  experiment,  or  from  the  serum  obtained  from  a 
blister,  'i'o  .1  ij  of  .eeruju  a(l(l  Tq,  v-vj  of  acetic  acid  in  a  watch-glass.  A 
thread  immersed  in  this  mayshow  in  a  few  hours  an  incrustation  of  uric  acid. 
The  experiment  is  rarely  successful  even  in  cases  of  manifest  gout.  This 
exc  -s,  also,  is  not  |)eculiar  to  gout,  but  occurs  in  leuka'mia  and  chlorosis. 

^n  181)4  Xeusser  descril)ed  a  peculiar  l)lack  granulation  over  and  about 
tlie  nuclei  of  the  leucocytes  in  the  blood  of  gouty  ])atients.  lie  termed  theui 
"  ])erinuch'ar  ])nsof)hilic  granules,"  and  demonstrated  them  by  using  a  modi- 
fied l']lirlich"s  triacid  nnxture.  They  were  j)articularly  numerous  about  the 
nuclei  of  the  mononuclear  leucocytes.  He  believed  that  they  were  of  the 
nature  of  a  nudeo-albumin,  and  claimed  that  cases  showing  them  eliminated 
uric  acid  in  excels.  Jle  held  tlnit  these  granules  constituted  the  mother 
sid)stance  from  which  the  uric  acid  was  formed,  and  tliat  ]iatients  showing 
these  granules  were  suffering  from  a  uratic  or  gouty  diathesis.  Subsequent 
work  bv  Futcher  and  others  seems  to  have  shown  that  there  is  no  associa- 
tion between  the  abundance  of  thr-.se  granules  and  the  elimination  of  uric 
acid  or  of  the  total  alloxuric  bodies. 

The  important  changes  are  in  the  articular  tissues.  The  first  joint  of 
the  great  toe  is  most  frequently  involved;  then  the  ankles,  knees,  and  the 
small  joints  of  the  hands  and  wrists.  The  deposits  may  be  in  all  the  joints 
of  the  lower  limbs  and  absent  from  those  of  the  up])er  limbs  (Xorman 
]\roore).  If  death  takes  place  during  an  acute  paroxysm,  there  are  signs 
of  inflammation,  hy])era'mia,  swelling  of  the  ligamentous  tissues,  and  of 
effusion  into  the  joint.  The  ])rimary  change,  according  to  Ebstein,  is  a 
local  necrosis,  due  to  the  presence  of  an  excess  of  urates  in  the  blood.  Thi^ 
is  seen  in  the  cartilage  and  other  articular  tissues  in  which  the  nutritional 
currents  are  slow,  ^fordhorst  holds  that  the  deposition  of  the  urates  is 
primary,  and  that  the  necrosis  of  the  tissues  takes  ]ilaco  as  a  result  of  this 
deposit.  In  these  areas  of  coagulation  necrosis  the  reaction  is  always  acid 
and  the  neutral  urates  are  deposited  in  crystalline  form,  as  insoluble  acid 
urates.  The  articular  cartilages  are  first  involved.  The  gouty  deposit  may 
be  uniform,  or  in  small  areas.  Though  it  looks  su]')('rficial,  the  deposit  is 
iuA'ariably  interstitial  and  covered  by  a  thin  lamina  of  cartilage.  The  do- 
posit  is  thickest  at  the  part  most  distant  from  the  circulation.  The  liga- 
ments and  fibro-cartilage  ultimately  become  involved  and  are  infiltrated 


nev 


GOUT. 


411 


and  of 
m,  i^^  a 
This 
ritioiiiil 
rate?  is 
ot  this 
Hvs  acid 
)lc  aciil 
?it  may 
popit  is 
10  (!'-- 
llio  lipi- 
Itratc'l 


with  chalky  deposits,  the  so-called  chalk-stones,  or  toi)lu.  These  are  nsually 
covered  \>y  skin;  but  in  some  cases,  particularly  in  the  metacurpo-i)halangeal 
articulations,  this  ulcerates  and  the  chalk-stones  a[)pcar  exteriuilly.  The 
synovial  lluid  may  also  contain  crystals.  In  very  lon«f-standiii<j;  cases,  owing 
to  an  excessive  deposit,  the  joint  becomes  immol)ile.  The  marginal  out- 
growths in  gouty  arthritis  arc  true  exostoses  (Wynne).  The  cartilage  of 
the  ear  may  contain  to])iii,  which  are  seen  as  whitish  nodules  at  the  margin 
of  the  helix.  The  cartilages  of  the  nose,  eyelids,  and  larynx  are  less  fre- 
tpiently  alfected. 

Of  changes  in  the  internal  organs,  those  in  the  renal  and  vascular  sys- 
tems are  the  most  important.  The  kidney  changes  believed  to  be  charac- 
teristic of  gout  are:  (a)  A  deposit  of  urates  chiefly  in  the  region  of  the 
]tapilla'.  This,  however,  is  less  common  than  is  nsually  sup[)osed.  Xorma;i 
.Moore  found  it  in  only  1:8  out  of  80  cases.  The  apices  of  the  pyramids  show 
lines  of  whitish  deposit.  On  microscopical  examination  the  material  is  seen 
to  be  largely  in  the  intcrtubular  tissue.  In  some  instances,  however,  the 
deposit  seems  to  be  both  in  the  tissue  and  in  the  tubules.  Kbstein  has  de- 
scrii)cd  and  iigured  areas  of  necrosis  in  both  cortex  and  medidla,  in  the 
interior  of  which  were  crystalline  dej)osits  of  urate  of  soda.  The  [)rcsence 
of  these  iiratie  concretions  at  the  apices  of  the  pyramids  is  not  .v  positive 
indication  of  gout.  They  are  not  infrecpient  in  this  country,  in  whi-h  gout 
is  rare,  (h)  An  interstitial  nei)hritis,  either  the  ordinary  "  contractei^  kid- 
ney "  or  the  arterio-sclerotic  form,  neither  of  which  are  in  any  way  dis- 
tinctive. It  is  not  possible  to  say  in  a  given  case  that  the  condition  has 
been  due  to  gout  unless  marked  evidences  of  the  disease  coexist. 

The  metatarso-])halangcal  joint  of  the  big  toe  should  be  carefully  ex- 
amined, as  it  may  show  typical  lesions  of  gout  without  any  outward  token 
of  arthritis. 

Arterio-sclerosis  is  a  very  constant  lesion.  AVith  it  the  heart,  particu- 
larly the  left  ventricle,  is  found  hypertrophicd.  According  to  some  authors, 
concretions  of  urate  of  soda  may  occur  on  the  valves. 

Changes  in  the  respiratory  system  are  rare.  Deposits  have  l)ceii  found 
in  the  vocal  cords,  and  uric-acid  crystals  have  heen  met  in  the  sputa  of  a 
gouty  patient  (J.  W.  ^Moore).  Emphysema  is  a  very  constant  condition 
in  old  cases. 

Symptoms. — (rOut  is  usually  divided  into  acute,  chronic,  and  irregti- 
lar  forms. 

Acute  Gout.— Premonitory  symptoms  are  common — twinges  of  pain  in 
the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irritability  of 
temper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high-colored.  It 
(lei)osits  urates  on  cooling,  and  there  may  be,  according  to  Garrod,  tran- 
sient al])uminuria.  There  may  he  traces  of  sugar  (gouty  glycosuria).  r)efore 
iin  attack  the  output  of  uric  acid  is  low  and  is  also  diminished  in  the  early 
part  of  the  paroxysm.  The  relation  of  uric  and  iihosphoric  acids  to  the 
acute  attacks  is  well  represented  m  Chart  XIV,*  prepared  by  Futcher. 


0 


*  The  uric  acifl  was  dpterminod  by  the  Gowhmd-Hopkins  method  and  the  phosphoric 
acid  by  the  uranium-nitrate  process. 


412 


CONSTITUTIONAL   DISEASES. 


Jiotli  wore  oxtrcinely  low  in  the  intervals,  hut  renehod  within  normal  limits 
shortly  after  tlie  onset  of  the  aeiite  8ymi)t()m«.  The  phospiioric  aeid  and 
urie  acid  show  almost  ])arallel  eiirves.  'JMie  ])alient  was  on  a  very  lij^dit  diet 
at  the  time  I  he  <leterminations  were  made,     in  some  instances  the  throat 


/ 


If- 


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Chart  XIV. — Showing  uric  acid  and  phospiioric  acid  output  in  case  of  acute  gout. 


is  sore,  and  there  may  be  asthmatic  sym])tonis.  The  attack  sets  in  usually  in 
the  early  morning  hours.  The  patient  is  aroused  by  a  severe  pain  in  the 
metatarso-phalangeal  articulation  of  the  big  toe,  and  more  commonly  on 


GOUT. 


413 


gout. 


IIr'  ri<;Iil  tlinn  on  tlio  K'ft  side.  The  pain  is  ngonizin<:,  jind,  as  Sydunluini 
says,  "  insinnatoM  ilsell'  willi  the  most  I'xqnisitc  crnclty  amon;,'  llic  nninur- 
oiis  small  hones  ol'  the  tarsus  and  mctalai'sns,  in  tin,"  li^ianu'iils  ol'  which  it 
is  lu^kint,^"  'J'he  joint  swells  rapidly,  and  heeomes  hot,  fl'nse,  and  shiny. 
The  sensitiveness  is  extreme,  and  the  pain  makes  the  jiatient  I'eel  as  if  the 
joint  we.'e  hein^^  jtressed  in  a  \\vv.  'I'here  is  I'ever,  and  the  temperature  may 
lise  to  l(»"-i°  or  lo.'r.  'J'oward  mornin*^  the  severity  of  the  symptoms  sub- 
sides, and,  although  the  joint  remains  swollen,  the  day  may  he  passed  in 
(■(tniparative  eoml'ort.  The  symptoms  reeur  the  next  niju'ht,  and  the  tit, 
as  it  is  called,  usually  lusts  for  from  live  to  eij^ht  days,  the  severity  of  the 
symptoins  {;rMdually  ahatinj;.  Occasionally  other  joints  are  involved,  ])ar- 
ticularly  the  hi^''  toe  of  the  o|)|)osite  foot.  The  iidlammation,  howevi'r  in- 
tense, never  fioes  on  to  suppuration.  With  the  subsidence  of  the  swelling 
the  skin  desquamates.  After  the  attack  the  general  health  may  be  much 
im])roved.  As  Aretanis  remarks,  a  person  in  the  interval  has  won  the  race 
at  the  Olympian  games.  K'ecurrences  arc  freciuent.  Some  ])atients  have 
three  or  four  attacks  in  a  year;  others  at  longer  intervals. 

The  term  rrlrorrdcnl  or  t^ii/iprcsscd  gout  is  ajiplied  to  serions  internal 
sym|)toms,  coincident  with  a  ra])i(l  disappearance  or  improvement  of  the 
local  signs,  ^'ery  remarkable  manifestations  may  occur  nnder  these  cir- 
cumstances. The  ])ati('nt  may  have  severe  gastro-intestinal  symptoms — 
pain,  vomiting,  diarrluea,  and  great  depression — and  death  may  occur  dur- 
ing snch  an  attack.  Or  there  may  be  cardiac  manifestations — dyspmea, 
])ain,  and  irregular  action  of  the  heart.  \n  some  instances  in  which  the 
gont  is  said  to  attack  the  heart,  an  acute  ])ericarditis  develo])s  and  ])roves 
fatal.  So,  too,  there  may  be  marked  cerebral  manifestations — delirium 
or  coma,  and  even  ajxtplexy — but  in  a  majority  of  these  instances  the 
?ym])toms  are,  in  all  prohability,  nra'inic. 

(iout  is  a  com])aratively  rare  disease  in  America.  Among  the  well-to-do, 
and  even  among  club-men — a  class  ])articularly  liable — it  is  infrequent,  in 
comparison  Avith  the  ])revalence  in  the  corres])onding  classes  in  I'lngland. 
Mvn  in  large  family  ]>ractice  may  i)ass  a  year  or  more  without  seeing  a  case. 
It  has  hecome  more  common,  however,  during  the  })ast  twenty-five  years, 
and  r  find  a  marked  increase  in  hos])ital  i)ractice. 

Chronic  Gout. — "With  increased  frequency  in  the  attacks,  the  articular 
symptoms  pei'sist  for  a  longer  time,  and  gradually  many  joints  become 
alTected.  Deposits  of  urates  take  place,  at  first  in  the  articular  cartilages 
and  then  in  the  ligaments  and  capsular  tissues;  so  that  in  the  course  of 
yciirs  the  joints  Ix'come  swollen,  irregular,  and  dt'formed.  The  feet  are 
usually  first  affected,  then  the  hands.  In  severe  cases  there  may  be  extensive 
(oncreti(ms  about  the  elbows  and  knees  and  along  the  tendons  and  in  the 
liursa\  The  to])hi  a])])ear  in  the  cars,  l-'inally,  a  unicpie  clinical  ])icture  is 
nroduced  which  cannot  he  mistr.ken  for  that  of  any  other  afTection.  The 
^kin  over  the  to])hi  may  ru])ture  or  ulcerate,  ami  ahout  the  knuckles  the 
I  linlk-stones  may  1k>  freely  exposed.  I'alients  with  chronic  gout  are  usually 
ilvspe])tic,  often  of  a  sallow  complexicui.  and  show  signs  of  arterio-sclcrosis. 
Tlu'  ])ulse  tension  is  incrensed,  the  vessels  are  stiff,  and  the  loft  ventricle 
i~  hypcrtrophied.  The  urine  is  increased  in  amount,  is  of  low  spoeiflc  grav- 
26 


I 

I 


I 


4U 


CONSTITUTIONAL  DISEASES. 


/ 


ity,  and  usimlly  contains  n  plight  amount  of  a]l)iiniin,  \v\i\\  a  few  liyalino 
casts.  Intcrcurrt'nt  attacks  of  acaito  i)()lyartiiritis  may  (l('velo|),  in  which 
the  joints  become  inllanied,  and  tiie  temperature  ranj^es  from  101°  to  1015°, 
'{'here  may  be  \)Mn,  redness,  and  swelling  of  several  joints  without  fever. 
Urieniia,  ]ilenrisy,  ])eric'arditis,  peritonitis,  and  meningitis  are  common  ter- 
minal all'ections.  I'atients  with  chronic  gout  may  show  renuirkable  mental 
and  even  bodily  vigor.  Certain  of  the  most  distinguished  membi'rs  of  our 
j)roi'esssion  have  l)een  terrible  sufferers  froui  tiiis  (.lisease,  notably  the  elder 
Scaliger,  Jerome  Cardan,  and  Sydenham,  whose  statement  that  '"  more 
wise  men  than  fools  are  victims  of  the  affection  "  still  holds  good. 

Irregular  Gout. — 'I'his  is  a  motley,  ill-defined  group  of  symptoms,  mani- 
festations of  a  coiulition  of  disordered  nutrition,  to  which  the  terms  (joulij 
dialliesis  or  Ulluvitnc  state  have  been  given.  Cases  are  seen  in  mend)ers  of 
gouty  families,  who  mav  never  themselves  have  suffered  from  the  acute 
disease,  and  in  persons  who  have  lived  not  wisely  but  too  well,  who  have 
eaten  and  drunk  largely,  lived  sedentary  lives,  and  yet  have  been  fortunate 
enough  to  cscajjc  an  acute  attack.  It  is  interesting  to  note  the  various 
manifestations  of  the  disease  in  a  family  M'ith  marked  hereditary  disposi- 
tion. The  daughters  often  escape,  -while  one  son  may  have  gouty  attacks 
of  great  severity,  even  though  he  lives  a  temperate  life  and  tries  in  every 
way  to  avoid  the  comlitions  favoring  the  disorder.  Another  .son  has,  i)er- 
ha])s,  only  the  irregular  manifestations  and  never  the  acute  articular  affec- 
tion. "While  the  irregular  features  are  perhaps  more  often  met  with  in 
the  hereditary  affection,  they  are  by  no  means  infrequent  in  persons  who 
a]i])ear  to  have  acquired  the  disease.  Tlie  tendency  in  some  families  is  to 
call  every  affection  gouty.  Even  infantile  comjdaints,  such  as  scald-head, 
naso-])haryngeal  vegetations,  and  enuresis,  are  often  regarded,  without  suf- 
ficient grounds,  I  l)elieve,  as  evidences  of  the  family  ailment.  Among  the 
commonest  manifestations  of  irregular  gout  are  the  following: 

(a)  Cutaneous  Eruptions. — Garrod  and  others  have  called  sjjccial  atten- 
tion to  the  frequent  association  of  eczema  with  the  gouty  habit.  The 
French  in  particular  insist  upon  the  special  liability  of  gouty  persons  to 
skin  affections,  the  arthritUlcs,  as  they  call  them. 

{h)  Gastro-intcstinal  Disorders. — Attacks  of  what  is  termed  biliousness, 
in  which  the  tongue  is  furred,  the  breath  foul,  the  bowels  constipated,  and 
the  action  of  the  liver  torpid,  are  not  imcommon  in  gonty  persons.  A 
gouty  ])arotitis  is  described. 

(r)  Cantin-rasnilar  Si/mptoms. — "With  the  litha>mia,  artcrio-sclerosis  is 
frequently  associated.  The  blood  tension  is  persistently  high,  the  vessel 
walls  bo'-'ome  stiff,  and  cardiac  and  renal  changes  gradually  develo]).  In 
this  condition  the  manifestations  may  he  renal,  as  when  the  albuminuria 
becomes  more  marked,  or  dropsical  symptoms  su])ervene.  The  manifesta- 
tions may  be  cardiac,  when  the  hypertrophy  of  tlie  left  ventricle  fails  and 
there  are  ]ialpitation,  irrcgidar  action,  and  ultimately  a  condition  of  asys- 
tole. Or,  finally,  the  manifestations  may  be  vascular,  and  thrombosis  of 
the  coronary  arteries  may  cause  sudden  death.  Aneurism  may  develop  and 
prove  fatal,  or,  as  most  frequently  happens,  a  blood-vessel  gives  way  in 
the  brain,  and  the  patient  dies  of  apojdexy.     It  makes  but  little  difference 


GOUT. 


415 


In 

muri'ci 

festa- 

Is  and 

a?y^- 

i8is  of 

])  and 

:ay  in 
erencc 


wlicthor  wo  rorfard  tliis  condition  as  jjriinarily  an  artcrio-sclcrosis,  or  as  a 
gouty  nephritis;  the  point  to  be  remeinbered  is  that  the  nutritional  dis- 
order with  wiiic'h  an  excess  of  iiric  acid  is  associated  induces  in  time  in- 
creased tension,  arterio-sclerosis,  chronic  interstitial  nephritis,  and  changes 
in  the  myocardium.  I'ericarditis  is  not  an  infrecpient  terminal  complica- 
tion of  gout. 

(</)  Xervons  Manifcfitations. — Headache  aiul  megrim  attacks  are  not 
infrequent.  ]laig  attril)utes  them  to  an  excess  of  uric  acid.  Neuralgias  arc 
not  uncommon;  sciatica  and  i)anvsthesias  may  develop.  A  common  gouty 
manifestation,  ui)on  which  Duckworth  has  laid  stress,  is  the  occurrence  of 
hot  or  itching  feet  at  night.  I'lutarch  mentions  that  Strabo  called  this 
sym])tom  "  the  lis])ing  of  tlie  gout."  Cramps  in  the  legs  may  also  be  very 
troublesome.  Hutchinson  has  called  attention  to  hot  aiul  itching  eyeballs 
as  a  frequent  sign  of  nuisked  gout.  ]\rore  serious  cerebral  manifestations 
result  from  a  condition  of  arterio-sclerosis.  Apofjlexy  is  a  common  termina- 
tion of  gout.    Meningitis  nuiy  develoj),  usually  basilar. 

(e)  Urinarij  Disorders. — The  urine  is  highly  acid  and  higli-colored,  and 
may  dejjosit  on  standing  crystals  of  litbic  acid.  Transient  and  temporary 
increase  in  this  ingredient  cannot  be  regarded  as  serious.  In  nuiny  cases 
of  chronic  gout  the  amount  nuvy  l)e  diminished,  and  only  increased  at  cer- 
in  periods,  forming  the  so-called  uric-acid  showers.  The  chart  on  page  4i'i 
illustrates  this  very  well.  Sugar  is  found  intermittently  in  the  urine  of 
gouty  persons — gouty  glycosuria.  It  nuiy  i)ass  into  true  diabetes,  Ijut  is 
usually  very  amenable  to  treatment.  Oxaluria  may  also  be  present.  Gouty 
])ersons  are  specially  prone  to  calculi,  Jerome  Cardan  to  the  contrary,  who 
reckoned  freedom  from  stone  among  the  chief  of  the  dona  padai/ra'.  Minute 
quantities  of  albumin  are  very  common  in  jjcrsons  of  gouty  dyscrasia,  and, 
when  the  renal  changes  arc  well  established,  tube-casts.  Urethritis,  accom- 
panied with  a  well-marked  ])urulent  discharge,  may  develop,  so  it  is  stated, 
usually  at  the  end  of  an  attack.  It  may  occur  spontaneously,  or  follow  a 
pure  connection. 

(/)  Pxdmonary  Disorders. — There  are  no  characteristic  changes,  but, 
as  (Ireenhow  has  pointed  out,  chronic  bronchitis  occurs  with  great  fre- 
quency in  persons  of  a  gouty  habit. 

(fl)  Of  eye  affections,  iritis,  glaucoma,  luTmorrhagic  retinitis,  and  sup- 
purative panopthalmitis  have  been  descril)ed. 

Diagnosis. — Recurring  attacks  of  arthritis,  limited  to  the  big  toe  and 
to  the  tarsus,  occurring  in  a  member  of  a  gouty  family,  or  in  a  man  who 
has  lived  too  well,  h  e  no  question  as  to  tlie  nature  of  the  trouble.  There 
are  many  cases  of  gout,  however,  in  which  the  feet  do  not  suffer  most  se- 
verely. After  an  attack  or  two  in  one  toe,  other  joints  may  1)0  affected, 
and  it  is  just  in  such  cases  of  polyarthritis  that  the  ditficulty  in  diagnosis  is 
apt  to  arise.  We  have  had  of  late  years  several  cases  admitted  for  the  third 
or  fourth  time  Avith  involvement  of  throe  or  more  of  the  larger  joints.  The 
presence  of  tophi  has  settled  the  nature  of  a  trouble  which  in  the  previous 
attacks  had  been  regarded  as  rheumatic.  The  following  are  suggestive 
points  in  such  cases:  (1)  The  patient's  habits  and  occupation.  In  this  coun- 
try the  brewery  men  and  barkeepers  are  often  aflFected.     (2)  The  presejioe 


^i 


416 


CONSTITUTIONAL.   DISEASES. 


/ 


of  loplii.  Tlie  ears  Hlioiild  iilway.s  hi'  IVIt  in  a  case  ol"  polyarthritis,  Tho 
iliagnosis  may  rest  with  a  *?iiiall  tophus.  Thu  student  shoukl  Icarii  to  rccoj^- 
iii/.c  on  tlic  car  margin  Woolncr's  tip,  fiiiroid  nodules,  and  small  si-hiict'ous 
tumors,  'i'he  latter  are  easily  reeo^Mii/.ed  nueroscopiciilly.  'I'he  urate  of 
Hoda  cystals  are  distinctive  in  thu  tophi.  (;{)  'JMie  condition  of  the  urine. 
As  shown  in  Chart  XW,  the  urir-Mcid  output  is  usually  vci'v  low  durin<; 
the  intervals  of  the  ])aroxysm.  There  nuiy,  indeed,  he  no  excretion  what- 
ever. At  the  heiiiht  of  the  attack  the  elimination,  as  a  rule,  is  <ireatly  in- 
creased. The  ratio  of  the  uric  acid  to  the  urea  excretion  is  dit^turhed  in 
gouty  eases,  and  may  fall  as  low  as  1  to  ()0  or  1  to  80.  { I)  The  gouty  poly- 
arthritis may  be  afebrile.  A  ])atient  with  three  or  four  joints  red,  swollen, 
and  ])ainfid  in  acute  rheumatism  has  fever,  and,  while  ])yrexia  may  be  ])res- 
ent  ami  often  is  in  gout,  its  absence  is,  I  tliink,  a  valuable  diagnostic  sign. 

Treatment. — ///////c/ftV.  —Individuals  who  have  inherited  a  tendency 
to  gout,  or  who  have  shown  any  manifestations  of  it,  should  live  temper- 
ately, abstain  from  alcohol,  and  eat  moderately.  An  open-air  life,  with 
])lenty  of  exercise  and  regular  hours,  does  much  to  counteract  an  inborn 
teiulency  to  the  disease.  The  skin  should  be  kei)t  active:  if  the  i)atient  is 
robust,  by  the  morning  cold  bath  with  friction  after  it;  but  if  he  is  weak 
or  del)ilitated  the  evening  warm  hath  should  be  substitutecl.  An  occa- 
sional Turkish  bath  with  active  shampooing  is  very  advantageous.  The 
])atient  should  dress  warndy,  avoid  rapid  alterations  in  temperature,  and 
be  careful  not  to  have  the  skin  suddenly  chilled. 

Dictelic. — "With  few  exce|)tions,  persons  over  forty  eat  too  much,  and 
the  first  injunction  to  a  gouty  ])erson  is  to  keep  his  a])pctite  within  reason- 
able bounds,  to  eat  at  stated  hours,  and  to  take  ])lenty  of  time  at  his  meals. 
In  the  matter  of  food,  quantity  is  a  factor  of  inore  importance  than  quality 
with  many  gouty  ])ersons.  As  Sir  William  Eoberts  well  says,  "  Xowdiero 
])erha])S  is  it  more  necessary  than  in  gout  to  consider  the  num  as  well  as 
the  ailment,  and  very  often  more  the  man  than  the  ailment." 

Xl'VX  renuirkable  diU'erences  of  opiiuon  exist  as  to  the  most  suitable 
diet  in  this  disease,  some  urging  warmly  a  vegetable  diet,  others  allowing 
a  very  liberal  amount  of  meat.  On  the  one  band,  the  author  just  quoted 
says:  '"  The  most  trustworthy  experiments  indicate  that  fat,  starch,  and 
sugar  have  not  the  least  direct  influence  on  the  ])roduction  of  uric  acid: 
but  as  the  free  consunijjtion  of  these  articles  naturally  o])erates  to  restrict 
the  intake  of  the  nitrogenous  food,  their  use  has  indirectly  the  effect  of 
diminishing  the  average  production  of  uric  acid.''  On  the  other  hand, 
\V.  11.  l)ra|)er  says:  "The  conversion  of  azotized  fo'  !  is  more  complete 
with  a  minimum  of  carbohydrates  than  it  is  with  an  excess  of  them;  in 
other  words,  one  of  the  best  means  of  avoiding  the  accumulation  of  lithio 
acid  in  the  blood  is  to  diminish  the  carbohydrates  rather  than  the  azotized 
foods."     The  weight  of  opinion  leans  to  the  use  of  a  modified  nitrogenous 


diet,  without 
tables  and  fru 


excess  in  starchy  and  saccharine  articles  of  food.     Fresh  vege- 
mav  be  used  freclv,  Imt  among  the  latter  straAvberries  and 


bananas  should  be  avoided. 

Elistcin  urges  strongly  the  use  of  fat  in  the  form  uf  good  fresh  butter, 
from  2-i  to  3-\  ounces  in  the  day.     lie  says  that  stout  gouty  subjects  not 


GOUT. 


417 


iital)k' 


only  do  not  incronsc  in  wcifjlit  witli  plenty  of  I'lit  in  tlic  I'ood,  luit  tluit  tlu'y 
iictiially  hi'conio  thin  and  the  jicnLTal  condition  iinprovos  very  much.  Hot 
bread  of  all  sorl.s  and  the  various  artieleri  of  food  {)re|)ared  from  Indian 
corn  should,  as  a  rule,  he  avoide  1.  Koherts  advises  ^'outy  ])atients  to  re- 
strict as  far  as  j)ractieahle  the  use  of  eonimon  salt  with  their  meals,  since 
the  sodium  hinrate  very  leadily  crystallizes  out  in  tissues  with  a  high  per- 
centage  )!'  sodium  salts. 

In  this  matter  of  diet  each  individual  case  must  receive  separate  con- 
sideration. 

There  are  very  k'w  conditions  in  the  gouty  in  which  stimulants  of  any 
sort  are  required.  Whenever  indicated,  whisky  will  be  found  perhaps  the 
most  serviceable.  AVJiile  all  are  injurious  to  these  i)atients,  some  are  much 
more  so  than  otliers,  particularly  malted  liijuors,  champagne,  i)ort,  and  a 
very  large  ])ro])ortion  of  all  the  light  wines. 

Mineral  Walcrs. — All  forms  may  l)e  said  to  be  beneficial  in  gout,  as  the 
main  element  is  the  water,  and  the  ingredients  are  usually  indill'erent. 
Much  of  the  hnnd)Uggery  in  the  profession  still  lingers  al)out  mineral  waters, 
more  particularly  about  the  so-called  lithia  waters.  For  a  careful  consid- 
eration of  the  (piestion  the  reader  is  referred  to  William  Muart's  recent 
work  on  (jout  and  Goutiness. 

The  question  of  the  utility  of  alkalies  in  the  treatment  of  gout  is 
closely  connected  with  this  subject  of  ndneral  waters.  This  deep-rooted 
belief  in  the  profession  was  rudely  shaken  a  few  years  ago  by  Sir  William 
Roberts,  who  claims  to  have  shown  conclusively  that  alkalescence  as  such 
has  no  influence  whatever  on  the  sodium  l)iurate.  The  sodium  salts  arc 
believed  by  this  author  to  be  particularly  harmful,  but,  in  spite  of  all  the 
theoretical  denunciation  of  the  use  of  the  sodium  salts  in  gout,  the  gouty 
from  all  i)arts  of  the  world  Hock  to  those  very  Continental  s])rings  in  which 
these  salts  are  most  predominant. 

Of  the  mineral  springs  best  suited  for  the  gouty  may  l)e  mentioned, 
in  this  country,  those  of  Saratoga,  Hedford,  and  the  White  Sulphur;  Jiuxton 
and  Bath,  in  England;  in  France,  Aix-les-jBains  and  Cuntrexeville;  and  in 
Germany,  ('ar]sl)ad,  Wildbad,  and  llomburg. 

The  eflficacy  in  reality  is  in  the  water,  in  the  way  it  is  taken,  on  an 
empty  stomach,  and  in  large  quantities;  and,  as  every  one  knows,  the  im- 
portant accessories  in  the  modified  diet,  i)roper  hours,  regular  exercise, 
with  l)aths,  douches,  etc.,  i)]ay  a  very  imjiortant  rule  in  the  "  cure." 

Medicinal  Treatment. — In  an  acute  attack  the  liml)  should  he  elevated 
and  the  affected  joint  wra])ped  in  cotton-wool.  Warm  fomentations,  or 
Fuller's  lotion,  may  be  used.  The  local  hot-air  t'-eatment  may  be  tried. 
A  Ijrisk  mercurial  ])urge  is  always  advantageous  at  the  outset.  I'he  wine 
or  tincture  of  colchicum,  in  doses  of  20  to  30  minims,  may  be  given  every 
four  hours  in  combination  with  tlie  citrate  of  potash  or  tlie  citrate  of 
lithium.  Tlie  action  of  the  colchicum  should  be  carefully  watched.  It 
has,  in  a  majority  of  the  cases,  a  ])owcrful  inlluencc  over  the  symptoms — 
relieving  the  pain,  and  reducing,  sometimes  with  great  rapidity,  the  swell- 
ing and  redness.  It  should  be  promptly  stopped  so  soon  as  it  has  relieved 
the  pain.    In  cases  in  which  the  pain  and  sleeplessness  are  distressing  and 


I 


418 


CONSTITUTIONAL   DISEASES. 


/ 


do  not  yield  to  coluliicniiii,  luorpliiii  is  lu'ccssary.  TIil'  patient  should  be 
pliiced  on  u  diet  cliielly  oi'  niiliv  and  barley-water,  but  it  tiierc  is  any  dc- 
l)ility,  stronj;  broths  may  l)e  ^dven,  or  v^aa.  It  is  oeeasionaily  necessary  to 
give  small  (juantities  of  stimulants.  I>uriu<,'  eonvaleseenee  meats  and  lish 
and  jrame  may  be  taken,  and  gradually  tiie  ])atient  may  resume  the  diet 
jireviousiy  laid  down. 

Jn  soine  of  the  sul)acute  intercurrent  attacks  of  arthritis  in  old,  de- 
formed joints,  the  sodium  salicylate  is  occasionally  useful,  but  its  adminis- 
tration must  be  watched  in  cases  of  cardiac  and  ri'ual  insulliciency.  It  is 
also  much  advocated  by  llaig  in  the  ui-ic-acid  habit. 

The  chronic  and  irregular  forms  of  gout  are  best  treated  by  the  dietetic 
and  hygienic  measures  already  referred  to.  Iodide  of  potassium  is  some- 
times useful,  and  ])rei)arations  of  guaiacum,  (luinine,  and  the  bitter  tonics 
combined  with  alkalies  are  undoubtedly  of  benefit. 

rijjerazin  has  been  much  lauded  as  an  eilicient  aid  in  the  Bolution  of 
uric  acid.  The  clinical  results,  however,  are  very  discordant.  It  may  be 
em))loyed  in  doses  of  from  15  to  30  grains  in  the  day,  and  is  conveniently 
given  in  aerated  water  containing  5  grains  to  the  tumblerful. 


V.    DIABETES    MELLITUS.* 

Definition. — A  disorder  of  nutrition,  in  which  sugar  accumulates  in 
the  blood  and  is  excreted  in  the  urine,  the  daily  amount  of  which  is  greatly 
increased. 

For  a  case  to  be  considered  one  of  diabetes  mellitus  it  is  necessary,  ac- 
cording to  von  Noorden,  that  the  form  of  sugar  eliminated  in  the  urine 
be  grape  sugar,  that  it  must  be  eliminated  for  weeks,  months,  or  years,  and 
that  the  excretion  of  sugar  must  take  place  after  the  ingestion  of  moderate 
amounts  of  carl)ohydrates. 

Etiology. — Ifcredilan/  influences  ])lay  an  important  role,  and  cases 
arc  on  record  of  its  occurrence  in  many  members  of  the  same  family.  Of 
the  77  cases  which  have  been  treated  in  the  medical  wards  and  dispensary 
of  the  Johns  Hopkins  Ilos])ital,  only  2  gave  a  history  of  diabetes  in  relatives 
(Futchcr).  '^riiere  are  instances  of  the  coexistence  of  the  disease  in  man  and 
wife.  Schmidt  first  drew  attention  to  the  ])ossil)ility  of  diabetes  being  con- 
tagious. Out  of  his  series  of  2,320  cases  he  believed  that  2fi  instances  were 
the  result  of  contagion.  In  the  majority  of  the  cases  the  wife  contracted 
the  disease  later  than  the  husband.  Sex. — ^len  are  more  frequently  affected 
than  women,  the  ratio  being  about  three  to  two.  Forty-seven  cases  of  the 
hos]ntnl  series  were  in  males  and  30  in  females.  It  is  a  disease  of  adult  life; 
a  majority  of  the  cases  occur  from  the  third  to  the  sixth  decade.  Of  the 
77  cases,  the  largest  number — 2-4,  or  31.1  per  cent — occurred  between  fifty 

*  Since  the  spcond  edition  of  this  work  the  literature  has  been  enricherl  by  Pavy's 
Croonian  Lectures,  the  second  edition  of  Saundby's  work,  the  monographs  of  von  Noor- 
den (2d  cd..  1808)  and  Williannson,  and  by  the  mapnifieent  work  of  Naunyn  (1898),  which 
unfortunately  arrived  too  late  to  be  fully  utilized  for  the  revision. 


DIAHETES  MELLITl'S. 


419 


ac- 


iind  sixty  years  of  n<:{\  'riicsci  li^Miri's  i\jn\'i.'  closely  with  thosu  of  Froru-lis, 
Sci'^'cii,  and  I'avy,  all  u!  whom  [omul  tlu-  larj^'csl  niiiiiber  ol'  cases  in  the 
sixth  decade,  tlieir  jjcrceiita^fi's  heiii},'  2(},  30,  and  30.7  respectivoly.  It  is 
rare  in  childhood,  hut  cases  are  on  record  in  children  under  one  year  of 
aj^e.  J'crsons  of  a  neurotic  tniijicnniinit  are  often  allVcted.  It  is  a  disease 
of  the  hi<,dier  classes.  \'on  Xoorden  states  that  the  statistics  for  London 
and  Berlin  show  that  the  nundjcr  of  cases  in  the  ui)|ier  ten  thousand  ex- 
ceeds that  in  the  lower  hundred  thousand  inhabitants.  Jiace. — Ilel)rews 
sfcni  especially  prone  to  it;  one  fourth  of  Frerichs'  patients  were  of  the 
Semitic  race.  I  have  hcen  much  impressed  with  the  frecjuency  of  the  dis- 
ease anu)njf  them.  Of  the  last  l(i  cases  which  1  have  had  in  private  practice,8 
were  in  Hebrews.  Diahetcs  is  comi>aratively  rare  in  the  colored  race,  but  not 
so  uncommon  as  was  formerly  supposed.  Of  the  series  of  77  cases,  8,  or  10.3 
per  cent,  were  in  negroes  (Futcher).  The  ratio  of  males  to  females  atfected 
is  almost  exactly  the  reverse  of  that  in  the  white  race;  3  of  the  8  cases  were 
in  males  and  5  in  females.  In  a  considerable  ])roi)ortion  of  the  cases  of 
diabetes  the  subjects  have  been  excessively  fat  at  the  beginning  of,  or  prior 
to,  the  onset  of  the  disease.  A  slight  trace  of  sugar  is  not  very  uncommon 
in  obese  persons.  This  so-called  lij)ogenic  glycosuria  is  not  of  grave  signiti- 
cance,  and  is  only  occasionally  followed  by  true  diabetes.  On  the  other 
hand,  as  von  Noorden  has  shown,  there  may  be  a  "  dialjetogenous  obesity," 
in  which  diabetes  and  obesity  develo])  in  early  life,  and  these  cases  are  very 
unfavorable.  There  are  instances  on  record  in  which  obesity  with  diabetes 
has  occurred  in  three  generations.  Diabetes  is  more  common  in  cities  than 
in  country  districts.  Gout,  syphilis,  and  malaria  have  been  regarded  as  pre- 
disposing causes.  Burdel  and  Calmette  think  that  malaria  is  an  important 
predisposing  etiological  factor.  In  only  1  of  the  77  cases  could  malaria 
be  considered  more  than  a  possible  cause  of  the  diabetes  (Futcher).  ^lental 
shock,  severe  nervous  strain,  and  worry  ])recede  many  cases.  In  one  case 
the  symptoms  came  on  suddenly  after  the  ])atient  had  been  nearly  suffocated 
by  smoke  from  having  been  confined  in  a  cell  of  a  burning  jail.  Shock 
and  the  toxic  effects  of  the  smoke  may  both  have  been  factors  in  this  case. 
The  combination  of  intense  application  to  business,  over-indulgence  in  food 
and  drink,  with  a  sedentary  life,  seems  particularly  prone  to  induce  the  dis- 
ease. Glycosuria  may  set  in  during  pregnancy,  and  in  rare  instances  may 
only  occur  at  this  period.  Trousseau  thought  that  the  offs])ring  of  phthisi- 
cal parents  were  particularly  prone  to  diabetes.  I njurii  to  or  disease  of  the 
spinal  cord  or  brain  has  been  followed  by  diabetes.  In  the  carefully  ana- 
lyzed cases  of  Frerichs  there  were  30  instances  of  organic  disease  of  these 
jiarts.  The  medulla  is  not  always  involved.  In  only  4  of  his  cases,  which 
showed  organic  disease,  was  there  sclerosis  or  other  anomaly  of  this  part. 
An  irritative  lesion  of  Bernard's  diabetic  centre  in  the  medulla  is  an  occa- 
sional cause.  I  saw  with  Eeiss.  at  the  ^  'edrichshain,  Berlin,  a  woman  who 
had  anomalous  cerebral  symptoms  and  diabetes,  and  in  whom  there  was 
found  post  mortem  a  cysticcrcus  in  the  fourth  ventricle.  Ebstcin  has  re- 
cently recorded  4  cases  in  which  there  was  a  coincident  occurrence  of  epi- 
lepsy and  diabetes  mellitus.  ITe  thinks  that  in  the  majority  of  cases  the 
two  diseases  are  dependent  on  a  common  cause.     He  believes  that  the  asso- 


420 


CONSTITUTIONAL  DISEASKS. 


/ 


ciation  woiiM  lie  loimd  iiiiicli  iiioro  commonly  in  iliU'k.soiuun  ('|tili'|isy  (luui 
lias  lii'cii  till'  cHisu  luTL'tolore,  ii'  more  curcl'iil  and  yvstcmatic  examinations 
(if  the  mine  ucrc  mado. 

'I'lic  disease  lias  occasionally  followed  the  iiifcrHoiis  fvri'rs.  Cases  have 
been  recorded  as  occurring'  during'  or  immediately  after  diiilitlieria,  inllii- 
eiiza,  rlieiiniatism,  enteric  fever,  and  sypliilis.  A  few  cutios  have  followed 
injury  without  involvement  of  the  hrain  or  cord. 

In  comparison  with  its  ineidenee  in  Kuropean  countries  diabetes  is  a  rare 
disease  in  Anu'rica.  'i'he  last  census  {jfavo  only  •'i.N  per  !()(», 000  of  popula- 
tion, ajjainst  a  ratio  of  from  .")  to  11  in  the  former.  The  death-rate  has  been 
jiradually  on  the  increase  in  Paris  durinff  the  last  three  or  four  decades, 
reachin;,'  11  to  the  100,000  of  ]iopulati()n  in  181>1.  I'or  the  same  year  the 
mortality  in  Malta  was  i;{.l  to  the  100.000  of  |»opulati(in.  The  disease  is 
^n'adually  on  the  increase  in  the  I'nited  States.  The  statistics  for  JSTO  ^^ave 
2A;  for  IHHO,  2.8;  and  for  1S!)0,  .'5.8  deaths  to  the  100,000  population.  In 
this  re^'ion  the  incidence  of  the  disease  may  be  gathered  from  the  fact  that 
among  170,000  ]iatients  binder  treatment  at  the  Johns  Hopkins  Hospital 
and  Dispensary  during  the  nine  years  since  its  opening  there  have  been  7T 
cases.  During  the  nine  year.s  5"^', 000  medical  cases  were  treated,  the  dia- 
betic patients  constituting  only  U.14  per  cent  of  these  (Futcher).  From  a 
study  of  the  statistics  of  JeH'erson  College  Ilosjiital,  Hare  concludes  that 
diabetes  is  becoming  more  common. 

We  are  ignorant  of  the  nature  of  the  disease.  Normally  the  carbo- 
hydrates taken  with  the  food  are  stored  in  the  liver  and  in  the  mnscles  as 
glycogen,  and  then  iitilized  as  needed  by  the  system.  (Ilycogen  can  also 
be  formed  from  the  proteids  of  the  food,  and  nndcr  certain  circumstances 
sugar  may  be  directly  formed  from  the  body  iiroteids.  Whenever  the 
sugar  in  the  systenuc  blood  exceeds  a  delinite  amount  (about  0.2  ]ier  cent) 
it  is  discharged  by  the  kidneys,  jjroducing  glycosnria.  Theoretically  dia- 
betes may  be  su})posed  to  be  induced  by: 

(a)  The  ingestion  of  a  larger  quantity  of  carboliydrates  and  ])e])tonos 
than  can  be  warehoused,  so  to  sjieak,  in  the  liver  as  glycogen,  so  that  ])art 
has  to  pass  over  into  the  hepatic  blood.  Some  of  the  instances  of  lipogenic 
or  dietetic  glycosuria  are  of  this  nature, 

(/>)  Disturbances  of  the  liver  function:  (1)  Changes  in  the  circulation 
under  nervous  influences.  Puncture  of  the  medulla,  lesions  of  the  cord, 
and  central  irritation  of  vario^is  kinds  are  followed  by  glycosuria,  which 
is  attributed  to  a  vaso-motor  ]iaralysis  (more  ra])id  lilood-How)  induced 
by  these  causes.  On  this  view  the  disease  is  a  neurosis.  (?)  Instability  of 
the  glycogen,  owing  eitlier  to  imperfect  formation  or  to  conditions  in  the 
cells  which  render  it  less  stable.  Phloridzin  and  other  substances  Avhich 
cause  diabetes  very  ])robably  act  in  this  Avay;  phloridzin  acts  ])rimarily  on 
the  renal  epitlieliuni,  destroying  its  power  of  keeping  back  the  sugar.  As 
to  the  possibility  of  a  renal  form  of  diabetes  in  man,  consult  Xaunyn, 
page  106. 

(c)  Defective  assimilation  of  the  glucose  in  the  system.  TTow  and  under 
what  normal  circumstances  the  sugar  is  utilized  we  do  not  yet  know. 
Theoretically  faulty  metabolism  would  explain  the  condition. 


DIAUKTKS   MKI.LlTrS. 


421 


olios 

l)!ll't 

it  ion 

.'ord, 

hicli 

need 

ty  of 

n  the 

vliich 

V  on 

Ah 

unvn, 


Morbid   Anatomy.— Siiimdliy  (hci-turi'Sdn  Dinhi'lcs,  IMU)  1ms  given 

U  ^^niiil  .xiiiiiiiiiliy  1)1'  the  iliuitoiiiinil  cliiili^^'s: 

'I'lit'  iicrnnis  t<!/.sl('in  cliown  iio  constant  IchioiiH.  In  a  iVw  instances  there 
Imivc  liccn  tuMioit)  ur  t«clorusis  in  tlic  nicihilla,  or,  us  in  the  ease  ahove  men- 
tioiKMJ,  II  (vsliccrciis  has  |»i'i'ss»'»l  on  llic  lloor.  Cysts  have  hceii  met  with 
in  tlie  while  matter  ol"  tlie  eereljiiiui  and  perivaseiihir  eiiangesi  liuve  been 
(leserihed.  (Jlyeojfen  has  heeii  found  in  the  spinal  cord.  In  the  peripheral 
nervourt  system  there  are  instances  in  which  tumors  have  been  found  press- 
in;;  on  the  va^Mis.  A  seconchiry  niultiplc  neuritis  is  not  rare,  and  to  it  the 
so-called  dialti'tic  tahes  is  prohahly  due.  K.  T.  Williamson  has  found 
chan^fcs  in  the  posterior  columns  of  the  cord  similar  to  tlujse  which  occur 
in  pernicious  nna-niia. 

In  the  sympathetic  pystcm  the  pinjjlia  have  hecn  cnlar;xed  and  in  some 
insliinccs  sclerosed,  hut  theic  is  nothing'  peculiar  in  these  chan^'cs.  The 
hloinl  may  contain  as  hi^di  as  0.1  per  cent  of  su^'ar  instead  •)!'  0.1")  per  cent. 
The  plasma  is  usually  loaded  with  fat,  the  molecules  of  which  nuiy  ho  soon 
as  line  particles.  When  drawn,  a  white  creamy  layer  coats  the  eoa^'ulum, 
ami  there  may  he  li|)a'mi(;  clots  in  the  snudl  vessels.  There  are  no  special 
changes  in  the  red  or  white;  corpuscles.  The  jtolynuch-ar  leiu'ocyles  con- 
tain ^dyco^fcn.  (llycop.'n  can  occur  in  normal  hlood,  l)Ut  it  is  here  extra- 
cellular. It  has  been  also  found  in  the  polynuclear  leucocytes  in  leukivmia. 
The  heart  is  liypertro|)hied  in  some  cases.  I'liulocarditis  is  very  rare. 
Arterio-sclerosis  is  common.  The  hiiuis  show  ini|)ortant  chancres.  Acute 
hroncho-pueumonia  or  croupous  pneumonia  (either  of  which  may  terminate 
in  pmgrcne)  and  tuberculosis  are  common.  The  so-called  diabetic  jjhthisi.s 
is  always  tuberculous  and  results  from  a  caseating  broncho-pneumonia.  In 
rare  cases  there  is  a  chronic  interstitial  i»neumonia,  non-tubei'culous.  Fat 
embolism  of  the  [)ulmonary  vessels  has  been  described  in  connection  with 
diabetic  conui. 

The  liver  is  usually  enlarged;  fatty  degeneration  is  common.  In  the 
so-called  diabetic  cirrhosis — the  rirrhose  pii/inentdire — the  liver  is  enlarged 
and  sclerotic, 'and  a  cachexia  develops  with  nu'lanoderma.  Possibly  the 
disease  is  a  sejjarate  morbid  entity.     Dilatation  of  the  stomach  is  common. 

The  Pancreas  in  Diabetes. — Lesions  of  this  organ  are  met  with 
in  about  50  per  cent  of  the  cases  (llansemann).  \on  Mering  and  ^lin- 
kowski  have  shown  that  extirpation  of  the  gland  in  dogs  is  followed  liy 
glycosuria,  but,  if  a  snudl  ])ortioii  remains,  sugar  does  not  a])pear  in  the 
urine,  facts  which  have  been  confirmed  by  Lepine  and  others.  'J'lio  pan- 
creas, on  this  view,  has,  like  the  liver,  a  double  secretion — an  external, 
which  is  ])oured  into  the  intestines,  and  an  internal,  which  ])asses  into  the 
blood.  This  latter  is  su])]iosed  to  be  of  tiie  nature  of  a  ferment,  in  the 
])i'esence  of  which  alone  the  nonnal  assimilative  ])rocesses  can  take  ])lace 
with  the  glycogen.  Disease  of  the  ])ancreas  causes  diabetes  by  preventing 
the  formation  of  the  glycolytic  ferment.  Even  when,  as  in  a  majority  of 
instances  of  diahotos,  the  organ  is  ap])arcntly  normal,  a  functional  trouhle 
may  disturb  the  formation  of  this  ferment.  The  fact  that  if  a  small  por- 
tion of  the  gland  is  left,  in  the  cx])eriments  upon  dogs,  diabetes  does  not 
occur,  is  analogous  to  the  remarkable  circumstance  that  a  small  fragment 


422 


CONSTITUTIONAL   DISKASKS. 


/ 


•  •r  the  tli^roiil  in  t^wttk'wwl  to  luvvciil  tliu  tluvcloinnent  of  urtilU-iiil  myx- 
iL'di'iiia. 

A  |iiiticiit  of  \V.  T.  Mull  (lii'd  of  (liulu'tt'S  iiftt-r  cxtirpntiun  of  tlu'  \)n\\- 
(■I'ciiH.  In  fuiiii'  iiisliiiici'H  (lu'ic  is  a  |ii;,Mii('iit)ii_v  tirrlKisis  aiiiilo^'uiis  In  that 
wliicli  oiiiir.>>  iit  the  liviT,  and  this  indiiratitm  hiTUis  to  he  an  ini|M)rtanL 
<lianj,'»'.  CaiUTr  and  falculi  have  l)i't'n  nii-t  with;  and  hon^'strcth  found, 
in  one  iuHtanci',  cvHtic  diHcast'  of  tlii'  imncri'aH.  I'nt  lU'croHirt  of  thf  orpin 
has  also  hccn  found. 

Williamson  *  i-xamini'd  tlu'  itancrcas  in  'i'.\  consccutivi!  vahva  of  tliaht'ti'rt 
jind  found  iialhological  changes,  ihiclly  ati'n|ihy,  in  II.  He  also  analy/rd 
|i>(»  casi'H  of  diaht'ti's  collocti'd  from  i\w  liti'i'aturc  in  which  the  pancrt'aH 
was  disi'ast'd.  More  than  M)  per  cent  of  tluw  showed  more  or  less  marked 
atrophy;  fatty  dcj^'cncration  was  jircscnt  in  17,  abscess  in  'A,  cancer  in  K, 
and  cystic  dc<,'eneration  in  K  cases.  Of  my  series  nf  T7  cases,  Ki  were 
treated  in  medical  wards  of  the  J(dinH  Hopkins  Hospital,  and  17  termi- 
nated fatally.  AutopsicH  were  olttained  in  S  cases  and  the  pancreas  was 
found  more  or  less  atrophied  in  <1  (d"  them.  In  oidy  on((  of  his  10  autop- 
sies in  diabetes  eould  Naunyn  attribute  the  disease  to  tin?  comlition  of  tin; 
pancreas. 

The  h'idnri/H  show  I'siially  a  dilfuse  nephritis  with  fatty  de^'neration. 
A  hyaline  chanj^'e  occurs  in  the  tubal  epithelium,  particularly  of  the  de- 
scending' lind)  of  the  loop  of  llenle,  and  also  in  the  capillary  vessels  of  the 
tufts. 

Symptoms. — Acvte  and  climnk  forms  are  recognized,  but  there  is 
no  essential  diil'erenee  between  them,  except  that  in  the  former  the  patients 
are  youiif^er,  the  course  more  rapid,  and  the  enuiciation  more  nuirked. 
Acute  cases  nuiy  occur  in  the  a<,'ed.  J  saw  with  Sowers  in  Washington  a 
man  aged  seventy-three  in  whom  the  entire  course  of  the  disease  was  less 
than  three  weeks. 

It  is  also  ])ossible  to  divide  the  cases  into  (1)  lipnf/onic  or  (Ilrfellr,  wliioh 
includes  the  transient  glycosuria  of  stont  ])ersons;  ('i)  iinirolir,  due  to  in- 
juries or  functional  disorders  (d'  the  nervous  system;  and  (.'5)  pdiicreatir, 
in  which  there  is  a  lesion  of  the  pancreas.  It  is,  however,  by  no  means 
easy  to  discriminate  in  all  cases  between  these  forms.  Attempts  have 
been  made  to  se|)arate  a  clinical  variety  analogous  to  e.\])erimental  ]ian- 
creatic  diabetes.  Ilirschl'eld,  from  (iuttmann's  clinic,  has  described  cases 
running  a  ra])id  and  severe  conrse  usnally  in  young  and  ndddle-aged 
persons.  The  polyuria  is  less  common  or  even  absent,  and  there  is  a  strik- 
ing defect  in  the  assimilation  of  the  albuminoids  and  fats,  as  shown  by 
the  examination  of  the  fjrces  and  urine.  In  4  of  7  cases  aiitopsies  were 
nuide  and  the  pancreas  was  found  atrophic  in  two,  cancerous  in  one,  and 
in  the  fourth  exceedingly  soft. 

The  onspf  of  the  disease  is  gradual  and  either  frequent  micturition  or 
inordinate  thirst  first  attracts  attention.  Very  rarely  it  sets  in  rapidly, 
after  a  sudden  emotion,  an  injury,  or  after  a  severe  chill.  "When  fully 
established  the  disease  is  characterized  by  great  thirst,  the  passage  of  large 


*  Medical  Chronicle,  May,  1897. 


DIAMKTKS  MIOIiMTl'S. 


4ii:J 


ion  nv 

ipiflly, 

fully 

largo 


4|iiiiiititii'H  of  Hiicchiiriiu'  uriiic,  u  vonicioiiH  ii|i|)i'tit«>,  uikI,  as  a  rule,  pro- 
^iTHftivL'  I'liiacialioii. 

Amonjf  till'  ijvhfral  Mi/mploniH  nt'  tlic  diHra**!'  lliirnt  in  oiu'  (tf  tlio  most 
<listri'MHiii^.  A  vt-ry  larp'  aiiioiiiit  of  water  is  rctniircd  to  keep  tlic  siij^ar 
ill  holutioii  tiiid  for  its  excretion  in  tiie  urine.  The  anioiint  of  water  eoii- 
siiineil  will  l)e  found  to  liear  a  definite  ratio  to  tlie  tpiantity  excreted.  Iii- 
.><tanceH,  liowevcr,  are  not  iincoiniiioii  of  pronounced  diuhetes  in  which  thu 
thii'Ht  in  not  cxceHsive;  hut  in  such  chhch  the  Hinount  of  urine  iiassed  in 
never  iar^'e.  The  thirst  is  most  intense  an  hour  or  two  after  meals.  A.s 
11  rule,  the  di^'cstion  is  jrood  and  the  appetite  inordinate.  The  condition 
is  s(»iiietiiiics  termed  hiiliinid  or  iKih/iiluK/ia. 

The  tonj^ue  is  usually  dry,  red,  and  j;la/ed,  and  the  saliva  scanty.  Tho 
gums  may  hecome  swollen,  and  in  the  later  staj,'es  aphthous  stomatitis  is 
c(uiimon.    Constipation  is  the  rule. 

In  spite  of  till'  enormous  amount  of  food  consumed  a  patient  may  be- 
come rapidly  emaciated.  TIiIh  Iohh  of  llesh  hears  some  ratio  to  the  poly- 
uria, and  when,  under  siiitahle  diet,  the  siipir  is  reduced,  the  jjatient  may 
(piiekly  ^'ain  in  llesh.  The  skin  is  dry  and  harsh,  and  sweating;  rarely  occurs, 
4'xeept  when  phthisis  coexists.  Drenchin;,'  sweats  have  heen  known  1  )  alt .r- 
iiate  with  excessive  ))olyuria.  Tlie  temperature  is  often  suhiiormal;  the 
pulse  is  tisually  fretpient,  and  the  tension  increased.  Many  diaheties,  how- 
ever, do  not  show  marked  emaciation.  I'atii'iits  past  the  middle  period 
■of  life  may  havi!  the  disease  for  years  without  niiicli  disturbance  of  tho 
health,  and  may  remain  well  iHuirished.  These  are  the  cases  of  the  diabete 
;/nis  in  contradistinction  to  didhrte  maitjre. 

The  Urine. — The  amount  varies  from  0  or  U  pints  in  mild  cases  to  30 
or  10  pints  in  very  severe  cases.  In  rare  instances  the  (piantity  of  urine 
is  not  mnch  increased.  I'nder  strict  diet  the  amount  is  much  lesseneil,  and 
in  intercurrent  febrile  affections  it  may  be  reduced  to  normal.  The  specific 
<rravity  is  hi^di,  ranging,'  from  1.025  to  1.0-45;  but  in  exceptional  eases  it 
may  be  low,  l.Ol.T  to  I.O'^O.  The  hi<;hest  specific  jiravity  recorded,  so  far 
ns  r  know,  is  by  Trousseau — 1.074.  ^'ery  hif,di  specific  fj;ravitie.s — 1.070  + 
— su<r<rcst  fraud.  The  urine  is  ])ale  in  color,  almost  like  water,  and  has  a 
sweetish  odor  and  a  distinctly  sweetish  taste.  The  reaction  is  acid.  Sugar 
is  present  in  varying  amounts.  In  mild  cases  it  does  not  exceed  H  or  2  per 
cent,  but  it  may  reach  from  5  to  10  per  cent.  The  total  amount  excreted 
in  the  twenty-four  hours  may  range  from  10  to  20  ounces,  and  in  exceptional 
cases  from  1  to  2  ponnds.    The  following  are  tho  most  satisfactory  tests: 

Fehlinf/'/i  Test. — The  solution  consists  of  sulphate  of  co])i)er  (grs.  00^), 
neutral  tartrate  of  jiotassium  (grs.  .'304),  solution  of  caustic  soda  (fl.  ozs.  4), 
and  distilled  water  to  make  up  H  ounces.  Put  a  drachm  of  this  in  a  test- 
tube  and  hoil  (to  test  the  reagent);  add  an  etjual  (piantity  of  urine  and  boil 
again,  when,  if  sugar  is  present,  the  yellow  suboxide  of  copper  is  thrown 
down.    The  solution  must  be  freshly  ])re]iared,  as  it  is  apt  to  decompose. 

Tmrnmer's  Teni. — To  n  drachm  of  urine  in  a  test-tube  add  a  few  dropg 
■of  a  dilute  sulphate-of-copper  solution  and  then  as  much  liqnnr  potasscB 
as  urine.  On  hoiling,  the  copper  is  reduced  if  sugar  be  present,  forming 
the  yellow  or  orange-red  suhoxide.    There  are  certain  fallacies  in  the  copper 


424 


CONSTITUTIONAL  DISEASES. 


/ 


tests.  Thus,  a  substance  called  glycuronic  acid  is  met  with  in  tlie  urine 
after  the  use  of  certain  drugs — chloral,  ])henacetin,  morphia,  chloroform, 
etc. — which  reduces  c(>i»i)er.  Houiogentisinic,  uroleucinic,  and  glycosuria 
acids,  which  are  held  to  be  the  cause  of  alca[)tonuria,  may  also  prove  a 
source  of  error  (sec  Alcaptonuria,  by  T.  Ji.  i-'utcher,  N.  Y.  Med.  Jour., 
18US,  i). 

Fennenlalion  Test. — This  is  free  from  all  doubt.  Place  a  small  frag- 
ment of  yea.st  in  a  test-tube  full  of  urine,  which  is  then  inverted  over  a 
glass  vessel  containing  the  same  lluid.  If  sugar  is  present,  fermentation 
goes  on  with  the  formation  of  carbon  dioxide,  which  accumulates  in  the 
iijjper  part  of  the  tube  and  gradually  expels  the  urine.  In  doidjtful  cases 
u  control  t'.'st  should  always  be  used.  For  laboratory  work  the  polariscope 
is  of  great  value. 

Of  other  ingredients  in  the  urine,  the  urea  is  increased,  the  uric  acid 
does  not  show  special  changes,  and  the  phosj)hates  may  be  greatly  in  ex- 
cess. Ealfe  has  described  a  great  increase  in  the  phosphates,  and  in  some 
of  these  cases,  with  an  excessive  excretion,  the  symptoms  may  be  very 
similar  to  those  of  diabetes,  though  the  sugar  may  not  be  constantly  pres- 
ent. The  term  phosphatic  diabetes  has  sometimes  been  applied  to  them. 
Acetone  and  acetone-forming  substances  are  not  infrequently  present. 
Lichen's  test  is  as  follows:  The  urine  is  distilled  and  a  few  cubic  centimetres 
of  the  distillate  are  rendered  alkaline  with  liquor  potassjE.  A  few  drops  of 
Lugol's  solution  are  then  added,  when,  if  acetone  be  present,  the  distillate 
assumes  a  turbid  yellow  color,  due  to  the  formation  of  iodoform,  which  is 
recognized  by  its  odor  and  by  the  formation  of  minute  hexagonal  and 
stellate  crystals.  Diacctic  acid  is  sometimes  present,  and  may  be  recognized 
from  the  fact  that  a  solution  of  the  chloride  of  iron  yields  a  beautiful 
Bordeaux-red  color.  Other  substances,  as  formic,  carbolic,  and  salicylic 
acids,  give  the  same  reaction  in  both  fresh  and  previously  boiled  urine, 
while  diacetic  acid  does  not  give  the  reaction  in  urine  previously  boiled. 
]\Iunson  holds  that  diacetic  acid  gives  the  characteristic  "  diazo-reaction  " 
of  r^hrlich.  In  testing  for  diacetic  acid  perfectly  fresh  urine  should  be 
used,  as  it  rapidly  becomes  broken  up  into  acetone  and  carbolic  acid.  /8-oxy- 
bufvric  acid  should  be  tested  for  where  coma  is  present.  A  quantity  of  the 
urine  is  thoroughly  fermented,  fdtered  till  perfectly  clear,  and  examined 
with  the  ]inlaris('ope.  If  it  be  present,  the  rays  of  polarized  light  are  de- 
flected to  the  left.  The  urine  also  yields  a-erotonic  acid  crystals  by  the 
metliod  recommended  by  Kulz. 

liremer  finds  that  diabetic  urine  has  the  power  of  dissolving  gentian 
violet,  whereas  normal  urine  fails  to  do  so.  Unfortunately,  the  urine  in 
diabetes  insipidus  and  in  certain  forms  of  polyuria  reacts  similarly.  Friih- 
lich  has  recently  devised  a  test  based  on  the  fact  that  diabetic  urine  has  the 
property  of  decolorizing  solutions  of  methylene  blue. 

Gh/cof]cn  has  also  been  described  as  present  in  the  urine. 

Athvmin  is  not  infrequent.  It  occurred  in  nearly  37  per  cent  of  the 
examinations  made  by  Lippman  at  Carlsbad. 

Pnc7imntvria,  the  formation  of  gas  in  the  urine,  due  to  fermentative 
processes  in  the  bladder,  is  occasionally  met  with. 


DIABETES  MELLITUS. 


425 


Fnt  may  l)e  passed  in  the  urine  in  the  i'onn  of  a  1,       emulsion  (lipuria). 

Diabetes  in  Children. — Stern  has  analyzed  117  cn,ses  in  children.  They 
usually  oecur  amoii;^  the  hetter  classes.  Six  were  imder  one  year  of  age. 
Hereditary  iniiuences  were  marked.  The  course  of  the  disease  is,  as  a  rule, 
much  more  rapid  than  in  adults.  The  shortest  duration  was  two  days.  In 
T  cases  i*  did  not  last  a  month.  One  case  is  mentioned  of  a  child  ai)parently 
born  with  the  glycosuria,  who  recovered  in  eight  months. 

Complications.— (rf)  Cutaneous. — IJoils  and  carbuncles  are  extremely 
connnon.  Painful  onychia  may  occur.  Eczema  is  also  met  with,  and  at 
times  an  intolerable  itching.  In  women  the  irritation  of  the  urine  may 
cause  the  most  intense  pruritus  pudendi,  and  in  men  a  l)alanitis.  Earer 
alfections  are  xanthonui  and  ])urpura.  (Jangrene  is  not  uncommon,  and 
is  associated  usually  Mith  arterio-sclerosis.  William  Hunt  Juis  analyzed 
G4  cases.  In  50  the  localities  were  as  follows:  Feet  and  legs,  37;  thigh  and 
buttock,  2;  nucha,  2:  external  genitals,  1;  lungs,  3;  lingers,  3;  back,  1; 
eyes,  1.  Perforating  icer  of  the  foot  may  occur.  Bronzing  of  the  skin 
{diajete  bronze),  a  rare  feature,  is  met  with  in  connection  with  a  peculiar 
type  of  cirrhosis  of  the  liver.  With  the  onset  of  severe  complications  the 
tolerance  of  the  carboh ,  Irates  is  much  increased. 

(b)  Pulmonary. — The  ])atients  arc  not  infrequently  carried  off  by  acute 
'pneumonia,  which  may  be  lobar  or  lobular.  Ganijrcne  is  very  apt  to  super- 
vene, but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordinary 
gangrene. 

Tulereiilovs  hroncho-pneumonia  is  very  common.  It  was  formerly 
thought,  from  its  rapid  course  and  the  limitation  of  the  disease  to  the  lung, 
that  this  Avas  not  a  true  tubercidous  affection;  but  in  tiie  cases  which  have 
come  under  my  notice  the  bacilli  have  been  present,  and  the  condition  is 
now  generally  regarded  as  tuberculous. 

(c)  Renal. — Alhutniiuiria  is  a  tolerably  frequent  eom])lication.  The 
amount  varies  greatly,  and,  when  slight,  does  not  seem  to  be  of  much  mo- 
ment. (Edema  of  the  feet  and  ankles  is  not  an  infrequent  symjitom.  Gen- 
eral anasarca  is  rare,  however,  owing  to  the  marked  polyuria.  It  was  pres- 
ent in  a  marked  degree  in  one  of  my  77  cases.  It  is  sometimes  associated 
with  arterio-sclerosis.  It  occasionally  ])recedes  the  development  of  the  dia- 
betic coma.     Occasionally  cystitis  develoj)S. 

{(I)  Nervous  System. — (1)  Diahofic  mma,  first  studied  by  Kussmaul, 
comes  on  in  a  consideralde  ])roportion  of  all  cases,  particularly  in  the  young. 
Stephen  ]\rackenzie  states  that  of  the  fatal  cases  of  diabetes  collected  from 
the  registers  of  the  London  Hospital,  all  under  the  age  of  twenty-five,  with 
hut  one  exce]ition.  had  died  in  conia.  In  Frcrichs'  series  coma  ]ireccded 
death  in  1.52  instances  out  of  a  total  of  250  fatal  cases.  Of  17  fatal  cases 
at  the  Johns  Hopkins  Hospital,  coma  occurred  in  12.  It  may  supervene 
when  diabetes  is  unsuspected,  as  in  2  cases  re])orted  by  Francis  ]\[inot. 
Frericlis  recognized  three  groups  of  cases:  (n)  Those  in  which  after  exer- 
tion the  patients  were  suddenly  attacked  with  weakness,  syncope,  somno- 
lence, and  gradually  deepening  unconsciousness;  death  occurring  in  a  few 
hours.  (^)  r  "s  with  preliminary  gastric  disturbance,  such  as  nausea  and 
vomiting,  or  some  local  affection,  as  pharyngitis,  phlegmon,  or  a  pulmonary 


426 


CONSTITUTIONAL  DISEASES. 


/ 


eoini)lication.  In  sucli  casi's  tlio  attack  l)Cf,nns  with  headaclie,  (Icliriiun, 
great  tlistross,  and  dyspncea,  all'octing  both  inspiration  and  expiration,  a 
coniHtion  called  by  Knssnianl  air-huiujcr.  Cyanosjis  may  or  may  not  be 
present.  If  it  is,  the  pulse  becomes  rapid  and  weak  and  the  patient  grad- 
ually sinks  into  coma;  the  attack  lasting  from  one  to  five  days.  There 
may  be  a  very  lieavy,  sweetish  odor  of  the  breath,  dne  to  the  ])resence  of 
acetone,  (y)  Cases  in  which,  without  any  j)revious  dysi)ncoa  or  distress,  the 
patient  is  attacked  with  headache  and  a  feeling  of  intoxication,  and  rapidly 
falls  into  a  deep  and  fatal  coma.  There  are  atyi)ical  cases  in  which  the  coma 
is  due  to  unemia,  to  ai)oi)lexy,  or  to  meningitis. 

There  has  been  much  dispute  as  to  the  nature  of  these  symptoms,  but 
our  knowledge  of  the  disease  is  not  yet  sulficiently  advanced  to  give  a 
rational  exjdanation.  The  character  of  the  attack  and  the  similarity,  in 
many  instances,  to  ura-mia  would  indicate  that  it  depended  U})on  some 
toxic  agent  in  the  blood.  For  many  years  it  was  almost  universally  held 
that  this  toxic  material  was  acetone,  but  this  theory  is  no  longer  tenable, 
as  it  has  heen  repeatedly  shown  experimentally  that  acetone,  when  admin- 
istered to  animals,  does  not  produce  symptoms  resembling  those  of  diabetic 
coma.  It  is,  however,  almost  constantly  ju'cscnt  in  the  urine  and  breath 
of  coma  patients.  Later,  the  coma  was  attributed  to  the  presence  of  dia- 
cetic  acid  in  the  blood,  but  this  theory  in  turn  gave  way  to  that  of  Stadel- 
niann,  Kiilz,  and  Minkowski,  who  believe  that  diabetic  coma  is  an  auto- 
intoxication due  to  )8-oxy-butyric  acid  in  the  circulating  blood.  In  188-t 
these  observers,  working  independently,  almost  simultaneously  found  this 
acid  in  the  urine  of  patients  with  diabetic  coma.  /8-oxy-hutyric  acid  is  now 
believed  by  mo^t  observers  to  be  the  exciting  cause  of  the  coma.  The 
amount  of  the  acid  excreted  in  the  twenty-four  hours  may  be  enormous. 
Kiilz  found  in  3  cases  07,  100,  and  226  grammes  respectively.  It  is  a  de- 
composition product,  lesulting  from  the  disintegration  of  the  tissue  albu- 
mins. Acetone  and  diacetic  acid  are  believed  to  be  derivative  from  /3-oxy- 
butyric  acid. 

Saunders  and  Hamilton  have  described  cases  in  which  the  lung  ca- 
pillaries were  blocked  with  fat.  They  attributed  the  symptoms  to  fat  em- 
bolism, but  there  are  many  cases  on  record  in  which  this  condition  was  not 
found,  though  lip.Tmia  is  by  no  means  infrequent  in  dial>etes. 

The  symptoms  have  been  attributed  to  urannia,  and  albuminuria  fre- 
quently precedes  or  acci    ipanies  the  attack. 

(2)  Peripheral  Neuritis. — The  neoralrjias,  numbness,  and  tingling,  which 
are  not  uncommon  sym])toms  in  diabetes,  p.ve  probably  minor  neuritic 
manifestations.  Herpes  zoster  may  occur.  Perforating  ulcer  of  the  foot 
may  develop. 

Diabetic  Tahes  (so  called). — This  is  a  peripheral  neuritis,  characterized 
by  lightning  pains  in  the  legs,  loss  of  knee-jerk — which  ^nay  occur  with- 
out the  other  symptoms — and  a  loss  of  power  in  the  extensors  of  the  feet. 
The  gait  is  the  characteristic  sfepparje,  as  in  arsenical,  alcoholic,  and  other 
forms  of  neuritic  paralysis.  Charcot  states  that  there  may  bo  atrophv  of 
the  optic  nerves.  Changes  in  the  posterior  columns  of  the  cord  have  been, 
found  by  Williamson  and  others. 


DIABETES  MELLITUS. 


427 


fre- 


izod 
•ith- 
feot. 
ithcr 
of 
beea 


Dinhetic  Paraplegia. — This  is  also  in  all  probability  duo  to  neuritis. 
There  are  cases  in  wlii'eh  i)o\ver  has  l)een  lost  in  both  arms  and  legs. 

(o)  Mental  Si/inptonis. — The  patients  are  often  morose,  and  there  is  a 
strong  tendency  to  become  hypochondriacal.  tJeneral  paralysis  has  been 
known  to  develoj).  Some  patients  disjjlay  an  extraordinary  degree  ol"  rest- 
lessness and  anxiety. 

(4)  Special  Senses. — Cataract  is  liable  to  occur,  and  may  develop  with 
rapidity  in  young  jiersons.  Diabetic  retinitis  closely  resembles  the  albu- 
minuric form.  Ihemorrhages  are  common.  Sudden  amaurosis,  similar 
to  that  which  occurs  in  uraemia,  may  occur.  Paralysis  of  the  muscles  of 
accommodation  may  be  present;  and  lastly,  atrophy  of  the  optic  nerves. 
Aural  symi)toms  nuiy  come  on  with  great  rapidity,  either  an  otitis  media, 
or  in  some  instances  intiammation  of  the  mastoid  cells. 

(.'))  Se.vual  Funclion. — Impotence  is  common,  and  may  be  an  early 
symi)tom.  Conception  is  rare;  if  it  occurs,  abortion  is  apt  to  follow,  A 
diabetic  mother  may  bear  a  healthy  child;  there  is  no  known  instance  of  a 
diabetic  mother  bearing  a  diabetie  child.  The  course  of  the  disease  is 
usually  aggravated  after  delivery. 

Course. — In  children  the  disease  is  rapidly  progressive,  and  may  prove 
fatal  in  a  few  days.  It  may  be  stated,  as  a  general  rule,  that  the  older  the 
patient  at  the  time  of  onset  the  slower  the  course.  Cases  without  hereditary 
influences  are  the  most  favorable.  In  stout,  elderly  men  diabetes  is  a  much 
more  hopeful  disease  than  it  is  in  thin  persons.  Middle-aged  patients  may 
live  for  many  years,  and  persons  are  met  with  who  have  had  the  disease 
for  ten,  twelve,  or  even  fifteen  years. 

Diagnosis. — As  stated  in  the  definition,  for  a  case  to  be  considered 
diabetes  the  sugar  eliminated  in  the  urine  must  be  grape  sugar,  it  should 
be  present  for  weeks,  months,  or  years,  and  the  excretion  of  sugar  must 
take  place  after  the  ingestion  of  moderate  amounts  of  carbohydrates.  xVs 
a  rule,  there  is  no  diflHcnlty  in  determining  the  ])resence  of  diabetes.  The 
urine  tests  already  given  are  distinctive. 

Bremer's  Blood  Test. — This  author  claims  that  he  is  able  to  make  a  diag- 
nosis of  diabetes  from  the  examination  of  a  drop  of  the  ])atient's  blood,  de- 
pending on  the  fact  that  it  reacts  differently  from  normal  blood  to  various 
aniline  dyes.  , 

His  latest  published  method  is  briefly  as  follows:  Eather  thick  smears 
of  suspected  and  normal  blood  are  made  on  ordinary  microscopic  slides. 
They  are  then  heated  in  a  thermostat  up  to  135°  C,  and  when  sufficiently 
cooled  are  stained  in  a  one-per-cent  a(|ueous  solution  of  Congo-red  for  one 
and  a  half  to  two  minutes.  Slides  of  the  non-diabetic  and  diabetic  blood 
are  placed  back  to  back,  so  that  each  will  be  exposed  to  the  same  conditions. 
The  excess  of  the  stain  is  Avashod  off,  and  if  the  suspected  patient  has  dia- 
1)etes  the  blood  will  be  unstained,  whereas  the  normal  blood  takes  a  dis- 
tinct Congo-red  stain.  P)remer  obtains  this  reaction  in  the  prediabetic 
stage,  and  also  in  the  intervals  when  the  patient's  urine  is  temporarily  free 
from  sugar.  He  thinks  the  reaction  is  due  to  a  qualitative  change  in  the 
hamioglobin  of  the  red  blood-cells,  and  not  to  an  excess  of  grape  sugar  in 
the  blood.     In  a  number  of  cases  in  my  wards,  in  which  the  test  has  been 


428 


CONSTITUTIONAL   DISEASES. 


/ 


jti'i'fonnt'd,  the  reaction  has  ])Con  ropcatcdly  olitaincd,  l)ut  it  was  not  pos- 
.-ilik'  to  fully  I'oudrm  iiroincr's  .'^tatciiu'iit  that  the  reaction  was  also  present 
when  the  urine  was  teiiii)orarily  free  t'roiii  su^ar.  Aecordin;^'  to  Ji.  T.  Wil- 
liamson, diahetic  blood  has  the  power  to  decolorize  weak  alkaline  solutions 
of  methylene  blue  to  a  yellowish-<ireen  or  yellow  color,  lie  has  devised  a 
Itlood  test  for  diaheles,  iisin^  (h'linite  proportious  of  blood  and  the  rea.";ent. 
Williamson  lias  obtained  the  reaction  in  every  one  ol;  11  cases  of  diabetes 
in  which  the  test  was  tried,  but  failed  to  get  it  in  a  single  instance  in  the 
blood  of  lOU  non-diabetic  cases,  lie  is  inclined  to  the  view  that  the  reaction 
is  due  to  nn  excess  of  sugar  in  the  blood.  The  reaction  was  obtained  by 
Futcher  in  7  cases  in  which  it  was  tried  in  my  wards  (I'hila.  Med.  Journal, 
l-'ebruary  l'.^  18!)^). 

l)ece])tion  may  be  ])ractised.  A  young  girl  nnder  my  care  had  urine 
with  a  specific  gravity  of  1.005.  The  reactions  were  for  cane  sugar.  There 
is  one  case  in  the  literature  in  wliich,  after  the  cane-sugar  fraud  was  de- 
tected, the  woman  bought  grape  sugar  and  ]mt  ic  into  her  bladder! 

Frogliosis. — In  true  diabetes  instances  of  cnre  are  rare.  On  the 
other  luind,  the  transient  or  intermittent  glycosuria,  met  with  in  stout 
overfeeders,  or  in  })ersons  who  have  undergone  a  severe  mental  strain,  is 
very  anienal)le  to  treatment.  Xot  a  few  of  the  cases  of  reituted  cures  be- 
long to  this  division.  Practically,  in  cases  under  forty  years  of  age  the 
outlook  is  bad;  in  older  ])ersons  the  disease  is  less  serious  and  much  more 
amenable  to  treatment.  It  is  a  good  plan  at  the  outset  to  determine  whether 
the  urine  of  a  ]»atient  contains  sugar  or  iu)t  on  a  diet  absolutely  free  from 
carbohydrates.  In  mild  cases  the  sugar  disappears;  in  the  severer  cases  it 
continues  to  be  formed  from  the  protcids. 

Treatment. — In  families  with  a  marked  predisjiosition  to  the  disease 
the  use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  ])ers()nal  hygiene  of  a  diabetic  ])atient  is  of  the  first  importance. 
Sources  of  worry  should  be  avoided,  and  he  should  lead  an  even,  quiet  life, 
if  ])ossiblt'  in  an  equable  clinuite.  Flannel  or  silk  should  be  worn  next  to 
the  skin,  and  the  greatest  care  should  be  taken  to  ]iromote  its  action.  A 
lukewarm,  or  if  tolerably  robust,  a  cold  bath,  should  be  taken  every  day. 
An  occasional  Turkish  bath  is  useful.  Systematic,  moderate  exercise  should 
be  taken.  When  this  is  not  feasible,  massage  should, be  given.  It  is  well 
to  study  accurately  the  dietetic  capabilities  of  each  case. 

Dirt. — Our  injunctions  to-day  are  those  of  Sydenham:  "Let  the  pa- 
tient cat  food  of  easy  digestion,  such  as  veal,  mutton,  and  the  like,  and  ab- 
stain from  all  sorts  of  fruit  and  garden  stutf."' 

Diabetic  patients  admitted  to  the  medical  wards  of.  the  Johns  Hopkins 
Hospital  are  kept  for  three  or  four  days  on  the  ordinary  ward  diet,  which 
contains  moderate  amounts  of  carbohydrates,  in  order  to  ascertain  the 
amount  of  sugar  excretion.  They  are  then  placed  on  the  following  stand- 
ard non-carbohydrate  diet,  arranged  from  a  diet  list  recommended  by  von 
Xoorden: 

BrcalifasI:  7.30,  5  grammes  (.1  i)  of  tea  steeped  in  200  cc.  (.^  vi)  of 
water;  150  grammes  (Ji\\)  of  boiled  ham;  one  o^fc. 

Lunch:  12.30,  20U  grammes  (5  vi)  cold,  roast  beef;  GO  grammes  (3  ij) 


.DIABETES  MELLITUS. 


41>U 


fresh  encumber  or  celery,  with  5  graninu's  (o  i)  vine<;ar;  10  graimncs 
(.")  iiss)  olive  oil,  with  siUt  and  |)i'|t|)t'r  to  tasti';  '-iO  cc.  (.■)  v)  whisky,  with 
WO  t'c.  (,')  i'j)  ^^■ator;  00  ec.  (5  iv)  coH't'o,  without  milk  or  HU>?ar. 

Dinner:  (i  p.m.,  200  cc.  clear  bouillon;  JioO  iframmcs  (5  viiss)  roast 
Ix'of;  10  grammes  (5  iiss)  butter;  80  grammes  (,")ij)  green  salad,  with  10 
;;rammes  (.1  iiss)  vint'gar  and  '20  grammos  (.">  v)  olive  oil,  or  three  tahle- 
f-poonslul  of  some  well-eooked  green  vcgetahle;  three  sardines  a  riiuille; 
:iO  cc.  (5  v)  whisky,  with  400  cc.  (jxiij)  water. 

Supper:  1)  i».  M.,  two  eggs  (raw  or  cooked);  400  cc.  (f)  xiij)  water. 

This  diet  contains  about  200  grammes  of  albumin  and  about  135 
grammes  of  fat.  The  ell'ect  of  the  diet  on  the  sugar  excretion  is  remark- 
able. In  many  cases  there  is  an  entire  disaijpearance  of  the  sugar  from 
the  urine  in  three  or  four  days.  Chart  XV'  shows  very  graphically  the 
remarkal)le  drop  in  the  sugar  excretion  for  the  first  twenty-four  hours  in 
a  case  placed  on  the  standard  diet.  The  sugar  failed,  however,  in  this  par- 
ticular case  to  entirely  disai)pear  from  the  urine  except  on  one  day,  al- 
though he  was  kept  on  the  diet  for  over  two  months.  In  cases  in  which* 
the  urine  becomes  free  from  sugar  gradually  increasing  quantities  of  starch 
up  to  20,  50,  and  100  grammes  are  added  daily.  White  bread  contains 
iU'ty-five  per  cent  of  starch.  The  effect  of  the  non-carbohydrate  diet,  ac- 
cording to  von  Xoorden,  is  to  improve  the  metabolic  functions  so  that  the 
system  can  warehouse  considerable  quantities  of  carbohydrates  without 
sugar  a]»pearing  in  the  nrine.  He  advises  that  patients  should  return  to 
the  strict  non-carbohydrate  regimen  at  intervals  of  three  or  four  months, 
so  as  to  increase  their  power  of  warehousing  carbohydrates. 

In  cases  in  which  a  standard  diet  is  not  ordered  it  is  well  to  l)egin  cut- 
ting off  article  by  article  until  the  sugar  disapjiears  from  the  nrine.  Within 
a  month  or  two  the  patient  may  be  allowed  a  more  liberal  diet,  testing  the 
different  kinds  of  food. 

The  following  is  a  list  of  articles  which  diabetic  patients  may  take: 

Liquids:  Sonps — ox-tail,  turtle,  bouillon,  and  other  clear  soups.  Lem- 
onade, coffee,  tea,  chocolate,  and  cocoa;  these  to  be  taken  without  sugar, 
but  they  may  be  sweetened  with  saccharin.  Potash  or  soda  water,  and 
Apollinaris,  or  the  Saratoga-Yichy,  and  milk  in  moderation,  may  be  used. 

Of  animal  food:  Fish  of  all  sorts,  including  crabs,  lobsters,  and  oysters; 
salt  and  fresh  butcher's  meat  (with  the  exception  of  liver),  poultry,  and 
game.     Eggs,  butter,  buttermilk,  curds,  and  cream  cheese. 

Of  bread:  Gluten  and  bran  bread,  and  almond  and  cocoanut  biscuits. 

Of  vegetables:  Lettuce,  tomatoes,  spinach,  chicory,  sorrel,  radishes, 
asparagus,  water-cress,  mnstard  and  cress,  cucumbers,  celery,  and  endives. 
I'ickles  of  various  sorts. 

Frnits:  Lemons  and  oranges.  Currants,  plums,  cherries,  pears,  ap])le3 
(tart),  melons,  raspberries  and  strawberries  may  be  taken  in  moderation. 
Xuts  are,  as  a  rule,  allowable. 

Among  prohihiied  orfirks  are  the  following:  Thick  soujis  and  liver. 

Ordinary  bread  of  all  sorts  (in  quantity),  rye,  wheaten,  brown,  or  white. 
All  farinaceous  preparations,  such  as  hominy,  rice,  tapioca,  semolina,  arrow- 
root, sago,  and  vermicelli. 


430 


CONSTITUTIONAL  DISKASKS. 


Of  v('<,'i'tal)lc's:  Potatoes,  tiinii|is,  |)arsni|»s,  stiuashcs,  vcjjjetablo  marrow 
of  all  kinds,  hccts,  corii,  artichokes. 

or  li(iiii(is:  JJeer,  sparkling-  wine  of  all  sorts,  luul  the  sweet  aerated 
drinks. 

in  ieeding  a  diabetic  patient  one  of  the  greatest  diHieulties  is  in  arrang- 
ing a  snhstitute  for  hread.  01'  the  gluten  breads,  many  are  very  im- 
palatahle;  others  arc  frauds. 


/ 


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Blu,ck,.Siigiir  in  gminnies 

Chart  XV. — Illustrating  influence  of  diet  on  sugar  and  amount  of  urine. 

A  good  gluten  flour  is  made  by  the  Battle  Creek  Sanitarium  Company, 
jMichigan.  Other  sul)stitutes  are  the  almond  food,  the  Aleuronat  bread, 
and  soya  bread,  but  these  and  other  substitutes  are  not  satisfactory  as  a 
rule.  For  sweetening  purposes  saccharin  may  be  used,  of  which  tablets  are 
pro]iared. 

Medicinal  Treatment. — This  is  most  unsatisfactory,  and  no  one  drug 
appears  to  have  a  directly  curative  influence.  Opium  alone  stands  the 
test  of  experience  as  a  remedy  capable  of  limiting  the  progress  of  the  dis- 
ease.    Diabetic  patients  seem  to  have  a  special  tolerance  for  this  drug. 


DIABETKS  MKLLITUS. 


431 


Codciii  is  prcl'iTrcd  liy  I'avy,  iiiid  has  the  advaiitn^'c  ol"  hoiiii,'  U'ss  consti- 
pating; than  morphia.  A  patient  may  hej^in  with  luill'  a  <,M'ain  tiiree  times 
a  (lay,  wliieh  may  he  ^ladnally  inereased  to  (i  or  S  ^M'ains  in  tiie  twenty- 
four  hours.  Xot  much  ell'eet  is  noticed  uuh'ss  the  patient  is  (»n  a  ri<;i(l  diet. 
When  till'  su^ar  is  reduced  to  a  minimum,  or  is  ai)sent,  the  opium  slioulU 
be  <,'radually  withdruwji.  'JMie  patients  Jiot  oidy  hear  well  tiiese  hir/^^e  doses 
of  the  drujr.  hut  they  stand  it«  ;!;rudual  reduction,  i'otassium  bromide  is 
often  a  usclul  adjunct.  'J'lie  arsenite  of  bromine,  a  solution  of  arsenious 
acid  witii  l)romine  in  <ilycerin  ((hxse,  U  to  5  minims  after  meals),  has  iteen 
very  lii^hly  recommended,  but  it  is  l)y  no  means  so  certain  as  opium. 
Arsenic  alone  may  l)e  used.  Antipyrin  may  be  j^'iven  in  doses  of  10  ^M-ains 
three  times  a  day,  and  in  cases  with  a  marked  neurotic  constitution  is  some- 
times satisfactory.  'IMie  salicylates,  iodoform,  nitro<,dyc;erin,  jaml)ul,  the 
lithium  salts,  strychnine,  creasote,  and  lactic  acid  have  been  employed. 

Preparations  of  the  pancreas  (j,'lycerin  extracts  of  the  dried  and  fresh 
••land)  have  been  used  in  the  hope  that  they  would  su[)ply  the  internal  secre- 
tion necessary  to  nornuil  supir  nietal)olism.  The  success  has  not,  however, 
been  in  any  way  comparalde  with  that  obtained  with  the  thyroid  extract  in 
myx(edenui.  Lepinc  has  isolated  a  |,dycolytic  ferment  from  the  pancreas 
and  also  from  the  malt  diastase,  and  has  used  it  with  Bomo  success  in  4  cases. 

Of  the  complications,  the  pruriliis  and  enema  are  best  treated  by  cool- 
inf;  lotions  of  boric  acid  or  hy])osulphite  of  soda  (1  ounce;  water,  1  quart), 
or  the  use  of  ichthyol  and  lanolin  ointment. 

In  the  thin,  nervous  cases  the  bowels  should  be  kept  open  and  the  urine 
tested  at  short  intervals  for  acetone  and  diacetic  acid — tiie  derivatives  of 
/3-oxy-1)utyric  acid. 

The  ronm  is  an  almost  ho])eless  comi)lication.  Inhalations  of  oxygen 
have  been  recommended.  The  use  of  bicarbonate  of  soda  in  very  large  doses 
is  recommended  to  neutralize  the  acid  intoxication.  It  may  be  used  intra- 
venously; as  much  as  80  grammes  have  been  injected. 

The  subcutaneous  and  intravenous  injection  of  ])hysiological  salt  solu- 
tion, though  rarely  curative,  has  ])robably  given  the  best  results.  This 
treatment  vras  used  in  my  wards  in  10  of  the  12  cases  in  which  coma  oc- 
curred. In  2  cases  the  patients  were  restored  to  com})lete  consciousness, 
so  that  they  would  have  been  quite  ca])able  of  making  a  will.  JJoth  cases 
eventually  terminated  fatally,  however.  Jn  three  instances  there  was  im- 
])rovement  in  the  pulse,  and  tlie  respirations  were  much  less  labored,  though 
consciousness  never  returned.  In  the  remaining  o  cases  there  was  no 
a])preciable  ini]irovenient.  lieynolds  publislied  2  cases  of  recovery  after 
the  administration  of  a  dose  of  castor  oil,  followed  by  30  to  00  grains  of 
citrate  of  jwtassiuni  every  hour  in  co])ious  draughts  of  water.  The  bowels 
of  a  dia1)ctic  ])atient  should  be  kept  acting  freely,  as  constipation  is  believed 
to  predispose  to  the  development  of  coma. 


27 


432 


CONSTITUTIONAL   DISEASFS. 


VI.    DIABETES    INSIPIDUS. 


/ 


Definition. — A  dironic  nfTcction  clinnu'torizcd  hy  tlio  pussnfio  of  Inrpo 
qiiaiilitiL's  of  iionnal  uriiiu  of  low  s|>('('i(i(,'  },'riivity. 

The  coiulition  is  to  l)o  (listiii^niislicd  from  diuresis  or  ))olyuria,  which 
is  a  fretiuunt  symptom  in  hysteria,  in  Urij^dit's  disease,  and  oceasionally 
in  eeri'hral  or  olhcr  all'cclions.  Willis,  in  1(!T 4,  first  reeo<,'nized  the  distine- 
tion  between  a  saccharine  and  non-saccharine  form  of  diahetes. 

Etiology. — 'I'iie  disease  is  most  common  in  youn<^  [)crsons.  Of  tiio 
85  cases  collected  by  Strauss,  I)  wore  under  five  years;  1^  between  five  and 
ten  years;  .'{(!  between  ten  and  twenty-five  years,  ^lales  are  more  fre- 
quently attacked  than  females.  The  all'cction  may  be  eonj^enital.  A  hered- 
itary tendency  has  l)een  noted  in  many  instances,  the  most  extraordinary 
of  which  has  been  reported  by  Weil.  Of  91  members  in  four  generations, 
23  had  ])ersistent  jjolyuria  without  any  deterioration  in  health.  Injury  to 
the  nervous  system  has  been  ])resent  in  certain  eases,  and  the  disease  has 
followed  sunstroke,  or  a  violent  enu)tion,  such  as  frif^ht.  Traumatism 
lias  occasionally  been  the  exciting  cause.  The  injury  may  have  been  to 
tlie  liead,  but  in  other  cases  it  has  I)een  to  the  trunk  or  to  the  limbs.  Trous- 
seau stated  that  the  ])arents  of  children  with  diabetes  insi])idus  fre(piently 
have  glycosuria  or  albuminuria.  J{alfe  stated  that  malnutrition  is  an  im- 
l)ortant  predisposing  factor  in  children.  The  disease  has  followed  rapidly 
the  copious  drinking  of  cold  water,  or  a  drinking-bout;  or  has  set  in  during 
the  convalescence  from  an  acute  disease.  Tumors  of  the  brain  and  lesions 
of  the  nu'dulla  have  been  mot  with  in  a  few  instances.  Cases  of  ])olyuriii 
have  l)ecn  accompanied  by  ])aralysis  of  the  sixth  nerve.  Maguire  has  seen  an 
instance  after  meningitis  in  which  ])aralysis  of  the  sixth  pair  occurred  with  it. 
Bernard,  it  will  be  remembered,  discovered  a  spot  in  the  floor  of  the  fourth 
ventricle  of  animals  which,  when  ])unctured,  j^roduced  polyuria.  Lesions 
of  the  organs  of  the  abdomen  nuiy  be  associated  with  an  ex'cessive  flow  of 
urine,  which,  however,  should  not  l)e  regarded  as  true  diabetes  insipidus. 
Dickenson  mentions  its  occurrence  in  abdominal  tumors;  Ralfe,  in  ab- 
dominal aneurism.  I  have  noted  it  in  several  cases  of  tul)erculous  peri- 
tonitis. There  have  been  only  2  cases  of  diabetes  insi])idus  out  of  a  total 
of  150,000  ]iatients  treated  at  the  Johns  Hopkins  Hos])ital  and  Dispensary. 

The  nature  of  the  disease  is  unknown.  It  is,  doubtless,  of  nervous 
origin.  The  most  reasonable  view  is  that  it  results  from  a  vaso-motor  dis- 
tur1)ance  of  the  renal  vessels,  due  either  to  local  irritation,  as  in  a  case  of 
abdominal  tumor,  to  central  disturbance  in  cases  of  brain-lesion,  or  to 
functional  irritation  of  the  centre  in  the  medulla,  giving  rise  to  continuous 
renal  congestion. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions.  The 
l-idncys  have  been  found  enlarged  and  congested.  The  hlnddcr  has  boon 
found  hypertrophied.  Dilatation  of  the  ureters  and  of  the  pelves  of  the 
kidneys  has  been  present.  Death  has  not  infrequently  resiilted  from  chronic 
])ulmonary  disease.  Very  varied  lesions  have  been  met  with  in  the  nervous 
system. 


DIAUKTKS  INSIPIDUS. 


433 


pen- 
total 


Symptoms. — Tlic  disciiso  mny  «'<)nu»  on  rapidly,  iih  aflcr  a  frij,'lit  or 
nn  injury.  i\Ioio  (.iininionly  it  develops  slowly.  Ai-cordinj;  to  Kall'u,  tlio 
patients  often  complain  in  tliu  early  sta^'es  of  severe  raekin;;  pains  in  llio 
hnnhar  region  shooting  down  thy  thigliH.  A  copious  seeretion  (d'  urine, 
vith  increased  thirst,  are  the  i)roniinent  features  of  the  disease.  'I'lie 
anKUint  of  urine  in  the  twenty- four  hours  nia>  range  from  JiO  to  lo  pints, 
or  even  more,  'i'rousseau  speaks  of  a  patient  who  consumed  aO  pints  of 
tluid  daily  and  passed  ahout  5(1  jjints  of  urin(!  in  the  twenty-four  hours. 
The  s[)ecilic  gravity  is  low,  l.OOl  to  l.OOo;  tiic  color  is  extremely  pale  and 
x.atery.  The  total  solid  constituents  may  not  he  reduced.  The  amount  of 
uvea  has  sonietinu.'s  heen  found  in  excess.  Ahnornuil  ingredients  are  rare. 
Mu.scle-sugar,  inosite,  has  heen  occasionally  found.  Alhumin  is  rare. 
Traces  of  sugar  have  heen  met  with.  Naturally,  with  the  passage  of  such 
enormous  (piantities  of  urine,  there  is  a  ])r()portionate  thirst,  and  the  oidy 
inconveiuem-e  of  the  disease  is  the  necessity  for  frecpient  micturition  and 
fre(pient  drinking.  The  a|>petite  is  usually  good,  rarely  excessive  as  in 
diahetes  mellitus;  but  Trousseau  tells  of  the  terror  inspired  hy  one  of  his 
jmtients  in  the  kee|)ers  of  those  eating-houses  where  bread  was  allowed  with- 
out extra  charge  to  the  extent  of  each  custonu'r's  wishes,  and  says  that  he 
was  |)resented  with  nu)ney  to  prevent  him  coming  back  to  dine.  The 
|)atient9  may  be  well  nourished  and  healthy-looking.  'IMie  disease  in  numy 
instances  does  not  appear  to  interfere  in  any  way  with  the  general  health. 
The  ])erspiration  is  naturally  slight  and  the  skin  is  harsh.  '^Fhe  amount 
of  saliva  is  small  and  the  mouth  usually  dry.  Cases  have  been  described 
in  which  the  tolerance  of  alcohol  has  been  remarkable,  and  patients  have 
been  known  to  take  a  couple  of  pints  of  brandy,  or  a  dozen  or  more  bottles 
of  wine,  in  the  day. 

The  conrse  depends  entirely  n])on  the  nature  of  the  jirimary  trouble. 
Sometimes,  with  organic  disease,  either  cerebral  or  abdominal,  the  general 
health  is  much  im])aired;  the  patient  becomes  thin,  and  rapidly  loses 
strength.  In  the  essential  or  idiopathic  cases,  good  health  may  be  main- 
tained for  an  indefinite  ])eriod,  and  the  affection  has  been  known  to  ])ersist 
for  fifty  years.  Death  usually  results  from  some  intercurrent  atfection. 
Spontaneous  cure  may  take  ])lace. 

Diagn^osis. — A  low  specific  gravity  and  the  absence  of  sugar  in  the 
urine  distingui.«h  the  disease  from  diabetes  mellitus.  Hysterical  polyuria 
may  sometimes  simulate  it  very  closely.  The  amount  of  urine  excreted 
may  be  enormous,  and  only  the  develojunent  of  other  hysterical  manifesta- 
tions may  enable  the  diagnosis  to  be  made.  This  condition  is,  however, 
always  transitory. 

In  certain  cases  of  chronic  Bright's  disease  a  very  large  amount  of 
urine  of  low  specific  gravity  may  be  passed,  but  the  presence  of  albumin 
and  of  hj^aline  casts,  and  the  existence  of  heightened  arterial  tension,  stiff 
vessels,  and  hypertrophied  left  ventricle  make  the  diagnosis  easy. 

Treatment. — The  treatment  is  not  satisfactory.  No  attcmi)t  should 
be  made  to  reduce  the  amount  of  liquid.  Opium  is  highly  recommended, 
but  is  of  doubtful  service.  The  preparations  of  valerian  may  bo  tried; 
either  the  powdered  root,  beginning  with  5  grains  three  times  a  day,  and 


iU 


CONSTITI'TIONAL   DISK  ASKS. 


incrciif'in;,'  until  l'  (Iracliins  nw  talu'ii  in  llic  ilnv,  or  tlio  vulorinnnlc  of  ■  «, 
in  l.")-;,Main  doses,  gnuhially  incri-ascd  to  ;{(>  j^rains,  tlin-c  times  a  day.  Ev^  , 
crgotin,  antipyrin,  the  nalieylales,  arsenic,  stryelinine,  iiir|ienline,  and  tlu) 
bromides  luive  lieeii   renmimended,      Mice!  ricil  y   mav   lie  nsed. 


/ 


VII.    RICKETS  (lihnchiliH). 

Definition. — A  disease  of  int'aids,  cliara'-teiized  liy  impaired  nntrition 
<ii  llie  t'ntire  body  and  alterations  in  llie  <fro\vin;i  hones. 

(Jliss(m,  the  anatonust  of  tiie  liver,  accurately  descril)ed  the  disease  in 
the  Heventeenth  centin'y.  'I'iie  name  is  (h-rived  I'ldm  the  old  l']nj,dish  word 
irrlrkh'ii,  to  twist.  Olisson  sn^^jfcsted  to  chan^<'  the  name  to  rhadiitis,  from 
the  (J reek,  /»"X''<  the  spine,  as  it  was  one  oi'  the  lirst  jtarts  all'ecled,  and 
also  I'roni  the  similarity  in  the  sound  to  rickets. 

Etiology. — Hickets  exists  in  all  parts  of  the  world,  hid  is  particularly 
marki'd  anion;,'  the  jioor  of  the  lar^^er  cities,  who  are  hadly  housed  and  ill 
iiv(\.  It  is  much  more  common  in  Murope  than  in  Anu'rica.  In  N'ieuna  and 
Ijondon  from  AO  to  HO  per  cent  (d'  all  the  childri-n  at  the  clinics  pri'seiit 
pilous  of  rickets.  It  is  a  comparatively  rare  disease  in  Canada.  In  the  cities 
of  this  continent  it  is  very  prevalent,  |)articularly  amon^'  the  children  of 
the  ne^i'ro  and  of  the  Italian  races.  AVant  of  suidi^dit  and  impnre  air  an' 
important  factors.  l*rolon<:e(l  lactation  and  suckling  the  child  durinf^  preg- 
nancy are  accessory  inlluences  in  some  cnse,". 

There  is  no  evidence  that  the  disease  is  iiereditary. 

Kickets  affects  male  and  female  children  eipially.  Tt  is  a  disease  of  the 
first  and  second  years  of  life,  rarely  heginninji'  hefore  the  sixth  month. 
Jenner  has  descrihed  a  late  rickets,  in  which  form  the  disease  may  not  ap- 
pear until  the  ninth  or  even  nntil  the  twelfth  year.  It  has  been  held  that 
rickets  is  only  a  manifestation  of  eon<j:enital  syjdulis  (Parrot),  but  this  is 
certainly  not  correct.  Sy])hi]itic  bones  rarely,  if  ever,  ])resent  the  spongy 
tissue  ])ectdiar  to  rickets,  and  rachitic  l)ones  never  show  the  muUi|)le  oste- 
ophytes of  syphilis.  "  Sy])hilis  modifies  rickets;  it  does  not  create  it  " 
(Cheadle).  A  faidty  diet  is  the  essential  factor  in  the  production  of  the 
disease.  Like  scurvy,  rickets  may  be  found  in  the  families  of  the  wealtliy 
under  ])erfcct  hygienic  conditions.  It  is  most  C()mnu)n  in  children  fed  on 
condensed  milk,  the  various  ])roprietary  foods,  cow's  milk,  aiul  food  rich 
in  starches.  "  An  analysis  of  the  foods  on  which  rickets  is  most  frequently 
and  certainly  produced  shows  invariably  a  deficiency  in  two  of  the  chief 
elements  so  ]dentiful  in  the  standard  food  of  young  animals — namely,  ani- 
mal fat  and  proteid  "  (Cheadle).  Bland  Sutton's  interesting  exju'rimeiil 
"with  the  lion's  cubs  at  the  "Zoo"  illustrates  this  point.  When  milk, 
pounded  bones,  and  cod-liver  oil  were  added  to  the  meat  diet  the  rickets 
disap])eared,  and  for  th?  first  time  in  the  history  of  the  society  the  cubs 
were  reared.  Associated  with  the  defect  in  food  is  a  lack  of  ])roper  assimila- 
tion of  the  lime  salts. 

Morbid  Anatomy. — The  bones  show  the  most  important  changes, 
particularly  the  ends  of  the  long  hones  and  the  ribs.     Between  the  shaft 


HICKETS. 


435 


nn<l  opipliywfl  a  nlipht  Itiil^in^  is  M|»|»iir('nl,  mikI  on  portion  tln'  /oiio  of  pro- 
lit'iTiitioo,  wliicli  ii(»rmiilly  is  roprchL-ntcd  hy  two  narrow  luimlo,  U  j^n-atly 
iliickeiit'd.  hliiish  in  color,  uioic  inH'j.Miliir  in  outline,  lunl  vrry  iniitli  sol'tcr. 
The  witllli  of  (his  ciisliion  ol'  <iiitilii;,'»!  varies  Ironi  ">  lo  l.">  mm.  'I'lit'  line 
ul'  ossification  iH  also  irrc^nilar  and  mon.'  nponjjy  and  vasi-nlar  than  normal. 
The  |icriosteiim  strips  oil"  very  rcailily  t'roin  tht?  shai't,  and  lu'iicath  it  there 
may  he  a  spon;,'ioid  tissue  not  nnlike  decalcified  hone.  The  practical  oiil- 
come  of  these  clian;j:es  is  a  delay  in,  and  imperfect  performance  of,  the 
o>silication,  so  that  the  hone  has  neither  the  natural  rate  of  ^Mouth  nor  the 
normal  lirmne.«s.  In  the  craninm  there  may  ho  lar«,'o  urt'a.«<,  partieiilarly  in 
the  parieto-occipital  re^non,  in  which  the  ossilication  is  delayed,  producing; 
the  so-called  cranio-tahes,  so  that  the  hone  yields  readily  to  |iressnre  with 
the  lin^icr.  There  are  li>cali/,e(l  depressed  sjiots  (d*  atrophy,  which,  on 
|ires6!iiro,  ^'ivo  tho  so-called  "  parchment  crackling'."  l-'lat  llyperoHto^<e8  de- 
\clop  from  llu)  outer  tahle,  ])articiilarly  on  the  frontal  and  parietal  hones, 
iind  produce  the  charactcrist  ic  hroad  forelieail  with  prominent  frcmtal  emi- 
nen(  es,  a  con<lition  sonictiuu's  nustaken  for  liy<lroceplialiis. 

Kassowitz,  the  leadinj,'  authority  on  the  anatomy  of  rickets,  re^^'ards 
the  hypera'mia  of  the  periosteum,  the  marrow,  the  cartila^n',  and  of  tin; 
hone  itself  as  the  prinniry  lesion,  out  of  which  all  the  others  develo|».  This 
<listurhs  the  normal  development  of  tho  jirowin;;  hone  and  excites  chaniies 
in  tluit  already  formetl.  Tin;  cartilage  cells  in  consc(|uenci;  proliferate,, 
the  nuitrix  is  Kol'ter,  ami  as  a  result  tho  hone  which  is  foruH'<|  from  this 
mdiealthy  cartila<i;e  is  lackintf  in  firmness  and  solidity,  in  the  hone;  already 
fornuMl  this  excessive  vascularity  exa^'^^erates  the  normal  process(;s  <d'  al»- 
sorjition,  so  that  the  relation  h(;tweon  removal  and  deposition  is  disturhed, 
idtsorption  takin<f  ])lace  too  ra|)idly.  The  new  material  is  poor  in  lime  salt.s. 
Kassowitz  has  |)roved  e\])erimentally  that  hypera'mia  of  hone  results  in 
(lefeetivo  depopition  of  lime  salts.  It  is)  interesting;  to  note  that  (llisson 
iittrihnted  rickets  to  disturhed  nutrition  hy  arterial  hlood,  and  helieved 
the  chan<res  in  the  lon«f  hoii.s  to  he  due  to  excessive  vascularity. 

The  chemical  analysis  of  rickety  hones  sliows  a  marked  diminution  in 
the  calcareous  salts,  which  may  ho  as  low  as  25  or  35  per  cent. 

The  liver  and  spleen  are  usually  enlarircd,  and  sometimes  the  niesen- 
\vr\f  <,dands.  As  (Jee  suff^osts,  thesi;  conditions  prohai)ly  result  from  the 
ireneral  state  of  the  health  associated  with  rickets.  Ueneke  has  descrihed 
a  relative  increase  in  the  size  of  the  arteries  in  rickets. 

Symptoms. — The  disease  comes  on  insidiously  ahout  the  period  of 
dentition,  l)el'oro  tlie  cliild  l)e<iins  to  walk,  ^lild  grades  of  it  are  ol'ten  over- 
looked in  the  families  of  the  well-to-do.  In  many  cases  ditrestive  disturh- 
iinces  precede  the  appearance  of  the  characteristic  lesions,  and  the  nutrition 
of  the  child  is  markedly  impairi'd.  There  is  usually  sli<rht  fever,  the  child 
is  irritahle  and  restless,  and  sleeps  hadly.  If  the  child  has  already  wnlkc(l. 
it  shows  a  marked  disinclination  to  do  so,  and  seems  feehle  and  unstea<ly 
in  its  ^ait.  Sir  William  Jenner  has  called  attention  to  three  general  symp- 
toms of  jrreat  importance:  First,  a  diffuse  soreness  of  the  l)ody,  so  that 
iho  cliild  cries  when  an  attcm])t  is  made  to  move  it,  and  ])refers  to  keep 
perfectly  still.    This  is  often  a  marked  and  suggestive  symptom.    Secondly, 


480 


CONSTITUTIONAL   DISRASKM. 


/ 


uliKlit  ft'vtr  (KM)'  (n  |()1. ,")"),  with  in»(tiiriiiil  n-stlfHunoBg,  nrul  a  t^-ndcn- 
cy  ti»  tlintw  nlf  till'  lu'di'lotlicrt.  TliiH  nuiy  lie  |tiirtly  duu  to  tlu'  tact 
that  the  ;,'i'ruTal  Hcri.silivciit'HH  \n  niich  tlint  cvt'ii  their  W('i;;ht  may  he  dis- 
trcssiii^'.  And,  tiiii'dl.v,  pnil'iisc  Hwcatiii^',  |iarti('uhirly  ahuul  the  iicad 
and  rit'ck,  hu  that  in  the  nmrnin^  thi'  pilhnv  is  found  Hoaki'd  with  pot-Hpi- 
lation. 

'V\h>  tJHHnt'H  hcconio  Hoft  nnil  (hihhy;  the  skin  is  pale;  and  i'rojn  a 
licalthy,  phinip  condition,  thr  child  hcconics  puny  and  IVchlc.  The  niUH- 
cnlar  wi'aknc.^s  may  he  marked,  particidarly  in  the  \i%>*,  and  paralysis  may 
be  HUHpt'ctt'd.  This  no-callt'd  jweudo-paresiH  of  riekt'tn  results  in  part  from 
tlu'  tiahhy,  weak  condition  of  the  Ic^'s  and  in  part  from  the  pain  associated 
with  the  movements.  Coincident  with,  or  fcdiowinj;  closely  u|»on,  the  ^'cn- 
cral  symptoniH  the  charactcristi<!  skeletal  lesions  are  ohsi-rved.  Amom; 
the  first  of  tht'sc  to  appear  are  the  chanjfcs  in  the  rihs,  at  the  junction  of 
the  hone  with  the  cartilaj,'e,  fornnni,'  the  so-called  rickety  rosary.  When 
the  child  is  thin  these  nodules  may  l)e  distinctly  seen,  and  in  any  case  can 
Ite  easily  made  out  hy  touch.  They  very  rarely  appear  hefore  the  third 
month.  'IMiey  may  increase  in  si/c  up  to  the  second  year,  and  are  rarely 
Keen  after  the  (iflh  year.  The  thora.x  underjioes  important  chanjfes.  ,Iust 
outside  the  junction  of  the  cartilages  with  the  rihs  there  is  an  ohlicpie, 
shalhnv  depression  extending;  downward  and  outward.  .\  transverse  curve, 
sometimes  calle(i  Harrison's  {groove,  ]»asses  outward  from  (he  level  of  the 
ensiform  cartilage  toward  the  a.xilla  and  nuiy  l)e  deepened  at  each  inspira- 
tion. Jt  is  rendered  more  pronnnent  hy  the  eversion  and  prominence  of 
the  costal  horder.  The  sternum  projects,  particularly  in  its  lower  half, 
forming  the  so-called  pigeon  or  chicken  hreasl.  These  chang<'s  in  tlu? 
thorax  are  not  peculiar,  however,  to  rickets,  and  are  much  more  commonly 
associated  with  hyfjcrtrophy  of  the  tonsils,  or  any  trouhle  which  interferes 
with  the  free  entrance  of  air  into  the  lungs.  The  spine  is  often  curved 
posti'riorly,  the  processes  are  prominent;  lafend  curvature  is  not  so 
common. 

The  head  of  u  rickety  child  nsnally  looks  large  in  ])ro))ortion  hoth  to 
the  body  and  the  face,  and  the  fontanelles  renuiin  open  for  a  long  time. 
There  are  areas,  ))articularly  in  the  |)arieto-occipitnl  regions,  in  which  ossi- 
lication  is  imperfect;  and  the  hone  may  yield  to  the  pressure  of  the  finger, 
a  condition  to  which  the  term  rraiiio-ldhi's  has  heen  given.  The  relation 
of  this  condition  to  rickets  is  still  somewhat  doid)tful,  as  it  is  very  often 
associated  with  syphilis — in  47  of  100  cases  studied  hy  fJeorgo  rar])enter. 
Coincidently  with  this,  hyjierplasia  ])roceeds  in  the  frontal  and  ])arietid 
eminences,  so  that  these  jxtrtions  of  the  skull  increase  in  thickness,  and 
may  form  irregular  bosses.  In  one  type  the  skull  may  be  large  and  elon- 
gated, with  the  top  considerably  llnttened.  In  another,  and  perhaps  more 
common  case,  the  shape  of  the  skull,  when  seen  from  above,  is  rectangular 
— the  nipuf  qvndrafiim.  The  skull  looks  large  in  ])roportion  to  the  face. 
The  forehead  is  broad  and  s(piare,  and  the  frontal  eminences  marked.  The 
anterior  fontanelle  is  late  in  closing  and  may  remain  open  until  the  third 
or  fonrth  year.  The  skin  is  thin,  the  veins  are  full  and  prominent,  and  the 
hair  is  often  rnbbcd  from  the  back  of  the  skull.    In  contradistinction  to  the 


T 


RICKKTS. 


487 


craiun-tiilicH  JH  the  ooiulition  of  cnmio-MclcrMHin,  which  hiH  uIho  la-oii  asi-rihod 
to  rickt'tH. 

Oil  |ihiciiij;  the  ciir  over  the  iiiitcrior  I'onfimcllc,  or  in  the  tcmponil 
rt'|,noii,  II  Hv>(olic  iiiiiriiiiir  iiiiiy  l'nM|iu'iill_v  he  lu'iinl.  'riii«  ('oiiiiitioM,  rust 
(IcHci'ilK'd  hy  tlohii  1).  Kif<hi'r,  of  HoHtoii,  in  iMMil,  iH  licuril  with  thi'  gri'iiti'Ht 
l'n'(|iicncy  in  ricketn,  hut  itH  pivr^i'iu-e  and  |H'rniHti'iU'e  in  iii'i'Tcrtly  hcallhy 
iiil'iiiils  liiivf  hccn  amply  (h'liionstratcd.*  Tiu'  iiiiinimr  in  rarely  heard  after 
the  lU'tli  year.  A  kno\vledj,'e  of  the  existeiiee  of  this  systidic  liiaiii  luiiniiiir 
may  prevent  errorn.  A  case  in  whieh  it  waa  well  niurked  was*  reported  as  un 
inntance  <d'  siippoHed  gummy  tumor  of  tiie  liraiii,  in  which  tlie  miirinur 
was  thoiijiiit  to  he  due  to  p/essiire  on  the  vessels  at  the  hase. 

Changes  occur  in  the  hones  of  the  face,  chielly  in  the  maxilla',  wiiich 
;ire  rccluced  in  size.  The  normal  process  of  deiitilit)n  is  much  distiirhed; 
indeed,  late  teething  is  one  of  the  markcfl  features  in  rickets.  The  tei'tli 
which  appear  may  he  small  and  hadly  formed. 

In  till'  upper  limits  changes  in  the  scapula'  are  not  common.  The 
clavicli!  may  he  thickened  at  the  sti-rnal  end,  and  there  may  lie  thickening 
near  the  attachment  of  the  st<'rno-cleido  muscle.  The  most  noticeahio 
changes  are  at  tlic  lower  ends  <>{  tin;  radius  and  ulna.  The  enlargement 
is  at  the  junction-ari-a  of  the  shaft  and  epiphysis.  Less  evident  enlargi'- 
nieiits  may  occur  at  the;  lower  end  of  the  humerus.  In  severe  cases  tho 
natural  sluipe  of  the  hones  of  the  arm  may  he  much  altered,  since  they  have 
had  to  support  llie  weight  of  the  child  in  crawling  on  the  lloor.  Tho 
changes  in  the  pelvis  are  of  sjtecial  importance,  particularly  in  female  chil- 
dren, as  in  extreme  cases  they  lead  to  great  defoniiity  and  narrowing  of  the 
outlet,  in  the  legs,  the  lower  end  of  the  tihia  lirst  hccome.s  enlarged;  ami 
in  slight  cases  it  may  alone  he  atl'ected.  In  the  severe  forms  the  upper  end 
of  the  hone,  the  corresponding  parts  of  tin.'  (ihula,  and  the  lower  end  of 
the  femur  hcconie  greatly  thickened.  If  the  child  walks,  slight  howing  of 
the  til)ia'  inevital)ly  ri'sults.  In  more  advanced  cases  the  tiltia-  and  even 
the  femora  may  Ite  arched  forward.  In  other  instances  the  condition  of 
knock-kneo  oceurs.  Vnipiestionahly  the  chief  cause  of  these  deformities  is 
the  weight  of  the  hody  in  walking,  l)ut  muscular  action  takes  ])art  in  it. 
Tho  green-stick  fracture  is  not  uncommon  in  tlu!  soft  hones  of  rickets. 

These  changes  in  the  skeleton  ])roceed  slowly,  and  the  general  symp- 
toms vary  n  good  deal  with  their  progress.  The  child  hecomes  more  or 
less  emaciated,  though  "  fat  rickets  "  is  hy  no  means  uncommon,  and  a  cliild 
may  he  well  nourished  hut  "pasty"  and  flahhy.  Fever  is  iU)t  constant,  hut 
in  actively  i)rogressing  chauges  in  the  hone  there  is  usually  a  slight  pyrexia. 
The  ahdomen  is  largo,  "  ])ot-l)cllied,"'  due  ]»artly  to  llatulent  disti'iition, 
])artly  to  enlargement  of  the  livor,  and  in  severe  cases  to  diminution  of 
the  volume  of  the  .thorax.  The,  spleen  is  often  enlarged  and  readily  ytal- 
imhlo.  Tho  urine  is  stated  to  contain  an  excess  of  lime  salts,  hut  Jacohi 
and  Harlow  say  this  has  not  hoon  proved.  Xo  special  or  peculiar  changes, 
indeed,  have  as  yet  heen  descrihed.     There  is  usually  .slight  anaemia,  the 


*  Osier.  On  the  Systolic  Brain  Murmur  of  Chililrcn,  Boston  Medical  m<\  Surgical 
Journal,  1880. 


438 


CONSTITUTIONAL  DISEASES. 


/ 


ha'magloljin  is  aljsolutely  nrid  relatively  decreased;  a  leucocytosis  may  or  may 
not  l)e  present;  it  is  more  coiiimoi'  ^itli  enlar^ciiient  of  the  spleen  (Morse). 
j\Iany  rickety  children  sliow  marked  nervous  sym})toms;  irritability,  pet'v- 
ishness,  and  sleeplessness  are  constantly  present.  Jenner  called  attention 
to  the  close  relationship  which  existed  between  rickets  and  infantile  con- 
vidsions,  particularly  to  the  fits  which  occur  after  the  sixth  month.  Tetany 
is  by  no  means  uncommon.  It  involves  most  freciuently  the  arms  and 
hands;  occasionally  the  le<,'s  as  well.  Jiaryn<fismus  stridulus  is  a  common 
com])licati()n,  and  though  not,  as  some  state,  invariably  associated  with 
this  disease,  yet  it  is  certainly  much  more  frequent  in  rickety  than  in  otiier 
children.  Severe  rickets  interfere  seriously  with  the  j.n'owth  of  a  child. 
Extreme  examjjles  of  rickety  dwarfs  are  not  uncommon.  The  disease  known 
as  acute  rickets  is  in  reality  a  mainfestation  of  scurvy  and  will  l)e  descriljed 
with  that  disease. 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition  of 
the  child  is  such  that  it  is  readily  carried  oif  by  intercurrent  affections, 
particularly  those  of  the  respiratory  orfjjans.  Spasni  of  the  larynx  and 
convulsions  occasionally  cause  death.  In  females  the  deformity  of  the 
pelvis  is  serious,  as  it  may  lead  to  dillieulties  in  parturition. 

Treatment. — The  better  the  condition  of  the  motlicr  durinfr  preir- 
nancy  the  less  likelihood  is  there  of  the  development  of  rickets  in  the 
child.  Eapidly  repeated  pregnancies  and  sucklinji'  a  child  during  preg- 
nancy seem  important  factors  in  the  jjroduction  of  the  disease.  Of  the 
general  treatment,  attention  to  the  feeding  of  the  child  is  the  first  con- 
sideration. If  the  mother  is  unhealthv,  or  cannot  from  any  cause  nurse 
the  child,  a  suitable  wet-nurse  shoidd  be  ])rovided,  or  the  child  must  be 
artififially  fed.  C'ov.s'  milk,  diluted  according  to  the  age  of  the  child, 
should  constitute  the  chic.  food.  Care  shoidd  be  taken  to  examine  the 
condition  of  the  stools,  and  if  curds  are  present  the  child  is  taking  too 
much,  or  it  is  not  sulliciently  diluted,  liarlcy-water  or  carefully  strained 
and  well-boiled  oatmeal  gruel  form  excellent  additions  to  the  milk. 

The  child  should  be  warmly  clad  and  should  be  in  the  fresh  air  and 
sunshine  the  greater  ])art  of  the  day.  It  is  a  "vulgar  error"  to  sup])ose 
that  delicate  children  cannot  stand,  when  carefully  wra])]K'd  iip.  an  even 
low  temperature.  The  child  should  be  bathed  daily  in  warm  water.  Care- 
ful friction  with  sweet  oil  is  very  advantageoiis,  and,  if  properly  performed, 
allays  rather  than  aggravates  the  sensitiveness.  S])ecial  care  should  be 
taken  to  prevent  deformity.  The  child  should  not  be  allowed  to  walk,  and 
for  this  purpose  S])lints  a]i]ilied  so  as  to  extend  beyond  the  feet  are  very 
effective.  Of  medicines,  ])hos])horus  has  been  warmly  recommended  by 
KassoAvitz,  and  its  use  is  also  advised  by  Jacobi.  The  child  may  be  given 
gr.  j^-ff  two  or  three  times  a  day,  dissolved  in  olive  oil.  Cod-liver  oil,  in 
doses  of  from  a  half  to  one  teas])oonful,  is  very  advantageous.  The  syrup 
of  the  iodide  of  iron  m  \v  be  given  with  the  oil.  The  digestive  disturbances, 
together  with  the  res])iratory  and  nervous  complications,  should  receive 
appropriate  treatment. 


OBESITV. 


439 


VNI.    OBESITY. 


Corpulonco,  an  excessive  development  of  the  l)0(lily  fat— nn  '*  oily 
dropsy/'  in  the  words  of  Lord  Byron — is  a  condition  for  which  the  physi- 
cian is  fre([uently  consulted,  and  for  which  much  may  l)e  done  by  a  judicious 
arran<:einent  of  the  diet.  The  tendency  to  ])olysarcia  or  ol)esity  is  often 
hereditary,  and  is  ])articularly  a])t  to  be  manifest  after  the  middle  period 
of  life.  It  may,  however,  be  seen  early,  and  in  this  couutiy  it  is  not  very 
uncommon  in  youn<?  girls  and  young  boys. 

A  very  important  factor  is  oven^ating,  a  vice  which  is  more  prevalent 
a'.d  only  a  little  behind  overdrinking  in  its  disastrous  etfects.  A  majority 
of  ])ersons  over  forty  years  of  age  habitually  eat  too  much.  In  some  of  the 
most  aggravated  cases  of  obesity,  however,  this  plays  no  part,  and  the  un- 
fortunate victim  may  be  a  notoriously  small  eater.  A  sec.nd  element  is 
lack  of  pro])er  exercise;  a  third  less  imj)()rtant  factor  is  the  taking  largely 
of  alcoholic  beverages,  jjarticularly  beer. 

In  obesity  it  is  now  generally  conceded  that  the  carbohydrates,  which 
were  so  long  blamed,  are  not  at  fault,  since  they  are  themselves  converted 
into  water  and  carbon  dioxide.  On  acconnt,  however,  of  the  facility  Mith 
which  they  are  utilized  for  the  purjjoses  of  oxidation,  the  albuminous  ele- 
ments of  the  food  arc  less  readily  oxidized,  and  not  so  fully  decomposed,  and 
the  fat  is  in  reality  separated  from  them.  So,  too,  the  fats  themselves  are 
not  so  prone  to  cause  obesity  as  the  carbohydrates,  being  less  readily  oxidized 
and  interfering  less  with  the  complete  metabolism  of  the  all)uniin()us  ele- 
ments. 

^lany  plans  arc  now  advis-.d  for  the  reduction  of  fat,  th.c  most  im[)ortant 
of  which  are  those  of  Banting,  h'bstein,  and  Oertel.  In  tiie  Banting  method 
the  amount  of  food  is  reduced,  the  liquids  are  restricted,  and  the  fats  and 
carbohydrates  excluded. 

Kl)stein  recommends  the  nsc  of  fat  and  the  rai)id  exclusion  of  the 
carbohydrates.     The  following  is  an  example  of  his  dietary: 

Brral-fdsf  (G  a.  i\r.  in  summer,  7.30  a.  m.  in  winter). — White  bread,  well 
toasted  (rather  less  than  2  ounces)  and  well  covered  with  butt(>r.  Tea, 
without  milk  or  sugar,  8  or  9  ounces. 

Dinner,  2  p.m. — Son])  made  with  beef-marrow.  Fat  meat,  with  fat 
sauce,  4  to  5  ounces.  A  moderate  quantity  of  as])aragus,  spinach,  cabbage, 
])cas,  or  beans.  Two  or  three  glasses  of  light  white  wine.  After  the  meal, 
a  large  cup  of  tea  without  milk  or  sugar. 

Svnper,  at  7.30  p.  m. — An  o^^fi:,  a  little  roast  meat,  with  fat.  About  an 
ounce  of  bread,  well  covered  with  butter.    A  large  cu]i  of  tea,  without  milk 


or  sugar. 


Oerters  nu>thod  will  be  considered  later  in  connection  with  the  treat- 
ment of  frUy  heart,  and  is  combined  w'*^h  systematic  bodily  exercise.  It 
is  particularly  adajited  for  stout  jiersons        '>  weak  hearts. 

The  so-called  Schweninger  cure  is  .  reality  Oertel's,  with  tlie  sole 
modification  of  the  forbidding  of  an  :  fluid  at  meals.  Liquids  must  bo 
taken  more  than  two  hours  aftqr  the  food. 


440 


CONSTITUTIONAL  DISEASES. 


/ 


Yeo,  after  a  full  consideration  of  the  various  methods,  gives  the  follow- 
ing useful  summary:  ' 

"  The  albuminates  in  the  form  of  animal  food  should  be  strictly  lim- 
ited. Farinaceous  and  all  starchy  foods  should  be  reduced  to  a  minimum. 
Sugar  should  be  entirely  prohibited.  A  moderate  amount  of  fats,  for  the 
reasons  given  by  Ebstein,  should  be  allowed. 

"  Only  a  snuill  quantity  of  fluid  should  be  permitted  at  meals,  but 
enough  should  be  allowed  to  aid  in  the  solution  and  digestion  of  the  food. 
Hot  water  or  warm  aromatic  beverages  may  be  taken  freely  between  meals 
or  at  the  end  of  the  digestive  process,  especially  in  gouty  cases,  on  account 
of  their  eliminative  action. 

"  Xo  beer,  porter,  or  sweet  wines  of  any  kind  to  be  taken;  no  spirit, 
except  in  very  small  quantity.  It  should  be  generally  recognized  that  the 
use  of  alcohol  is  one  of  the  most  common  provocatives  of  obesity.  A  little 
Hock,  still  Moselle,  or  light  claret,  with  some  alkaline  table  water  is  all 
that  should  be  allowed.  The  beneficial  effects  of  such  diet  will  be  aided 
by  abundant  exercise  on  foot  and  by  the  free  use  of  saline  purgatives,  so 
that  we  may  insure  a  complete  daily  unloading  of  the  intestinal  canal. 

"  It  is  only  necessary  to  mention  a  few  other  details.  Of  animal  foods, 
all  kinds  of  lean  meat  may  be  taken,  poultry,  game,  fish  (eels,  salmon, 
and  mackerel  are  best  avoided),  eggs. 

"  Meat  should  not  be  taken  more  than  once  a  day,  and  not  more  than 
6  ounces  of  cooked  meat  at  a  time.  Two  lightly  boiled  or  poached  eggs 
may  be  taken  at  one  other  meal,  or  a  little  grilled  fish. 

"  Bread  should  be  toasted  in  thin  slices  and  completely,  not  browned  on 
the  surface  merely. 

"  Hard  captain's  biscuits  may  also  be  taken. 

"  Soups  should  be  avoided,  except  a  few  tablespoonfuls  of  clear  soup. 

"  Milk  should  be  avoided,  unless  skimmed  and  taken  as  the  chief  article 
of  diet.  All  milk  and  farinaceous  puddings  and  pastry  of  all  kinds  are 
forbidden.    Fresh  vegetables  and  fruit  are  permitted. 

"  It  is  important  to  bear  in  mind  that  the  actual  quantity  of  food  per- 
mitted must  have  a  due  relation  to  the  physical  development  of  the  indi- 
vidual, and  that  what  would  be  adequate  in  one  case  might  he  altogether 
inadequate  in  the  case  of  another  person  of  larger  physique."  * 

The  thyroid  extract  has  been  used  in  obesity,  in  a  few  cases  with  suc- 
cess.   It  may  be  tried  beginning  with  small  doses,  as  in  myxoedema. 

*  A  System  of  Therapeutics,  vol.  i,  edited  by  H.  A.  Hare,  Philadelphia,  1891. 


SECTION  V. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


suc- 


I.   DISEASES   OF  THE  MOUTH. 
STOMATITIS. 

(1)  Acute  Stomatitis. — Simple  or  erythematous  stomatitis,  the  com- 
monest form  of  inflammation  of  the  moutli,  results  from  the  action  of 
irritants  of  various  sorts.  It  is  frequent  at  all  ages.  In  children  it  is  often 
associated  with  dentition  and  with  gastro-intestinal  disturbance,  particu- 
larly in  ill-nourished,  unhealthy  subjects.  In  adults  it  follows  the  overuse 
of  tobacco  and  the  use  of  too  hot  or  too  highly  seasoned  food.  It  is  a  fre- 
quent concomitant  of  indigestion,  and  is  met  with  in  the  acute  specific 
fevers. 

The  affection  may  be  limited  to  the  gums  and  lips  or  may  extend  over 
the  whole  surface  of  the  mouth  and  include  the  tongue.  There  is  at  first 
superficial  redness  and  dryness  of  the  membrane,  followed  by  increased 
secretion  and  swelling  of  the  tongue,  which  is  furred,  and  indented  by  the 
teeth.  Tliere  is  rarely  any  constitutional  disturbance,  but  in  children  there 
may  be  slight  elevation  of  temperature.  The  condition  is  sufficient  to 
cause  considerable  discomfort,  sometimes  amounting  to  actual  distress  and 
pain,  particularly  in  mastication. 

In  infants  the  mouth  should  be  carefully  sponged  after  each  feeding. 
A  mouth-wash  of  borax  or  the  glycerin  of  borax  may  be  used,  and  in  se- 
vere cases,  which  tend  to  ])ecome  chronic,  a  dilute  solution  of  nitrate  of 
silver  (3  or  4  grains  to  the  ounce)  may  be  applied. 

(2)  Aphthous  Stomatitis. — This  form,  also  known  as  fnUicnlar  or  vesicu- 
lar stomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised 
spots,  from  2  to  4  mm.  in  diameter,  surrounded  by  reddened  areolae.  Tlie 
spots  appear  first  as  vesicles,  which  rupture,  leaving  small  ulcers  with 
grayish  bases  and  bright-red  margins.  They  are  seen  most  frequently  on 
the  inner  surfaces  of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks. 
They  are  seldom  present  on  the  mucous  membrane  of  the  pharynx.  This 
form  is  met  with  most  often  in  children  under  three  years.  It  may  occur 
either  as  an  independent  affection  or  in  association  with  any  one  of  the 
febrile  diseases  of  childhood  or  with  an  attack  of  indigestion.     The  crop 

441 


442 


DISEASES  OE  THE  DIGESTIVE  SYSTEM. 


/ 


of  vesicles  comes  out  with  y:vt'i\{  rapidity  and  the  little  ulcers  may  he  fully 
formed  within  tweuty-l'our  hours.  The  child  complains  of  sorenes:?  of  the 
mouth  and  takes  food  with  reluctance.  The  l)Uccal  secretions  are  increased, 
and  the  hri'ath  is  heavy,  hut  not  foul.  The  constitutional  symptoms  are 
usually  those  of  the  disease  with  wliicli  the  aphtha'  are  associated.  The 
disease  must  not  be  confounded  with  thrush.  Ko  special  parasite  has  been 
found  in  connection  with  it.  It  is  not  a  serious  condition,  and  heals  rapidly 
with  the  improvemi'iit  of  the  constitutional  state,  in  severe  cases  it  may 
extend  to  the  pillars  of  the  fauces  and  to  the  pharynx,  and  produce  ulcers 
which  are  irritatin^^  and  dillicult  to  heal. 

Kach  ulcer  should  l)e  touched  with  nitrate  of  silver  and  the  moutli 
should  he  thorou<;hly  cleansed  after  taking'  food.  A  wash  of  chlorate  of 
])otassium,  or  of  borax  iMid  glycerin,  nuiy  Ije  u.sed.  Tiie  constitutional  symj)- 
toms  should  receive  cf.reful  attention. 

Here  may  l)e  mentioned  a  curions  affection  which  has  been  ob- 
served cliielly  in  southern  Italy,  and  which  is  characterized  by  a  jiearly- 
colored  membrane  with  induration,  immediately  beneath  the  tongue  on 
the  fra'num  (Kiga's  disease).  There  may  be  much  induration  and  ultimately 
ulceration.  It  occurs  in  both,  healthy  and  cachetic  children,  usually  about 
the  time  of  the  eruption  of  the  first  teeth.    It  is  sometimes  c|)idemie. 

(3)  Ulcerative  Stomatitis. — This  form,  which  is  also  known  by  the 
names  of  fclid  sfomnlitis,  or  putrid  sore  inovfh,  occurs  ])articularly  in  chil- 
dren after  the  first  dentition.  It  may  ])revail  as  a  widespread  epidemic  in 
institutions  in  which  the  sanitary  conditions  are  defective.  It  lias  been 
met  with  in  jails  and  camjis.  Insufficient  and  unwholesome  food,  impro]ior 
ventilation,  and  ])rolonged  dam]),  cold  weather  seem  to  be  s])ecial  predis- 
posing causes.  Tjack  of  cleanliness  of  the  mouth,  the  ])resence  of  carious 
teeth,  and  the  collection  of  tartar  around  them  favor  the  develoj)ment  of 
the  disease.  The  affection  s])reads  like  a  s]iecifie  disease,  but  the  microbe 
has  not  yet  been  isolated.  It  has  l)een  held  that  the  disease  is  the  same 
as  the  foot-and-mouth  disease  of  cattle,  and  that  it  is  conveyed  by  the  milk, 
but  there  is  no  positive  evidence  on  these  points.  Payne  suggests  that  the 
virus  is  identical  with  that  of  contagious  im]ietigo. 

The  morbid  jjrocess  begins  at  the  margin  of  the  gums,  which  become 
swollen  and  red,  and  bleed  readily.  Fleers  form,  the  bases  of  which  are 
covered  with  a  grayish-white,  firmly  adherent  membrane.  In  severe  cases 
the  teeth  may  become  loosened  and  necrosis  of  the  alveolar  process  may 
occur.  The  ulcers  extend  along  the  gum-line  of  the  Tipper  and  lower 
jaws;  the  tongue,  lips,  and  mucosa  of  the  cheeks  are  usually  swollen,  but 
rarely  ulcerated.  There  is  salivation,  the  breath  is  foul,  and  mastication 
is  painful.  The  submaxillary  ]ym]ih-g]ands  are  enlarged.  An  exanthem 
often  develops  and  may  be  mistaken  for  measles.  The  constitutional  symp- 
toms are  often  severe,  and  in  institutions  death  sometimes  results  in  the 
case  of  debilitated  children. 

In  the  treatment  of  this  form  of  stomatitis  chlorate  of  potassium  has 
been  found  to  be  almost  specific.  It  should  be  given  in  doses  of  10  grains, 
three  times  a  day,  to  a  child,  and  to  an  adult  double  that  amount.  Locally 
it  may  be  used  as  a  mouth-wash,  or  the  i)owdercd  salt  may  he  applied  di- 


STOMATITIS. 


443 


rectly  to  the  ulcerated  surraccs.  W'lieii  tlicre  i.s  much  fetor,  a  i)eraianga- 
nate-of-))otash  wash  may  be  used,  aud  an  application  of  nitrate  of  silver  uuiy 
l»e  made  to  tiie  ulcers. 


There  are  several  allirr  rarirlies  of  ulcerative  sore  mouth,  which  dill'er 
entirely  from  this  form.  I'lcers  of  the  mouth  are  common  in  nursing 
woiuen,  and  are  usually  seen  on  the  mucous  mendjrane  of  the  lii)8  and 
cheeks.  They  develop  frr»m  the  mucous  follicles,  and  are  from  3  to  5  mm. 
in  diameter.  They  uuiy  cau.<e  little  or  no  inconvenienLe;  hut  in  some  in- 
stances ihey  are  very  painful  and  interfere  seriously  with  the  taking  of 
food  and  its  mastication.  As  a  rule  they  heal  readily  after  the  application 
of  nitrate  of  silver,  and  the  condition  is  an  ijidication  for  tonics,  fresh  air, 
and  a  better  diet. 

Itecurrinfi  outbreaks  of  an  herpetic,  even  i)emplii<,foid,  eruption  are 
seen  in  neurotic  individuals  {stuinaliliii  neurulica  chronica,  Jacobi).  Jn 
.some  cases  it  is  associated  with  an  erythema  multiforme. 

Parrot  describes  the  occasional  ap])earance  in  the  new-horn  of  small 
idcers  symmetrically  ])laced  on  the  hard  ])alate  on  either  side  of  the  middle 
line.  They  are  met  with  in  very  debilitated  children.  The  ulcers  rarely 
heal;  usually  they  tend  to  increase  in  size,  and  may  involve  the  bone. 

Bednar's  a]ihthfc  consist  of  small  patches  and  ulcers  on  the  hard  |)alatc, 
caused  as  a  rule  in  young  infants  by  the  artificial  ni])ple  or  the  nurse's 
fmger. 

(4)  Parasitic  Stomatitis  (ThrusJi;  Soar;  Mngml). — This  atTection,  most 
commonly  seen  in  children,  is  dependent  upon  a  fungus,  the  saccharomyccs 
albicans,  called  by  IJobin  the  uuliiim  albicans.  It  belongs  to  the  order  of 
yeast  fungi,  and  consists  of  branching  filaments,  from  the  ends  of  which 
ovoid  torula  cells  develoj).  The  disea,>ie  does  not  arise  a[)parently  in  a  nor- 
mal mucosa.  The  nse  of  an  impro])er  diet,  uncleanliness  of  the  mouth, 
the  acid  fermentation  of  remnants  of  food,  or  the  develoy)ment,  from  any 
cause,  of  catarrhal  stomatitis  ])redis])Ose  to  the  growth  of  the  fungus.  In 
institutions  it  is  frequently  transmitted  by  nnclean  feeding-bottles,  spoons, 
etc.  It  is  not  confined  to  children,  but  is  met  with  in  adults  in  the  final 
stages  of  fever,  in  chronic  tuberculosis,  diabetes,  and  in  cachectic  states. 
The  parasite  develops  in  the  upper  layers  of  the  mucosa,  and  the  filaments 
form  a  dense  felt-work  among  the  e])ithclial  cells.  The  disease  begins  on 
the  tongue  and  is  seen  in  the  form  of  slightly  raised,  ])carly-white  s])ots, 
which  increase  in  size  and  gradually  coalesce.  The  membrane  thus  formed 
can  be  readily  scraped  off,  leaving  an  intact  mucosa,  or,  if  the  process  ex- 
tends dee])ly.  a  bleeding,  slightly  ulcerated  surface.  The  disease  s])reads  to 
the  cheeks,  lips,  and  hard  palate,  and  may  involve  the  tonsils  and  pharynx. 
In  very  severe  cases  the  entire  buccal  mucosa  is  covered  hy  the  grayish- 
vrhite  membrane.  It  may  eA-en  extend  into  the  oesophagus  and,  according 
to  Parrot,  to  the  stomach  and  ca>cum.  It  is  occasionally  met  with  on  the 
vocal  cords.  Eohust,  tt-ell-nouri-hed  children  are  sometimes  affected,  but 
it  is  usually  met  with  in  enfeebled,  emaciated  infants  vrith  digestive  or  in- 
testinal troubles.     In  such  cases  the  disease  may  persist  for  months. 

The  affection  is  readily  recognized,  and  must  not  be  confounded  with 


444 


DISEASES  OP  THE  DIOESTIVE  SYSTEM. 


/ 


ajdithoiis  stomatitis,  in  which  the  uh'ors,  preceded  by  the  formation  of 
vesicles,  are  perfectly  distinctive.  In  thrush  the  microscopical  examination 
shows  the  presence  of  the  characteristic  funf,'iis  throughout  the  meinl)rane. 
In  this  condition,  too,  the  mouth  is  usually  dry — a  striking'  contrast  to 
the  salivation  accompanying  a|)htha'. 

Thrush  is  more  readily  ])revented  than  removed.  The  child's  mouth 
should  he  kept  scru])ulously  clean,  and,  if  artificially  fed,  the  bottles  should 
be  thoroughly  sterilized.^  Jjime-watcr  or  any  other  alkaline  fluid,  such  a.s 
the  bicarbonate  of  soda  (a  drachm  to  a  tiuubler  of  water),  may  be  em- 
])loye(l.  When  the  patches  are  present  these  alkaline  mouth-washes  may 
l)e  continued  after  each  feeding.  A  spray  of  borax  or  of  suli)hite  of  soda 
(a  drachm  to  the  ounce)  or  the  black  wash  with  glycerin  nuiy  be  employed. 
The  pernumganate  of  ])otassium  is  also  useful.  The  constitutiomd  treat- 
ment is  of  equal  im])ortance,  and  it  will  often  be  found  that  the  tiirush 
])ersists,  in  s])ite  of  all  local  measures,  until  the  general  health  of  the  infant 
is  im])roved  by  change  of  air  or  the  relief  of  the  diarrluea,  or,  in  obstinate 
cases,  the  substitution  of  a  natural  for  the  artificial  diet. 

(5)  Gangrenous  Stomatitis  {Canrmm  Oris;  Xoma). — An  afTectif)n 
characterized  by  a  rapidly  ])rogressing  gangrene,  starting  on  the  gums  or 
cheeks,  and  leading  to  extensive  sloughing  and  destruction.  This  terrible, 
but  fortunately  rare,  disease  is  seen  only  in  children  under  very  insanitary 
conditions  or  during  convalescence  from  the  acute  fevers.  It  is  more 
common  in  girls  than  in  boys.  It  is  met  with  between  the  ages  of  two 
and  five  years.  In  at  least  one  half  of  the  eases  the  disease  has  developed 
during  convalescence  from  measles.  Cases  have  been  seen  also  after  scar- 
let fever  and  ty])hoid.  The  mucons  membrane  is  first  affected,  usually  of 
the  gums  or  of  one  cheek.  The  process  begins  insidiously,  and  when  first 
seen  there  is  a  sloughing  ulcer  of  the  mucous  membrane,  which  spreads  rap- 
idly and  leads  to  brawny  induration  of  the  skin  and  adjacent  parts.  The 
sloughing  extends,  and  in  severe  cases  the  check  is  perforated.  The  disease 
may  spread  to  the  tongue  and  chin;  it  may  invade  the  bones  of  the  jaws  and 
even  involve  the  eyelids  and  ears.  In  mild  cases  an  idcer  forms  on  the  inner 
surface  of  the  cheek,  which  heals  or  may  perforate  and  leave  a  fistulous  open- 
ing. Xaturally  in  such  a  severe  affection  the  constitutional  disturbances 
is  very  great,  the  pidse  is  rapid,  the  prostration  extreme,  and  death  usually 
takes  place  within  a  week  or  ten  days.  The  temperature  may  reach  103°  or 
104°.  Diarrha>a  is  usually  present,  and  aspiration  pneumonia  often  de- 
velo]is.  H.  T?.  AVharton  has  described  a  case  in  which  there  was  extensive 
colitis.  Bisho])  and  Ryan  have  isolated  an  organism  wdiich  resembles  in 
all  points  the  dijihtheria  bacillus  of  reduced  virulence. 

The  treatment  of  the  disease  is  unsatisfactory.  In  many  cases  the 
onset  is  so  insidious  that  there  is  an  extensive  sloughing  sore  when  the  case 
first  comes  under  observation.  Destruction  of  the  sore  by  the  cautery, 
either  the  Paquclin  or  fuming  nitric  acid,  is  the  most  effectual.  Antisei)tic 
a])])lications  should  be  made  to  destroy  the  fetor.  The  child  should  be 
carefully  nourished  and  stimulants  given  freely. 

(6)  iVTercurial  Stomatitis  (Pti/nlism). — An  inflammation  of  the  mouth 
and  salivary  glands  may  be  caused  by  mercury.     It  occurs  chiefly  in  persons 


STOMATITIS. 


445 


who  have  a  special  puscoptihility,  imd  rarely  now  as  a  result  of  tiie  excessive 
use  of  the  dru^f.  Jt  is  met  with  also  in  persons  whose  occupation  neces- 
sitates tiie  constant  handling'  of  mercury.  It  often  fitllows  tiie  adminis- 
tration of  re|»eate<l  snuill  doses.  'IMius,  a  ]»atient  with  heart-disease  wiio 
was  ordered  an  eiffhtii  of  a  ^I'aiii  of  calomel  every  tliree  hours  h)V  diuretic 
purposes  had,  after  takinj;  eif,dit  or  ten  doses,  a  severe  stomatitis,  whii-ii 
|)ersisted  for  several  weeks.  1  have  known  it  to  follow  tiu'  administra- 
tion of  small  doses  of  ^n-ay  powder.  The  ])atient  comi)lains  first  of  a  metallic 
taste  in  the  mouth,  the  f,'ums  hecoine  swollen,  red,  and  sore,  mastication 
is  dillicult,  and  soon  there  is  a  f^n-eat  increase  in  the  secretion  of  the  saliva, 
which  flows  freely  from  the  mouth.  The  tongue  is  swollen,  the  breath  has 
a  foul  odor,  and,  if  the  all'ection  i)roj?resses,  there  nuiy  lie  ulceration  of  the 
mucosa,  and,  in  rare  instances,  necrosis  of  the  jaw.  Althou.trh  troulde- 
souie  and  distrcssin-;,  the  disease  is  rarely  serious,  and  recovery  usually 
takes  i)lace  in  a  couple  of  weeks.  Instances  in  which  the  teeth  become 
loosened  or  detached  or  in  which  the  inilammation  extends  to  the  pharynx 
and  i'lustachian  tul)es  are  rarely  seen  now. 

The  administration  of  mercury  should  be  susjiended  so  soon  as  the 
gums  are  "  touched."  ]\lild  cases  of  the  aifection  subside  within  a  few  days 
and  re(piirc  only  a  simple  mouth-wash.  In  severer  cases  the  chlorate  of  po- 
tassium may  l)e  given  internally,  and  used  to  rinse  the  mouth.  The  bowels 
should  be  freely  o])ened;  the  ])aticnt  should  take  a  hot  bath  every  evening 
and  should  drink  })lentifully  of  alkaline  mineral  waters.  Atropine  is  some- 
times serviceable,  and  may  be  given  in  doses  of  y^^rof  ^  grain  twice  a  day. 
Iodine  is  also  recommended.  "When  the  salivation  is  severe  and  protracted, 
the  ]iatient  becomes  much  debilitated,  anu'mia  develojis,  and  a  supporting 
treatment  is  indicated.  The  diet  is  necessarily  li(piid,  for  the  patient  finds 
the  chief  dilliculty  in  taking  food.  If  the  pain  is  severe  a  Dover  powder 
may  be  given  at  night. 

Here  may  be  a])])ropriately  mentioned  the  influence  of  stomatitis,  par- 
ticularly the  mercurial  form,  n])on  the  develo])ing  teeth  of  children.  The 
condition  known  as  erosion,  in  which  the  teeth  are  honcycond)ed  or  ])ittcd 
owing  to  defective  formation  of  enamel,  is  indicative,  as  a  rule,  of  infantile 
stonuititis.  Such  teeth  must  be  distinguished  carefully  from  those  of  con- 
genital sy])hilis,  which  may  of  course  coexist,  but  the  two  conditions  are 
distinct.  The  lioncycombing  is  fre(iuently  seen  on  the  incisors;  but,  ac- 
cording to  Jonathan  Hutchinson,  the  test  teeth  of  infantile  stomatitis  are 
tlie  first  permanent  molars,  then  the  incisors,  "which  are  almost  as  con- 
stantly iiittcd,  eroded,  and  of  bad  color,  often  showing  the  transverse  fur- 
row which  crosses  all  the  teeth  at  the  same  level."  ^Magitot  regards  these 
transverse  furrows  as  the  result  of  infantile  convulsions  or  of  severe  illness 
(luring  early  life.  He  thinks  they  are  analogous  to  the  furrows  on  the 
nails  which  so  often  follow  a  serious  disease. 

(7)  Eczema  of  the  Tongue  {GeorjrapMcal  Tonf/ue). — A  remarkable 
desquamation  of  the  superficial  epithelium  of  the  tongue  in  circinate 
patches,  which  spread  while  the  central  portions  heal.  Fusion  of  patches 
leads  to  areas  with  sinuous  outlines.  When  extensive  the  tongue  may  be 
covered  with  these  areas,  like  a  geographical  map.    The  affection  causes  a 


k 


446 


DISK  ASKS  OP  THE  DIOESTIVK  SYSTEM. 


/ 


;:o<m1  (It'iil  of  iuliiii^i  iiiul  heat,  and  may  be  u  source  of  inui'li  mental  worry 
Id  tlu'  |»atifnts,  wlio  often  dread  ie.st  it  may  he  a  eommencinj?  cancer. 

'L'he  etiology  of  tlie  disca^se  iu  unkno>vii.  It  oecurn  in  iiifunts  and  diil- 
drcii,  and  it  is  not  very  inliXMiiicnl  in  itdults.  It  has  hccn  re^^arded  as  a 
<i(iiity  iiiaMii'fstation,  and  transient  attai-ks  may  aeeompany  indigestion. 
It  16  vi-ry  lial)le  to  rela|)se.  Jn  adults  it  nuiy  |)rove  very  ol)stinate,  and  1 
know  (>[  one  instance  in  wliicii  tlie  disease  jiersisted  in  spite  of  all  treut- 
juent  for  more  than  two  years.  Soluti(tns  of  nitrate  of  silver  give  the  most 
satisfactory  residts  in  relieving,'  the  inleiise  hurninjj;. 

(8)  Letlkoplakia  bticcalis. — Sannul  IMnmUe  ileseril)ed  the  condition  as 
icllij/dxis  liuijitdliv.  It  has  jdso  been  called  buccal  psuriusis  ami  licrulusix 
iiiunhsd'  urin.  'J'here  are  unsymmetrical  [(atches  of  various  shHi>es,  whitish 
or  often  peiirly  wliite  in  color,  smooth,  and  without  any  tendency  to  ulcer- 
ate. 'J'liey  have  been  called  Jin;4ual  corns.  The  intensity  of  the  opaque 
white  color  depejids  upon  the  thickness  of  the  e])idermis.  The  putcheii 
may  extend  and  become  slijihtly  |)apillonmtous.  There  are  instances  in 
which  jrenuine  epilhelionia  has  developed  from  them.  'J'he  condition  hi 
met  with  jnost  commonly  in  heavy  smokers,  and  is  sometinu'S  kno\v)i  as 
the  smoker's  tongue.  An  intei'csting  (piestion  is  the  relation  to  syphilis. 
While  somewhat  similar  ]tatches  develop  in  infected  jjcrsons,  the  true 
syphilitic  glossitis  rarely  presents  the  same  ojmque  white,  smooth  apjiear- 
ance.  Jt  is  more  commoidy  at  the  edge  and  the  ])oint  of  the  tongue  than 
on  the  dorsum,  and  yields  ])r()m|)tly  to  speeiiie  treatment. 

Iieuko])lakia  is  a  very  obstinate  atl'ection  and  resists  as  a  rule  all  forms 
of  treatment.  All  irritants,  such  as  smoke  and  very  hot  food,  should  be 
avoided.  J.ocal  treatment  with  one-half-iter-ceut  corrosive  sublinuite  or  :i 
one-])er-cent  chromic-acid  solution  has  been  recommendech  The  i)ropriety 
of  active  local  treatment  is  doubtfxd.  The  appearance  of  anything  like 
])apillomatons  outgrowths  should  be  regarded  as  an  indication  for  surgical 
intervention. 


II.    DISEASES   OF  THE   SALIYARY   GLANDS. 

1.  Supersecretion  {Pii/flism). — The  normal  amount  of  saliva  varies 
from  2  to  '3  ]iints  in  the  twenty-four  hours.  The  secretion  is  increased 
during  the  taking  of  food  and  in  the  i)hysiological  ])rocesses  of  dentition. 
A  great  increase,  to  which  the  term  pfi/alism  is  applied,  is  met  with  under 
many  circumstanci's.  It  occurs  occasionally  in  mental  and  nervous  affec- 
tions and  in  rabies.  Occasionally  it  is  seen  in  the  acute  fevers,  ])articularly 
in  small-])ox.  It  occurs  sometimes  with  di.sea.«e  of  the  ]iancreas.  It  ha^ 
been  met  with  during  gestation,  usually  early,  though  it  may  persist 
throughout  the  entire  course.  It  has  l)een  known  to  occur  at  each  men- 
strual ]>eriod;  and,  lastly,  it  is  a  common  effect  of  certain  drugs.  ^lereury, 
gold,  co))per,  the  iodine  com]>ounds.  and  (among  vegetahle  remedies) 
jaborandi,  musearin,  and  tobacco  excite  the  salivary  secretion.  Of  these 
we  most  frequently  see  the  effect  of  mercury  in  producing  ptyalism.  The 
salivation  may  he  present  without  any  inflammation  of  the  mouth. 


DISKASRS  OF  TIIR  SALIVARY   (UiANDri. 


447 


''i.  Xerostomia  {Arrcsl  nf  Ihr  Siillniri/  iiiiil  IliicntI  Si'crrlidiis ;  Pii/ 
Miiiilli). —  111  iliiM  I  iHMlilioi).  lirst  (li'MTil)C(l  li_v  .Joimtliaii  llutcliiiisiiii,  llie 
.-(■(•rc'tiuiiri  of  tlio  iiioiith  ami  salivary  ^ilaiitls  arc  sii|t[»r('SK('(l.  'I'lit-  l()ii;;ii(' 
i-  led,  somctiiiH's  cinckcd,  and  (|iiitc  drv;  the  iiiii(<iiis  niriiiliiaiic  ol!  llit; 
I  liccks  aixl  of  the  palatL'  is  siikmiUi,  sliiiiin;^',  and  iIit;  and  maslicat  inn, 
il(  ,ulMtiti(in,  and  art  icniation  arc  Ncry  dillicidt.  'I'lic  ciinditiun  is  not  coni- 
iimn.  A  majority  of  (lie  caM's  arc  in  wnnicn,  and  in  .-cvci'nl  instances  Inivo 
i  ccn  associat<'<l  wiili  nervous  pliciionuna.  Tlic  j^cncral  licalth,  as  a  rule, 
i,«  unim|iaired.  lladdcn  suf.'-;ii'sts  that  it  is  due  to  inv(tlvcment  of  some 
lentrt'  wliicli  controls  the  secretion  (d'  the  salivary  and  l)Uccal  ^ilands.  A 
\u'll-marked  i^asc  came  under  my  ol)>crvat  ion  in  a  man  a^^cd  tliii'l  v-two, 
who  was  sent  to  me  hy  Donald  iJaynes  on  acfounl  of  a  pt'culiar  growth 
m  the  mouth.  This  provctl  to  Ix;  the  remnants  of  food  which,  owin;;'  to 
the  ai)sence  of  any  salivary  or  Imccai  secretions,  collected  alon;;  the  ^nnis, 
liecame  hardened,  and  adhered  to  theni.  The  condition  lusted  for  three 
weeks,  and  was  cured  hy  the  <;ulv'aiiic  current. 

;j.  Inflammation  of  the  Salivary  Glands. 

(./)  Spcci/ic  J'antlillx.     (See  ^li:.Mi's.) 

{!))  Siimplonuilic  /jurolllis  or  /ximliil  bubo  occurs: 

(1)  In  the  course  of  the  infections  fevers — ty|thus,  typhoid,  pneumonia, 
]iya'niia,  etc.  In  ordinary  practice  it  occurs  ofteiiest,  perhaps,  in  ty|»hoid 
lever.  Jt  is  the  I'esult  either  of  septic  infection  throuuii  the  hlood,  or  tlu; 
iiitlammation,  in  many  ca.^es,  ])asses  u|)  the  salivary  duct,  ami  so  reaches 
the  tfland.  The  ]»rocess  i.s  usually  very  intense  and  leads  rapidly  to  sup- 
puration. It  is,  as  a  rule,  an  unfavorahle  indication  in  the  course  oi'  a  I'ever. 
I  have  seen  recently  parotitis  in  secondary  sy])hilis. 

Ct)  In  connection  with  injury  or  disease  of  the  al)domen  oi"  pelvis,  a 
idudition  to  which  Stephen  I'aji'ot  has  called  special  attention.  Of  lot 
case  of  this  kind,  '*  10  followed  injury  or  disease  of  the  urinary  tract,  18 
were  i\\\('  to  injury  or  disease  of  the  alimentary  canal,  and  23  were  <'iie  to 
injui'y  OI'  disease  of  the  abdominal  wall,  the  ]»eriton!eiim,  or  the  pelvic 
cellular  tissue.  The  remainin,i;  oO  were  due  to  injury,  disease,  or  tempo- 
rary deranjrement  of  the  genital  or<;an9,"  Dy  temporary  deran^jenient  is 
meant  slii^ht  injuries  or  natnral  processes — a  &li<rht  blow  on  the  testis,  the 
introduction  of  a  pessary,  menstruation,  or  ]ire,i,niancy.  'J'he  etiolo<iy  of 
ill  is  form  of  parotitis  is  obscnre.  A\'e  have  had  3  cases.  ^lany  of  them 
;ire  nndoubtedly  septic. 

(3)  In  association  witli  facial  paralysis,  as  in  a  case  of  fatal  periplu'ral 
neuritis  described  by  (Jowers. 

In  tbe  treatnuMit  of  parotid  Inibo  the  ap])lication  of  balf  a  dozen  li'cches 
will  sometimes  reduce  the  inHammation  and  i)romote  resohition.  When 
suppuration  seems  inevitable  hot  fomentations  should  be  ai)plied.  A  free 
incision  shonld  be  made  early. 

{(•)  Chronic  parotitis,  a  condition  in  which  the  glands  are  enlarged, 
rarely  jiainful,  may  follow  iidlannnation  of  the  throat  or  mumps.  Sali- 
vation may  be  present.  It  may  be  duo  to  lead  or  mercury.  It  occurs 
also  in  chronic  Bright's  disease  and  in  secondary  sy])hilis.  Mikulicz  has 
tlescribed  a  remarkable  condition  of  chronic  symmetrical  enlargement  of 
28 


44S 


DrsKASES  OP  THE  DIORSTIVE  HYSTKM. 


the  Hiilivnry  and  liicliryimil  gltids.  'I'lic  condition  may  persist  for 
yj'jirH.  'I'lio  ciifto  under  my  {are  mentioned  in  the  neeond  edition  (tf 
this  work  died  HuhHiMjuenlly  of  tuliercidosiH  (Am.  Jr.  Med.  Sci.,  January, 
IH'JH). 

((I)  (lusnnis  Tinnors  of  t^lcnu's  Duel  (iiid  of  llir  I'tiraliil  (Ihiiiil. —  In 
ghiss-hh)\vers  and  mnsicianH  Steno'H  duet  may  b'jeoint'  inllated  witii  air 
and  form  a  tun'  "  tiie  Hizu  of  a  nut  or  of  an  v^}!.  Some  have  eoi.  iied  a 
mixture  of  air,  si  'iva,  and  pus.  In  rare  cases  tiu're  are  ^oiseous  tumors  of 
llie  glands,  which  give  a  sensation  of  cre]>italion  on  palpation. 


III.    DISEASES  OF  TIIE  PIIARYXX. 


/ 


(1)  Circulatory  Disturbances. — (^0  Ifi/pcrcrtnia  is  a  common  condition 
in  acute  and  ciironic  alfection.s  of  the  throat,  and  is  frecjuently  seen  as  a 
result  of  irritation  from  tobacco  Hnu)ko.  A'enous  stasis  is  seen  in  valvular 
disease  of  the  heart,  and  in  nu'chanical  obstruction  of  the  superior  vena 
cava  by  tumor  or  aneurism.  In  aortic  insulliciem-y  the  (ii|»illary  pulse  may 
sometinu's  be  seen  and  the  intense  throbbing  of  the  internal  carotid  may 
be  mistaken  for  aneurism. 

(h)  If(rniorrli(i(/('  is  found  in  association  with  bleeding  from  other  niucoiis 
surfaces,  or  it  is  due  to  local  causes  in  the  pharynx  itself,  in  the  latter 
case  it  may  be  mistaken  for  lueniorrhage  from  the  lungs  or  stomach.  The 
bleeding  may  come  from  granulations  or  vegetations  in  the  naso-pharyn\. 
Sometimes  the  ])atient  finds  the  |)illow  stained  in  the  morning  with  bloody 
secretion.  The  condition  is  rarely  .serious,  and  only  recpiires  suitable  local 
treatment  of  the  ])haryu.v.  Occasiomdly  a  hu'inorrhage  takes  ])lace  into 
the  mucosa,  ])r()ducing  a  pbaryngeal  luematonui.  I  have  thrice  seen  a 
condition  of  the  uvula  resembling  luvmorrhagic  infarction.  One  was  in  a 
])atient  with  acute  rheumatism,  to  whom  large  doses  of  salicylic  acid  had 
been  given;  the  other  two  were  instances  of  ])eliosis  rheumatica,  in  both 
of  which  ])artial  sloughing  of  the  uvula  took  ])lace. 

(c)  Oedema. — An  infiltrated  (edematous  condition  of  the  uvula  and 
adjacent  parts  is  not  very  uncommon  in  conditions  of  debility,  in  ])rofound 
ana'Uiia,  and  in  ^right's  disease.  The  uvula  is  sometimes  from  this  cause 
enormously  enlarged,  whence  may  arise  dilliculty  in  swallowing  or  in 
breathing. 

(2)  Acute  Pharyngitis  (Sore  Thmat;  A)u/ina  Simpler). — The  entire 
pharyngeal  structures,  often  -with  the  tonsils,  arc  involved.  The  condition 
may  follow  cold  or  exposure.  In  other  instances  it  is  associated  with  con- 
stitutional states,  such  as  rheumatism  or  gout,  or  with  digestive  disorders. 
The  patient  comjdains  of  uneasiness  and  soreness  in  swallowing,  of  a  feel- 
ing of  tickling  and  dryness  in  the  throat,  together  with  a  cou.stant  desire 
to  hawk  and  cough.  Frccjuently  the  inflammation  extends  into  the  larynx 
and  produces  hoarseness.  Xot  uncommonly  it  is  only  ])art  of  a  general 
riaso-])haryngeal  catarrh.  The  process  may  pass  into  the  Eustachian  tid)es 
and  cause  slight  deafness.  There  is  stiffness  of  the  neck,  the  lymph-glands 
of  which  may  be  enlarged  and  painful.    The  constitutional  symptoms  are 


DISRASRS  OP  TIIK   PIIAUYNX. 


441) 


ftrl- 


riircly  Kovcrc.  Tlic  (Mhcuhi'  wts  in  with  a  chill}'  IVrling  nnd  hli;4ht  fever; 
tlie  |)Ii1k'  is  incrnised  in  l"n'(|iH'Mcy.  Occasioinilly  thu  febrilu  Hymptnmd 
lire  iiinro  si'vcrc,  particiihirly  it  tho  toiisila  are  wpfcially  involved.  Tho  e.\- 
iiiiiiiiation  dl'  the  throat  shows  p'lieral  eonj^eslion  of  the  mucous  nieiiihrane, 
wliich  is  dry  and  j,distenin^',  and  in  [ilaeew  eovered  with  slieky  seLivtion. 
The  uvnhi  may  ho  much  swoMeti. 

Acntc  |»lnirynj,'itiH  hists  only  a  few  days  and  re(|uires  mild  measures. 
If  the  tonsils  are  involve(|  and  the  fever  is  hi<,di,  aconite  or  sodium  salicvlate 
may  he  ^nvcn.  (iiiaiacum  also  is  henelicial;  hut  in  a  majority  of  the  cases 
a  calomel  pnrgo  or  a  nalino  aperient  and  inhalations  with  steam  meet  the 
indications. 

{;{)  Chronic  Pharyngitis.— This  may  follow  repeated  acnte  attacks.  Tt 
is  very  common  in  person.s  who  smoke  (»r  drink  to  excess,  and  in  those 
who  nsc  the  voice  very  much,  such  as  cler<iymen,  hucksters,  and  others. 
It  is  fre(|uently  met  with  in  chronic  nasal  catarrh.  The  naso-pharyn.\  and 
the  posterior  wall  are  the  parts  most  frecpiently  alVectecl.  The  mucous 
niemhrane  is  relaxed,  the  venules  are  dilated,  and  roundish  hodies,  from 
)i  to  4  mm.  in  diameter,  reddish  in  color,  project  to  a  variahle  distance 
heyond  the  mucous  niend)ranc.  These  represent  the  proliferations  of  lyni|tli 
tissue  about  tho  ninoons  j^dands.  They  may  he  very  ahundant.  forming 
eloiifrnted  rows  in  the  lateral  walls  of  the  pharynx.  With  this  there  may 
lie  a  dry  j,distenin^'  state  of  the  pharyn;^('al  mucosa,  sometimes  known  as 
jilidryiKjitis  sired.  Tho  pillars  of  the  fauces  and  the  inida  are  often  much 
rela.xed.  The  secretion  forms  at  the  hack  of  tho  pharynx  and  the  patient 
may  feel  it  drop  down  from  the  vault,  or  it  is  tenacious  and  adherent,  and 
is  only  removed  hy  repeate(l  ell'orts  at  hawkinj?. 

In  the  trcdhnnif,  special  attcidion  must  ho  ])aid  to  the  <,'enend  health. 
If  ])ossil)le,  the  cause  should  ho  ascertained.  The  condition  is  almost 
(onstant  in  smokers,  and  cannot  be  cured  without  stopping,'  the  use  of 
tobacco.  The  use  of  food  either  too  hot  or  too  much  s|)ice(l  should  be  for- 
bidden. When  it  de|>ends  upon  excessive  exercise  of  tho  voice,  rest  should 
lie  enjoined.  Tn  nuiny  of  these  cases  chanjife  of  air  and  tonics  help  very 
iinu'h.  In  the  local  treatment  of  the  throat  ftarjiles,  washes,  and  i)astilIo.s 
(if  various  .^orts  jjive  tem])orary  ri'lief,  but  when  tho  hypertro|»hie  condi- 
tion is  marked  the  spots  should  bo  thoroufrlily  destroyed  by  the  f^alvano- 
cnutery.  In  many  instances  this  alTords  ^nvat  and  ])ermant'nt  relief,  but 
ill  others  the  condition  persists,  and  as  it  is  not  unbearable,  the  i)ationt 
<:ives  up  all  hoi)e  of  ponnanont  relief. 

(4)  Ulceration  of  the  Pharynx. — (a)  Follicular.  The  nlcers  are  usually 
siiinll,  superficial,  and  generally  a.^sociatod  with  chronic  catarrh. 

(h)  Sy])hilitic  nlcers  are  usually  painless,  and  mo.st  freipu-ntly  situated 
I'll  the  posterior  wall  of  the  pharynx.  They  occur  in  tho  secondary  sta*;e 
lis  small,  shallow  excavations  with  the  mucous  jiatchcs.  In  the  tertiary 
stiijro  tho  ulcers  arc  duo  to  erosion  of  "lummata,  and  in  bealin<;  they  leave 
whitish  cicatrices. 

(r)  Tuberculous  ulceration  is  not  very  uncommon  in  advanced  eases 
of  jihthisis,  and,  if  extensive,  is  one  of  the  most  distressin<r  features  of  tho 
later  stages  of  the  disease.     The  ulcers  are  irregular,  with  ill-definod  edges 


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DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


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ajid  grayish-yellow  bases.  The  posterior  wall  of  the  jjharynx  may  have  an 
eroded,  worm-eaten  ai)})earance.  These  nlcers  are,  as  a  rule,  intensely  pain- 
ful. Occasionally  the  primary  disease  is  about  the  tonsils  and  the  pillars 
of  the  fauces. 

{(I)  I 'leers  occur  in  connection  with  ])seudo-membranous  inflanmiation, 
particularly  the  dii)htheritic.    In  cancer  and  in  lupus  ulcers  are  also  present. 

(e)  Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in  typhoid. 

In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is 
very  difficult.  The  tuberculous  and  cancerous  varieties  arc  readily  recog- 
nized, but  it  ha])])ens  not  infrequently  that  a  dou1)t  arises  as  to  the  syi)h- 
ilitic  character  of  an  iilcer.  In  many  instances  the  local  conditions  may 
be  uncertain.  Then  other  evidences  of  syphilis  should  be  sought  for, 
and  the  ])atient  should  be  placed  on  mercury  and  iodide  of  ])otassium, 
under  Avhich  remedies  sy])hilitic  idcers  usually  heal  Avith  great  rapidity. 

(5)  Acute  Infectious  Phlegmon  of  the  Pharynx. — lender  this  term 
Senator  has  described  cases  in  which,  along  with  difficulty  in  swallowing, 
soreness  of  the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the 
pharyngeal  mucosa  becomes  swollen  and  injected,  the  fever  is  h'gh,  the 
Constitutional  symptoms  are  severe,  and  the  inflammation  passes  on  rap- 
idly to  sn])puration.  The  symptoms  are  very  intense.  The  swelling  of  the 
pharyngeal  tissues  early  reaches  such  a  grade  as  to  impede  resi)iration.  Very 
similar  symptoms  may  be  produced  by  foreign  bodies  in  the  ])harynx. 

(6)  Retro-pharyngeal  abscess  occurs:  (1)  In  healthy  children  Ijetween 
six  months  and  two  years  of  age.  The  child  becomes  restless,  the  voice 
■changes;  it  becomes  nasal  or  metallic  in  tone,  and  there  are  pain  and  diffi- 
culty in  swallowing.  Inspection  of  the  jiharynx  reveals  a  projecting  tumor 
in  the  middle  line,  or  if  it  be  not  visible,  it  is  readily  felt,  on  palpation,  pro- 
jecting from  the  posterior  wall.  This  form  has  been  carefully  described  by 
Koplik.  (3)  As  a  not  infrequent  sequel  of  the  fevers,  particularly  of  scarlet 
fever  and  diphtheria.     (3)  In  caries  of  the  bodies  of  the  cer\-ical  vertebnc. 

The  diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  or 
felt  with  the  finger  on  the  posterior  wall  of  the  pharynx. 

(7)  Angina  Ludovici  (Lndicig's  Angina;  Cellulitis  of  the  NecTc). — In 
medical  practice  this  is  seen  as  a  secondary  inflammation  in  the  specific 
fevers,  particularly  diphtheria  and  scanet  fever.  It  may,  however,  occur 
idio])athically  or  result  from  trauma.  It  is  probably  always  a  streptococcus 
infection  M'hich  spreads  rapidly  from  the  glands.  The  swelling  at  first  is 
most  marked  in  the  sid)maxillary  region  of  one  side.  The  symptoms  are, 
as  a  rule,  intense,  and,  unless  early  and  thorough  surgical  measures  are  em- 
])loyed,  there  is  great  risk  of  systemic  infection.  Felix  Semon  holds  that 
the  various  acute  septic  inflammations  of  the  throat — acute  oedema  of  the 
larynx,  phlegmon  of  the  pharynx  and  larynx,  and  angina  Ludovici — 
**  represent  degrees  varying  in  virulence  of  one  and  the  same  process.'" 


ACUTE  TONSILLITIS. 


451 


OVICI 

J 


;ss. 


lY.    DISEASES  OF  THE  TONSILS. 
ACUTE   TONSILLITIS. 

(1)  Follicular  or  Lacunar  Tonsillitis. — For  practical  purposes,  under 
this  name  may  be  described  the  various  forms  wliich  have  been  called  ca- 
tarrlial,  erythematous,  ulcero-membranous,  and  lierpetic, 

£jtiology. — The  disease  is  met  witli  most  frequently  in  young  persons, 
l)Ut  in  cJiiidren  u/;der  ten  it  is  less  common  than  the  chronic  form.  It  is 
rare  in  infants.  Sex  has  no  special  inlluence.  Exposure  to  wet  and  cold, 
and  bad  hygienic  surroundings  appear  to  have  a  direct  etiological  connec- 
tion with  the  disease.  In  so  many  instances  defective  drainage  Jias  been 
found  associated  witii  outbreaks  of  follicular  tonsillitis  that  sewer-gas  is 
regarded  as  a  common  exciting  cause.  One  attack  renders  a  pa  dent  more 
liable  to  subsequent  infection.  Special  stress  is  laid  by  some  writers  upon 
the  coexistence  of  tonsillitis  with  rheumatism.  Cheadle  describes  it  as 
one  of  the  ])hases  of  rheumatism  in  childhood  with  which  articular  attacks 
juay  alternate.  I  cannot  say  that,  in  my  experience,  the  connection  betwcGii 
the  two  afrections  has  been  very  striking,  except  in  one  point,  viz.,  that 
iin  attack  of  acute  rheumatism  is  not  infrequently  preceded  by  inilamma- 
tion  of  the  ton.-?iis.  The  existence  of  pains  in  the  limbs  is  no  evidence  of 
the  connection  of  the  affection  with  rheumatism.  A  disease  so  common 
and  widespread  as  acute  tonsillitis  necessarily  attacks  many  persons  in 
^\hose  families  rheumatism  prevails  or  who  may  themselves  have  had  acute 
attacks. 

Mackenzie  gives  a  table  showing  that  in  four  successive  years  more 
eases  occurred  in  September  than  in  any  other  month;  in  October  nearly 
as  many,  with  July,  August,  and  Xovember  next.  In  this  country  it  seems 
more  prevalent  in  the  spring.  So  many  cases  develop  within  a  short  time 
that  the  disease  may  be  almost  e])idemic.  It  spreads  through  a  family  in 
such  a  way  that  it  must  be  regarded  as  contagious. 

An  old  notion  prevails  that  there  is  a  definite  relation  between  the 
tonsils  and  the  testes  and  ovaries.  F.  J.  Shepherd  has  caled  attention  to 
the  circumstance  that  acute  tonsillitis  is  a  very  common  affectioii  in  newly 
married  persons.  That  view  is  ]irobably  correct  which  regards  tonsillitis 
as  a  local  disease  M'itli  severe  constitutional  manifestations,  although  the 
fever  is  often  out  of  proportion  to  the  local  symptoms.  The  commonest 
organism  found  in  tonsillitis  is  a  streptococcus.  Staphylococci  also  occur. 
In  some  cases  the  iacilhis  dipldliericB  of  Loeffler  have  been  found,  but  it 
does  not  always  possess  the  full  virulence  (see  Atyjtical  Forms  of  Diph- 
theria). 

Morbid  Anatomy. — The  lacuna  of  the  tonsils  become  filled  with 
exudation  i)roducts,  which  form  cheesy-looking  masses,  projecting  from 
the  orifices  of  the  crypts.  Xot  infrequently  the  exudations  from  contiguous 
laeuiiffi  coalesce.  The  intervening  mucosa  is  usually  swollen,  deep-red  in 
color,  and  may  present  herpetic  vesicles  or,  in  some  instances,  even  mem- 
branous exudation,  in  which  case  it  may  be  difficult  to  distinguish  the  con- 


/' 


p 


452 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


dition  from  diplitlioria.  The  creamy  contents  of  the  crypt  are  made  up  of 
micrococci  and  epitliehal  debris. 

Symptoms. — Chilly  feelings,  or  even  a  definite  chill,  and  aching  pains 
in  the  back  and  limbs  may  i)recede  the  onset.  The  fever  rises  rapidly,  md 
in  the  case  of  a  young  child  may  reach  105°  on  the  evening  of  the  first  day. 
The  patient  complains  of  soreness  of  the  throat  and  difficulty  in  swallow- 
ing. On  examination,  the  tonsils  are  seen  to  be  swollen  and  the  crypts 
present  the  characteristic  creamy  exudate.  The  tongue  is  furred,  the 
breath  is  heavy  and  foul,  and  the  urine  is  highly  colored  and  loaded  with 
urates.  In  children  the  respirations  are  usually  very  hurried,  and  the 
pulse  is  greatly  increased  in  rapidity.  Swallowing  is  })ainful,  and  the  voice 
often  becomes  nasal.  Slight  swelling  of  the  cervical  glands  is  present.  In 
severe  cases  the  symptoms  increase  and  the  tonsils  become  still  more  swollen. 
The  inflammation  gradually  subsides,  and,  as  a  rule,  within  a  week  the 
fever  departs  and  the  local  condition  greatly  improves.  The  tonsils,  how- 
ever, remain  somewhat  swollen.  The  prostration  and  constitutional  dis- 
turbance are  often  out  of  proportion  to  the  intensity  of  the  local  disease. 

There  are  complications  which  occasionally  excite  uneasiness.  Febrile 
albuminuria  is  not  uncommon,  as  Haig-Brown  has  pointed  out.  Cases  of 
endocarditis  or  pericarditis  have  been  found.  It  is  to  be  borne  in  mind 
that  in  children  an  apex  systolic  murmur  is  by  no  means  uncommon  at 
the  height  of  any  fever.  The  disease  may  extend  to  the  middle  ear.  The 
development  of  paralytic  symptoms,  local  or  general,  after  an  attack  which 
has  been  regarded  as  follicular  tonsillitis  indicates  an  error  in  diagnosis. 
A  diffuse  erythema  may  develop,  simulating  that  of  scarlet  fever. 

Diagnosis. — It  may  be  difficult  to  distinguish  follicular  tonsillitis 
from  diphtheria.  It  would  seem,  indeed,  as  if  there  were  intermediate 
forms  between  the  mildest  lacunar  and  the  severer  pseudo-membranous 
tonsillitis.  In  the  follicular  form  the  individual  yellowish-gray  masses, 
separated  by  the  reddish  tonsillar  tissue,  are  very  characteristic;  whereas 
in  diphtheria  the  membrane  is  of  ashy  gray,  and  uniform,  not  patchy.  A 
point  of  the  greatest  importance  in  diphtheria  is  that  the  membrane  is  not 
limited  to  the  tonsils,  but  creeps  up  the  pillars  of  the  fauces  or  appears  on 
the  uvula.  The  diphtheritic  membrane  when  removed  leaves  a  bleeding, 
eroded  surface;  whereas  the  exudation  of  lacunar  tonsillitis  is  easily  sepa- 
rated, and  there  is  no  erosion  beneath  it.  In  all  doubtful  cases  cultures 
should  be  made  to  determine  the  presence  or  absence  of  Loeffler's  bacillus. 

(2)  Suppurative  Tonsillitis. 

Etiology. — This  arises  under  conditions  very  similar  to  those  men- 
tioned in  the  lacunar  form.  It  may  follow  exposure  to  cold  or  wet,  and  is 
particularly  liable  to  recur.  It  is  most  common  in  adolescence.  The  in- 
flammation is  here  more  deeply  seated.  It  involves  the  stroma,  and  tends 
to  go  on  to  suppuration. 

Symptoms. — The  constitutional  disturbance  is  very  great.  The  tem- 
perature rises  to  104°  or  105°,  and  the  pulse  ranges  from  110  to  130.  Noc- 
turnal delirium  is  not  uncommon.  The  prostration  may  be  extreme.  There 
is  no  local  disease  of  similar  extent  which  so  rapidly  exhausts  the  strength 
of  a  patient.    Soreness  and  dryxi^ss  of  the  throat,  with  pain  in  swallowing, 


ACUTE  TONSILLITIS. 


453 


are  the  syniptonis  of  wliicli  the  patient  first  comphiins.  One  or  both  tonsils 
may  be  involved.  Tliey  are  enlarged,  firm  to  the  touch,  dusky  red  and 
(edematous,  and  the  contiguous  parts  are  also  much  swollen.  The  swelling 
of  the  glanus  may  be  so  great  that  they  meet  in  the  middle  line,  or  one 
tonsil  may  even  i)ush  the  uvula  aside  and  almost  touch  the  other  gland. 
The  salivary  and  buccal  secretions  are  increased.  The  glands  of  the  neck 
enlarge,  the  lower  jaw  is  fixed,  and  the  patient  is  unable  to  ojjcn  his  mouth. 
In  from  two  to  four  days  the  enlarged  gland  becomes  softer,  and  fluctuation 
can  be  distinctly  felt  by  placing  one  finger  on  the  tonsil  and  the  other  at 
the  angle  of  the  jaw.  The  abscess  points  usually  toward  the  mouth,  but  in 
some  cases  toward  the  pharynx.  It  may  burst  spontaneously,  affording 
instant  and  great  relief.  Suffocation  has  followed  the  rupture  of  a  large 
abscess  and  the  entrance  of  the  pus  into  the  larynx.  When  the  suppura- 
tion is  peritonsillar  and  extensive,  the  internal  carotid  artery  may  bo 
opened;  but  these  are,  fortunately,  very  rare  accidents. 

Treatment. — In  the  follicular  form  aconite  may  be  given  in  full  doses. 
It  acts  very  beneficially  in  children.  The  salicylates,  given  freely  at  the 
outset,  are  regarded  by  some  as  specific,  but  I  have  seen  no  evidence  of 
such  prompt  and  decisive  action.  At  night,  a  full  dose  of  Dover's  powder 
may  be  given.  The  use  of  guaiacum,  in  the  form  of  2-grain  lozenges,  is 
M'armly  recommended.  Iron  and  quinine  should  be  reserved  until  the  fever 
has  subsided.  A  pad  of  spongio-piline  or  thick  flannel  dipped  in  ice-cold 
water  may  be  applied  around  the  neck  and  covered  with  oiled  silk.  More 
convenient  still  is  a  small  ice-bag.  Locally  the  tonsils  may  be  treated  with 
the  dry  sodium  bicarbonate.  The  moistened  fingertip  is  dipped  into  the 
soda,  which  is  then  rubbed  gently  on  the  gland  and  repeated  every  hour. 
Astringent  preparations,  such  as  iron  and  glycerin,  alum,  zinc,  and  nitrate 
of  silver,  may  be  tried.  To  cleanse  and  disinfect  the  throat,  solutions  of 
borax  or  thymol  in  glycerin  and  water  may  be  used. 

In  suppurative  tonsillitis  hot  applications  in  the  form  of  poultices  and 
fomentations  are  more  comfortable  and  better  than  the  ice-bag.  The 
gland  should  be  felt — it  cannot  always  be  seen — from  time  to  time,  and 
should  be  opened  when  fluctuation  is  distinct.  The  progress  of  the  dis- 
ease may  be  shortened  and  the  patient  spared  several  days  of  great  suffer- 
ing if  the  gland  is  scarified  early.  The  curved  bistoury,  guarded  nearly 
to  the  point  with  plaster  or  cotton,  is  the  most  satisfactory  instrument. 
The  incision  should  be  made  from  above  downward,  parallel  with  the  an- 
terior pillar.  There  are  cases  in  which,  before  suppuration  takes  place,  the 
])arenchymatous  swelling  is  so  great  that  the  patient  is  threatened  with 
suffocation.  In  such  instances  the  tonsil  must  either  be  excised  or  trache- 
otomy or,  possibly,  intubation  performed.  Delavan  refers  to  two  cases  in 
which  he  states  that  tracheotomy  would,  under  these  circumstances,  have 
saved  life.  Patients  with  this  affection  rec|nire  a  nourishing  liquid  diet, 
and  during  convalescence  iron  in  full  doses. 


454 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


1/ 


■■SHI:' 


.•■I 


CHRONIC  TONSILLITIS. 

{Chrunic  Naao-pharyuyeal  Obstruction ;  Mouth-Breathing ;  Aprosexia.) 

Under  this  lieading  will  be  considered  also  hypertrophy  of  the  adenoid 
tissue  in  the  vault  of  the  pharynx,  sometimes  known  as  the  i)haryngeal 
tonsil,  as  the  all'ection  usually  involves  both  tlie  tonsils  proi)er  and  .this 
tissue,  and  the  syni])toms  are  iwt  to  be  diU'erentiated. 

C'lironie  enlargement  of  the  tonsillar  tissues  is  an  aft'ection  of  great  ini- 
])ortance,  and  may  influence  in  an  extraordinary  way  the  mental  and  bodily 
development  of  children. 

Etiology. — Hypertrophy  of  the  tonsillar  structures  is  occasionally  con- 
genital. Cases  are  perhaps  most  frequent  in  children,  during  the  thir;' 
hemi-decade.  The  condition  also  occurs  in  young  adults,  more  rarely  ni 
the  middle-aged.  The  enlargement  may  follow  diphtheria  or  the  eru}^tive 
fevers.  The  frequency  of  the  occirrence  of  adenoid  growths  in  the  naso- 
])harynx  has  ])een  variously  stated.  Meyer,  to  whom  the  y)rofession  is  in- 
debted for  calling  attention  to  the  subject,  found  them  in  about  one  ])er 
cent  of  the  children  in  Co])enhagen,  while  Chap])ell  found  GO  cases  in  the 
examination  of  2,000  children  in  New  York.  These  figures  give  a  veiy 
moderate  estimate  of  the  prevalence  of  the  trouble.  It  occurs  e(iually  in 
boys  and  girls,  according  to  some  writers  with  greater  })revalence  in  the 
former. 

Morbid  Anatomy. — The  tonsils  pro]ier  present  a  condition  of 
chronic  hypertrophy,  due  to  multiplication  of  all  the  constituents  of  the 
glands.  The  lymphoid  elements  may  be  chiefly  involved  without  much 
develoimient  of  the  stroma.  In  other  instances  the  fibrous  matrix  is  in- 
creased, and  the  organ  is  then  harder,  smaller,  firmer,  and  is  cut  with  much 
greater  diiTiculty. 

The  adenoid  growths,  Avliich  spring  from  the  vault  of  the  ])harynx, 
form  masses  varying  in  size  from  a  small  pea  to  an  almond.  They  may 
be  sessile,  with  broad  bases,  or  peduncidated.  They  are  reddish  in  color, 
of  moderate  firmness,  and  contain  nimierous  blood-vessels.  "  Al)undant, 
as  a  rule,  over  the  vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube, 
the  growths  may  lie  posterior  to  the  fossa — namely,  in  the  depression  known 
as  the  fossa  of  Eosenmiiller,  or  upon  the  parts  which  are  parallel  to  the 
posterior  Avail  of  the  pharynx.  The  growths  appear  to  spring  in  the  main 
from  the  mucous  membrane  covering  ilie  localities  where  the  connective 
tissue  fills  in  the  inequalities  of  the  base  of  the  skull "  (Harrison  Allen). 
The  growths  are  most  frequently  pa])illomatous  Avith  a  lymi)hoid  par- 
enchyma. Hypertrophy  of  the  pharyngeal  adenoid  tissue  may  be  present 
Avithout  great  enlargement  of  the  tonsils  proper.  Chronic  catarrh  of  the 
nose  usually  coexists. 

Symptoms. — The  direct  effect  of  chronic  tonsillar  hypertrophy  is 
the  establishment  of  mouth-breathing.  The  indirect  effects  are  deforma- 
tion of  the  thorax,  changes  in  the  facial  expression,  sometimes  marked 
alteration  in  the  mental  condition,  and  in  certain  cases  stunting  of  the 
groAvth.    Woods  Hutchinson  has  suggested  that  the  cmbryological  relation 


CHRONIC  TONSILLITIS. 


455 


of  these  Btructures  with  the  pituitary  l)ody  may  account  for  the  interfer- 
ence with  development.  The  establishment  of  mouth-breathing  is  the 
pyni})tom  which  first  attracts  the  attention.  It  is  not  so  noticeable  by  day, 
although  the  child  nuiy  i)resent  the  vacant  expression  characteristic  of  tliis 
condition.  At  night  the  child's  sleep  is  greatly  disturbed;  the  respirations 
are  loud  aud  snorting,  and  there  are  sometimes  prolonged  jtauses,  followed 
Ijy  deep,  noisy  inspirations.  The  pulse  may  vary  strangely  during  these 
attacks,  and  in  the  prolonged  intervals  may  be  slow,  to  increase  greatly 
with  the  forced  ins])irations.  The  ahc  nasi  should  be  ol)served  during 
the  sleep  of  the  child  as  they  arc  sometimes  much  retracted  during  in- 
spiration, due  to  a  laxity  of  the  walls,  a  condition  readily  remedied  by  the 
use  of  a  soft  wire  dilator.  ]S'igIit  terrors  are  common.  The  child  nuiy  wako 
up  in  a  paroxysm  of  shortness  of  l)reath.  Some  of  tbese  nocturiuil  attacks 
may  be  due  to  reflex  spasm  of  the  glottis.  During  the  day  there  may  be 
choking  fits  wlien  eating. 

When  the  mouth-breathing  has  persisted  for  a  long  time  definite  changes 
are  brought  about  in  the  face,  mouth,  and  chest.  The  facies  is  so  peculiar 
and  distinctive  that  tlie  conditioii  nuiy  be  evident  at  a  glance.  The  ex- 
])ression  is  dull,  heavy,  and  apiitlietic,  due  in  i)art  to  the  fact  that  the  mouth 
is  liabitually  left  o])on.  In  long-standing  cases  the  child  is  very  stupid- 
looking,  responds  slowly  to  questions,  and  may  be  sullen  and  cross.  The 
lips  are  tliick,  the  nasal  orifices  snuill  and  ])inc]ied-in  looking,  the  sui)e- 
rior  dental  arch  is  narrowed  and  the  roof  of  the  mouth  cousideral)ly  raised. 

The  remarkable  alterations  in  the  shape  of  the  chest  in  connection 
witli  enlarged  tonsils  were  first  carefully  studied  by  Du])uytren  (1828), 
who  evidently  fully  api)reciated  the  great  importance  of  the  condition. 
He  noted  "  a  lateral  depression  of  the  parietes  of  tlie  chest  consisting  of  a 
dci)rcssion,  more  or  less  great,  of  the  ribs  on  each  sid  ,  and  a  proportionate 
protrusion  of  the  sternum  in  front."  J.  ]\lason  "Warren  (Medical  Exam- 
iner, 1839)  gave  an  admirable  description  of  the  constitutional  sym})toms 
and  the  thoracic  deformities  induced  by  enlarged  tonsils.  These,  with 
the  memoir  of  Lambron  (ISGl),  constitute  the  most  imj)ortant  contribu- 
tions to  our  knowledge  on  the  subject.  Three  types  of  deformity  may  be 
recognized: 

(a)  The  Pigeon  or  Chicken  Breast,  by  far  the  most  common  form,  in 
Mhich  the  sternum  is  prominent  and  there  is  a  circular  dej)ression  in  the 
lateral  zone  (Harrison's  groove),  corresponding  to  the  attachment  of  the 
diaphragm.  The  ribs  are  prominent  anteriorly  and  the  sternum  is  angu- 
lated  forward  at  the  manubrio-gladiolar  junction.  As  a  mouth-breather 
is  watched  during  sleep,  one  can  see  the  loM'cr  and  lateral  tlioracic  regions 
retracted  during  inspiration  by  the  action  of  the  diaphragm. 

(b)  Barrel  Chest. — Some  children,  the  sul)ject  of  chronic  naso-pharyn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  s]u>rt, 
and  the  shoulders  and  back  bowed.  A  child  of  ten  or  eleven  may  have  tlie 
thoracic  conformation  of  an  old  man  with  em])hysema. 

(c)  The  Funnel  Breast  (Trichtcr-hmst). — This  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  excited  much 


w 


456 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ri  / 


.■VI  I,  , 


controversy  as  to  its  mode  of  ori^nii.  I  believe  that  in  some  instances,  at 
least,  it  is  due  to  the  oI)structed  breathing'  in  connection  with  adenoid 
vegetations.  1  have  seen  two  cases  in  children,  in  which  the  condition  was 
in  i)rocess  of  development.  During  inspiration  the  lower  sternum  was 
forcibly  retracted,  so  much  so  that  at  the  height  the  depression  corresi)onded 
to  a  well-inarked  "  Irichfer-hrusi."  While  in  repose,  the  lower  steriuil  re- 
gion was  distinctly  excavated. 

The  voice  is  altered  and  acquires  a  nasal  quality.  The  pronunciation 
of  certain  letters  is  changed,  and  there  is  inal)ility  to  pronounce  the  nasal 
consonants  n  and  m.  Bloch  lays  great  stress  ujjon  the  association  of  mouth- 
breathing  with  stuttering. 

The  hearing  is  im|)aired,  usually  owing  to  the  extension  of  inflamma- 
tion along  the  Kustachian  tubes  and  the  obstruction  with  mucus  or  the 
narrowing  of  their  orifices  by  pressure  of  the  adenoid  vegetations.  In  some 
instances  it  may  be  due  to  retraction  of  the  drums,  as  the  ui)per  pharynx 
is  insufficiently  sn])plied  with  air.  Naturally  the  senses  of  taste  and  smell 
are  much  impaired.  With  these  symptoms  there  nuiy  be  little  or  no  nasal 
catarrh  or  discharge,  but  the  pharyngeal  secretion  of  mucus  is  always  in- 
■creased.  Children,  however,  do  not  notice  this,  as  the  mucus  is  usually 
swallowed,  but  older  persons  expectorate  it  with  difficulty. 

Among  other  symi)toms  may  be  mentioned  headache,  which  is  by  no 
means  imcommon,  general  listlessness,  and  an  indisposition  for  physical 
or  mental  exertion.  Habit-spasm  of  the  face  has  been  described  in  con- 
nection with  it.  I  have  known  several  instances  in  which  jiermanent  relief 
has  been  afforded  by  the  removal  of  the  adenoid  vegetations.  Enuresis 
is  occasionally  an  associated  symptom.  The  influence  upon  the  mental 
•development  is  striking.  Mouth-breathers  are  usually  dull,  stupid,  and 
backward.  It  is  impossible  for  them  to  fix  the  attention  for  long  at  a  time, 
'nnd  to  this  impairment  of  the  mental  function  Guye,  of  Amsterdam,  has 
given  the  name  aprosexia.  Headaches,  forgetfulness,  inability  to  study 
without  discomfort,  are  frequent  symptoms  of  this  condition  in  students. 
There  is  more  than  a  grain  of  truth  in  the  aphorism  shut  your  mouth  and 
save  your  life,  vhich  is  found  on  the  title-page  of  Captain  Catlin's  cele- 
brated pamphlet  on  mouth-breathing. 

A  symptom  specially  associated  with  enlarged  tonsils  is  fetor  of  the 
breath.  In  the  tonsillar  crypts  the  inspissated  secretion  undergoes  de- 
"Co  '.position  and  an  odor  not  unlike  that  of  Koquefort  or  Limburger  cheese 
is  produced.  The  little  cheesy  masses  may  sometimes  be  squeezed  from 
the  crypts  of  the  tonsils.  Though  the  odor  may  not  apparently  be  very 
strong,  yet  if  the  mass  be  squeezed  between  the  fingers  its  intensity  will  at 
once  be  appreciated.  In  some  cases  of  chronic  enlargement  the  cheesy 
masses  may  be  deep  in  the  tonsillar  crypts;  and  if  they  remain  for  a  pro- 
longed period  lime  salts  are  deposited  and  a  tonsillar  calculus  in  this  way 
produced. 

Children  with  enlarged  tonsils  are  especially  prone  to  take  cold  and  to 
recurring  attacks  of  follicular  disease.  They  are  also  more  liable  to  diph- 
theria, and  in  them  the  anginal  features  in  scarlet  fever  are  always  more 
«erious.     The  ultimate  results  of  mitreated  adenoid  hypertrophy  are  im- 


CHRONIC  TONSILLITIS. 


457 


portant.  In  some  cnscs  the  vogctations  disappear,  leaving  an  atrophic 
condition  of  the  vault  of  the  pharynx.  >Jegleet  may  also  lead  to  the  so- 
called  Tliornwaldt's  disease,  in  which  there  is  a  cystic  condition  of  the 
jiharyngcal  tonsil  and  constant  secretion  of  imico-pus. 

Diagnosis. — The  facial  aspect  is  usually  distinctive.  l']nlargcd  ton- 
sils are  readily  seen  on  inspection  of  the  pharynx.  There  nuiy  he  no  great 
enlargement  of  the  tonsils  and  nothing  apjmrent  at  the  back  of  the  throat 
even  when  the  naso-i)harynx  is  completely  blocked  with  adenoid  vegeta- 
tions. In  children  tiie  rhinoscopic  examination  is  rarely  practicable.  Digi- 
tal examimition  is  the  most  satisfactory.  The  growtlis  can  then  ])e  felt 
either  as  small,  flat  bodies  or,  if  extensive,  as  velvety,  grape  like  }>ai)illo- 
mata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evidently 
influenced  by  them  they  should  be  at  once  removed.  Ajjplications  of 
iodine  and  iron,  or  pencilling  the  crypts  with  nitrate  of  silver,  are  of  service 
in  the  milder  grades,  but  it  is  waste  of  time  to  ap])ly  them  in  very  enlarged 
glands.  There  is  a  condition  in  which  the  tonsils  are  not  much  enlarged, 
but  the  crypts  are  constantly  filled  with  cheesy  secretions  and  cause  a 
very  bad  odor  in  the  breath.  In  such  instances  the  removal  of  the  secre- 
tion and  thorough  pencilling  of  the  crypts  with  chronuc  acid  nuiy  be  prac- 
tised. The  galvano-cautery  is  of  great  service  in  many  cases  of  enlarged 
tonsils  when  there  is  any  objection  to  the  more  radical  surgical  procedure. 

The  treatment  of  the  adenoid  growths  in  the  ])harynx  is  of  the  great- 
est importance,  and  should  be  thoroughly  carried  out.  Parents  should 
be  frankly  told  that  the  affection  is  serious,  one  which  impairs  the  mental 
not  less  than  the  bodily  development  of  the  child.  In  spite  of  the  thorough 
ventilation  of  this  subject  by  specialists,  practitioners  do  not  appear  to 
have  grasped  as  yet  the  full  importance  of  this  disease.  They  are  far  too 
apt  to  temporize  and  unnecessarily  to  postpone  radical  measures.  The 
•child  must  be  etherized,  when  the  growths  can  be  removed  either  with  the 
finger-nail,  which  in  most  instances  is  suflficient,  or  with  a  suitable  curette. 
Considerable  haemorrhage  may  follow,  but  it  is  usually  checked  quickly. 
The  good  eifects  of  the  operation  are  often  apparent  within  a  few  days, 
and  the  child  begins  to  breathe  through  the  nose.  In  some  instances  the 
habit  of  mouth-breathing  persists.  As  soon  as  the  child  goes  to  sleep  the 
lower  jaw  drops  and  the  air  is  drawn  nto  the  mouth.  In  these  cases  a 
chin  strap  can  be  readily  adjusted,  which  the  chiVl  may  wear  at  night.  In 
severe  cases  it  may  take  months  of  careful  training  before  the  child  can 
speak  properly. 

Throughout  the  entire  treatment  attention  should  be  paid  to  hygiene 
and  diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  be  administered  with 
benefit. 


\. 


458 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


/   / 


y.    DISEASES   OV  THE   (ESOPHAGUS. 
I.    ACUTE    OESOPHAGITIS. 

Etiology. — Acute  inllaiiuiiation  occurs  {a)  in  tlic  catarrlial  proccsacs 
of  tlic  Hpccilic  i'ovorK;  more  rarely  an  an  exten(*ion  from  catarrh  of  tlie 
pharynx,  (h)  As  a  result  o!  intense  niecliaiiical  or  cheinicHl  irritation, 
])ro(liice(l  by  foreign  Ixxlies,  by  very  hot  li([ui(ls,  or  hy  stron<;  corrosives. 
(r)  in  the  i'orni  of  pseuclo-nieniljraiU)us  intlamniation  in  diphtheria,  and 
occasionally  in  pneumonia,  ty])hoid  I'evcr,  and  pya'mia.  (d)  As  a  pustular 
inllammatioii  in  small-j)ox,  and,  accordinjf  to  Laennec,  as  a  result  of  a  i)ro- 
lonjicd  administration  of  tartar  emetic,  [r)  Jii  connection  with  local  dis- 
ease, |tarticuhirly  cancer  either  of  tlie  tui)e  itself  or  extension  to  it  from 
witliout.  And,  lastly,  acute  ci'sophagitis,  occasionally  with  ulceration,  may 
occur  s|)ontaneously  in  sucklin<rH. 

Morbid  Anatomy.— It  is  extremely  rare  to  see  redness  of  the 
mucosa,  except  when  ciiendcal  irritants  have  been  swallowed.  .More  com- 
monly the  epithelium  is  thickened  and  has  descpuimated,  so  that  the  sur- 
face is  covered  with  a  line  granular  substance.  The  mucous  follicles  are 
swollen  and  occasionally  there  may  be  seen  snudl  erosions.  In  the  ])seudo- 
meml)ran()us  inllammation  there  is  a  grayish  croupous  exudate,  usually  lim- 
iti'd  in  extent,  at  the  upper  poi'tion  of  the  gullet.  'J'liis  must  not  l)e  con- 
founded with  the  grayish-white  deposit  of  thrush  in  children.  The  ])us- 
tular  disease  is  very  rare  in  small-pox.  In  the  })lilegmonous  inllamnuition 
the  mucous  membrane  is  greatly  swollen,  and  there  is  ])urulent  infiltration 
in  the  sid)muc()sa.  This  may  l)e  limited  as  al)out  a  foreign  l)ody,  or  ex- 
tremely diffuse.  It  may  even  extend  throughout  a  large  part  of  the  gullet. 
Gangrene  occasionally  supervenes.  There  is  a  remarkable  fibrinous  or 
membranous  cesophagitis,  which  is  most  frecpienlly  met  with  in  the  fevers, 
sometimes  also  in  hysteria,  in  Mhich  long  casts  of  the  tube  may  be  vomited. 

Symptoms. — I'ain  in  deglutition  is  always  present  in  severe  inliam- 
niation  of  the  a!SO])hagus,  and  in  the  form  which  follows  the  swallowing 
of  strong  irritants  may  prevent  the  taking  of  food.  A  dull  pain  beneath 
the  sterniim  is  also  present.  In  the  milder  forms  of  catarrhal  inflamma- 
tion there  are  usualb  no  symptoms.  The  ])resence  of  a  foreign  ])ody  is 
indicated  by  dysphagia  and  spasm  with  the  regurgitation  of  i)ortions  of 
the  food.  Later,  blood  and  pus  may  be  ejected.  It  is  surprising  how  ex- 
tensive the  disease  may  be  in  the  a'so]ibagus  without  producing  much  ]iain 
or  great  discomfort,  excei)t  in  swallowing.  The  intense  inflammation 
which  follows  the  swallowing  of  corrosives,  when  not  fatal,  gradually  sub- 
sides, and  often  leads  to  cicatricial  contraction  and  stricture. 

The  treatment  (f  acute  inflammation  of  the  oosophagus  is  extremely  un- 
satisfactory, partic  darly  in  the  severer  forms.  The  slight  catarrhal  cases 
require  no  special  t 'eatmen{.  When  the,dys]ihagia  is  intense  it  is  best  not 
to  give  food  by  the  mouth,  l)ut  to  feed  entirely  by  enemata.  Fragments  of 
ice  may  be  giA'cn,  and  as  the  pain  and  distress  subside,  demulcent  drinks. 
External  applications  of  cold  often  give  relief. 


SPASM  OF  THE  CES(^)P1IA0US. 


469 


A  rlimnie  form  of  (ps(iiilin>:itis  !■»  (Icscrilu'd.  hut  this  result**  usiuilly  from 
the  prohiii^ed  action  nl'  tlie  causes  which  prndiici'  tiie  acute  Innu. 

rirrralioii  of  (he  (KsuplKif/iis. — In  numy  caelieetie  eoiiditions  catarrhal 
uU'eratioM  is  found.  In  a  lew  rare  instances  uh-ers  of  tiie  u'sopha^aia  arc 
met  witli  in  typhoid  fevi'r.  Aculi'  niali;,Muint  ulceration  may  |»erforiito  the 
teso))ha<rus  and  open  into  the  aorta. 

Associated  with  chronic  heart-disease  and  more  frecjuently  witli  the 
senile  and  the  cirrhotic  liver,  tlie  <eso|»ha^'eal  veins  nuiy  he  enornu)Usly 
distended  and  varicose,  jtarticularly  toward  the  stonuich.  In  tiiese  cases 
the  mucous  nu'iuhrane  is  in  a  .-tale  of  chnmic  catarrh,  and  tiie  patient  iiaii 
fre(iueut  eructations  of  mui'iis.  Ifupture  of  these  (esophaj,'eal  veins  nuiy 
cause  fatal  hii'iuorrhage.  Two  cases  of  the  kind  have  occurred  in  my  o.\- 
[terience.  The  blood  may  pass  per  rectum  alone,  aa  in  a  case  reported  by 
L'ower,  of  Maltimore,  in  18139. 


leath 


II.    SPASM    OF    THE    OESOPHAGUS  {(EHophtujismns). 

This  so-cnlli'<l  spasmodic  stricture  of  the  jjullet  is  met  with  ir  hysterical 
patients  and  hypochondriacs,  also  in  chorea,  epile[»sy,  aiul  especially  hydro- 
phobia. It  is  sometimes  associated  also  with  the  h)dgment  of  foreign  bodies. 
The  idiopathic  form  is  found  in  females  of  a  marked  neurotic  habit,  but 
may  also  occur  in  elderly  men.  It  may  be  present  only  during?  pregnam-y. 
Of  4  cases  which  have  come  under  my  observation,  2  were  in  men,  one  a 
hy])ochondriac  over  sixty  years  of  age  who  for  many  months  had  taken 
only  liquid  food,  and  with  great  dilHculty,  owing  to  a  spasm  M'hich  accom- 
panied every  attempt  to  swallow.  The  readiivss  with  which  the  bougie 
passed  and  the  subseciuent  history  showed  the  true  nature  of  tiie  case.  The 
patient  complains  of  inability  to  swallow  solid  fo(jd,  and  in  extreme  in- 
stances even  liquids  are  rejected.  The  attack  may  come  or.  <d5ruj)tly,  and 
be  associated,  with  emotional  disturbances  and  with  substernal  pain.  The 
iiougie,  when  ])assed,  may  be  arrested  temporarily  at  the  seat  of  the  s])asm, 
which  gradually  yield:.,  or  it  may  slip  through  without  the  slightest  effort. 
The  condition  is  rr.i-ely  serious.     Death  has,  however,  followed  it. 

The  didf/nnsis  is  not  difficult,  y)articularly  in  young  persons  with  marked 
nervous  manifestations.  In  elderly  persons  (esophagismus  is  almost  always 
connected  with  hypochondriasis,  l)ut  great  care  must  be  taken  to  exclude 
cancer. 

In  some  cases  a  cure  is  at  once  effected  by  the  passage  of  a  bougie, 
general  neurotic  condition  also  requires  special  attention. 

Parah/sis  of  the  oesophagus  scarcely  demands  separate  consideration. 
It  is  a  very  rare  condition,  due  most  often  to  central  disease,  particularly 
bulbar  paralysis.  It  may  l)e  peripheral  in  origin,  as  in  diphtheritic  paraly- 
sis. Occasionally  it  occurs  also  in  hysteria.  The  essential  symptom  is 
dysphagia.  - 


I    r 


400 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


III.    STRICTURE   OF   THE   CESOPHAGUS. 


.  \ 
/ 


Tliis  rt'Hults  from:  («)  t'ongenital  narrowing.  (6)  The  cietttricial  con- 
traction of  iieulcd  ulcers,  usuully  tliio  to  corrosive  jJoiHons,  occasionally 
to  Bypliilis,  and  in  rare  instances  after  typlioid  fever,  (r)  The  growth  of 
tumors  in  the  walls,  as  in  the  so-called  cancerous  stricture.  Occasionally 
polypoid  tumors  )>rojectiug  from  tlie  luucosa  produce  great  narrowing,  (dy 
K.vternal  pressure  by  aneurism,  enlarged  lymph-glaiuls,  enlarged  thyroid,, 
other  tumors,  and  sometimes  hy  pericardial  elfusion. 

The  cicatricial  stricture  may  occur  anywhere  in  the  gullet,  and  in  ex- 
treme cases  may,  indeed,  involve  the  whole  tuhe,  hut  in  a  nuijority  of  in- 
stances it  is  found  cither  high  up  near  the  pharynx  or  low  down  tt)war(l 
the  stomach.  The  narrowing  nuiy  he  extreme,  so  that  only  small  quanti- 
ties of  food  can  trickle  through,  or  the  obstruction  may  be  quite  slight. 
There  is  usually  no  dilliculty  in  nuiking  a  diagnosis  of  the  cicatricial  strict- 
ure, as  the  history  of  mechanical  injury  or  the  swallowing  of  a  corrosive 
fluid  nuikcs  clear  the  nature  of  the  case.  When  the  stricture  is  low  down 
the  a'sophagus  is  dilated  and  the  walls  arc  usually  much  hyi»ertrophied. 
When  the  obstruction  is  high  in  the  gullet,  the  food  is  usually  rejected  at 
once,  whereas,  if  it  is  low,  it  may  be  retained  and  a  considerable  (}uantity 
collects  before  it  is  regurgitated.  Any  doubt  as  to  its  having  reached  the 
stomach  is  removed  by  the  alkalinity  of  the  material  ejected  and  the  absence 
of  the  characteristic  gastric  odor.  Auscultation  of  the  rosophagus  may  be 
practised  and  is  sometimes  of  service.  The  patient  takes  a  mouthful  of 
water  and  the  auscultator  listens  along  the  left  of  the  spine.  The  normal 
a'sophageal  hritit  may  be  heard  later  than  seven  seconds,  the  normal  time,  oi 
there  may  be  heard  a  loud  splashing,  gurgling  sound.  The  secondary  mur- 
mur, heard  as  the  fluid  enters  the  stomach,  may  be  absent.  The  passage  of 
the  (esophageal  bougie  will  determine  more  accurately  the  locality.  Conical 
bougies  attached  to  a  flexible  whalebone  stem  are  the  most  satisfactory,  but 
the  gum-elastic  stomach  tube  may  be  used;  a  large  one  should  be  tried  first. 
The  patient  should  be  placed  on  a  low  chair  with  the  head  well  thrown 
back.  The  index  finger  of  the  left  hand  is  y)assed  far  into  the  pharynx, 
and  in  some  instances  this  ])rocedure  alone  may  determine  the  presence  of 
a  new  growth.  The  bougie  is  passed  beside  the  finger  until  it  touches  the 
posterior  wall  of  the  pharynx,  then  along  it,  more  to  one  side  than  in  the 
middle  line,  and  so  gradually  pushed  into  the  gullet.  It  is  to  be  borne 
in  mind  that  in  passing  the  cricoid  cartilage  there  is  often  a  slight  ol)- 
rtruction.  Great  gentleness  should  be  used,  as  it  has  happened  more  than 
once  that  the  bougie  has  been  passed  through  a  cancerous  nicer  into  the 
mediastinum  or  through  a  diverticulum.  I  have  known  this  accident  to 
happen  twice — once  in  the  case  of  a  distinguished  surgeon,  who  performed 
o^sophagotomy  and  passed  the  tube,  as  he  thought,  into  the  stomach.  The 
]iost  mortem  on  the  next  day  showed  that  the  tube  had  entered  a  diverticu- 
lum and  through  it  the  left  pleura,  in  which  the  milk  injected  through 
the  tidDc  was  found.  In  the  other  instance  the  tube  passed  through  a  can- 
cerous nicer  into  the  lung,  which  was  adherent  and  inflamed.     Fortunately 


CANCEIl  OF  TIIK  (ESOPHAGUS. 


401 


these  accklents,  sonietiiiu's  iiiuivoidalilc,  are  extremely  raro.  It  is  well 
always,  as  u  preeautioiiary  iiK'asiirc  ht'l'ore  passing'  the  hoti^'le,  to  examine 
careliilly  for  uneiirism,  which  may  produce  all  the  symptoms  of  organic 
strict  lire.  In  cases  in  which  the  narrowing  is  extreme  there  is  always  ema- 
ciation.    For  treatment,  surgical  works  must  be  consulted. 


1 


can- 
lately 


IV.    CANCER    OF   THE   CESOPHAGUS. 

This  is  usually  epithelionui.  It  is  not  an  ur.rommon  disenso,  and  ooours 
more  rrccpiently  in  males  than  in  I'enuiles.  'I'he  common  situation  is  in 
the  upper  third  of  the  tube.  At  first  confined  to  the  mucous  membrane, 
the  cancer  gradually  increases  and  soon  ulcerates.  The  lumen  of  the  tube 
is  luirrowed,  but  when  ulceration  is  extensive  in  the  later  stages  the  stricture 
may  l)e  less  nuirked.  ])ilatat:')n  of  the  tube  and  hypertrophy  of  the  walls 
usually  take  i)lace  above  the  cancer.  The  can.jrouh,  idcer  may  perforate 
the  trachea  or  a  bronchus,  tho  lung,  the  mediastinum,  the  aorta  or  one  of 
its  larger  branches,  the  pericitrdium,  or  it  nuiy  erode  the  vertebral  column. 
In  my  experience  perforation  of  the  lung  has  been  the  most  frequent,  pro- 
ducing, as  a  r\ile,  local  gangrene. 

Symptoms. — The  earliest  8ynii)toni  is  dys])bagia,  which  is  progressive 
and  may  become  extreme,  so  that  the  patient  emaciates  rapidly.  Regurgita- 
tion nuiy  take  place  at  once;  or,  if  the  cancer  is  situated  near  the  stomachy 
it  may  be  deferred  for  ten  or  fifteen  niiniites,  or  even  longer  if  the  tube 
is  much  dilated.  The  rejected  materials  nuiy  be  iuixed  with  blood  and  nuiy 
contain  cancerous  fragments.  In  persons  over  fifty  years  of  age  i)ersistent 
difficulty  in  swallowing  accompanied  by  rapid  emaciation  usually  indicates 
resophageal  can?cr.  The  cervical  lymph-glands  are  frecjuentl)  enlarged  and 
may  give  early  indication  of  the  nature  of  the  trou1)le.  Pain  may  be  per- 
sistent or  be  present  only  when  food  is  taken.  In  certain  instances  the  pain 
is  very  great.  I  saw  an  autopsy  on  a  case  of  cancer  of  the  oeso))hagus  in 
which  the  patient  gradually  became  emaciated,  but  had  no  special  symp- 
toms to  call  attention  to  the  disease.  I'hese  latent  cases  are,  '.owever,  very 
rare. 

The  prognosis  is  hopeless;  the  i)atients  usually  become  progressively 
emaciated,  and  die  either  of  asthenia  or  sudden  perforation  of  the  ulcer. 

In  the  diagnosis  of  the  condition  it  is  important,  in  the  first  ])lace,  to 
exclude  pressure  from  without,  as  '  •  aneurism  or  other  tumor.  The  his- 
tory enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  Tho' 
pound  may  be  passed  and  the  presence  of  the  stricture  determined.  As. 
mentioned  above,  great  care  should  be  exercised.  Fragments  of  carcinom- 
atous tissue  may  in  some  instances  l)e  removed  with  the  tube.  On  aus- 
cultation along  the  left  side  of  the  spine  the  primary  oesophageal  murmur 
may  be  much  altered  in  quality. 

Treatment. — In  most  cases  milk  and  liquids  can  be  swalloAvcd,  but  sup- 
plementary nourishment  should  be  given  by  the  rectum.  It  may  be  ad- 
visable in  some  instances  to  pass  a  tube  into  the  stomach  and  attempt  to 
feed  in  this  way.    When  there  is  difficulty  in  feeding  the  patient  it  is  very- 


i'S 


46a 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


much  Letter  to  have  gastrotoniy  ])erfnrnie(l  at  once,  as  it  gives  the  greatest 
comfort  and  ease,  and  prolongs  the  patient's  life. 


/ 


V.    RUPTURE    OF   THE   CESOPHAGUS. 

This  may  occur  in  a  lioalthy  orgar  as  a  result  of  i)rolonged  vomiting, 
lioerhaave  described  tlie  first  case  in  J?aron  Wassennar,  avIio  "  broke  asunder 
tile  tul)e  of  the  a'sojjhagus  near  the  diajjhragm,  so  that,  after  tlie  most  ex- 
cruciating ])ain,  the  elements  wliicli  he  swallowed  passed,  together  with  the 
air,  into  the  cavity  of  the  thorax,  and  he  expired  in  twenty-four  hours.'' 
Fitz  has  reported  a  case  and  lias  analyzed  tlie  literature  on  tlie  subject  up 
to  1877.  The  accident  has  usually  occurred  during  vomiting  after  a  full 
meal  or  when  i"*:oxicatetl.    It  is,  of  course,  invarial)ly  fatal. 

]\Iuch  more  common  is  the  post-mortem  digestion  of  the  oesophagus, 
which  was  first  described  by  King,  of  Guy's  IIosi)ital.  It  is  not  very  infre- 
quent. In  one  instance  I  found  the  contents  of  the  stomach  in  the  left 
pleura.  The  erosion  is  in  the  posterior  wall,  and  may  be  of  considerable 
extent. 


If 


VI.    DILATATIONS   AND    DIVERTICULA. 

Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube 
above  the  constriction  and  great  hypertrophy  of  the  walls.  Primary  dila- 
tation is  extremely  rare.  The  tiibe  may  attain  extraordinary  dimensions — 
30  cm.  in  circumference  in  Luschka's  case.  Regurgitation  of  food  is  the 
most  common  symptom.  There  may  also  be  difficulty  in  breathing  from 
pressure. 

Diverticula  are  of  two  forms:  (a)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  Avail. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  Indging  occurs,  which 
is  gradiially  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular 
pouch,  (h)  The  traction  diverticula  situated  on  the  anterior  wall  near  the 
bifurcation  of  the  trachea,  result,  as  a  rule,  from  the  extension  of  inflam- 
mation from  the  lymph-glands  with  adhesion  and  sid^sequent  cicatricial 
contraction,  by  which  the  wall  of  the  gullet  is  drawn  out.  Diverticula  have 
been  successfully  extirpated  by  von  Bergmann  and  by  Mixter. 

A  rare  and  remarkable  condition,  of  which  a  case  has  been  recorded 
by  MacLachlan,  and  of  which  a  second  is  in  attendance  at  my  clinic,  is  the 
ccsophago-pleuro-cutancous  fistula.  In  my  patient  fluids  are  discharged 
at  intervals  through  a  fistula  in  the  right  infra-clavicular  region,  A\hich 
appears  to  communicate  Avith  a  cavity  in  the  upper  part  of  the  pleura  or 
lung.    The  condition  has  persisted  for  more  than  tAventy  years. 


ACUTE  GASTRITIS. 


463 


from 


most 

wall. 

kvhicli 


ir  the 
iflam- 
tricial 
L  have 


worried 
1  is  the 
mrged 
iM'hich 
ira  or 


Vl'.   DISEASES  OF  THE   STOMACH.       • 
I.    ACUTE  GASTRITIS. 

{Simple  Gastritis ;  Acute  Gastric  Catarrh  •  Acrtte  Dyspepsia.) 

Sitiology. — Acute  gastric  catarrh,  ojie  of  the  most  common  of  com- 
plaints, occurs  at  all  ages,  and  is  usually  traceahle  to  errors  in  diet.  It  may 
follow  the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it  may 
result  from  taking  unsuitable  articles,  which  either  themselves  irritate  the 
nuicosi'  or,  remaining  undigested,  decompose,  and  so  excite  an  acute  dys- 
l)ei)sia.  A  frequent  cause  is  the  taking  of  food  which  has  begun  to  decom- 
pose, particularly  in  hot  weather.  In  children  these  fermentative  processes 
are  very  apt  to  excite  acute  catarrh  of  the  bowels  as  well.  Another  very 
common  cause  is  the  abuse  of  alcohol,  and  the  acute  gastritis  which  fol- 
lows a  drinking-bout  is  one  of  the  most  typical  fonus  of  the  disease.  The 
tendency  to  acute  indigestion  varies  very  much  in  dilferent  individuals, 
and  indeed  in  families.  We  recognize  this  in  using  the  expressions  a  "  deli- 
cate stomach "  and  a  "  strong  stomach."  Gouty  persons  are  generally 
thought  to  be  more  disposed  to  acute  dyspepsia  than  others.  Acute  catarrh 
of  the  stomach  occurs  at  the  outset  of  many  of  the  infectious  fevers. 

Lebert  described  a  special  infectious  form  of  gastric  catarrh,  occurring 
in  epidemic  form,  and  only  to  be  distinguished  from  mild  typhoid  fever  by 
the  absence  of  rose  spots  and  swelling  of  the  spleen.  Many  practitioners 
still  adhere  to  the  belief  that  there  is  a  form  of  r/axtric  fever,  but  the  evidence 
of  its  existence  is  by  no  means  satisfactory,  and  certainly  a  great  majority 
of  all  cases  in  this  country  are  examples  of  mild  ty])hoid. 

Morbid  Anatomy. — Beaumont's  study  of  St.  IMartin's  stomach 
showed  that  in  acute  catarrh  the  mucous  membrane  is  reddened  and  swol- 
len, less  gastric  Juice  is  secreted,  and  mucus  covers  the  surface.  Slight 
haemorrhages  may  occur  or  even  small  erosions.  The  submucosa  may  be 
somewhat  «?dematous.  Microscopically  the  changes  are  chiefly  noticeable 
in  the  mucous  and  peptic  cells,  which  are  swollen  and  more  granular,  and 
there  is  an  infiltration  of  the  intertubular  tissue  with  leucocytes. 

Symptoms. — In  mild  cases  the  symptoms  are  those  of  slight  "indi- 
gestion " — an  uncomfortable  feeling  in  the  abdomen,  headache,  depression, 
nausea,  eructations,  and  vomiting,  Avhich  usually  gives  relief.  The  tongue 
is  heavily  coated  and  the  saliva  is  increased.  In  children  there  are  intes- 
tinal symptoms — diarrhoea  and  colicky  pains.  There  is  usually  no  fever. 
The  duration  is  rarely  more  than  twenty-four  hours.  In  the  severer  forms 
the  attack  may  set  in  with  a  chill  and  febrile  reaction,  in  which  the  tem- 
perature rises  to  102°  or  103°.  The  tongue  is  furred,  the  breath  heavy,  and 
vomiting  is  frequent.  The  ejected  substances,  at  first  mixed  with  food, 
subsequently  contain  much  mucus  and  bile-stained  fluids.  There  may  be 
constipation,  but  very  often  there  is  diarrhoea.  The  urine  presents  the 
usual  febrile  characteristics,  and  there  is  a  heavy  deposit  of  urates.  The 
abdomen  may  be  somewhat  distended  and  slightly  tender  in  the  epigastric 
Heri:>€S  may  appear  on  the  lips.  The  attack  may  last  from  one 
29 


region. 


If 


464 


DISEASES  OP  THE   -DIGESTIVE  SYSTEM. 


/ 


to  three  days,  and  occasionally  longer.  The  examination  of  the  vomitus 
shows,  as  a  rule,  ahsence  of  the  hydrochloric  acid,  presence  of  l&ctic  and 
fatty  acids,  and  marked  increase  in  the  mucus. 

Diagnosis. — The  ordinary  afehrile  gastric  catarrh  is  readily  recog- 
nized. The  acute  febrile  form  is  so  similar  to  the  initial  symptoms  of  many 
of  the  infectious  diseases  that  it  is  impossible  for  a  day  or  two  to  make  a 
definite  diagnosis,  particularly  in  the  cases  which  have  come  on,  so  to  speak, 
spontaneously  and  indei)endently  of  an  error  in  diet.  Some  of  these  re- 
semble closely  an  acute  infection;  the  symi)toms  may  be  very  intense,  and 
if,  as  sometimes  hai)})ens,  the  attack  sets  in  with  severe  headache  and  de- 
lirium the  case  may  be  mistaken  for  meningitis.  When  the  abdominal 
pains  are  intense  the  attack  may  be  confounded  with  gallstone  colic.  In 
discriminating  between  acu+^e  febrile  gastritis  and  the  abortive  forms  of 
typhoid  fever  it  is  to  be  borne  in  mind  that  in  the  former  the  temperature 
rises  abruptly,  the  remissions  are  slighter  and  the  drop  is  more  sudden. 
The  initial  bronchitis,  the  well-marked  splenic  enlargement,  and  the  rose 
spots  are  not  ii^^sent.  It  is  a  very  common  error  to  class  under  gastric 
fever  the  mild  forms  of  the  various  infectious  disorders.  The  gastric  crises 
in  locomotor  ataxia  have  in  many  instances  been  confounded  with  a  simple 
acute  gastritis,  and  it  is  always  wise  in  adults  to  test  the  knee-jerks  and 
pupillary  reactions. 

Treatment. — Mild  cases  recover  spontaneously  in  twenty-four  hour's, 
and  require  no  treatment  other  than  a  dose  of  castor  oil  in  chddren  or  of 
blue  mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  in  the 
region  of  the  stomach,  the  vomiting  should  be  promoted  by  warm  water 
or  the  simple  emetics.  A  full  dose  of  calomel,  8  to  10  grains,  should  be 
given,  and  followed  the  next  morning  by  a  dose  of  Hunyadi-Janos  or  Carls- 
bad water.  If  there  is  eructation  of  acid  fluid,  bicarbonate  of  soda  and 
bismuth  may  be  given.  The  stomach  should  have,  if  possible,  absolute 
rest,  and  it  is  a  good  plan  in  the  case  of  strong  persons,  particularly  in  those 
addicted  to  alcohol,  to  cut  off  all  food  for  a  day  or  two.  The  patient  may 
be  allowed  soda  water  and  ice  freely.  It  is  well  not  to  attempt  to  check 
the  vomiting  imless  it  is  excessive  and  protracted.  Recovery  is  usually 
complete,  though  repeated  attacks  may  lead  to  subacute  gastritis  or  to  the 
establishment  of  chronic  dyspepsia. 

Phlegmonous  Gastritis ;  Acute  Suppurative  Gastritis. — This  is  an  ex- 
cessively rare  disease,  characterized  by  the  occurrence  of  suppurative  pro- 
cesses in  the  submucosa.  The  affection  is  more  common  in  men  than  in 
women.  Leith  has  collected  85  cases,  and  has  given  the  best  account  in 
the  literature  (Edinburgh  Hospital  Reports,  vol.  iv).  The  cause  is  seldom 
obvious.  It  has  been  met  with  as  an  idiopathic  affection,  but  it  has  occurred 
also  in  puerperal  fever  and  other  septic  processes,  and  has  occasionally 
followed  trauma.  Anatomically  there  a^^pear  to  be  two  forms,  a  diffuse 
purulent  infiltration  and  a  localized  abscess  formation,  in  which  case  the 
tumor  may  reach  the  size  of  an  egg,  and  may  burst  into  the  stomach  or 
into  the  peritoneal  cavity.  In  two  of  the  cases  I  have  seen,  the  abscess  was 
in  connection  with  cancer  of  the  stomach,  and  it  is  interesting  to  note 
that  in  both  there  were  recurring  chills.    In  a  third  case,  in  a  diffuse  car- 


ACUTE  GASTRITIS. 


465 


an  ex- 
re  pro- 
lan in 
lunt  in 
seldom 
;curre(l 
ionally 
diffuse 
,se  the 
lach  or 
ess  was 
o  note 
se  car' 


cinomn,tliero  was  extensive  phlegmonous  inflammation  with  vomiting  of  a 
horribly  fetid  material. 

The  symptoms  are  varial)lc.  There  are  usually  pain  in  the  ahdomcn, 
fever,  dry  tongue,  and  symptoms  of  a  severe  infective  process,  delirium 
and  coma  preceding  death.  Jaundice  has  been  met  witli  in  some  instances. 
Occasionally,  when  the  abscess  tumor  is  large,  it  has  been  felt  externally, 
in  one  case  forming  a  mass  as  large  as  two  lists.  There  are  instances  which 
run  a  more  chronic  course,  with  pains  in  the  abdomen,  fever,  and  chills. 

The  diagnosis  is  rarely  i)ossible,  even  when  witii  abscess  ru|)ture  oceurs, 
and  the  pus  is  vomited,  as  it  is  not  possible  to  differentiate  this  coiulition 
from  an  a])scess  perforating  into  the  stomach  from  without.  It  is  stated, 
however,  that  Chvostek  made  the  diagnosis  in  one  of  his  cases. 

Toxic  Gastritis. — This  most  intense  form  of  inflammation  of  the  stom- 
ach is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong 
alkalies,  or  by  such  poisons  as  phosphorus,  corrosive  sublimate,  ammonia, 
arsenic,  etc.  In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic, 
and  antimony,  the  process  consists  of  an  acute  degeneration  of  the  glandular 
elements,  and  ha^morrhagr  In  the  powerful  concentrated  poisons  the 
mucous  memhrane  is  extensively  destroyed,  and  may  l)e  converted  into  a 
brownish-black  eschar.  In  the  less  severe  grades  there  may  l)e  areas  of 
necrosis  surrounded  by  inflammatory  reaction,  while  the  submucosa  is  hem- 
orrhagic and  infiltrated.  The  process  is  of  course  more  intense  at  the 
fundus,  but  the  active  peristalsis  may  drive  the  poison  through  the  pylorus 
into  the  intestine. 

The  symptoms  are  intense  pain  in  the  mouth,  throat,  and  stomach, 
salivation,  great  difficulty  in  swallowing,  and  constant  vomiting,  the  vom- 
ited materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  painful  on 
])ressure.  In  the  most  acute  cases  symptoms  of  collapse  supervene;  the 
pulse  is  weak,  the  skin  pale  and  covered  with  sweat;  there  is  restlessness, 
and  sometimes  convulsions.  There  may  be  albumin  or  blood  in  the  urine, 
and  petechias  may  develop  on  the  skin.  When  the  poison  is  less  intense, 
the  sloughs  may  separate,  leaving  ulcers,  which  too  often  lead,  in  the 
oesophagus  to  stricture,  in  the  stomach  to  chronic  atrophy,  and  finally  cO 
death  from  exhaustion. 

The  diagnosis  of  toxic  gastritis  is  usually  easy,  as  inspection  of  the 
mouth  and  pharynx  shows,  in  many  instances,  corrosive  effects,  while  the 
examination  of  the  vomit  may  indicate  the  nature  of  the  poison. 

In  poisoning  by  acids,  magnesia  should  be  administered  in  milk  or 
with  e^g  albumen.  When  strong  alkalies  have  been  taken,  the  dilute  acids 
should  be  administered.  If  the  case  is  seen  early,  lavage  should  be  used. 
For  the  severe  inflammation  which  follows  the  swallowing  of  the  stronger 
poisons  palliative  treatment  is  alone  available,  and  morphia  may  be  freely 
employed  to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis. — This  condition  is  met  with 
occasionally  in  diphtheria,  but  more  commonly  as  a  secondary  process  in 
typhus  or  typhoid  fever,  pneumonia,  pyfemia,  small-pox,  and  occasionally 
in  debilitated  children.    An  instance  of  it  came  under  my  notice  in  pneu- 


466 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


monia.  The  cxiulation  may  be  extensive  and  uniform  or  in  ])atclu's.  The 
condition  is  not  recognizable  during  lite,  uidess,  as  in  a  case  of  Jolm  Tbom- 
eon's,  the  membranes  are  vomited. 

Mycotic  and  Parasitic  Gastritis. — It  occasionally  happens  that  fungi 
develop  in  the  stomach  and  excite  inllammation.  One  of  the  most  remark- 
able cases  of  the  kind  is  that  reported  by  Ivundrat,  in  which  the  favus 
fungus  developed  in  the  stomach  and  intestine. 

In  cancer  and  in  dilatation  of  the  stomach  the  sarcinas  and  yeast  fungi 
prol)ably  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  capable  of  killing  the  ordinary  bacteria.  Orth  states  that  the 
anthrax  bacilli,  in  certain  cases,  ))roduce  swelling  of  the  mucosa  and  ulcera- 
tion. Eug.  Fraenkel  has  re})orted  a  case  of  acute  emphysematous  gastritis 
probably  of  mycotic  origin.  The  larva?  of  certain  insects  may  excite  gas- 
tritis, as  in  the  cases  reported  by  Gerhardt,  Meschede,  and  others.  In  rare 
instances  tuberculosis  and  syphilis  attack  the  gastric  mucosa. 


M.    CHRONIC  GASTRITIS. 

(Chronic  Catarrh  of  the  Stomach  ;  Chronic  Dyspepsia) 

Deflnition. — A  condition  of  disturbed  digestion  associated  with  in- 
-creased  mucous  formation,  qualitative  or  quantitative  changes  in  the  gastric 
juice,  enfeeblement  of  the  muscular  coats,  so  that  the  food  is  retained  for 
.an  abnormal  time  in  the  stomach;  and,  finally,  with  alterations  in  the 
structure  of  the  mucosa. 

Etiology. — The  causes  of  chronic  gastritis  may  be  classified  as  fol- 
lows: (1)  Dietetic.  The  us  of  unsuitable  or  improperly  prepared  food. 
The  persistent  use  of  certaii  articles  of  diet,  such  as  very  fat  substances 
or  foods  containing  too  much  the  carbohydrates.  New  England  pie  and 
the  hot  breads  of  the  Southern  States  are  responsible  for  many  cases  of 
chronic  dyspepsia.  The  use  in  excess  of  tea  or  coffee,  and,  above  all,  of  alco- 
hol in  its  various  forms.  Under  this  heading,  too,  may  be  mentioned  the 
habits  of  eating  at  irregular  hours  or  too  rapidly  &  '  imperfectly  chewing 
the  food.  In  this  country  excess  in  eating  does  more  damage  than  excess  in 
drinking.  A  common  cause  of  chronic  catarrh  is  drinking  too  freely  of  ice- 
water  during  meals,  a  practice  which  plays  no  small  part  in  the  prevalence  of 
dyspe])sia  in  America.  Ano''"  r  frequent  cause  is  the  abuse  of  tobacco,  par- 
ticularly chewing.  (2)  Constitutional  causes.  Anaemia,  chlorosis,  chronic 
tuberculosis,  gout,  diabetes,  and  Bright's  disease  are  often  associated  with 
chronic  gastric  catarrh.  (3)  Local  conditions:  (a)  of  the  stomach,  as  in  can- 
cer, ulcer,  and  dilatation,  which  are  invariably  accompanied  by  catarrh;  {b) 
conditions  of  the  portal  circulation,  causing  chronic  engorgement  of  the 
mucous  membrane,  as  in  cirrhosis,  chronic  heart-disease,  and  certain  chronic 
lung  affections. 

Morbid  Anatomy. — Anatomically  two  forms  of  chronic  gastritis 
may  be  recognized,  the  simple  and  the  sclerot.  j. 

(«)  Simple  Chronic  Gastritis. — The  organ  is  usually  enlarged,  the 
mucous  membrane  pale  gray  in  color,  and  covered  with  closely  adherent, 


mmm 


CURONIC  GASTRITIS. 


467 


tenacious  miiciis.  The  veins  are  large,  patches  of  eccliyniosis  are  not  in- 
frequently seen,  and  in  the  chronic  catarrh  of  |)ortal  ol)struction  and  of 
chronic  heart-disease  small  Juvniorrhagic  erosions.  Toward  the  pylorus  the 
mucosa  is  not  infrequently  irregularly  i>igniented,  and  presents  a  rough, 
wrinkled,  nuimmillated  surface,  the  etat  matninclane  of  the  French,  a  con- 
dition which  nuiy  sometimes  he  so  ])rominent  that  writers  have  descrihcd 
it  as  yustrilis  poli/jiosu.  The  mendjrane  may  be  thinner  than  normal,  and 
much  firmer,  tearing  less  readily  with  the  finger-nail.  Ewald  thus  de- 
scribes the  histological  changes:  The  minute  anatomy  shows  tlie  ))icture 
of  a  parenchymatous  and  an  interstitial  inthimniation.  Tlie  gland  cells 
are  in  part  eroded  or  show  cloudy  granular  swelling  or  atro])hy.  The  dis- 
tinction between  the  i)rincipal  and  marginal  cells  cannot  l)e  recognized, 
and  in  many  ])laces,  particularly  in  the  pyloric  region,  the  tubes  have  lost 
their  regular  form  and  show  in  many  places  an  atypical  branching,  like 
the  lingers  of  a  glove.  Individual  glands  are  cut  oif  toward  the  fundus, 
but  api)ear  at  the  border  of  the  submucosa  as  cysts,  ]mrtly  empty,  with  a 
smooth  membrane,  partly  filled  with  remnants  of  hyaline  and  refractile 
epithelium.  An  abundant  small-celled  infiltration  presses  ajiart  the  tubules 
being  particularly  marked  toward  tlie  surface  of  the  mucosa,  and  from 
the  submucosa  extensions  of  the  connective  tissue  may  be  seen  ])assing 
between  the  glands.  The  mucoid  transformation  of  the  cells  of  the  tubules 
is  a  striking  feature  in  the  process  and  may  extend  to  the  very  fundus  of 
the  glands. 

(b)  Sclerotic  Gastritis. — As  a  final  result  of  the  parenchymatous  and 
interstitial  changes  the  mucous  membrane  may  undergo  complete  atrophy,, 
so  that  but  few  traces  of  secreting  substance  remain.  There  appear  to 
be  two  forms  of  this  sclerotic  atro])hy — one  with  thinning  of  the  coats  of 
the  stomach,  phthisis  veniricnli,  and  a  retention  or  even  increase  of  the 
size  of  the  organ;  the  other  with  enormous  thickening  of  the  coats  and 
great  reduction  in  the  volume  of  the  organ,  the  condition  which  is  usually 
described  as  cirrhosis  ventricvU.  Extreme  atrophy  of  the  mucous  mem- 
brane of  the  stomach  has  been  carefully  studied  by  Fenwick,  Ewald,  and 
others,  and  we  now  recognize  the  fact  that  there  may  be  such  destruction 
and  degeneration  of  the  glandular  elements  by  a  progressive  development 
of  interstitial  tissue  that  ultimately  scarcely  a  trace  of  secreting  tissue  re- 
mains. In  a  characteristic  case,  studied  by  Henry  and  myself,  the  greater 
portion  of  the  lining  membrane  of  the  stomach  was  converted  into  a  per- 
fectly smooth,  cuticular  structure,  showing  no  trace  whatever  of  glandular 
elements,  with  enormous  hypertrophy  of  the  muscularis  mucossv,  and  here 
and  there  formation  of  cysts.  In  the  other  form,  with  identical  atrophy 
and  cyst  formation,  there  is  enormous  increase  in  the  connective  tissue,  and 
the  stomach  may  be  so  contracted  that  it  does  not  hold  more  than  a  couple 
of  ounces.  The  walls  may  measure  from  2  to  3  cm.;  the  greatest  increase 
in  thickness  is  in  the  submucosa,  but  the  hypertrophy  also  extends  to  the 
muscular  layers.  A  similar  affection  may  coexist  in, the  CtTcum  and  colon. 
The  condition  may  be  difficult  to  distinguish  from  diffuse  carcinoma.  There 
may  be  also  pr-^H.^erative  peritonitis,  with  perihepatitis,  perisplenitis,  and 
ascites.    Whil      ne  is  not  justified  in  saying  that  all  cases  of  cirrhosis  of 


468 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


/' 


the  etomach  rt'iircsent  a  final  stage  in  the  liistory  of  a  cliroiiic  catarrh,  it  is 
true  that  in  most  cases  tiie  })rocese  "s  associated  with  atrophy  of  the  gastric 
mucosa,  while  the  hi^story  indicates  the  existence  of  chronic  dyspepsia. 

Erosions  of  the  Sioinach. — Small  su])erficial  losses  of  substance  are  met 
with  in  the  stomach  under  a  great  variety  of  conditions,  usually  in  connec- 
tion with  chronic  gastritis,  diseases  of  the  liver,  particularly  cirrhosis,  and 
chronic  diseases  of  the  heart.  Kinhorn  has  described,  too,  a  special  con- 
dition in  which  in  the  washings  from  the  fasting  stomach  little  shreds  of 
gastric  mucous  membrane  are  found,  and  there  is  tenderness  and  soreness  on 
passing  the  tube  and  a  little  staining  of  the  water.  These  are  probably  the 
result  of  passing  the  tube.  True  erosions  are  usually  multiple,  more  com- 
mon, I  think,  in  th6  pyloric  region,  and  are  usually  without  any  symptoms. 
The  mucosa  in  the  neighborhood  of  the  erosion  may  be  deejjly  hasmor- 
rhagic.  When  one  sees  a  large  number  of  erosions,  which  may  be  present 
in  some  cases,  it  is  difficult  to  understand  why  larger  ulcers  do  not  form 
at  their  site.  The  only  ill  effect  I  know  of  is  the  occurrence  o^'  profuse  or 
even  fatal  haemorrhage. 

Symptoms. — The  affection  persists  for  an  indefinite  period,  and,  as 
is  the  case  with  most  chronic  diseases,  changes  from  time  to  time.  The 
appetite  is  variable,  sometimes  greatly  impaired,  at  others  very  good. 
Among  early  symptoms  are  feelings  of  distress  or  oppression  after  eating, 
which  may  become  aggravated  and  amount  to  actual  pain.  When  the 
stomach  is  empty  there  may  also  be  a  painful  feeling.  The  pain  differs  in 
different  cases,  and  may  be  trifling  or  of  extreme  severity.  When  localized 
and  felt  beneath  the  sternum  or  in  the  prai'cordial  region  it  is  known  as 
heart-burn  or  sometimes  cardialgia.  There  is  pain  on  pressure  over  the 
stomach,  usually  diffuse  and  not  severe.  The  tongue  is  coated,  and  the 
patient  comploins  of  a  bad  taste  in  the  mouth.  The  tip  and  margin  of  the 
tongue  are  very  often  red.  Associated  with  this  catarrhal  stomatitis  there 
may  be  an  increase  in  the  salivary  and  pharyngeal  secretions.  Nausea  is  an 
early  symptom,  and  is  particularly  apt  to  occur  in  the  morning  hours.  It 
is  not,  however,  nearly  so  constant  a  symptom  in  chronic  gastritis  as  in 
cancer  of  the  stomach,  and  in  mild  grades  of  the  affection  it  may  not  occur 
at  all.  Eructation  of  gas,  which  may  continue  for  some  hours  after  taking 
food,  is  a  very  prominent  feature  in  cases  of  so-called  flatulent  dyspepsia, 
and  there  may  be  marked  distention  of  the  intestines.  With  the  gas,  bitter 
fluids  may  be  brought  up.  Vomiting,  which  is  not  very  frequent,  occurs 
either  immediately  after  eating  or  an  hour  or  two  later.  In  the  chronic 
catarrh  of  old  topers  a  bout  of  morning  vomiting  is  common,  in  which  a 
slimy  mucus  is  brought  up.  The  vomitus  consists  of  food  in  various  stages 
of  digestion  and  slimy  mucus,  and  the  chemical  examination  shows  the 
presence  of  abnormal  acids,  such  as  butyric,  or  even  acetic,  in  addition  to 
lactic  acid,  while  the  hydrochloric  acid,  if  indeed  it  is  present,  is  much  re- 
duced in  quantity.  The  digestion  may  be  much  delayed,  and  on  washing 
out  the  stomach  as  late  as  seven  hours  after  eating,  portions  of  food  are 
still  present.  The  prolonged  retention  favorr,  v'^-composition,  the  stomach 
becomes  distended  with  gas,  and  this,  with  the  chronic  catarrh,  may  induce 
gradually  an  atony  of  the  muscular  walls.     The  absorption  is  slow,  and 


I 
I 


T 


ymmmm 


"m 


CHRONIC  GASTRITIS. 


4G9 


iodide  of  potassium,  given  in  capsules,  whieii  should  normally  reach  the 
saliva  within  lil'teeii  minutes,  nuiy  not  be  evident  lV)r  more  than  half  an 
hour. 

Constipation  is  usually  i)resent,  but  in  some  instances  there  is  diarrhaia, 
and  undigested  food  passes  rapidly  through  the  bowels.  The  urine  is  often 
scanty,  high-colored,  and  dej)osits  a  heavy  sediment  of  urates. 

Of  other  symptoms  headache  is  common,  and  the  patient  feels  constantly 
out  of  sorts,  indisposed  for  exertion,  and  low-spirited.  In  agi^ravated  eases 
melancholia  may  develop.  Trousseau  called  attention  to  the  occurrence 
of  vertigo,  a  nuirked  feature  in  certain  cases.  The  i)ulse  is  small,  some- 
times slow,  and  there  may  be  ])alpitation  of  the  heart.  Fever  does  not 
occur.  Cough  is  sometimes  present,  but  the  so-called  stomach  cough  of 
chronic  dyspeptics  is  in  all  probability  dependent  u])on  })haryngeal  irri- 
tation. 

The  Gastric  Contents. — The  fasting  stomach  may  he  empty  or  it  may 
contain  much  mucus — gastritis  mucipara  of  Boas.  In  the  test  breakfast, 
withdrawn  in  an  hour,  the  HCL  is  usually  diminished,  though  it  may  be 
normal — gastritis  acida.  In  other  cases  the  free  IICl  may  be  absent — 
gastritis  anacida.  While  in  the  advanced  forms  of  atroj)hy  of  the  mucosa 
there  may  be  neither  acids  nor  ferments — gastritis  atrophicans. 

The  motor  function  of  the  stomach  is  not  usually  much  im])air(.d. 

The  symptoms  of  atrophy  of  the  mucous  membrane  of  the  stomach,  with 
or  without  contraction  of  the  organ,  are  very  com})lex,  and  cannot  be  said 
to  present  a  uniform  picture.  The  majority  of  the  cases  present  the  symp- 
toms of  an  aggravated  chronic  dyspepsia,  often  of  such  severity  that  cancer 
is  suspected.  In  one  of  the  cases  which  I  examined,  the  persistent  distress 
after  eating,  the  vomiting,  and  the  gradual  loss  of  flesh  and  strength,  very 
naturally  led  to  this  diagnosis,  but  the  duration  of  the  disease  far  ex- 
ceeded that  of  ordinary  carcinoma.  In  the  cirrhotic  form  the  tumor  mass 
may  sometimes  be  felt.  In  atrophy  of  the  stomach,  whether  associated 
with  cirrhosis  or  not,  the  clinical  picture  may  be  that  of  pernicious  anaemia. 
As  early  as  1860,  Flint  called  attention  to  this  connection  between  atrophy 
of  the  gastric  tubules  and  anaimia,  an  observation  which  Fenwick  and 
others  have  amply  confirmed. 

Diagnosis. — Ewald  distinguishes  three  forms  of  chronic  gastritis:  (1) 
Simple  gastritis;  (2)  mucous  (schleimige)  gastritis;  (3)  atrophic  gastritis. 

In  (1)  the  fasting  stomach  contains  only  a  small  quantity  of  a  slimy 
fluid,  while  after  the  test  breakfast  the  HCl  is  diminished  in  qiiantity  or 
may  be  absent.  Lactic  acid  and  the  fat  acids  may  be  present.  After  Boas's 
more  rigid  test  meal  the  organic  acids  are  rarely  found.  The  pepsin  and 
rennet  are  always  present. 

In  (2)  the  acidity  is  always  slight  and  the  condition  is  distinguished 
from  (1)  chiefly  by  the  large  amount  of  mucus  present. 

In  (3)  the  fasting  stomach  is  generally  empty,  while  after  the  test 
breakfast  HCl,  pepsin,  and  the  curdling  ferment  are  wholly  wanting. 

The  diagnosis  of  cancer  of  the  stomach  from  chronic  gastritis  may  be 
very  difficult  when  a  tumor  is  not  present.  The  cases  require  most  careful 
study,  and  it  may  take  several  months  before  a  decision  can  '     reached. 


m 


470 


DISEASES  OF  TIIL  DIGESTIVE  SYSTEM. 


.   \ 
/ 


P 


Treatment.— AVIicn  ])()ssil)lo  llic  cnuse  in  cnch  cnsc  Khoiild  be  nscer- 
taiiR'tl  1111(1  an  atleiiipt  made  to  dctfrmino  the  .s|)('eial  form  of  indigestion. 
Ubuaily  there  is  no  dillieuity  in  diU'erentiating  tiie  ordinary  eataniial  and 
the  nervous  varieties,  A  careful  study  of  the  i)hen()inenu  of  digestion  in 
the  way  already  laid  down,  though  not  essential  in  every  instance,  should 
certainly  be  carried  out  in  the  more  obstinate  and  obscure  forms.  Two  im- 
jwrtant  (juestions  should  be  asked  of  every  dyspejjtic — first,  as  to  the  time 
taken  at  his  meals;  and,  second,  as  to  the  (juantity  lie  eats.  I'ractically 
a  large  majority  of  all  cases  of.  disturl)ed  digestion  come  from  hasty  and 
inqiert'ect  mastication  of  the  food  aiul  from  overeating.  Especial  stress 
should  be  laid  upon  the  former  jioint.  In  some  instances  it  will  alone  suf- 
fice to  cure  dys])cpsia  if  the  ])atient  will  count  a  certain  number  before 
swallowing  each  mouthful.  The  second  i)oint  is  of  even  greater  imj)or- 
tance.  IVopIe  habitually  eat  too  much,  and  it  is  ])robably  true  that  a 
greater  number  of  maladies  arise  from  excess  in  eating  than  from  excess 
in  drinking.  Particularly  is  this  the  case  in  America,  where  the  average 
man  is  abstemious  in  the  matter  of  alcohol,  but  imprudent  to  a  degree 
in  all  matters  relating  to  food,  ^[oreover,  ])eople  have  not  had  time  to 
learn  the  art  of  cooking,  and  much  of  the  indigestion,  ])articiilarly  in  the 
country  districts,  may  be  charged  to  the  l)arbarous  methods  of  ])rei)aring 
the  food.  The  treatment  may  be  considered  under  the  headings  of  dietetic 
and  medicinal. 

(n)  General  ami  Dietetic. — A  careful  and  systematically  arranged  di- 
etary is  the  first,  sometimes  the  only  essential  in  the  treatment  of  a  case  of 
chronic  dyspe])sia.  It  is  impossible  to  lay  down  ndes  apjdicable  to  all  cases. 
Individuals  ditfer  extraordinarily  in  their  capability  of  digesting  different 
articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "  One  man's  food 
is  another  man's  poison."  The  individual  preferences  for  dilferent  articles 
of  food  should  be  permitted  in  the  milder  forms.  Physicians  have  probably 
been  too  arbitrary  in  this  direction,  and  have  not  yielded  sufficiently  to  the 
intimations  given  by  the  appetite  and  desires  of  the  patient. 

A  rigid  milk  diet  may  be  tried  in  obstinate  cases.  ^luch  depends  upon 
whether  the  y)atient  is  able  to  take  and  digest  milk  properly.  In  the  forms 
associated  with  Bright's  disease  and  chronic  portal  congestion,  as  ■well  as  in 
many  instances  in  which  the  dyspepsia  is  part  of  a  neurasthenic  or  hysterical 
troidde,  this  plan  in  conjunction  Avith  rest  is  most  efficacious.  If  milk 
is  not  digested  well  it  may  be  diluted  one  third  with  soda  water  or  Vichy, 
or  5  to  10  grains  of  carbonate  of  soda,  or  a  pinch  of  salt  may  bo  added  to 
each  tumblerful.  In  many  cases  the  milk  from  which  the  cream  has  heen 
taken  is  better  borne.  Buttermilk  is  particularly  suitable,  but  can  rarely 
he  taken  for  so  long  a  time  alone,  as  patients  tire  of  it  much  more  readily 
than  they  do  of  ordinary  milk.  Not  only  can  the  general  nutrition  be 
maintained  on  this  diet,  hut  patients  sometimes  increase  in  weight,  and  the 
unpleasant  gastric  symptoms  disappear  entirely.  It  should  be  given  at 
fixed  hours  and  in  definite  quantities.  A  patient  may  take  6  or  8  mmccs 
every  three  hours.  The  amount  necessary  varies  a  good  deal,  hut  at  least 
3  to  5  pints  should  he  given  in  the  twenty-four  hours.  This  form  of  diet  is 
not,  as  a  rule,  well  borne  when  there  is  a  tendency  to  dilatation  of  the 


CHRONIC  GASTRITIS. 


471 


ptomndi.  The  milk  may  he  prc'viout<ly  peptonized,  but  it  is  impossible  to 
IVt'd  a  cliroiiie  (lysiR'ptie  in  tlii^  way.  'i'lio  stools  should  be  earefully 
watched,  and  ii'  more  milk  is  taken  tiian  can  be  iligested  it  io  well  to  Bupple- 
ment  the  diet  with  cg^s  and  dry  toast  or  biscuits. 

In  a  large  i)r()portion  of  the  cases  of  chronic  indigestion  it  is  not  neces- 
sary to  annoy  the  ])atient  with  such  strict  dietaries.  It  may  be  c|uite  euf- 
licient  to  cut  oil'  certain  articles  of  lood.  Tlius,  if  there  are  acid  eructations 
or  llatulency,  the  farinaceous  foods  should  be  restricted,  ]).irticuhirly  pota- 
toes and  the  coarser  vegetables.  A  fruitful  source  ui  indigestion  is  the 
liot  bread  which,  in  ditforent  forms,  is  regarded  as  an  essential  ])art  of  an 
American  breakfast.  This,  as  well  as  (he  various  forms  of  pancakes,  ])ii'8 
and  tarts,  with  heavy  ])astry,  and  fried  articles  of  all  sorts,  should  be  strictly 
forbidden.  As  a  rule,  white  bread,  toasted,  is  nuire  reailily  digested  than 
bread  made  from  the  whole  meal.  Persons,  however,  dilfer  very  much  in 
this  respect,  and  the  (Jraham  or  brown  bread  is  for  numy  peojile  most 
digestible.  Sugar  and  very  sweet  articles  of  food  should  be  taken  in  great 
moderation  or  avoided  altogether  by  i)ersons  with  chronic  dyspejjsia.  Many 
instances  of  aggravated  indigestion  have  come  to  my  notice  due  to  the 
])revalent  practice  of  eating  largely  of  ice-cream.  One  of  the  most  po\v'erful 
enemies  of  the  American  stomach  in  the  ])resent  day  is  the  sofla-watcr 
fountain,  m  hich  has  usurped  so  important  a  ])lace  in  the  a[)othecary  shop. 

Fats,  with  the  exception  of  a  moderate  amount  of  good  butter,  very 
fat  meats,  and  thick,  greasy  soups  should  be  avoided.  Kipe  fruit  in  modera- 
tion is  often  advantageous,  ])articularly  when  cooked.  IJananas  are  not,  as 
a  rule,  well  borne.  Strawberries  are  to  nuiny  ])ersons  a  cause  of  an  annual 
attack  of  indigestion  and  sore  throat  in  the  spring  months. 

As  stated,  in  the  matter  of  special  articles  of  food  it  is  impossible  to 
lay  down  rigid  rules,  and  it  is  the  common  experience  that  one  ])aticnt 
with  indigestion  will  take  with  impunity  the  very  articles  which  cause  the 
greatest  distress  to  another. 

Another  detail  of  im])ortance  which  may  be  mentioned  in  this  con- 
nt'ction  is  the  general  hygienic  management  of  dyspeptics.  These  pa- 
tients are  often  introspective,  dwelling  in  a  morl)id  manner  on  their  syni])- 
tnnis,  and  much  inclined  to  take  a  des])ondent  view  of  their  condition. 
Very  little  progress  can  be  made  unless  the  physician  gains  their  confidence 
from  the  ontset.  Their  fears  and  whims  should  not  be  made  too  light  of 
or  ridiculed.  Systematic  exercise,  carefully  regulated,  ])articularly  Avhen, 
as  at  watering  places,  it  is  combined  with  a  restricted  diet,  is  of  special 
service.  Change  of  air  and  occupation,  a  y)rolonged  sea  voyage,  or  a  summer 
in  the  mountains  will  sometimes  cure  the  most  obstinate  dyspepsia. 

(h)  Medicinal. — The  special  therapeutic  measures  may  be  divided  into 
tliose  which  attempt  to  rc]dace  in  the  digestive  juices  important  elements 
which  are  lacking  and  those  which  stimidate  the  weakened  action  of  the 
organ.  In  the  first  group  come  the  hydrochloric  acid  and  ferments,  which 
are  so  freely  em])loyed  in  dyspepsia.  The  former  is  the  most  im])ortant. 
Tt  is  the  ingredient  in  the  gastric  juice  most  commonly  deficient.  It  is  not 
only  necessarv  for  its  own  important  actions,  but  its  presence  is  intimately 
associated  with  that  of  the  pepsin,  as  it  is  only  in  the  presence  of  a  suffi- 


472 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


V' 


.  \ 

/ 


cient  quantity  that  tho  pepsinogen  ia  cojiverted  into  the  active  digostivo 
ferment.  Jt  is  be^t  j,'iven  as  the  dihite  ac^l  taken  in  somewhat  hirj,'er  (pian- 
tities  than  are  usually  advised,  Kwald  reeommends  hirge  doses — of  from 
i)()  to  loo  drops — at  iidervals  of  fifteen  minutes  after  the  meals.  Leuhe 
and  Kiej^el  advise  smaller  doscB.  I'rohably  from  15  to  20  drops  is  sutlieient. 
The  pr()lonf,'e(l  use  of  it  does  not  appear  to  bo  in  any  way  hurtful.  The  use, 
liowever,  should  be  restrieted  to  cases  of  neurosis  aiul  atrophy  of  the  mucous 
inend)rane.    Jn  actual  pistritis  its  value  is  doubtful. 

Nitrate  of  silver  is  a  jfood  remedy  in  some  cases,  used  in  solution  in 
the  lavage  (1  to  1,500  or  1  to  2,000),  or  in  })ill  form,  one  eighth  to  one 
fourth  of  a  grain  three  times  a  day.  For  many  years  Pepper  has  advocated 
the  more  extended  use  of  this  drug  in  chronic  gastritis.  1  have  seen  an 
instance  of  argyria  after  its  j)rotracted  nse. 

The  digestive  ferments:  These  are  extensively  employed  to  strengthen 
the  weakened  gastric  and  intestinal  secretions.  The  use  of  pepsin,  ac- 
cording to  Kwald,  may  be  limited  to  the  cases  of  advanced  mucous  catarrh 
and  the  instances  of  atro])hy  of  the  stomach,  in  which  it  should  be  given, 
in  doses  of  from  10  to  15  grains,  with  dilute  hydrochloric  acid  a  quarter 
of  an  hour  after  meals.  It  may  be  used  in  various  diiferent  forms,  either 
as  a  {)owder  or  in  solution  or  given  with  the  acid.  The  })owder  is  much 
more  certain.  l'e])8in  wine  is  generally  inert,  as  there  is  little  of  the  fer- 
ment taken  up  by  alcohol.  It  is  important  to  use  a  reliable  article.  Much 
that  is  in  the  market  is  valueless. 

Pancreatin  is  of  equal  or  even  greater  value  than  the  pepsin.  Pains 
should  be  taken  to  use  a  good  article,  such  as  that  prepared  by  ^lerck.  It 
should  be  given  in  doses  of  from  15  to  20  grains,  in  combination  with 
bicarbonate  of  soda.  It  is  conveniently  administered  in  tablets,  each  of 
which  contains  5  grains  of  the  pancreatin  and  the  soda,  and  of  these  two 
or  three  may  be  taken  fifteen  or  twenty  minutes  after  each  meal.  Ptyalin 
and  diastase  are  particularly  indicated  when  the  acid  is  excessive.  The 
action  of  the  former  continues  in  the  stomach  during  normal  digestion. 
The  malt  diastase  is  often  very  serviceable  given  with  alkalies. 

Of  measures  which  stimulate  the  glandular  activity  in  chronic  dys- 
pepsia lavag*^  is  by  far  the  most  important,  particularly  in  the  forms  char- 
acterized by  the  secretion  of  a  large  quantity  of  mucus.  Luke-warm  water 
should  be  used,  or,  if  there  is  much  mucus,  a  1-per-cent  salt  solution,  or 
a  3-  to  5-per-cent  solution  of  bicarbonate  of  soda.  If  there  is  much  fer- 
mentation the  3-per-cent  solution  of  boric  acid  may  be  used,  or  a  dilute 
solution  of  carbolic  acid.  It  is  best  employed  in  the  morning  on  an  empty 
stomach,  or  in  the  evening  some  hours  after  the  last  meal.  It  is  perhaps 
preferable  in  the  morning,  except  in  those  cases  in  which  there  is  much 
nocturnal  distress  and  flatulency.  Once  a  day  is,  as  a  rule,  sufficient,  or, 
in  the  case  of  delicate  persons,  every  second  day.  The  irrigation  may  be 
continued  until  the  water  which  comes  away  is  quite  clear.  It  is  not  neces- 
sary to  remove  all  the  fluid  after  the  irrigation. 

While  perhaps  in  some  hands  this  measure  has  been  carried  to  ex- 
tremes, it  is  one  of  such  extraordinary  value  in  certain  cases  that  it  shoidd 
be  more  widely  employed  by  practitioners.    When  there  is  an  insuperable 


CnRONIC  GASTRITIS. 


478 


ol)jocti()n  to  Invairo  n  Hubntituto  iiiny  bo  used  in  the  form  of  wnrni  alka- 
line ilrinkrt,  taken  slowly  in  the  early  morning'  »>r  the  last  thing  at 
iii<,'ht. 

(M'  iiiedicinps  which  stimulate  tlie  gastric  secretion  the  most  important 
are  the  latter  tonics,  such  as  (juassia,  gentian,  ealiimha,  eundurango,  ipei'aeu- 
anha,  strychnia,  and  cardamoms.  These  are  prohahly  of  more  value  in 
ihronie  gastritis  than  the  hydrochloric  acid.  Of  these  strychnia  is  the  most 
powerful,  though  none  of  them  have  prohahly  any  very  great  stimulating 
action  on  the  secretion,  and  inlluence  rather  the  ap|)etite  than  the  diges- 
tion. Of  stomachics  which  are  believed  to  favorably  influence  digestion 
the  most  important  are  alcohol  and  connnon  salt.  The  former  would  appear 
to  act  in  nioderate  ([uantities  by  increasing  the  acid  in  the  gastric  juice,  aiul 
with  it  probably  tiie  pepsin  fonmition.  Others  hold  that  it  is  not  so  much 
the  secretory  as  the  motor  function  of  the  stomach  which  tlu-  alcohol 
stimulates.  In  moderate  quantities  it  has  certainly  no  directly  injurious 
inlluence  on  the  digestive  jjrocesses.  Special  care  should  bo  taken,  how- 
ever, in  ordering  alcohol  to  dys|)ej)tics.  If  a  patient  has  been  in  the  habit 
of  taking  beer  or  light  wines  or  stinudants  with  his  meals,  the  practice 
may  be  continued  if  moderate  quantities  are  taken.  Jieer,  as  a  rule,  is  not 
well  borne.  A  dry  sherry  or  a  class  of  claret  is  preferable.  Jn  the  ease  of 
women  with  any  form  of  dyspepsia  stimulants  should  be  employed  with 
the  greatest  caution,  and  the  practitioner  should  know  his  i)atient  well 
before  ordering  alcohol. 

The  importance  of  salt  in  gastric  digestion  rests  upon  the  fact  that  its 
jiresence  is  essential  in  the  formation  of  the  hydrochloric  acid.  An  in- 
crease in  its  use  may  be  advised  in  all  cases  of  chronic  dyspepsia  in  which 
the  acid  is  defective. 

Treatment  of  Special  Conditions. — lermentation  and  flatu- 
lency. When  the  digestion  is  slow  or  imperfect,  fermentation  goes  on  in 
the  contents,  with  the  formation  of  gas  and  the  production  of  lactic,  butyric, 
and  acetic  acids.  For  the  treatment  of  this  condition  careful  dieting  may 
suffice,  particularly  forbidding  such  articles  as  tea,  pastry,  and  the  coarser 
vegetables.  It  is  usually  combined  with  pyrosis,  in  which  the  acid  fluids 
are  brought  into  the  mouth.  Bismuth  and  carbonate  of  soda  sometimes 
suffice  to  relieve  the  condition.  Thymol,  creasote,  and  carbolic  acid  may 
be  employed.  For  acid  dyspepsia  Sir  William  Roberts  recommends  the 
bismuth  lozenge  of  the  British  Pharmacopoeia,  the  antacid  properties  of 
which  depend  on  chalk  and  bicarbonate  of  soda.  It  should  be  taken  an 
hour  or  two  after  meals,  and  only  when  the  pain  and  uneasiness  are  pres- 
ent. The  burnt  magnesia  is  also  a  good  remedy.  Glycerin  in  from  20-  to 
(lO-minim  doses,  the  essential  oils,  animal  charcoal  alone  or  in  combination 
with  compound  cinnamon  powder,  may  bo  tried.  If  there  is  much  pain, 
chloroform  in  20-minim  doses  or  a  toaspo  nful  of  Hoffman's  anodyne  may 
be  used.  In  obstinate  cases  lavage  is  indicated  and  is  sometimes  striking  in 
its  effects.     Alkaline  solutions  may  be  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chronic 
flyspepsia;  sometimes  in  children  it  is  a  persistent  symptom.  Creasote  and 
carbolic  acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hydro- 


474 


DISKASKS  OF  THE  DinKSTIVK  SYSTKM. 


( yimic;  iicid,  cocaiiu',  hisimith,  niid  oxnlaU?  nf  ((.Tium  may  bu  ut^vd.  11' 
ohstiiialc,  tlio  stoiiiacli  nlioiild  Iil>  waHluMt  out  daily. 

CoiiHtipatioii  is  a  fi-(>(|ii(>nt  and  trouhlfHoim'  feature  of  numt  forins  of 
indifjcHtion.  Ot'casioJially  hiiihII  doses  of  niereury,  |to(lo|»liylliii.  the  laxative 
mineral  waters,  siii|iliiir,  uiid  easeara  ma\  l»e  emiiloyed.  (ilyei'riu  su|i- 
positories  or  liie  injection  of  i'rom  half  u  teaspoonful  to  u  leaspoonful  ui 
glycerin  in  very  ollicaciouH. 

Many  cases  of  chronic  dyspepsia  arc  jfrcatly  henefited  hy  llu*  nso  of 
mineral  waters,  particularly  a  residence  at  the  si)rin;rs  with  a  careful  super- 
vision (d"  the  diet  and  systematic  exercise.  The  strict  irijinic  (»f  certain 
(Jernwm  S|)a8  js  particularly  advanta^icous  in  the  cases  in  which  the  chronic 
dyspepsia  has  resulted  from  excess  in  eatinj;  and  in  drinkinj:.  Kissingen, 
('arlsl)U(l,  Kim,  and  Wieshaden  arc  to  he  specudly  recommended. 


Ml.     DILATATION   OF  THE  STOMACH  {(iaHtrect.siH). 

litiolog^y. — This  ni;.y  occur  cither  as  an  acute  or  a  chronic  condition. 

Ariilc  (lildldlioii  is  rarely  seen,  thou^^h  it  occurs  whenever  enoruinus 
quantities  of  food  and  drink  are  quickly  in<,'ested.  Occasionally  this  leads 
to  extreme  paralytic  dilatation,  and  i''a<:;j:e  has  described  two  cases  wliic'i 
came  on  in  this  way,  one  of  which  proved  fatal.  Allbult  nu'utions  c  -"e- 
miirkiible  instiiuce  of  acute  dilatation  of  the  stomach  under  ihe  cai .  of 
JJroadbent,  in  which  8  pints  of  tluid  were  siphoned  from  the  stomach.  "  Xo 
sooner,  however,  was  this  volume  of  Huid  removed  than  the  stomach  be<:an 
to  refill,  and  was  rapidly  distended  a<;ain  to  its  fornu-r  dimensions." 

Cliroiiir  (lihildlion  residts  from:  (^0  Xarrowinj,^  of  the  pylorus  or  of  the 
duodenum  by  the  cicatrization  of  -m  idcer,  hypertrophic  stenosis  of  the 
pylor.is  (whether  cancerous  or  simiiiv.,,  congenital  stricture,  or  occasionally 
by  pressure  from  without  of  a  tumor  or  of  a  floating  kidney.  Without  any 
organic  disease  the  jiylorns  may  be  tilted  up  by  adb  «sion  to  the  liver  or 
gall-bladder,  or  the  stomach  may  be  so  dilated  that  the  jjylorus  is  draggetl 
down  and  kinked.  (/.)  Relative  or  absolute  insulllciency  of  the  muscular 
power  of  the  stomach,  due  en  the  one  hand  to  repeated  overdlliug  of  the 
organ  with  food  and  drink  (Uehcrnnfthriifjvnfi  drs  Mm/ens,  Striimpoll). 
and  on  the  other  to  at(mi  of  the  coats  induced  by  clironic  inflammation  or 
degeneration  of  im])aire(1  nutrition,  the  result  of  constitutional  aU'ections, 
as  cancer,  tuberculosis,  ana-mia,  etc. 

It  is  important  to  distinguisli  between  a  dilated  stomach  and  a  dis- 
"ilaoed  organ,  Avhicb  will  be  considered  under  the  section  on  entero]itosis. 

The  most  extreme  forius  are  met  with  in  the  first  group,  and  most 
commonly  as  a  sequence  of  the  cicatricial  contraction  of  an  ulcer.  There 
nuiy  bo  considerable  stenosis  without  much  dilatation,  the  obstruction  being 
compensated  by  hypertro]iliy  of  the  muscular  coats.  Considerable  atten- 
tion has  been  directed  in  Cienuany  by  Litten,  Ewald,  and  others  to  the 
association  of  dilatation  M-ith  dislocation  of  the  right  kidney. 

In  the  second  group,  due  to  atony  of  the  muscular  coats,  we  mu.=it  dis- 
tinguish between  instances  in  which  the  stomach  is  simply  enlarged  and 


niLATATtoX  OP  THE  STOMACH. 


47: 


thofio  witii  nrtual  diliitation,  the  cotxIitioiiH  which  Mwahl  iluiractt'ti/od  m 
iiifijtistric  and  i/nntri'ilttsis  n'f*|i«'{jliv«'|y.  The  mIzu  ol'  the  ntumuch  varh.'S 
;;;ivatly  in  diirotviit  itidivi(hials,  and  the  niaxiuium  cnpncity  of  a  normal 
iiiyan  I'^vald  phui's  at  ahoiit  1,«)00  cc.  McaHurenients  uhovo  thiM  point  in- 
ilicate  aliKohitc  dihitntioii. 

Atonic  (lihitation  of  tiu>  stomach  may  rcsnlt  from  wcakncHK  of  the  coutr'>, 
(hie  to  repeated  overdiistention  or  to  chronic  catarrh  of  the  mucous  mem- 
hrane,  or  to  the  geiu'ral  muscuhir  <lehility  which  in  associatecl  with  chronic 
wasting  dis<»nh'rH  of  all  horts.  The  conihinalion  o*  chronic  j,'aHtri(!  catarrh 
with  overfeedinf,'  and  excessive  drinking'  is  one  of  the  most  frnitfid  sources 
•  if  atonic  dilatation,  an  pointed  out  hy  Naunyn.  The  condition  is  fre- 
quently seen  in  diabetics,  in  the  insane,  and  in  l)eer  drinkers.  In  (iernumy 
this  form  Ih  very  comnKui  in  men  employed  in  the  hrewericH.  i'ossihly 
iiitiscular  weakness  of  the  coats  nuiy  result  in  some  cases  from  <!]sturl»rd 
innervation.  Dilatation  of  the  stomach  is  most  fre(|uent  in  middle-aj,'ed 
or  (ddc'ly  persons,  hu^  the  condition  i.s  not  uneonimon  in  children,  us|)o- 
cially  i"  association  with  rickets. 

SSTlAix'^Ol^''* — 'I'hese  are  very  varialde  and  depend  upon  tlie  cause  and 
the  d('>rree  of  dilatation.  Naturally  the  fi-atures  in  caruer  of  the  pylorus 
would  he  very  dill'erent  from  those  met  with  in  an  excessive  drinker.  Dys- 
pepnia  is  jiresent  in  nearly  all  eases,  and  there  are  feelin^fs  of  distress  and 
nneasiness  in  the  region  of  the  stonuich.  The  patient  m^y  complain  much 
of  liun<,'er  and  thirst  and  eat  and  drink  freely.  The  most  characteristic 
siymptom  is  the  vomit inj;  at  intervals  of  enormous  (luantities  of  liquid  and 
of  food,  amounting,'  sonu'times  to  four  or  nu)re  litres.  The  nuiterial  is  often 
of  a  dark-fjrayish  color,  with  a  characteristic  sour  odor  due  to  the  organic 
iicids  ju'esent,  and  contains  mucus  and  remnant.s  of  food.  On  standing  it 
separates  into  three  layers,  the  lowest  consisting  of  food,  the  middle  of 
a  turhid,  dark-griy  fluid,  and  the  uppermost  of  a  hrownish  froth.  The 
microscopical  examination  shows  a  large  variety  of  bacteria,  yeast  fungi, 
and  the  sarcina  ventriculi.  There  may  also  he  cherry  stones,  plum  stones, 
and  gra])e  seeds. 

The  hydrochloric  acid  nuiy  he  absent,  diminished,  normal,  or  in  excess, 
depending  U])on  the  cause  of  the  dilatation.  The  fermentation  produces 
lactic,  butyric,  and,  ])ossibly,  acetic  acid  and  various  gases. 

In  consequence  oi'  the  small  amount  of  fluid  which  passes  from  the 
stomach  or  is  absorbed  there  arc  oonstijjation,  somiy  urine,  and  extreme 
dryness  of  the  skin.  The  general  nutrition  of  the  patient  suffers  greatly; 
there  is  loss  of  flesh  and  strength,  and  in  some  cases  the  most  extreme 
emaciation.  A  very  remarkable  symptom  which  occurs  occasionally  is 
tetany,  first  described  by  Kussmaul. 

Physical  Signs — Tnspi'Hion. — The  abdomen  may  be  large  and  promi- 
nent, the  greatest  ])rojection  occurring  below  the  navel  in  the  standing 
posture.  In  some  instances  the  outline  of  the  distended  stomach  can  be 
])liunly  seen,  the  small  curvature  a  couple  of  inches  below  the  ensiform 
cartilage,  and  the  greater  curvature  passing  obliquely  from  the  tip  of  the 
tenth  rib  on  the  left  side,  toward  the  pubes,  and  then  curving  upward  to 
the  right  costal  margin.    Too  much  stress  cannot  be  laid  on  the  import'  \ce 


A 


476 


DISEASES  OF  TOE  DIGESTIVE  SYSTEM. 


ii 


lit: 
I? 


v 


m 


of  inspection.  In  10  of  13  cases  of  dilated  stomach  in  my  wards  during 
one  year  the  diagnosis  was  made  de  visu.  Active  jjcristalsis  may  be  seen 
in  the  dilated  organ,  the  waves  passing  from  left  to  right.  Occasionally 
anti-peristalsis  may  ho  seen.  In  cases  of  stricture,  particularly  of  hyper- 
tro[)hic  stenosis,  as  the  peristaltic  wave  reaches  the  i)ylorus,  the  tumor- 
like  thickening  can  sometimes  be  distinctly  seen  through  the  thin  ab- 
dominal wall.  To  stimulate  the  peristalsis  the  abdomen  nuiy  be  tlipi)c(l 
with  a  wet  towel.  Inflation  may  be  practised  with  carbonic-acid  gas. 
A  small  tcaspoonful  of  tartaric  acid  dissolved  in  an  ounce  of  water  is 
first  given,  then  a  rather  larger  quantity  of  bicarbonate  of  soda.  In 
many  cases,  particularly  in  thin  persons,  the  outline  of  the  dilated  "stom- 
ach stands  out  with  great  ^stinctness,  and  waves  of  peristalsis  are  seen 
in  it. 

Palpation. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  the 
tumor  is  evident  at  the  pylorus.  The  resistance  of  a  dilated  stomach  is 
peculiar,  and  has  been  ai)tly  compared  to  that  of  an  air  cushion.  Biman- 
ual palpation  elicits  a  si)lasliing  sound — clapotagc — which  is,  of  course,  not 
distinctive,  as  it  can  be  obtained  whenever  there  is  much  liquid  and  air 
in  the  organ,  but  which  cannot  be  elicited  in  a  healthy  person  two  or  throe 
hours  after  eating.  The  splashing  may  be  very  loud,  and  the  patient  may 
produce  it  himself  by  suddenly  depressing  the  diaphragm,  or  it  may  be 
readily  obtained  by  shaking  him.  A  tube  passed  into  tlie  stomach  may 
be  felt  externally  through  the  skin,  a  procedure  no  longer  recommended  l)y 
Leube,  who  suggested  it.  The  gurgling  of  gas  through  the  pylorus  may 
be  felt. 

Percvssion. — The  note  is  tympanitic  over  the  greater  portion  of  a 
dilated  stomach;  in  the  dependent  part  the  note  is  dull.  In  the  upright 
position  the  percussion  should  be  made  from  above  downward,  in  the  left 
parasternal  line,  until  a  change  in  resonance  is  reached.  The  line  of  this 
shoiild  be  marked,  and  the  patient  examined  in  the  recumbent  position, 
when  it  will  be  found  to  have  altered  its  level.  When  this  is  on  a  line  with 
the  navel  or  below  it,  dilatation  of  the  stomach  may  generally  be  assumed 
to  exist.  The  fluid  may  be  withdrawn  from  the  stomach  with  a  tube,  and 
the  dulness  so  made  to  disappear,  or  it  may  be  increased  by  pouring  in  more 
fluid.  In  cases  of  doubt  the  organ  should  be  artificially  distended  with 
carbonic-acid  gas  in  the  manner  described  above.  The  most  accurate 
method  of  «lete"mining  the  size  of  the  stomach  is  by  inflation  through  a 
stomach-tube  with  a  Davidson's  syringe.  Pacanowski  has  shown  that  the 
greatest  vertical  diameter  of  gastric  resonance  in  the  normal  stomach  varies 
from  10  to  14  cm.  in  the  male  and  is  about  10  cm.  in  the  female. 

Avaniltafinn. — The  clnpotement  or  succussion  can  be  obtained  readily. 
Frequently  a  curious  sizzling  sound  is  present,  not  nnlike  that  heard  when 
the  ear  is  placed  over  a  soda-water  bottle  when  first  opened.  It  can  be 
heard  naturally,  and  is  usually  evident  when  the  artificial  gas  is  being 
generated.  The  heart  sounds  may  sometimes  be  transmitted  with  great 
clearness  and  with  a  metallic  quality. 

Mensuration  may  be  used  by  passing  a  hard  sound  into  the  stomach 
until  the  greater  curvature  is  reached.     Normally  it  rarely  passes  more 


mm 


DILATATION  OF  TIIK  STOMACH. 


47* 


eaclily. 

wlien 
■an  bo 

bein<? 

great 


tlinn  00  cm.,  nioasurod  from  tho  teeth,  but  in  cases  of  dilatation  it  may 
]»a8H  as  much  as  70  cm. 

Diag^nosis. — The  diagnosis  can  usually  be  made  without  much  dilTi- 
culty.  1  would  like  to  em[)hasize  again  the  great  value  of  inspection,  partic- 
ularly in  combination  with  inflation  of  the  stomach  with  carbonic-acid  gas. 
Curious  errors,  however,  are  on  record,  one  of  the  most  renuirkable  of  which 
was  the  confounding  of  dilated  stomach  with  an  ovarian  cyst;  even  after 
lajjping  and  the  removal  of  portions  of  food  and  fruit  seeds,  abdominal 
section  was  performed  and  the  dilated  stomach  opened.  I  notice  the  rei)ort 
of  a  recent  case  in  which  the  diagnosis  of  ascites  was  made  and  the  abdomen 
was  opened.  The  proijnosis  is  bad  in  cases  in  which  there  is  stenosis  of  the 
jtylorus,  either  simjjle  or  cancerous. 

Treatment. — In  the  cases  due  to  atony  careful  regulation  of  the 
diet  and  projier  treatment  of  the  associated  catarrh  will  sutlice  to  effect  a 
cure.  Strychnine,  ergot,  and  iron  are  recommended.  Washing  out  the 
stomach  is  of  great  service,  though  Ave  do  not  see  such  striking  and  imme- 
diate results  in  this  form.  In  cases  of  mechanical  obstruction  the  stomach 
should  be  emptied  and  thoroughly  washed,  either  with  warm  water  or  with 
an  antisejjtic  solution.  We  accomplish  in  this  way  three  important  things: 
We  remove  the  weight,  which  helps  to  distend  tlie  organ;  we  renmve  the 
mucus  and  the  stagnating  and  fermenting  material  which  irritates  and  in- 
flames the  stomach  and  impedes  digestion;  and  we  cleanse  the  inner  sur- 
face of  the  organ  by  the  application  of  water  and  medicinal  sidjstances. 
The  patient  can  usually  be  taught  to  wash  out  his  own  stomach,  and  in  a 
case  of  dilatation  from  sim])le  stricture  I  have  known  the  practice  to  be 
followed  daily  for  three  years  with  great  l)enefit.  The  rapid  reduction  in 
the  size  of  the  stomach  is  often  remarkable,  the  vomiting  ceases,  the  food 
is  taken  readily,  and  in  many  cases  the  general  nutrition  improves  rapidly. 
As  a  rule,  once  a  day  is  sufficient,  and  it  may  be  practised  either  the  first 
thing  in  the  morning  or  before  going  to  bed.  So  soon  as  the  fermentative 
])rocesses  have  been  checked  lukewarm  water  alone  should  be  used. 

The  food  should  be  taken  in  small  quantities  at  frequent  intervals,  and 
should  consist  of  scraped  beef,  Leube's  beef  solution,  and  tender  meats 
of  all  sorts.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided.  Liquids 
should  be  taken  sparingly. 

When  the  condition  becomes  aggravated  a  resort  to  surgery  is  justifi- 
able. Here  may  be  mentioned  the  recent  statistics  of  gastric  surgery. 
Pyloric  stenosis  is  the  common  condition.  Dreydorff  has  collected  442 
cases — 188  cases  of  pylorcctomy,  mortality  57.4  per  cent;  315  gastro-enter- 
ostomies,  mortality  43.3  per  cent;  pyloroplasty,  29  cases,  mortality  20.7 
]icr  cent.  On  an  average,  after  pylorectomy  the  patient  remained  free  from 
recurrence  for  a  little  over  a  year. 


478 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


K' 


IV.    THE  PEPTIC   ULCER-GASTRIC  AND   DUODENAL, 

The  rouud,  perforating,  or  sinii)le  ulcer  is  usually  single,  and  occurs 
in  the  stomach  and  in  the  duodenum  as  far  as  the  papilla  hiliaria.  It  fol- 
lows nutritional  disturbance  in  a  limited  region  of  the  mucosa,  which  re- 
sults in  the  gradual  destruction  of  this  area  by  the  gastric  juice.  The  con- 
dition is  usually  associated  with  superacidity. 

Etiology. — Incidence  in  the  Post-mortem  llooin. — In  the  extensive 
records  collected  by  W.  H.  Welch,  ulcer,  cicatrized  or  open,  was  present  in 
about  5  per  cent  of  persons  dying  from  all  causes.  Others  give  percentages 
as  high  as  10.  The  scars  are  more  frequent  than  the  open  ulcers.  Among 
the  first  thousand  autojjsies  at  the  Johns  Ilo})kins  Hospital  there  were  !) 
cases  of  ulcer  of  the  stomach. 

Incidence  Clinically. — The  disease  is  much  less  common  in  some  coun- 
tries than  in  others,  and  in  some  parts  of  this  country.  It  is  certainly  less 
frequently  seen  in  IJaltimore  than  in  Massachusetts  or  in  Canada.  In  nine 
years  there  were  in  my  wards  only  25  instances  with  a  diagnosis  of  ulcer. 

Sex. — Of  1,GD9  cases  collected  from  hospital  statistics  by  W.  H,  Welch 
and  examined  post  mortem,  40  per  cent  were  in  males  and  GO  per  cent  were 
in  females. 

Af/e. — In  females  the  largest  number  of  cases  occurs  between  twenty 
and  thirty;  in  males  between  thirty  and  forty.  It  is  by  no  means  uncom- 
mon in  old  ])eople.  On  the  other  hand,  it  is  not  very  rare  in  children. 
Goodhart  reported  a  case  in  an  infant  thirty  hours  old;  indeed,  ulcers  of 
the  stomach  have  been  found  in  the  foetus  and  in  the  new-born  shortly 
after  birth.  Of  390  autopsies  at  the  Baby's  Hospital  in  Xew  York,  Martha 
Wollstein  foimd  5  cases. 

Ileraditi/  appears  to  play  a  part  in  some  cases  (Dreschfeld). 

Occupation. — Servant  girls  seem  particularly  prone  to  the  disease.  This 
is  to  be  explained  partly  by  their  careless  habits  in  eating,  partly  in  connec- 
tion with  the  associated  anaunia.  The  special  liability  of  shoemakers,  weav- 
ers, and  tailors  to  ulcer  is  probably  connected,  as  Habershon  suggested,  with 
pressure  on  the  stomach. 

Trauma. — I'lcers  have  been  known  to  follow  a  blow  in  the  rejiion  of 
the  stomach.  Easmussen  holds  that  pressure  of  the  costal  margin  from 
various  causes  induces  aufemia  and  atrophy  of  the  mucous  membrane,  par- 
ticularly in  the  region  of  the  smaller  curvature. 

Associated  Diseases. — Anaemia  and  chlorosis  predispose  strongly  to  gas- 
tric ulcer,  particularly  in  w'omen  and  in  association  with  menstrual  dis- 
orders. A  very  considerable  number  of  all  cases  of  gastric  ulcer  occur  in 
chlorotic  girls.  It  has  been  fuund  also  in  connection  with  disease  of  the 
heart,  arterio-sclerosis,  and  disease  of  the  liver.  The  tubercidous  and  syph- 
ilitic ulcers  of  the  stomach  have  already  been  considered. 

The  duodenal  ulcer  is  less  common  than  the  gastric  ulcer,  and  occurs 
most  frequently  in  males.  The  combined  statistics  of  Krauss,  Chvostek, 
Lebert,  and  Trier  give  171  cases  in  males  and  39  in  females.  In  9  of  my 
cases  7  were  in  males  and  2  in  females;  one  of  these  was  in  a  lad  of  twelve. 


THE  PEPTIC  ULCER— GASTRIC  AND  DUODENAL. 


479 


It  has  been  fniind  in  apsncintion  with  tuhorciilosip,  and  may  follow  large 
.supcrlicial  burns.  Terry  and  Shaw  iound  it  livo  tinaos  in  lil)  autopsies  in 
cases  of  burns. 

Morbid  Anatomy. — Though  usually  single,  the  ulcers  may  be  niul- 
tii)le.  Jn  none  of  my  eases  were  there  more  than  live,  ])ut  there  is  an  in- 
stance on  record  of  thirty-four.  The  ulcer  is  situated  most  commonly  on 
the  posterior  wall  of  the  pyloric  portion  at  or  near  the  lesser  curvature.  It 
is  not  nearly  so  frequent  on  the  anterior  wall.  Of  793  cases  collected  by 
Welch  from  hospital  statistics,  288  were  on  the  lesser  curvature,  235  on 
the  ])osterior  wall,  Do  at  the  pylorus,  (!!)  on  the  anterior  wall,  50  at  the 
cardia,  2"J  at  the  fundus,  27  on  the  greater  curvature.  The  duodenal  ulcer 
is  usually  situated  just  outside  the  ring  in  the  first  portion  of  the  gut. 

Acute  and  chronic  forms  of  gastric  ulcer  may  be  described.  The  former 
is  usually  small,  ])unched  out,  the  edges  clean-cut,  the  floor  smooth,  and 
the  peritoneal  surface  not  thickened.  The  chronic  ulcer  is  of  larger  size, 
the  margins  are  no  longer  sharj),  the  edges  are  indurated,  and  the  border 
is  sinuous.  The  gastric  ulcer  sometimes  reaches  an  enormous  size.  The 
largest  of  which  I  have  any  knowledge  is  one  reported  by  I'eabody,  which 
measure'^  l)y  10  cm.  and  involved  all  of  the  lesser  curvature  and  spread 
over  a  I  part  of  the  anterior  and  jiosterior  walls.  It  is  often  distinctly 
terraced,  fhe  floor  is  formed  either  by  the  sul)mucosa,  by  the  muscular 
hiyers,  or,  not  infrequently,  by  the  neighboring  organs,  to  which  the  stom- 
ach has  l)ecome  attached.  In  the  healing  of  the  ulcer,  if  the  mucosa  is 
alone  involved,  the  granulation  tissue  develops  from  the  edges  and  the 
floor  and  the  newly  formed  tissue  gradually  contracts  and  unites  the  mar- 
gins, leaving  a  smooth  scar.  In  larger  ulcers  which  have  become  deep  and 
involved  the  muscular  coat  the  cicatricial  contraction  may  cause  serious 
changes,  the  most  important  of  which  is  narrowing  of  the  pyloric  orifice 
and  consequent  dilatation  of  the  stomach.  In  the  case  of  a  girdle  lUcer, 
liour-glass  contraction  of  the  stomach  nuiy  be  produced.  It  is  probable 
that  large  ulcers  persist  for  years  without  any  attemi)t  at  healing. 

Among  the  more  serious  changes  which  may  proceed  in  an  ulcer  are 
the  following: 

Prrforafion. — Fortunately,  in  a  majority  of  the  cases,  adhesions  form 
between  the  stomach  and  adjacent  organs,  particularly  with  the  pancreas, 
the  left  lobe  of  the  liver,  and  the  omental  tissues.  On  the  anterior  surface 
of  the  stomach  adhesions  do  not  so  readily  form,  hence  the  great  danger 
of  the  ulcer  in  this  situation,  which  more  readily  ])erforates  and  excites  a 
ditfuse  and  fatal  peritonitis.  On  the  posterior  wall  the  ulcer  penetrates 
directly  into  the  lesser  peritoneal  cavity,  in  which  case  it  may  produce  an 
air-containing  abscess  with  the  symjitoms  of  the  condition  known  as  sub- 
jilirenic  ])yo-pneumothorax.  In  rare  instances  adhesions  and  a  gastro- 
(utaneous  fistula  form,  usually  in  the  umbilical  region.  Fistulous  com- 
munication with  the  colon  may  also  occur,  or  a  gnstro-duodenal  fistula. 
The  pericardium  may  be  perforated,  and  even  the  left  ventricle.  Porfora- 
iion  into  the  ])leura  may  also  occur.  It  h  to  be  noted  that  general  em- 
Ithysema  of  the  subcutaneous  tissues  occasionally  follows  perforation  of  a 


:astric  ulcer. 


80 


480 


DISEASES  OP  TUE  DIGESTIVE  SYSTEM. 


I'i' 

,'(  * 


V: 


Erosion  of  Blood-vessels. — Tlie  h.-icmorrhage  may  occur  in  the  acutely 
formed  ulcer  or  in  the  ulceration  which  takes  place  at  the  base  of  the  chronic 
form;  it  is  in  the  latter  condition  that  the  bleeding  is  most  conunon.  Ulcers 
on  the  posterior  wall  may  erode  the  splenic  artery,  but  perhaps  more  fre- 
quently the  bleeding  proceeds  from  the  artery  of  the  lesser  curve.  In  the 
case  of  duodenal  ulcer  the  pancreatico-duodenal  artery  may  be  eroded  or 
(as  in  one  of  my  cases)  fatal  ha^norrhage  may  result  from  the  oj)ening  of 
the  hepatic  artery,  or  more  rarely  the  portal  vein.  Interesting  changes  occur 
in  the  vessels.    Embolism  of  the  artery  supplying  the  ulcerated  region  has 


been  met  with  in  several  eases;  in  others  diffuse  endarteritis.  Small 
aneurisms  have  been  found  in  the  floor  of  the  ulcers  by  Douglas  Powell, 
Welch,  and  others. 

Cicatrization. — Superficial  ulcers  often  heal  without  leaving  any  seri- 
ous damage.  Stenosis  of  the  pyloric  orifice  not  infrequently  follows  the 
healing  of  an  ulcer  in  its  neif.hborhood.  In  other  instances  'the  large  an- 
nular ulcer  may  cause  in  its  cicatrization  an  hour-glass  contraction  of  the 
stomach.  The  adhesion  of  tho  ulcer  to  neighboring  parts  may  subsequently 
be  the  cause  of  much  pain.  The  parts  of  the  mucosa  in  the  neighborhood  of 
the  ulcer  frequently  show  signs  of  chronic  gastritis. 

The  origin  of  the  peptic  ulcer  is  still  obscure.  Ulcers  have  been  pro- 
duced in  animals  in  many  ways,  both  by  artificial  emboli  and  by  direct 
chemical  and  mechanical  irritants  applied  to  the  mucosa.  The  ulcers  thus 
produced  heal  with  great  rapidity  unless  the  animals  have  been  rendered 
anaemic  by  re])eated  abstraction  of  blood.  Virchow's  view  that  the  process 
may  result  from  plugging  the  nutrient  artery  of  the  part,  either  by  an 
embolus  or  by  a  thrombus,  and  that  the  infarct  so  produced  is  destroyed  by 
the  gastric  juice,  has  gained  general  acceptance.  It  is  in  conformity  with 
Pavy's  well-known  experiments  and  with  the  anatomical  facts  already  men- 
tioned, particularly  with  the  funnel-like  shape  of  the  ulcer,  and  the  actual 
demonstration,  in  some  cases,  of  the  plugged  vessels;  but  this  view  scarcely 
meets  all  the  cases,  in  many  of  which  the  etiology  is  still  obscure.  Mere 
mechanical  injury  to  the  miicous  membrane  is,  however,  in  most  cases,  in- 
sufficient cause  for  an  ulcer,  for  normally  the  stomach  is  perfectly  al)le 
to  withstand  such  insults.  Ewald  concludes  that  certain  predisposing 
causes  play  an  important  role  in  its  development.  He  points  to  its  fre- 
quency in  conditions  of  amenorrhcea,  chlorosis,  anaemia  after  confinements, 
etc.,  where  one  may  assume  that  the  condition  of  the  blood  is  not  wholly 
normal,  and  also  to  the  fact  that  in  the  majority  of  cases  of  this  affection 
there  is  a  superacidity  of  the  gastric  juice.  One  or  both  of  these  predis- 
posing factors  seem  to  be  present  in  most  cases,  and  it  has  been  recently 
shown  that  in  the  various  anaemije  there  is  an  appreciable  diminution  in 
the  normal  alkalinity  of  the  blood,  a  fact  which  tends  to  explain  one  of 
the  predisposing  causes  in  these  affections,  and  which  is  in  accord  with  the 
"alkalescence  theory  "  of  Cohnheim.  Of  late  the  view  has  been  advanced, 
particularly  l)y  Letulle  and  by  Sydney  Martin,  that  the  ulceration  is  due 
to  a  bacterial  necrosis  of  the  gastric  mucosa,  and  the  latter  suggests  that  the 
frequency  of  the  ulcer  at  the  pyloric  region  is  associated  with  the  absence 
of  the  glands  at  this  part,  which  form  the  hydrochloric  acid.     The  duo- 


THE  PEPTIC  ULCER— GASTRIC  AND  DUODENAL. 


481 


>g 


dcnal  ulcer  lias  an  identical  origin,  but  a  fon-  cases  of  acute  ulcer,  as 
already  mentioned,  have  a  curious  relation  with  superficial  burns.  Bar- 
deen's  researches  upon  the  necroses  in  the  viscera  following  extensive  burns 
throw  an  important  light  upon  these  cases,  showing  especially  how  the 
gastro-intestinal  mucous  membrane  is  implicated  in  the  toxic  elFects.  In 
one  of  my  cases  there  was  an  ulcer  in  the  posterior  wall  of  the  duodenum, 
1.5  cm.  in  diameter,  with  overlapping  edges,  and  not  far  from  it  was  a 
cyst-like  cavity  in  the  submucosa  associated  with  Jirunner's  glands,  and  it 
is  jiossible  that  the  open  ulcer,  with  undermined  edges,  resulted  from  the 
rupture  of  one  of  these  cysts. 

SyxuptoniS. — The  condition  may  be  met  with  accidentally,  i)ost  mor- 
tem. The  first  symptoms  may  l)e  those  of  perforation.  In  other  cases  again, 
for  months  and  years,  the  patient  has  had  dyspepsia,  and  the  ulcer  may 
not  have  l)een  suspected  until  the  occurrence  of  a  siulden  htumorrhage. 

The  sym])toms  suggestive  of  peptic  ulcer  are:  (a)  Dyspepsia,  which  may 
l)e  slight  and  trifling  or  of  a  most  aggravated  character.  In  a  consideral)le 
])roportion  of  all  cases  nausea  and  vomiting  occur,  the  latter  not  for  two 
or  more  hours  after  eating.  The  vomitus  usually  contains  a  large  amount 
of  HCl. 

{h)  Ila'tncrrhage  is  present  in  at  least  one  half  of  all  cases.  It  may  be 
slight,  biit  more  commonly  is  profuse,  and  may  be  in  such  quantities  and 
lu'ought  up  so  quickly  that  it  is  fluid,  bright  red  in  color,  and  quite  un- 
altered. "When  the  blood  remains  for  some  time  in  the  stomach,  and  is 
mixed  with  food  it  may  be  great  I3  changed,  but  the  vomiting  of  a  large 
quantity  of  unaltered  blood  is  very  characteristic  of  ulcer.  Syncope  or  con- 
vulsions may  follow,  or  death  may  directly  result  from  the  haemorrhage.  A 
most  extreme  grade  of  ana!mia  may  be  produced.  I  have  known  hemi- 
plegia to  develop  after  a  series  of  profuse  haemorrhages.  In  either  the  gas- 
tric or  duodenal  ulcer,  more  commonly  in  the  latter,  the  blood  may  be 
passed  in  the  stools  and  not  be  vomited.  This  may  occur  when  the  haem- 
orrhage is  slight,  but  also  when  it  is  profuse  enough  to  produce  collapse 
and  extreme  anaemia.  Profuse,  eveji  fatal,  haemorrhage  may  come  from 
small,  superficial  ulcers,  or  even  from  the  hasmorrhagic  erosions.  Prob- 
ably it  is  from  such  that  in  elderly  persons  profuse  haemorrhage  occurs 
without  previous  gastric  symptoms. 

{c)  Pain  is  perhaps  the  most  constant  and  distinctive  feature  of  ulcer. 
It  varies  greatly  in  character;  it  may  be  only  a  gnawing  or  burning  sensa- 
tion, which  is  particularly  felt  when  the  stomach  is  empty,  and  is  relieved 
by  taking  food,  but  the  more  characteristic  form  comes  on  in  paroxysms 
of  the  most  intense  gastralgia,  in  which  the  pain  is  not  only  felt  in  the 
epigastrium,  but  radiates  to  the  back  and  to  the  sides.  In  many  cases  tlie 
two  points  of  epigastric  pain  and  dorsal  pain,  about  the  level  of  the  tenth 
dorsal  vertebra,  are  very  well  marked.  These  attacks  are  most  frequently 
induced  by  taking  food,  a:  they  may  recur  at  a  variable  period  after  eat- 
ing, sometimes  Avithin  fifteen  or  twenty  minutes,  at  others  as  late  as  two 
or  three  hours.  It  is  usually  stated  that  wdien  the  ulcer  is  near  the  cardia 
the  pain  is  apt  to  set  in  earlier,  but  there  is  no  certainty  on  this  point.  In 
some  cases  it  comes  on  in  the  early  morning  hours.      The  attacks  may 


i82 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


tm 


/ 


r 


occur  at  intervals  with  great  intensity  for  weeks  or  months  at  a  time,  so  that 
the  ])atient  constantly  requires  morphia,  then  again  they  may  disappear 
entirely  for  a  ])rolonge(l  period.  In  the  attack  the  'patient  is  usually  hent 
forward,  and  finds  relief  from  pressure  over  the  epigastric  region;  one 
patient  during  the  attack  would  lean  over  the  hack  of  a  chair;  another 
would  lie  ilat  on  the  floor,  with  a  hard  ])illow  under  the  abdomen.  Pres- 
sure is,  as  a  rule,  grateful.  It  has  been  thought  that  the  posture  assumed 
during  the  attack  would  indicate  the  site  of  the  ulcer,  but  this  is  very 
d     '.tfuh 

Venderness  on  pressure  is  a  common  symptom  in  ulcer,  and  patients 
wc„  iie  waist-baml  very  low.  Pressure  should  be  made  with  great  care, 
as  rujjture  of  an  xdcer  has  been  induced  by  careless  manipulation. 

(r)  In  old  ulcers  with  thickened  bases  an  indurated  mass  can  usually  be 
felt  iu  the  neighborhood  of  the  pylorus. 

(/)  Of  general  symptoms,  loss  of  tveiyht  results  from  the  prolonged  dys- 
pepsia, but  it  rarely,  except  in  association  with  cicatricial  stenosis  of  the 
pylons,  reaches  the  high  grade  met  with  in  cancer.  The  anmnia  may  be 
extreme,  and  in  one  case  of  duodenal  ulcer,  which  I  examined,  the  blood- 
count  was  as  low  as  700,000  per  c.  mm.  There  are  instances,  such  as  the 
one  reported  by  Pepper  and  Griifith,  in  Mhich  the  extreme  anannia  cannot 
be  explained  by  the  occurrence  of  haemorrhage.  In  a  few  cases  parotitis 
occurs.  In  one  of  my  cases  there  was  a  remarkable  pigmentation  of  the 
face  and  axillary  folds. 

(g)  Perforation. — This  occurs  in  about  6^  per  cent  of  all  cases.  The 
acute,  perforating  forms  is  much  more  common  in  women  than  in  men. 
The  symptoms  are  those  of  perforative  peritonitis.  Particular  attention 
must  be  given  to  this  accident  since  it  has  come  so  successfully  within  the 
sphere  of  the  surgeon.  As  already  mentioned,  perforation  may  take  place 
•either  into  the  lesser  peritona-um  or  into  the  general  peritoneal  cavity,  in 
both  of  which  cases  operation  is  indicated;  in  rare  instances  the  ulcer  may 
perforate  the  pericardium.  This  was  tlid  case  in  10  of  28  cases  in  which  the 
diaphragm  was  perforated  (Pick).        ^ 

Localized,  more  frequently  subphrenic,  abscess  may  follow  perforation. 

The  course  of  the  disease  is,  in  the  majority  of  cases,  chronic.  Only  a 
few  instances  run  a  very  acute  course.  The  following  group  of  clinical 
forms,  described  ])y  Welch,  indicate  the  diversity  of  this  affection: 

"  1.  Latent  ulcers,  with  entire  absence  of  symptoms,  and  revealed  as 
open  ulcers  or  as  cicatrices  at  the  autopsy. 

"  2.  Acute  perforating  idcers.  With  or  without  a  period  of  brief  gas- 
tric disturbance,  perforation  occurs  and  causes  speedy  death. 

"  3.  Acute  ha^morrhagic  form  of  gastric  ulcer.  After  a  latent  or  a 
brief  course  of  the  idcer,  profuse  gastrorrhagia  occurs,  which  may  termi- 
nate fatally  or  may  be  followed  by  the  symptoms  of  chronic  idcer. 

"  4.  Gastralgic-dyspeptic  form.  In  this,  which  is  the  most  common 
form  of  gastric  ulcer,  gastralgia,  dyspepsia,  and  vomiting  are  the  symptoms. 
Sometimes  one  of  the  symptoms  predominates  greatly  over  the  others,  so 
that  Lebert  distinguishes  separately  a  gastralgic,  a  dyspeptic,  and  a  vomit- 
ive variety.     Gastralgia  is  the  most  frequent  symptom. 


THE  PEPTIC  ULCER-GASTRIC  AND  DUODENAL. 


488 


"  5.  Chronic  ha-iiiorrhnpic  form.  f!fl?trorrhapia  is  n  iiinrkofl  fiymptom, 
and  occurs  usually  in  combination  with  the  syinptonis  just  montioncd. 

"  G.  Cachectic  I'onn.  This  usually  corresponds  only  to  the  liual  staj^e 
of  one  of  the  preceding  forms,  but  the  cachexia  may  develop  so  rajjidly 
and  become  so  nuirked  that  the  course  of  the  disease  closely  resembles  that 
of  gastric  cancer. 

"  7.  Kecurrent  form.  In  this  the  symptoms  of  gastric  idcer  disappear, 
and  then  follow  intervals,  often  of  considerable  duration,  in  which  there 
is  ap})arent  cure,  but  the  symi)toms  return,  especially  after  some  indiscre- 
tion in  the  mode  of  living.  This,  intermittent  course  may  continue  for 
many  years.  Jn  these  cases  it  is  prol)able  either  that  fresh  ulcers  form  or 
that  the  cicatri.x  of  an  old  ulcer  becomes  ulcerated. 

"  8.  Stenotic  form.  By  the  formation  of  cicatricial  tissue  in  and  around 
the  ulcer,  the  pyloric  orifice  becomes  obstructed  and  the  symptoms  of  dila- 
tation of  Ihe  stomach  develop."  And  to  this  may  be  added  the  form  in 
which  cancer  de\ clops,  which  will  be  referred  to  later. 

The  course  may  be  very  protracted,  and  there  are  cases  \a  which  the 
disease  has  persisted  for  over  twenty  years.  I  have  reported  two  instances 
of  peptic  ulcer,  probably  duodenal,  in  which  well-marked  symi)toins  were 
present,  in  one  case  for  eighteen,  and  in  the  other  for  twelve  years.  Both 
were  of  the  chronic  ha'morrhagic  form. 

Diagnosis. — The  recognition  of  gastric  nicer  is  in  many  cases  easy, 
PS  the  combination  of  dyspepsia,  gastralgic  attacks,  and  luvmatemesis  is 
very  characteristic.  Of  the  symptoms,  lia;morrhage  with  the  gastralgic 
attack  is  the  most  characteristic.  The  distinctions  between  ulcer  and  can- 
cer will  he  given  later.  The  greatest  ditliculty  is  offered  by  certain  cases 
of  gastralgia,  which  may  jsemble  ulcer  very  closely,  as,  with  the  exception 
of  the  hipmorrhage,  there  is  no  single  symptom  which  may  not  be  present. 
A  difficulty  also  results  from  the  fact  that  in  many  instances  gastralgia  is 
one  of  the  symptoms  of  nervous  dyspepsia,  and  may  exist  with  marked 
emaciation. 

The  following  points  are  of  value  in  discriminating  between  these  two 
conditions: 

(a)  In  ulcer  the  pain  is  more  definitely  connected  with  taking  food, 
though  this  is  not  always  the  ease,  as  in  the  duodenal  form  the  gastralgic 
attacks  may  occur  at  night  when  the  stomach  is  empty.  Relief  of  pain 
after  eating  is  certainly  less  common  in  ulcer  than  in  gastralgia,  though  it 
is  a  very  uncertain  feature,  and  in  certain  cases  the  pain  in  ulcer  is  always 
relieved  by  taking  food. 

(h)  In  ulcer  dyspeptic  symptoms  are  almost  invariably  present  in  the 
intervals  between  the  attacks,  and  even  when  pain  is  absent  there  is  slight 
distress. 

(c)  Local  sensitiveness  over  a  particular  spot  in  the  epigastrium  is  sug- 
gestive of  ulcer.  External  pressure  usually  aggravates  the  pain  in  ulcer, 
and  often  relieves  it  in  gastralgia.  This  is,  however,  a  very  uncertain  fea- 
ture, as  patients  writhing  with  the  pains  of  ulcer  may  press  the  abdomen 
over  the  back  of  a  chair  or  place  a  hard  pillow  under  it. 

(d)  The  general  condition  and  history  of  the  patient  often  give  the 


484 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


P. 


Pi 


most  trustworthy  inl'ornintion.  The  nutrition  is  impaired  more  frequently 
in  ulcer  than  in  gastralgia.  In  the  former  we  liiid  more  eommonly  (in 
women)  dysmenorrluea  and  chlorosis,  while  in  the  latter  there  are  airssoci- 
ated  nervous  phenomena — hysterical  manifestations  or  neuralgias  in  other 
regions. 

((')  On  examination  of  tlie  abdomen,  not  only  is  pain  on  pressure  much 
more  common  in  ulcer,  but  there  may  also  be  thickening  about  the  pylorus 
and,  in  many  cases,  signs  of  dilatation  of  the  stomach. 

(/■)  Superacidity  and  often  supersecretion  of  the  gastric  juice  exists  with 
ulcer. 

The  gastric  crises  which  occur  in  afTections  of  the  spinal  cord,  particu- 
larly in  locomotor  ataxia,  may  simulate  very  closely  the  gastralgic  attacks 
of  ulcer,  and  as  they  so  often  exist  in  the  preataxic  stage  their  true  nature 
may  be  overlooked;  but  the  occurrence  of  lightning  pains,  the  ocular  symp- 
toms, and  the  absence  of  the  knee  retlex  are  indications  usually  sutHcient 
to  render  the  diagnosis  clear. 

Can  the  gastric  and  duodenal  ulcer  be  distinguished  clinically?  As 
already  stated,  they  originate  in  the  same  way  and  present  the  same  ana- 
tomical characters.  In  the  great  majority  of  cases  they  cannot  be  sejja- 
rated  during  life,  as  the  symptoms  prodxiced  are  identical.  Ikicquoy  has 
suggested  that  the  duodenal  ulcer  can  be  distinguished  by  the  following 
definite  characters:  (a)  Sudden  intestinal  hemorrhage  in  an  apparently 
healthy  person,  which  tends  to  recur  and  produce  a  profound  ana'mia. 
Hemorrhage  from  the  stomach  may  precede  or  accompany  the  melaana. 
(h)  Pain  in  the  right  hypochondriac  region,  coming  on  two  or  three  hours 
after  eating,  (c)  Gastric  crises  of  extreme  violence,  during  which  the 
hemorrhage  is  more  apt  to  occur.  Certainly  the  occurrence  of  sudden 
intestinal  hemorrhage  with  gastralgic  attacks  is  extremely  suggestive  of 
duodenal  ulcer.  W.  W.  Johnston  has  reported  an  instance  in  which 
he  made  the  diagnosis  on  these  symptoms,  and  in  one  of  the  Montreal 
cases  Palmer  Howard  suggested  correctly  the  presence  of  a  duodenal 
ulcer  on  similar  grounds.  A  patient  imder  my  care  who  had,  during 
eigliteen  years,  frequent  attacks  of  hematemesis  with  gastraigia  had 
nielena  repeatedly  without  vomiting  blood;  but  as  a  rule  in  the  at- 
tacks the  blood  was  vomited  first,  and  did  not  appear  in  the  stools  un- 
til later.  Occasionally  this  symptom  will  be  found  an  important  aid 
in  diagnosis.  The  situation  of  the  pain  is  too  uncertain  a  factor  on 
which  to  lay  much  stress,  and  the  character  of  the  crises  is  usually 
identical. 

Gall-stone  colic  may  occasionally  simidate  the  pains  of  gastric  ulcer. 
The  sudden  onset  and  as  sudden  termination,  the  swelling  and  tenderness 
of  the  liver,  the  enlargement  of  the  gall-bladder,  if  present,  and  the  occur- 
rence of  jaundice  are  points  to  be  considered.  The  experience  of  surgeons 
has  taught  us  that  a  number  of  cases  in  which  the  pains  were  regarded  as 
gastraigia  have  in  reality  been  due  to  gall-stones,  with  which,  as  is  now  well 
known,  jaundice  is  not  necessarily  connected. 

Treatment. — Post-mortem  observations  show  that  a  very  large  num- 
ber of  ulcers  heal  completely,  but  the  process  is  slow  and  tedious,  often 


THE  PEPTIC  ULCER— GASTRIC  AND  DUODENAL, 


485 


requiring  niontlis,  or,  in  ecvere  cases,  years.     The  following  are  the  im- 
jiortant  points  in  trcatinont: 

(a)  AI)sohite  re«t  in  bed. 

{h)  A  cart'fully  and  systeniatioally  reguhitcd  diet.  While  theoretically 
it  is  hotter  to  give  the  stoinacii  t'oinpic'ti.'  rest  l)y  rectal  feeding,  yet  in  i)rac- 
tiee  this  strict  limitation  is  not  found  satisfactory.  The  food  should  ho 
hland,  easily  digested,  and  given  at  stated  intervals.  The  following  dietary 
will  be  found  useful:  At  8  a.  m.  give  200  ce.  of  Leube's  beef  solution;  at 
\2  M.,  300  cc.  of  milk  gruel  or  pejjtonized  milk.  The  gruel  should  be  made 
with  ordinary  flour  or  arrowroot,  and  is  mixed  with  an  ecjual  (juantity  of 
milk.  If  necessary  it  may  be  ])ei)tonized.  JUittermilk  is  very  well  homo 
I)y  these  i)atient8.  At  4  p.  m.  the  beef  solution  again,  and  at  8  r.  m.  the 
milk  gruel  or  the  buttermilk. 

The  stonuK'h  in  some  cases  is  so  irritable  that  the  smallest  amount  of 
food  is  not  well  borne.  In  such  cases  lavage  may  be  practised,  if  necessary, 
every  morning,  with  mildly  alkaline  water,  after  which  the  beef  solution 
is  given  and  the  feeding  supi)lemented  by  the  rectal  injections.  Ill  efl'ecta 
rarely  follow  the  careful  use  of  the  stomach  tube  in  gastric  ulcer.  There 
are  some  cases  which  do  well  from  the  outset  on  a  milk  diet,  given  at  regu- 
lar intervals,  3  or  4  ounces  every  two  hours.  When  milk  is  not  well  borne 
egg  albumen  may  be  substituted,  or  the  whites  of  eight  eggs  may  be  alter- 
nated with  Leube's  beef  solution.  At  the  end  of  a  month,  if  the  condition 
has  improved,  the  i)atient  may  be  allowed  scraj)ed  beef  or  young  chicken, 
l)erfectly  fresh  sweet-bread,  and  farinaceous  puddings  made  with  milk  and 
eggs.  Jjocal  applications,  such  as  warm  fomentations,  over  the  abdomen 
are  very  useful.  The  patient  should  be  told  that  the  treatment  will  take 
at  least  three  months,  and  for  the  greater  portion  of  the  time  he  should 
be  in  bed. 

(c)  ^ledicinal  measures  are  of  very  litle  value  in  gastric  ulcer,  and  the 
remedies  employed  do  not  probably  benefit  the  ulcer,  but  the  gastric  ca- 
tarrh. The  Carlsbad  salts  are  warmly  recommended  by  von  Ziemssen.  The 
artificial  preparation  (sulphate  of  sodium,  50;  bicarbonate  of  sodium,  G; 
chloride  of  sodium,  3)  may  ])e  substituted,  of  which  a  teaspoonful  is  taken 
every  morning.  Bismuth,  in  doses  of  30  to  (50  grains  three  times  a  day,  * 
and  nitrate  of  silver  may  be  given,  but  they  influence  the  associated  con- 
ditions rather  than  the  ulcer. 

The  pain,  if  severe,  requires  opium.  Unless  the  gastralgia  is  intense 
morphia  should  not  be  given  hypodermically,  as  there  is  a  very  serious 
danger  in  these  cases  of  establishing  the  morphia  habit.  Doses  of  an 
eighth  of  a  grain,  with  the  bicarbonate  of  soda  and  bismuth,  will  allay  the 
mild  attacks,  but  the  very  severe  ones  require  the  hypodermic  injection  of 
a  quarter  or  often  half  a  grain.  Antipyrin  and  antifebrin  may  be  tried, 
hut,  as  a  ride,  are  quite  ineffectual.  In  the  milder  attacks  Hoffman's  ano- 
dyne, or  20  or  30  drops  of  chloroform,  or  the  spirits  of  camphor  will  give 
relief.  Counter-irritation  over  the  stomach  with  mustard  or  cantharides  is 
often  useful. 

When  the  stomach  is  intractable,  the  patient  should  be  fed  per  rectum. 
He  will  sometimes  retain  food  which  is  passed  into  the  stomach  through  the 


w 


480 


DISEASES  OP  TIIK  DIGESTIVE  SYSTEM. 


■/ 


tiibo,  and  Loube'H  hoof  nolution  or  milk  may  ho  given  in  tliis  way.  Cracked 
ice,  chloroform,  oxalate  of  cerium,  hiwnmth,  hydrocyanic  acid,  and  ingluvin 
may  he  tried.  When  hu'iiiorrhaj^a'  occurn  the  patient  should  l»e  put  under 
the  inlhicnce  of  opium  as  rii|»i(lly  as  possihie.  No  attempt  should  he  made 
to  check  the  hienu)rrha':e  hy  administering'  medieines  hy  the  mouth;  as 
the  profuse  bleedinj?  is  always  from  nn  erotled  artery,  fre(|Uently  from 
one  of  considerable  size,  it  is  doid)tful  if  acetate  of  lead,  tannic  and  gallic; 
acids,  and  the  usual  remedies  have  the  slightest  inlliu'iu'c.  'i'he  essential 
point  is  to  give  rest,  which  in  best  obtained  by  oiiiuni.  Mrgotin  nuiy  be 
administered  hypodermically  in  two-grain  doses.  Nothing  should  be 
given  by  the  mouth  except  small  cpuuitities  of  ice.  in  pi-ofuse  bleeding 
a  ligature  may  be  applied  around  a  hg,  or  a  leg  ami  arm.  iNot  infreciuently 
the  loss  of  blood  is  so  great  that  the  patient  faints.  A  fatal  result  is  not, 
however,  very  common  from  Jia'morrhagc.  Transfusion  may  l)e  necessary, 
or,  still  better,  the  subcutaneous  infusion  of  saline  solution. 

The  i)atients  usually  recover  ra])idly  from  the  luemorrhage  and  rec^uire 
iron  in  full  doses,  which  may,  if  necessary,  be  given  bypodenuic-ally. 

Surgical  interference  in  uleer  of  the  stomach  is  indicate(l:  (<i)  When 
p  foration  has  taken  ])lace.  The  statistics  collected  by  J>arling  and  Miku- 
licz indicate  how  successful  this  operation  has  become,  (h)  In  very  in- 
tractable cases  Mhich  have  resisted  all  treatment,  and  Avhich  are  accom- 
])anied  by  attacks  of  very  severe  i)ain  and  recurring,  almost  fatal  luemor- 
rhage, the  idccr  may  be  excised,  (r)  For  hiemateniesis.  A  number  of  cases 
have  now  been  successfully  operated  upon  for  the  recurring  bleeding.  The 
surgeon  must  bear  in  mind  that  the  very  severe,  profuse  linemorrhage  does 
not  always  come  from  the  large  ronnd  ulcers,  but,  as  Dieulafoy  has  recently 
pointed  out,  from  c]uite  small  erosions.  In  a  case  of  this  kind  the  operation 
was  performed  successfully.  For  a  full  consideration  of  this  question  the 
reader  is  referred  to  Keen's  Cartwright  Lectures  on  the  Surgery  of  the 
Stomach,  in  the  Philadelphia  Medical  Journal  for  May  and  June,  1898. 


V.    CANCER  OF  THE  STOMACH. 


Etiology. — Til  ride  lice. — In  an  analysis  of  30,000  cases  of  cancer,  W. 
II.  Welch  found  the  stomach  involved  in  21.4  per  cent,  this  organ  thus 
standing  next  to  the  uterus  in  order  of  frequency.  Among  8,464  cases  ad- 
mitted to  my  M'ards,  there  were  150  cases  of  cancer  of  the  stomach.  There 
were  39  cases  among  the  first  1,000  autopsies  in  the  post-mortem  room  of 
the  Johns  IIoi)kins  Hospital.  The  disease  is  more  common  in  some  coun- 
tries. Figures  indicate  that  cancer  of  the  stomach,  as  of  other  organs,  is 
increasing  in  frequency. 

Sex. — T.  McCrae  has  analyzed  150  cases  from  my  wards  and  found  that 
there  w^ere  126  males  and  24  females.    Welch  gives  the  rat'o  as  5  to  4. 

Age. — Of  our  150  cases  the  ages  were  as  follows:  Between  twenty  and 
thirty,  6;  from  thirty  to  forty,  17;  forty  to  fifty,  38;  fifty  to  sixty,  49; 
sixty  to  seventy,  36;  seventy  to  eighty,  4.  Fifty-eight  per  cent  occurred 
between  the  ages  of  forty  and  sixty.    Of  the  6  cases  occurring  under  the 


CANCER  OP  TIIK  STOMACH. 


487 


tliirficth  yt'iir,  the  youiip'st  was  twi'iity-lwo.  Of  llic  liip^c  imiiilicr  of  cnses 
iiiial}/('(l  liy  Wi'kli,  tliivi'  I'ourtlis  ociiinvd  lntwccii  tlic  lu'tictli  and  sevcii- 
tic'tli  years.  Conjiriiital  caiictT  of  the  Htoiiuuh  lias  Imcm  tlcscrihi'cl,  mul 
cases  have  l)een  nict  with  in  chihlrcii. 

liucc. — AinoM",'  our  \'.A)  cases,  l.'U  were  wiiite;    1!)  were  n(%'roes. 

Ihicditjl. — Of  the  JoO  eases  in  only  II  was  there  a  positive  hi.-tory  of 
cancer  in  the  family.  Jn  some  families,  as  the  IJonapartes,  the  disease  seenw 
to  |)revail.  in  our  series  a  very  jnuch  larger  number — 38 — had  a  family 
history  of  tuherculosis. 

I'irvious  JJiscdscn,  Habits,  vie. — A  history  of  dyspepsia  was  |»n'scnt  in 
only  33  cases;  of  these,  IT  had  had  attacks  at  intervals,  J I  had  had  ehrctnie 
stonuich  troul)le,  an<l  .">  had  had  dyspepsia  for  one  or  two  years  before  the 
symptoms  of  cancer  developed.  Napoleon,  discussing  this  interesting  point 
with  his  physician  Automiiuirclii,  said,  that  he  had  always  had  a  stomat  h 
of  iron  and  felt  no  inconvenience  until  tlie  unset  of  what  proved  to  be 
his  fatal  illness. 

Alto/idl. — Scventy-fieven  of  our  patients  liad  used  it  regularly,  ()5  of 
these  moderately  (?),  8  excessively.  'J'niinim. — Only  one  case  gave  a  posi- 
tive history,  in  a  recent  case  the  cancer  develo|)ed  rapidly  after  a  blow  on 
the  stomach,  and  the  ])atient  lost  sixty  pounds  in  weight  in  three  months. 
Uaslric  Ulcer. — Four  ca4;es  gave  a  history  pointing  to  ulcer,  but  there  was 
no  instance  of  ulcus  carcinomatosuni  among  the  autopsies. 

^rental  worry  and  strain  were  given  occasionally  as  causes  of  the  illness. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer 
arc  the  cylindrical-celled  adeno-carcinonui  and  the  ence])haloid  or  medul- 
lary carcinoma;  next  in  freciuency  is  s(;irrhous,  and  then  colloid  cancer. 
"With  reference  to  the  situation  of  the  tumor,  Welch  analyzed  1,300  cases, 
in  which  the  distri])ution  was  as  follows:  l*yloric  region,  T!)l;  lesser  ciu'va- 
turc,  148;  cardia.  104;  ])osterior  wall,  (18;  the  whole  or  greater  ])art  of  the 
stomach,  01;  niultii)]e  tumors,  45;  greater  curvature,  34;  anterior  wall,  30; 
fundus,  19. 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  villous 
projections  or  cauliflower-like  outgrowths.  It  is  soft,  grayish  white  in 
color,  and  contains  much  blood.  Microscopically  it  shows  a  scanty  stroma, 
enclosing  alveoli  which  contain  irregular  ])olyhedral  and  cylindrical  cells. 
The  cylindrical-celled  epithelioma  may  also  form  large  irregular  masses, 
hut  the  consistence  is  usually  firmer,  ]iarticularly  at  the  edges  of  the  can- 
cerous ulcers.  Mierosco])ically  the  section  shows  elongated  tubular  spaces 
filled  with  columnar  epithelium,  and  the  intervening  stroma  is  abundant. 
Cysts  are  not  uncommon  in  this  form.  The  scirrhous  variety  is  character- 
ized by  great  hardness,  due  to  the  abundance  of  the  stroma  and  the  limited 
amount  of  alveolar  structures.  It  is  seen  most  frequently  at  the  pylorus, 
where  it  is  a  common  cause  of  stenosis.  It  may  be  combined  with  the 
medullary  form.  It  may  be  diffuse,  involving  all  parts  of  the  organ,  and 
leading  to  a  condition  which  cannot  be  recognized  macroscopically  from 
cirrhosis.  This  form  has  also  been  seen  in  the  stomach  secondary  to  cancer 
of  the  ovaries.    The  colloid  cancer  is  peculiar  in  its  widespread  invasion 


488 


niSKASES  OP  TIIK  DIQESTIVR  SVSTEM. 


:/ 


of  all  tilt'  t'oatrt.  It  also  Hproadn  with  gn-ator  frtniiu'iicy  to  tlio  nciglihoriiig 
partH,  and  it  (U'caHionally  caiiHCH  oxtciiHive  nccomlary  j^rowtlin  of  tlio  »anit' 
nature  in  other  orgnnH.  Tho  appcaranre  on  Hirtion  in  very  tliHtinitivo, 
anil  even  with  the  naked  eye  larjjc  alveoli  can  he  seen  filled  with  the  trann- 
hiictit  colloid  material.  The  term  alveolar  "aneer  in  often  a|)plied  to  thin 
form,  rieeration  Ih  not  constantly  ])reHcnt,  and  there  are  instanccH  in 
which,  with  most  e-xtenwive  diseaHc,  digestion  hnti  been  but  Blightly  dis- 
turhed.  There  is  a  Hju'cimen  in  the  Warren  Mnseiim,  at  the  Harvard  Me<li- 
cal  School,  of  the  most  wi(les|>read  colloid  cancer,  in  which  the  Htomach 
contained  after  death  Lirge  pii'ces  of  iindigested  heef-steak. 

liecondary  Cancer  of  the  Stomach.-  0(  'Ml  cases  collected  by  Welch,  17 
were  Hccondary  to  cancer  of  the  breast.  Among  the  first  1,(M»)  autopsierf 
at  the  .lohns  Hopkins  liospital  there  were  'A  cases  of  secondary  cancer. 

Chaiu/ps  in  the  iStonidch. — Cancer  at  the  cardia  is  usually  associated  with 
wasting  of  the  organ  and  reduction  in  its  size.  The  (esophagus  above  the 
obstruction  niny  be  greatly  dilated.  On  the  other  hand,  annular  cancer 
at  the  pylorus  causes  stenosis  with  ,"reat  dilatation  of  the  organ.  In  a  few 
rare  instances  the  ])ylorus  has  been  e.\tr"mely  narrowed  without  any  in- 
crease in  the  size  of  the  stonuu'h.  In  diffuse  scirrhous  cancer  the  stomach 
may  be  very  greatly  thickened  and  contracted.  It  nuiy  be  displaced  or 
altered  in  8haj)e  by  the  weight  of  the  tumor,  particularly  in  cancer  of  the 
])yloru8;  in  such  cases  it  has  been  found  in  every  region  of  the  abdomen,  and 
even  in  the  true  pelvis.  The  nu)bility  of  the  tumors  is  at  times  extraordi- 
nary and  very  deceptive,  and  they  may  be  i)ushed  into  the  right  hyjmchon- 
drium  or  into  the  splenic  region,  entirely  beneath  the  ribs.  Adhesions  very 
frecjnently  occur,  particidarly  to  the  colon,  the  liver,  and  the  anterior 
abdominal  wall. 

Secondary  cancerous  growths  in  otlier  organs  arc  very  frequent,  as 
shown  by  the  following  analysis  by  Welch  of  1,574  cases:  Metastasis  oc- 
curred in  the  lymphatic  glands  in  ST)!;  in  the  liver  in  475;  in  the  ])eri- 
tonjvum,  omentum,  and  intestine  in  357;  in  the  pancreas  in  122;  in  the 
])leura  and  lung  in  98;  in  the  spleen  in  2(5;  in  the  brain  and  meninges  in 
9;  in  other  parts  in  92.  The  lymidi-glands  affected  are  usually  those  of 
the  abdomen,  but  the  cervical  and  inguinal  glands  are  not  infrequently 
attacked,  and  give  an  important  clue  in  diagnosis.  Secondary  metastatic 
growths  occur  subcutaneously,  either  at  the  navel  or  beneath  the  skin  in 
the  vicinity,  and  are  of  great  value  in  diagnosis.  In  one  instance  a  ])atient 
with  jaundice,  which  had  developed  somewhat  suddenly  and  was  believed  to 
be  catarrhal,  presented  no  signs  of  enlargement  of  the  liver  or  tumor  of  the 
stomach,  but  a  nodular  body  appeared  at  the  navel,  which  on  removal 
])roved  to  be  typical  seirrhus.  A  second  ease  in  the  ward  at  the  same 
time,  with  an  obscure  doubtful  tumor  in  the  left  hypochondriiim,  developed 
a  painful  nodular  subcutaneous  growth  midway  between  the  navel  and  the 
left  margin  of  the  ribs. 

Perforation. — In  the  extensive  ulceration  which  occurs  perforation  of 
the  stomach  is  not  uncommon.  It  occurred  into  the  peritonaeum  in  17  of 
the  507  cases  of  cancer  of  the  stomach  collected  by  Brinton.  In  our  series 
perforation  is  recorded  in  4  cases.    When  adhesions  form,  the  most  extensive 


CANCEU  OK  TIIK  STOMACH. 


480 


(Icstnictinii  of  tli(>  walls  may  take  idaco  without  jn'rforatinn  into  the  pori- 
tniual  cavity.  In  one  iuhtancc  wliuli  canii!  umlcr  luy  olmi'i-vatimi  a  lar^'c 
portion  of  tlif  left  lobu  of  tlio  liver  lay  within  the  Htonuuii.  Occasionally 
a  ^antro-cutancouH  tistula  in  cntahlishcd.  I'crforiition  may  (UTur  into  the 
colon,  tlir  sninil  liowcl,  tlu>  pleura,  flic  hinf.  '  r  into  the  pcricanliuin. 

SymptomB. — l.tilml  Ctircinitma. — 'I'he  'es  are  not  very  inrrc(|uent. 
There  may  he  no  symptoms  pointing  to  the  stomach,  and  the  tumor  may 
ho  diHcoverud  nceidcntally  after  death.  In  a  secon<l  ^'roup  the  symptoniH 
of  rarcinonni  are  pn-sent,  not  of  the  stomach,  hut  of  the  liver  or  Home  other 
orpin,  or  there  are  suhcutaneous  noduh's,  or,  as  in  oim  of  our  cases,  second- 
ary masses  on  the  ril)s  ami  vcrtehne.  In  a  third  group,  seen  particularly  in 
elderly  persoiiH  in  institutions,  there  Ih  gradual  asthenia,  witaout  nausea, 
vomiting,  or  other  local  symptoms. 

Frahnrs  of  Onsrt. — Of  the  loO  cases  in  our  series,  -IS  complained  of 
pain,  II  of  dyspepsia,  '^i\  of  vomiting,  \',\  of  loss  in  weight,  :{  of  ditliculty 
in  swallowing,  1  of  tunu)r.  in  7  the  features  of  onsi't  suggested  pernioioua 
anu'inia.    In  :i7  cases  thcro  was  a  history  of  sudden  onset. 

General  Symptoms. — Lnsn  of  WviijhL — Progressive  emnciation  is  one 
of  the  most  constant  features  of  the  disease.  In  7i)  of  our  cases  in  which 
exact  ligures  were  taken:  To  30  pounds,  [Vi  cases;  30  to  50  pounds,  30  cases; 
50  to  GO  ])ound8,  5  cases;  (10  to  70  pounds,  4;  over  70  pounds,  1;  1*^0 
poumls,  a  caso  of  cancer  at  the  cardiac  end  with  ohstruction  to  swallowiii^ 
The  loss  in  weight  is  not  always  progressive.  We  see  increase  in  weight 
under  three  conditions:  {a)  I'roper  dieting,  with  treatment  of  the  associated 
catarrh  of  the  stonuich;  {h)  in  cases  of  cancer  of  the  ))ylorus  after  relief  of  the 
dilatation  of  the  organ  hy  lavage,  etc;  (c)  after  a  profound  mental  imi)re8- 
sio«.  I  have  known  a  gain  of  ten  pounds  to  follow  the  visit  of  an  oi)timistic 
consultant.  7n  Keen  and  I).  D.  Stewart's  case  there  was  a  gain  of  seventy 
pounds  after  an  ex))loratory  ojjeration! 

Loss  in  strentjlh  is  usually  pro;  .  .rtionate  to  the  loss  in  weight.  One  sees 
sometimes  remarkahle  vigor  almost  to  the  close,  hut  this  is  exceptional, 

Ann'min  is  i)resent  in  a  large  pro])ortion  of  all  cases,  and  with  the  emaci- 
ation gives  the  jjicture  of  cachexia.  There  is  often  a  yellow  or  lemon  tint 
of  the  skin.  In  51)  cases  careful  hlood-counts  were  made,  in  3  the  red  cor- 
puscles were  ahove  0,000,000  per  cuhic  millimetre.  This  occurs  in  the 
concentrated  condition  of  the  hlood  in  certain  cases  of  cancer  of  the  pylorus 
with  dilatation  of  the  stomach.  The  average  count  in  the  5!)  cases  was 
3,712,180  per  cuhic  millimetre.  In  only  8  cases  was  the  count  below  2,000,- 
000,  and  in  none  below  1,000,000.  The  average  of  the  haemoglobin  was 
44.9  per  cent.  In  only  9  was  it  below  30  per  cent.  In  62  cases  in  which 
the  leucocytes  were  counted  there  were  only  18  cases  in  which  they  were 
above  12.000  per  cubic  millimetre;  in  only  3  cases  were  they  above  20,000, 
As  mentioTied,  there  were  7  cases  in  which  the  features  of  onset  suggested 
a  primary  ansemia.     To  this  question  we  shall  return  under  diagnosis. 

Among  other  general  symptoms  may  be  mentioned  fever.  Of  our  150 
oases,  74  showed  some  fever.  In  only  13  of  these  was  the  temperature 
above  101°.  In  2  it  was  aboA'e  103°.  Fifteen  presented  fairly  constant 
elevation  of  temperature.    Eight  presented  sudden  rises.     Two  cases  had 


490 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


svt-  '- 


■/. 


chill,  with  elevntion  to  103°  and  104°,  Chills  may  bo  associated  witli  sup- 
puration at  the  base  of  the  cancer. 

Urine. — There  may  be  no  changes  throufrjiout;  in  05  of  our  cases  there 
were  no  alterations,  in  30  albumin  was  found,  aiul  in  151  albumin  witli  tube- 
casts.  (ji]}-cosuria,  peptonuria,  and  acetbnuria  have  been  described.  Indican 
is  common. 

(Edema. — Swelling  of  the  ankles  is  of  frequent  occurrence  toward  the 
close.  In  some  cases  there  is  even  early  a  general  anasarca,  usually  in  com- 
bination with  extreme  ana^nia.    The  cancer  is  usually  overlooked. 

The  bowels  are  often  constipated.  In  only  1^  cases  in  our  series  was 
diarrhoea  present.  In  2  cases  blood  was  passed  per  rectum.  There  are  no 
Fl)ecial  cardiac  sijmptoms;  the  pulse  becomes  progressively  weaker.  Throm- 
bosis of  one  femoral  vein  may  occur  or,  as  in  one  of  our  cases,  widespread 
thrombosis  in  the  superiicial  veins  of  the  body. 

,jymi)toms  on  the  part  of  the  nervous  system  arc  rare;  consciousness 
is  often  retained  to  the  end.  Coma  may  develoj) — viz.,  similar  to  that  seen 
in  diabetes,  and  is  believed  to  be  due  to  an  acid  intoxication. 

Functional  Disturbances. — Anorexia,  loss  of  desire  for  food,  is  a  fre- 
quent and  valuable  symptom,  more  constant  perhaps  than  an_v  other. 
Nausea  is  a  striking  feature  in  many  cases;  there  is  often  a  sudden  re- 
pulsion at  the  sight  of  food.  In  exceptional  cases  the  appetite  is  retained 
throughout. 

Vomiting  may  come  on  early,  or  only  after  the  dyspepsia  has  persisted 
for  some  time.  It  occurred  in  128  cases  in  our  series.  At  first  it  is  at  long 
intervals,  biit  sid)sequently  it  is  more  frequent,  and  may  recur  several  times 
in  the  day.  There  are  cases  in  which  it  comes  on  in  paroxysms  and  then 
subsides;  in  other  cases,  it  sets  in  early,  persists  with  great  violence,  and 
may  cause  a  fatal  termination  within  a  few  weeks.  Vomiting  is  more  fre- 
quent when  the  cancer  involves  the  orifices,  particularly  the  pylorus,  in 
which  case  it  is  usually  delayed  for  an  hour  or  more  after  taking  the  food. 
"When  the  cardiac  orifice  is  involved  it  may  follow  at  a  shorter  interval. 
Extensive  disease  of  the  fundus  or  of  the  anterior  or  posterior  wall  may 
be  present  without  the  occurrence  of  vomiting.  The  food  is  sometimes  very 
little  changed,  even  after  it  has  remained  in  the  stomach  for  twenty  four 
hours. 

Hamorrliarje  occurred  in  36  of  our  150  cases;  in  352  the  blood  was  dark 
and  altered,  in  3  it  was  bright  red.  In  2  cases  vom'ting  of  blood  was  the 
first  symptom.  The  bleeding  is  rarely  profuse;  more  commonly  there  is 
slight  oozing,  and  the  blood  is  mixed  with,  or  altered  by  the  secretions, 
and,  when  .'omited,  the  material  is  dark  brown  or  black,  the  so-called 
"  coffee-ground  "  vomit.  The  blood  can  be  recognized  by  the  microscope  as 
shadows  of  the  red  blood-corpuscles  and  irregular  masses  of  altered  blood 
pigment.  In  cases  of  doubt  the  spectroscope  may  be  employed  or  haemin 
crystals  obtained. 

Pain,  an  early  and  important  symptom,  was  present  in  130  of  our  cases. 
It  is  very  variable  in  situjuion,  and  while  most  common  in  the  epigastrium, 
it  may  be  referred  to  the  shoidders,  the  back,  or  the  loins.  The  pain  is 
described  as  dragging,  burning,  or  gnawing  in  character,  and  very  rarely 


CANCER  OF  THE  STOMACH. 


4»1 


sistcd 
;  long 
times 
then 
and 
fre- 
us,  in 
'ood. 
erval. 
may 
very 
four 


eases, 
rium, 
ain  is 
rarely 


nccnrs  in  severe  paroxysms  of  gnstralgia,  as  in  gastrie  nicer.  As  a  rule,  the 
jiain  is  aggravated  by  tailing  Uhh].  There  is  usually  marked  tenderness  on 
l)ressnre  in  the  epigastric  region.  The  areas  of  skin  tenderness  are  referred, 
as  Head  has  shown,  to  the  region  l)etween  the  nipple  and  the  umbilicus 
in  front  and  hehind  from  the  fifth  to  the  twelfth  thoracic  spine. 

Examination  of  the  Stomach  Contents. — The  vomitus  in  susiieetcd  cases 
siiould  l)e  carefully  studied,  i)articularly  as  to  quantity  and  cluiracter  of 
ingredients.  Large  amounts  brought  np  at  intervals  of  a  few  days,  with 
the  ai)i)earances  already  described,  are  characteristic  of  dilatation  of  the 
stomach.  Some  of  the  material  should  be  si)read  in  a  large  glass  plate  and 
any  suspicious  portions  picked  out  for  examination.  lUicterla  in  large  num- 
bers occur,  one,  the  Oppler-lJoas  bacillus — an  nnusually  long  non-mobile 
form — is  supposed  to  be  of  diagnostic  value,  and  to  be  largely  responsible 
for  the  formation  of  lactic  acid.  The  yeast  fungus  is  very  commonly  found, 
sarcina>  less  frecpiently  than  in  dilatation  from  stricture.  IJlood  is  a  most 
important  ingredient;  the  persistent  presence  microscopically  of  red  cor- 
])uscles  in  the  early  morning  washings  is  always  very  suspicious.  Later, 
when  coifee-ground  vomiting  takes  jjlace,  the  macroscopic  evidence  is  suf- 
ficient. In  cases  of  doubt  the  si)ectroscope  may  be  used  or  the  test  made 
for  luvmin  crystals.  Fragments  of  the  new  growth  may  be  vomited  or  may 
appear  in  the  washings.  Positive  evidence  of  cancer  may  be  obtained  from 
them. 

Examination  of  the  Test  Breal-fast. — The  Ewald  test  meal,  consisting 
of  a  slice  of  stale  bread  and  a  large  cup  of  weak  tea  without  cream  or  sugar, 
is  given  at  7  a.  m.  and  withdrawn  at  8  a.  m.  The  Boas  test  meal,  consisting 
of  a  gruel  made  of  a  tables])oonful  of  oatmeal  flour  in  a  litre  of  water,  is 
used  in  the  estimation  of  lactic  acid.  As  an  outcome  of  the  enormous 
numl)er  of  observations  made  of  late  years,  it  may  be  said  that  free  HCl 
is  absent  in  a  large  ])roi)ortion  of  all  cases  of  cancer  of  the  stomach.  Of 
94  cases  in  which  the  contents  were  examined  in  84  free  HCl  was  absent. 
In  5  undoul)ted  cases  the  reaction  was  good;  in  2  of  these  the  history  sug- 
gested previous  ulcer.  HCl  may  be  al)sent  in  chronic  gastritis  and  in 
atrophy  of  the  gastric  mucosa.  (For  a  good  discussion  of  hydrochloric-acid 
determinations  see  J.  S.  Thatcher,  Presbyterian  Hospital  Eeports,  vol.  iii!) 
The  presence  of  lactic  acid  after  Boas'  test  meal  is  regarded  as  a  valuable 
sign.  It  is  rarely  present  in  chronic  catarrhal  conditions,  but,  as  Stockton 
and  Jones  conclude,  it  is  by  no  means  positive  evidence  of  carcinoma  ven- 
triculi. 

Physical  Examination. — {a)  Lifipcction. — x\fter  a  preliminRry  sur- 
vey, embracing  the  facies,  state  of  nutrition,  etc.,  particular  direction  is 
given  to  the  abdomen.  An  all-important  matter  is  to  have  the  patient  in 
a  good  light.  Fulness  in  the  epigastric  region,  inequality  in  the  infracostal 
grooves,  the  existence  of  peristalsis,  a  wide  area  of  aortic  pulsation,  the 
presence  of  subcutaneous  nodules  or  small  masses  about  the  navel,  and, 
lastly,  a  well-defined  tur.ior  mass — these,  together  or  singly,  may  be  seen 
on  careful  ins])ection.  I  cannot  emphasize  too  strongly  the  value  of  this 
method  of  examination.  In  63  of  the  150  cases  a  positive  tumor  could  be 
seen.    In  53  the  tumor  descended  with  inspiration;  in  3G  peristalsis  was 


492 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


'V 


visible;  in  3  cases  movements  were  visible  in  the  tumor  itself.  In  10  cases 
with  visible  peristalsis  no  tumor  was  seen,  but  could  be  felt  on  i)alpation. 
Inllation  with  carljonic-acid  gas  may  be  tried,  except  when  Ih-vmorrhage 
has  been  profuse  or  the  cancer  is  very  extensive.  The  dilatation  often  ren- 
ders evident  the  peristalsis  or  nuiy  bring  a  tumor  into  view.  The  presence 
of  subcutaneous  and  umbilical  nodules  is  sometimes  a  very  great  help.  They 
were  found  in  5  of  our  series.  Palpation. — In  115  cases  a  tumor  could  be 
felt;  in  48  in  the  epigastric  region,  in  25  in  the  umbilical,  in  18  in  the  left 
hypochondriac,  in  17  in  the  right  hypochondriac  region,  while  in  7  cases  a 
mass  descended  in  deep  inspiration  from  beneath  the  left  costal  margin. 
These  figures  illustrate  in  how  large  a  proportion  of  the  cases  the  tumor  is  in 
evidence.  In  rare  cases  examination  in  the  knee-elbow  position  is  of  value. 
Muhility  in  gastric  tumor  is  a  point  of  much  importance.  First,  the  change 
with  respiration,  already  referred  to;  a  mass  may  descend  3  or  4  inches 
in  deep  inspiration;  secondly,  the  communicated  pulsation  from  the  aorta, 
which  is  often  in  its  extent  suggestive;  thirdly,  the  intrinsic  movements 
in  the  hypertrophied  muscularis  in  the  neighborhood  of  the  cancer.  This 
may  give  a  remarkable  character  to  the  mass,  causing  it  to  appear  and  disap- 
pear, lifting  the  abdominal  wall  in  the  epigastric  region;  and,  fourthly, 
mechanical  movements,  with  inflation,  with  change  of  posture,  or  com- 
municated with  the  hand.  Tumors  of  the  pylorus  are  the  most  movable, 
and  in  extreme  cases  can  be  displaced  to  either  hypochondrium  or  pushed 
far  down  below  the  navel  (see  illustrative  cases  in  my  Lectures  on  the  Diag- 
nosis of  Abdominal  Tumors).  Pain  on  palpation  is  common;  the  mass  is 
usually  hard,  sometimes  nodular.  Gas  can  at  times  be  felt  gurgling  through 
the  tumor  at  the  pyloric  region. 

Pernission  gives  less  important  indications — the  note  over  a  tumor  is 
rarely  flat,  more  often  a  flat  tympany.  Auscultation  may  reveal  the 
gurgling  through  the  pylorus;  sometimes  a  systolic  bruit  is  transmitted 
from  the  aorta,  and  when  a  local  peritonitis  exists  a  friction  may  be  heard. 

Complications. — Secondary  grotvths  are  common.  In  44  autopsies  in 
our  series  there  were  metastases  in  38;  in  29  the  lymph-glands  were  in- 
volved; in  23  the  liver,  in  11  the  peritonaeum,  in  8  the  pancreas,  in  8  the 
bowel,  in  4  the  lung,  in  3  the  pleura,  in  4  the  kidneys,  and  in  S  the  spleen. 
In  8  no  deposits  were  found. 

Perforation  may  lead  to  peritonitis,  but  in  3  of  our  4  cases  there  was 
no  general  involvement.  Cancerous  ascites  is  not  very  uncommon.  Dock 
has  called  attention  to  the  value  of  the  examination  of  the  fluid  in  such 
cases  as  a  help  to  diagnosis.  The  cells  show  mitoses  and  are  very  charac- 
teristic. Secondary  cancer  of  the  liver  is  very  common;  the  enlargement 
may  be  very  great,  and  such  cases  are  not  infrequently  mistaken  for 
primary  cancer  of  the  organ.  Involvement  of  the  lymph-glands  may  give 
valuable  indications.  There  may  be  early  enlargement  of  a  gland  at  the 
posterior  border  of  the  left  sterno-cleido-mastoid  muscle;  later  adjacent 
glands  may  become  afl'ected.  This  occurs  also  in  uterine  cancer.  Accord- 
ing to  AVilliams,  Trosier  was  the  first  to  describe  this  condition,  which  must 
not  be  confounded  Avith  the  psendo-lipome  sns-claviculaire  of  Verneuil. 

A  very  remarkable  picture  is  presented  when  the  cancer  sloughs  or  be- 


CANCER  OF  THE  STOMACH. 


493 


comes  gangrenous;  the  vomitus  has  a  foul  odor,  often  of  a  penetrating  na- 
ture, to  be  perceived  throughout  tlie  room.  In  cases  in  which  the  ulcer 
l)erforates  the  colon,  the  vomiting  may  he  ftvcal.  I  have,  however,  met  with 
the  fffical  odor  in  a  case  with  incessant  vomiting;  there  was  no  perforation  of 
the  colon  at  autopsy. 

Course. — While  usually  chronic  and  lasting  from  a  year  to  eighteen 
months,  amte  cancer  of  the  stomach  is  by  no  means  infrequent.  Of  the 
G9  cases  in  which  we  could  determine  accurately  the  duration,  15  lasted 
under  three  months,  IG  from  three  to  six  months,  14  from  six  to  twelve 
months — a  total  of  -15  under  one  year.  Four  cases  lasted  for  two  years  or 
over.     One  case  lived  for  at  least  two  years  and  a  half. 

Diagnosis. — In  115  of  our  150  cases  a  tumor  existed,  and  with  this 
the  recognition  is  rarely  in  doubt.  Practically  the  chief  dilficulty  is  in 
those  cases  which  present  gastric  symptoms  or  antcmia,  or  both,  without 
the  presence  of  tumor.  In  the  one  a  chronic  gastritis  is  suspected;  in  tlic 
other  a  primary  anaemia.  In  chronic  gastritis  the  history  of  long-standing 
dyspepsia,  the  absence  of  cachexia,  the  absence  of  lactic  acid  in  the  test 
meal,  and  the  less  striking  blood  changes  are  the  important  points  for  con- 
sideration. The  cases  with  grave  anceinia  without  tumor  offer  the  greatest 
difficulty.  The  blood-count  is  rarely  so  low  as  m  pernicious  ana}mia,  a 
point  on  which  F.  P.  Henry  has  laid  special  stress.  In  only  8  of  our  59 
cases  with  careful  blood  examination  was  the  number  below  2,000,000 
per  cubic  millimetre.  The  lower  color  index,  as  in  secondary  ana}mia,  the 
absence  of  megaloblasts,  and  a  leucocytosis  speak  for  cancer.  Some  lay 
stress  on  the  differential  count  of  the  leucocytes,  but  there  is  not  evidence 
enough  to  enable  us  to  speak  positively  on  this  point.  The  digestion  leuco- 
cytosis might  be  a  help  in  some  cases.  The  chemical  findings  are  of  greater 
value.  The  constant  presence  of  lactic  acid  and  the  absence  of  HCl  have 
in  several  of  owt  cases  suggested  the  diagnosis  of  cancer,  which  has  been 
verified  later  on  by  the  development  of  a  tumor. 

From  ulcer  of  the  stomach  malignant  disease  is,  as  a  rule,  readily  recog- 
nized. The  nlcus  carcinomatosum  usually  presents  a  well-marked  history  of 
ulcer  for  years.  Hemmeter  has  given  a  good  account  of  this  rare  condi- 
tion in  his  recent  work  on  the  stomach.  The  greatest  difficulty  is  offered 
when  there  is  ulcer  with  tumor  due  to  cicatricial  contraction  about  the 
pylorus.  In  3  such  cases  we  mistook  the  mass  for  cancer,  and  even  at 
operation  it  may  (as  in  one  of  them)  be  impossible  to  say  whether  a  neo- 
plasm is  present.  The  persistent  hyperchlorhydria  is  the  most  important 
single  feature  of  ulcer,  and,  taken  with  the  gastralgic  attacks  and  the  haem- 
orrhages, rarely  leave  doubt  as  to  the  condition. 

Nowadays,  when  exploratory  laparotomy  may  be  advised  with  such 
safety,  the  surgeon  often  makes  the  diagnosis. 

The  practitioner  should  recognize  the  fact  that  there  are  cases  of  cancer 
of  the  stomach  in  which  a  positive  diagnosis  cannot  be  reached  for  weeks 
or  months  by  any  known  means  at  our  command. 

Treatment. — The  disease  is  incurable  and  palliative  measures  are 
alone  indicated.  The  diet  should  consist  of  readily  digested  substances  of 
all  sorts.     Many  patients  do  best  on  milk  alone.     "Washing  out  of  the 


m 


94 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


1/ 


™ 


stomach,  which  may  he  clone  with  a  soft  tuhe  without  any  risk,  is  particu- 
larly advantngeous  when  there  is  obstruction  at  the  pylorus,  and  is  by  far 
the  most  satisfactory  means  of  combatting  the  vomiting.  The  excessive 
fermentation  is  also  best  treated  by  lavage.  Wlien  the  pain  becomes  se- 
vere, })articularly  if  it  disturbs  tlie  rest  at  night,  morphia  must  be  given. 
One  eighth  of  a  grain,  combined  with  carbonate  of  soda  (gr.  v),  bismuth 
(gr.  v-x),  usually  gives  prom])t  relief,  and  the  dose  does  not  always  require 
to  be  increased.  Creasote  (lUj-ij)  and  carbolic  acid  are  very  useful.  The 
bleeding  in  gastric  cancer  is  rarely  amenable  to  treatment.  0])erative 
measures  have  been  advised  and  practised,  and  in  exceptional  instances 
there  are  cases  in  which  the  limited  cancer  or  even  the  entire  organ  has 
been  resected. 

Other  Forms  of  Tumor. — Non-cancerous  tumors  of  the  stomach  rarely 
cause  inconvenience.  Polypi  (polyadenomata)  are  common  and  they  may 
be  numerous;  as  many  as  150  have  been  reported  in  one  ease.  There  is  a 
form  in  which  the  adenoma  exists  as  an  extensive  area  slightly  raised  above 
the  level  of  the  mucosa — polyadenome  en  nappe  of  the  French.  H.  B.  An- 
derson has  described  a  case  of  remarkable  multiple  cysts  in  the  walls  of  the 
stomach  and  small  intestine.  Sarcomata  are  very  rare.  FiJjromata  and 
lipomata  have  been  described. 

Foreign  bodies  occasionally  produce  remarkable  tumors  of  the  stomach. 
The  most  extraordinary  is  the  hair  tumor,  of  which  there  are  10  cases  in  the 
literature.  The  cases  occur  in  hysterical  women  who  have  been  in  the  ha'bit 
of  eating  their  own  hair.  A  specimen  in  the  medical  museum  of  McGill 
University  is  in  two  sections,  which  form  an  exact  mould  of  the  stomach. 
The  tumors  are  large,  very  puzzling,  and  are  usually  mistaken  for  cancer. 
Of  7  cases  operated  upon,  6  recovered;  in  9  cases  the  condition  was  found 
post  mortem  (Schulten). 


VI.  HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS. 

(a)  In  Adults. — Any  one  with  a  large  post-mortem  experience  has  met 
with  instances  of  dilated  stomachs  in  connection  with  thickening  or  hyper- 
trophy of  the  pylorus,  sometimes  forming  a  tumor  large  enough  to  be  felt, 
and  suggesting  the  presence  of  a  new  growth.  ]\Iicroscopically,  however, 
the  condition  is  found  to  be  very  largely  hypertrophy  of  the  muscularis  and 
submucosa  of  the  pylorus.  It  was  well  described  by  the  older  writers.  The 
symptoms  are  those  of  dilatation  of  the  stomach.  The  condition  has  been 
fully  discussed  recently  by  Boas  (Archiv  flir  Verdaiiungskrankheiten,  Bd.  4, 
I),  who  reports  two  interesting  cases  with  successful  gastro-enterostomy. 
The  question  is  whether  some  of  these  cases  may  not  really  be  congenital, 
as  there  have  been  instances  reported  in  girls  as  early  as  the  twelfth  and 
sixteenth  years. 

(h)  Congenital  Hypertrophy  of  the  Pylorus. — To  this  interesting  condi- 
tion much  attention  has  been  paid  of  late.  John  Thomson,  of  Edin- 
burgh, EoUeston  and  Hayne,  IMeltzer  and  I.  Adler,  of  New  York,  have 
recently  reported  cases.     The  average  age  in  17  cases  was  five  months. 


HEMORRHAGE  FROM  THE  STOMACL. 


495 


Three  cases  have  l)een  met  with  in  mie  family.  Thomson  suggests  the  name 
coiKjenital  (jaslric  spasm,  and  tliinks  it  is  due  to  nervous  incoordination, 
but  tlie  obstruction  is  usually  tliought  to  be  mechanical.  Histologically 
tlie  changes  appear  to  be  similar  to  (hose  in  the  adult.  In  both  ^leltzcr's 
and  I.  Adler's  case  gastro-enterostomy  was  performed,  but  in  neither  in- 
stance with  success. 


I 

1 


VII.     HAEMORRHAGE   FROM   THE  STOMACH  (ncpmatemesis). 

Etiology. — Gastrorrhagia,  as  this  symptom  is  called,  may  result  from 
many  conditions,  some  of  which  are  local,  others  general. 

1.  In  local  disease  in  the  stomach  itself:  (a)  cancer;  (h)  ulcer;  (c) 
disease  of  the  blood-vessels,  such  as  miliary  aneurisms  of  the  snudler  arte- 
ries, and  occasionally  varicose  veins;  (d)  acute  congestion,  as  in  gastritis, 
and  possibly  in  vicarious  luemorrhage,  but  both  of  these  are  extremely 
rare  causes. 

2.  Passive  congestion  due  to  obstruction  in  the  ])ortal  system.  This 
may  be  either  («)  hepatic,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the 
I)ortal  vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in 
cases  of  chronic  disease  of  the  heart  and  lungs;  (h)  splenic.  Gastrorrhagia 
is  by  no  means  an  uncommon  symptom  in  enlarged  spleen,  and  is  ex- 
plained by  the  intimate  relations  which  exist  between  the  vasa  brevia  and 
the  splenic  circulation. 

3.  Toxic:  (a)  The  poisons  of  the  specific  fevers,  small-pox,  measles, 
yellow  fever;  (h)  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy 
and  in  purpura;  (c)  phosjihorus. 

4.  Traumatism:  (a)  Mechanical  injuries,  such  as  blows  and  wounds, 
and  occasionally  by  the  stomach-tube;  (b)  the  result  of  severe  corrosive 
poisons. 

5.  Certain  constitutional  diseases:  (a)  Haemophilia;  (h)  profound  ana3- 
niias,  whether  idiopathic  or  due  to  splenic  enlargements  or  to  malaria;  (c) 
oholaMuia. 

6.  In  certain  nervous  affections,  particularly  hysteria,  and  occasionally 
in  progressive  jiaralysis  of  the  insane  and  epilepsy. 

7.  The  ])lood  may  not  come  from  the  stomach,  but  flow  into  it.  Thus 
it  may  pass  from  the  nose  or  the  ])harynx.  In  hamoptysis  some  of  the 
blood  may  find  its  way  into  the  stomach.  The  bleeding  may  take  place 
from  the  oesophagus  and  trickle  into  the  stomach,  from  which  it  is  ejected. 
This  occurs  in  the  case  of  rupture  of  aneurism  and  of  the  oosophagcal  varices. 
A  child  may  draw  blood  with  the  milk  from  the  mother's  breast  even  in 
considerable  quantities  and  then  vomit  it. 

8.  ^liscellaneous  causes:  Aneurism  of  the  aorta  or  of  its  branches  may 
rupture  into  the  stomach.  There  are  instances  in  which  a  patient  has  vom- 
ited blood  once  without  ever  having  a  recurrence  or  without  developing 
symiitoms  pointing  to  disease  of  the  stomach. 

In  new-horn  infants  ha?matemesis  may  occur  alone  or  in  connection 
tn  other  mucous  membranes. 


ig 


31 


!!■!' 


496 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


V 


Hi 


In  medical  i)ractice,  hemorrhage  from  the  stomach  occurs  most  fre- 
quently in  connection  with  cirrhosis  of  the  liver  and  ulcer  of  the  stomach. 
It  is  more  frequent  in  women  than  in  men,  owing  to  the  greater  prevalence 
of  round  ulcer  in  the  former. 

Morbid  Anatomy. — When  death  has  occurred  from  the  ha'mate- 
mesis  there  are  signs  of  intense  anaemia.  The  condition  of  the  stomach 
varies  extremely.  The  lesion  is  evident  in  cancer  and  in  ulcer  of  the  stom- 
ach. It  is  to  be  borne  in  mind  that  fatal  haemorrhage  may  come  from  a 
small  miliary  aneurism  communicating  with  the  surface  by  a  pin-hole  per- 
foration, or  the  bleeding  nuiy  be  due  to  the  rupture  of  a  submucous  vein 
and  the  erosion  in  the  mucosa  may  be  small  and  readily  overlooked.  It 
may  require  a  careful  and  prolonged  search  to  avoid  overlooking  such 
lesions.  In  the  large  group  associated  with  portal  obstruction,  whether 
due  to  hc])atic  or  splenic  disease,  the  mucosa  is  usually  pale,  smooth,  and 
shows  no  trace  of  any  lesion.  In  cirrhosis,  fatal  by  hemorrhage,  one  may 
sometimes  search  in  vain  for  any  focal  lesion  to  account  for  the  gastror- 
rhagia,  and  we  must  conclude  that  it  is  possible  for  even  the  most  profuse 
bleeding  to  occur  by  diapedesis.  The  stomach  may  be  distended  with  blood 
and  yet  the  source  of  the  hemorrhage  be  not  apparent  either  in  the  stomach 
or  in  the  portal  system.  In  such  cases  the  oesophagus  should  be  examined, 
as  the  bleeding  may  come  from  that  source.  In  toxic  cases  there  are  in- 
variably hemorrhages  in  the  mucous  membrane  itself. 

Symptoms. — In  rare  instances  fatal  syncope  may  occur  without  any 
vomiting.  In  a  case  of  the  kind,  in  which  the  woman  had  fallen  over  and 
died  in  a  few  minutes,  the  stomach  contained  between  three  and  four 
pounds  of  blood.  The  sudden  profuse  bleedings  rapidly  lead  to  profound 
anemia.  When  due  to  nicer  or  cirrhosis  the  bleeding  nsnally  recurs  for 
several  days.  Fatal  hemorrhage  from  the  stomach  is  met  with  in  ulcer, 
cirrhosis,  enlargement  of  the  spleen,  and  in  instances  in  which  an  aneurism 
ruptures  into  the  stomach  or  oesophagus.  Gastrorrhagia  may  occur  in 
splenic  anemia  or  in  leukemia  before  the  condition  has  aroused  the  at- 
tention of  friends  or  physician. 

The  vomited  blood  may  be  fluid  or  clotted;  it  is  usually  dark  in  color, 
but  in  the  basin  the  outer  part  rapidly  becomes  red  from  the  action  of  the 
air.  The  longer  blood  remains  in  the  stomach  the  more  altered  is  it  when 
ejected. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  course  of  a  day 
the  patient  may  bring  up  three  or  four  pounds,  or  even  more.  In  a  case 
under  the  care  of  George  Ross,  in  the  Montreal  General  Hospital,  the  pa- 
tient lost  during  seven  days  ten  pounds,  by  measurement,  of  blood.  Tlie 
usual  symptoms  of  anemia  develop  rapidly,  and  there  may  be  slight  fever, 
and  subsequently  oedema  may  occur.  Syncope,  convulsions,  and  occasion- 
ally hemiplegia  occur  after  very  profuse  hemorrhage.  An  interesting  cir- 
cumstance connected  with  gastro-intestinal  hemorrhage  is  the  development 
of  amaurosis,  the  mode  of  production  of  wdiich  is  still  under  discussion. 

Diagnosis. — In  a  majority  of  instances  there  is  no  question  as  to 
the  origin  of  the  blood.  Occasionally  it  is  difficult,  particularly  if  the  case 
has  not  been  seen  during  the  attack.    Examination  of  the  vomit  readily 


B-  ' 


NEUROSES  OF  THE  STOMACH. 


497 


if  a  day 
a  case 
the  pa- 
The 
t  fever, 
ceasi  oil- 
ing cir- 
opment 
ion. 

n  as  to 
the  case 
readily 


determines  whether  blood  is  jjresent  or  not.  Tlie  materials  vomited  may 
be  stained  by  wine,  tbe  juice  of  strawberries,  rasi)berries,  or  cranberries, 
wiiicb  give  a  color  very  c'lo.><ely  reseml)ling  that  of  fresh  Ijlood,  wbile  iron 
and  bismutli  and  bile  may  proiluee  tiie  bhickish  color  of  altered  blood.  In 
such  cases  the  microscope  will  show  clearly  the  presence  of  the  shadowy 
outlines  of  the  red  blood-corpuscles,  and,  if  necessary,  spectroscopic  and 
chemical  tests  may  be  applied. 

Deception  is  sometimes  jiractised  by  hysterical  patients,  who  swallow 
and  then  vomit  blood  or  colored  liquids.  With  a  little  care  such  cases  can 
usually  be  detected.  The  cases  must  be  excluded  in  whicli  the  blood  passes 
from  the  nose  or  pharynx,  or  in  which  infants  swallow  it  with  tlie  milk. 

There  is  not  often  difficulty  in  distinguisiiing  between  h}emoj)tysi8  and 
hamiatemesis,  though  the  coughing  and  the  vomiting  are  not  infrequently 
combined.    The  following  are  points  to  be  borne  in  mind  in  the  diagnosis: 


H.EMATEMESIS. 

1.  Previous  history  points  to  gas- 
tric, hepatic,  or  splenic  disease. 

2.  The  blood  is  brought  up  by 
vomiting,  prior  to  which  the  patient 
may  exjjerience  a  feeling  of  giddiness 
or  faintness. 

3.  The  blood  is  usually  clotted, 
mixed  with  ])articles  of  food,  and 
has  an  acid  reaction.  It  may  be 
dark,  grumous,  and  fluid. 

4.  Subsequent  to  the  attack  the 
patient  passes  tarry  stools,  and  signs 
of  disease  of  the  abdominal  viscera 
may  be  detected. 


IliEMOPTYSIS. 

1.  Cough  or  signs  of  some  pul- 
monary or  cardiac  disease  precedes, 
in  many  cases,  the  luemorrhage. 

2.  The  blood  is  coughed  up, 
and  is  usually  preceded  by  a  sensa- 
tion of  tickling  in  the  throat.  If 
vomiting  occurs,  it  follows  the 
coughing. 

3.  The  blood  is  frothy,  bright 
red  in  color,  alkaline  in  reaction. 
If  clotted,  rarely  in  such  large  co- 
agula,  and  muco-pus  may  be  mixed 
with  it. 

4.  The  cough  persists,  physical 
signs  of  local  disease  in  the  chest 
may  usually  be  detected,  and  the 
sputa  may  be  blood-stained  for  many 
days. 


Prognosis. — Except  in  the  case  of  rupture  of  an  aneurism  or  of  large 
veins,  hgematemesis  rarely  proves  fatal.  In  my  experience  death  has  fol- 
lowed more  frequently  in  cases  of  cirrhosis  and  splenic  enlargement  than 
in  ulcer  or  cancer.  In  \ilcer  it  is  to  be  remembered  that  in  the  chronic 
hiipmorrhagic  form  the  bleeding  may  recur  for  years.  The  treatment  of 
ha^matemesis  is  considered  under  gastric  ulcer. 


VIII.     NEUROSES   OF  THE  STOMACH  (Nenmia  Dyspepsia). 

The  studies  of  Leube,  Ewald,  Oser,  Rosenbach,  and  many  others  have 
sliown  that  serious  functional  disturbances  of  the  stomach  mav  occur  with- 
out any  discoverable  anatomical  basis.     The  cases  are  met  with  most  fre- 


i 


\-t] 


i 


W: 


':/ 


498 


DISKASKS  OF  THE   DIfJKSTIVK  SYSTKM. 


((iipiitly  in  those  who  hnvo  cither  itiiicritcd  n  nervous  constitution  or  who 
luive  gniduHlly,  through  in<liserelions,  l)r()Ught  ahout  a  condition  of  nervous 
prostration.  Xot  infre([iu'ntly,  however,  the  gastric  synii)tonis  stand  so  fjir 
in  the  foreground  that  tlie  general  neuropathic  character  of  tlie  patient 
(piit(!  escapes  notice.  Sonictinies  tlie  gastric  nuinifestations  have  appar- 
ently a  relie.x  origin  dejiending  on  oiganic  disturbances  in  remote  parts  of 
the  hody. 

The  nervous  derangements  of  the  stouuich  may  be  divided  into  motor, 
secretory,  and  sensory  neuroses.  These  disturbances  rarely  occur  singly; 
tJiey  are  usually  met  with  in  combined  forms.  The  clinical  picture  result- 
ing from  such  a  complex  of  gastric  neuroses  is  known  as  nervous  (h/tipepsiii. 
There,  as  Leube  has  pointed  out,  the  sensory  disturbances  usually  i)lay  the 
more  important  ])art. 

The  suiferer  from  nervous  dyspepsia  presents  a  varying  picture.  All 
grades  occur,  from  the  emaciated  skeleton-like  i)atient  with  anorexia 
nervosa  to  the  well-nourished,  healthy-looking,  fresh-complexioned  indi- 
vidual whose  only  comjilaint  is  distress  and  uneasiness  after  eating.  I  have 
followed  liiegel's  classification  as  given  in  his  recent  exhaustive  work  on 
the  stomacli. 

I.  Motor  Neuroses. — (a)  Jlyperl-inesis  or  Supermotilily. — An  increase  in 
ihe  normal  motor  activity  of  the  stomach  results  iu  too  early  a  discharge  of 
the  ingesta  into  the  intestine.  It  is  more  commonly  a  secondary  neurosLs 
dependent  upon  superacidity  or  supersccretion  of  the  gastric  juice;  but  it 
may  occur  ])rimarily,  possibly  from  reflex  causes.  The  diagnosis  is  to  be 
reached  only  by  means  of  the  stomach-tube.  It  gives  rise  to  no  charac- 
teristic clinical  symptoms. 

{h)  reristaUic  Unrest. — This  condition,  as  described  by  Kussmaul,  is 
an  extremely  common  and  distressing  symptom  in  neurasthenia.  Shortly 
after  eating  the  ])eristaltic  movements  of  the  stomach  are  increased,  and 
borborygmi  and  gurgling  may  be  heard,  even  at  a  distance.  The  sub- 
jective sensations  are  most  annoying,  and  it  would  appear  as  if  in  the  hyper- 
ssthetic  condition  of  the  nervous  system  the  patient  felt  normal  peristalsis, 
just  as  in  these  states  the  usual  beating  of  the  heart  may  be  perceptible 
to  him.  A  further  analogy  is  afforded  by  the  fact  that  emotion  increases 
this  peristalsis.  It  may  extend  to  the  intestines,  particularly  to  the  duode- 
num, and  on  palpation  over  this  region  the  gurgling  is  most  marked.  The 
movement  may  be  anti-peristalsis,  in  which  the  wave  passes  from  right  to 
left,  a  condition  which  may  also  extend  to  the  intestines.  There  are  cases 
on  record  in  which  colored  enemata  or  even  scybala  have  been  discharged 
from      a  mouth. 

(. ,  Nervnvs  Erndaiions. — In  this  condition  severe  attacks  of  noisy 
eructations,  following  one  another  often  in  rapid  succession,  occur.  "When 
violent  they  last  for  hours  or  days.  At  other  times  they  occur  in  paroxysms, 
depending  often  upon  mental  excitement.  They  are  move  commonly  ob- 
served in  hysterical  women  and  neurasthenics,  but  also,  not  infrequently, 
in  children.  The  hysterical  nature  of  the  affection  is  sometimes  testifiefl 
to  by  the  occurrence,  especially  in  children,  of  several  instances  in  one 
household. 


T 

or  as 

obser 

(piite 

the  p 

the  a 

NEL'llOSES  OP  THE  HTOMAC^II. 


409 


only  ol)- 

!qnently. 

testified 

1  in  one 


The  expelled  ^'ns  in  these  eases  is  ntmosphcric  nir,  wliicli  is  swallowed 
or  aspirated  I'lom  without.  Soiiietimes  thi'  whole  process  may  he  elearlv 
(iliserved,  Idit  in  other  instances  the  act  of  swallowing,'  may  he  almost  or 
(|iMte  impereeptihle.  Bonveret  considers  the  condition  due  to  a  spasm  of 
the  pharynx  which  causes  involuntary  swullowinj;.  User  has  8U};<;ested  that 
the  air  may  enter  hy  aspiration,  the  stomach  acting'  like  an  elastic  ruhher 
hajJT  which  tends  to  till  aj^ain  after  the  air  is  expressed.  It  is  (piite  possihle 
that  in  some  instances  tiie  eructations  consist  of  yas  which  has  never  actually 
reached  the  stonuich,  but  is  brought  up  from  tiie  (esophagus. 

{(l)  Xervous  YoinUlntj. — A  condition  which  is  not  associated  with  nnn- 
tomical  changes  in  the  stomach  or  with  any  state  of  the  contents,  hut  is  duo 
to  nervous  iniluenees  acting  eithei'  directly  or  indirectly  upon  the  centres 
presiding  over  the  act  of  vomiting.  The  jmtients  are,  as  a  rule,  women — 
usually  brunettes- -and  the  subject  of  more  or  less  marked  hysterical  mani- 
Icstations.  A  special  feature  of  this  form  is  the  absence  of  the  preliminary 
nausea  and  of  the  straining  elt'orts  of  the  ordinary  act  of  vomiting,  it  is 
rather  a  regurgitation,  and  without  visible  etfort  and  without  gagging  the 
mouth  is  tilled  with  the  contents  of  the  stomach,  which  are  then  spat  out. 
It  comes  on,  as  a  v\\\(\  after  eating,  but  may  occur  at  irregular  intervals. 
In  some  cases  the  nutrition  is  not  impaired,  a  feature  which  may  give  a 
clew  to  the  true  nature  of  the  dif^ease,  as  there  nuiy  be  no  other  hysterical 
manifestation  present.  As  )ioted  by  Tuckwell,  it  may  occur  in  children. 
Nervous  vomiting  is  rarely  serious. 

A  tyi)e  of  vomiting  is  that  associated  with  certain  diseases  of  the  nerv- 
ous system — ])articidarly  locomotor  ataxia — forming  part  of  the  gastric 
crises.  Leyden  has  reported  cases  of  primary  periodic  vomiting,  which  he 
regards  as  a  neurosis. 

{e)  Bnmiiiation  ;  Menjntimnn. — Tn  this  remarkable  and  rare  condition 
the  patients  regurgitate  and  chew  the  cud  like  ruminants.  It  occurs  in 
jicurasthenic  or  hysterical  ])ersons,  epileptics,  and  idiots.  In  some  patients 
it  is  hereditary.  There  is  an  instance  in  which  a  governess  taught  it  to  two 
children.  The  habit  may  persist  for  years,  and  does  not  necessarily  impair 
the  health. 

if)  Spasm  of  fhe  Cardin. — Spasmodic,  usually  y)ainful  contraction  of  the 
circular  muscle  fil)res  at  the  cardiac  orifice  may  follow  the  introduction  of 
a  sound,  hasty  eating,  or  the  taking  of  too  hot  or  too  cold  food.  It  may 
occur  in  tetanus  and  also  in  hysterical  and  neurasthenic  individuals,  espe- 
cially in  air  swallowers,  in  whom,  if  it  be  combined  with  pyloric  spasm,  it 
may  result  in  painful  gastric  distention — "  pneumatosis."  Here  the  spasm 
may  be  of  considerable  duration.  The  condition  is  rare  and  practically 
not  of  much  moment. 

(ff)  Pyloric  Spasm. — This  is  usually  a  secondary  occurrence,  following 
snperacidity,  supersecretion,  ulcer,  or  the  introduction  into  the  stomach 
of  irritating  substances.  The  spasm  often  causes  pain  in  the  region  of  the 
liylorus  and  increased  gastric  peristalsis.  In  cases  where  the  spasm  is  com- 
hined  with  snperacidity  and  supersecretion  marked  dilatation  with  atony 
may  folloAv;  it  is  questionable,  however,  whether  a  primary  nervous  pyloric 
ppasm  ever  gives  rise  to  serious  results.     I  have  already  referred  to  John 


f^ 


k  :]• 


600 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


i;^. 


'V 


Tliomson's  views  of  i)yloric  spasm  in  association  with  tlie  coiigciiital  form 
of  iiyiicrtropliif  stt'iiosis  of  the  ])yloru8. 

(//)  Atony  of  the  Stomach. — Motor  insiilViciency  of  the  stomach  is  gen- 
erally due  to  injiulicions  feeding,  to  organic  disease  of  the  stomach  itself, 
or  to  general  wasting  processes.  In  some  otherwise  normal  individuals  of 
neurotic  temperaments  an  atony  may,  however,  occur  which  possil)ly  dc- 
Bervee  to  be  classed  among  the  neuroses.  The  symptoms  are  xisually  those 
of  a  moderate  dilatation,  and  are  often  associated  with  marked  sensory  dis- 
turhances — feelings  of  weight  and  pressure,  distention,  eructations,  and  so 
forth. 

Great  care  must  be  taken  in  the  diagnosis  to  rule  out  all  other  possible 
causes. 

(/)  Insiifficienry  or  Incontinence  of  the  J'l/lorns. — This  condition  was  de- 
scribed first  by  de  Sere  and  later  by  Kbstein.  It  may  be  recognized  by  the 
rajtid  passing  of  gas  from  the  stomach  into  the  bowel  on  attemj)t8  at  infla- 
tion of  the  former,  as  well  as  by  the  presence  of  bile  and  intestinal  contents 
in  the  stomach.    There  are  no  distinctive  clinical  symptoms. 

(j)  Insufficiency  of  the  Cardia. — This  condition  is  only  recognized  by 
the  occurrence  of  eructations  or  in  rumination. 

II.  Secretory  Neuroses. — (a)  Hyperacidity ;  Supcracidity ;  Ifyprr- 
chliirhydria. — Nervous  dyspe])sia  with  hyperacidity  of  the  gastric  juices. 
The  symi)toms  de))end  upon  the  secretion  of  an  abnormally  acid  gastric  juice 
at  the  time  of  digestion.  This  is  a  common  form  of  dyspepsia  in  young  and 
neurotic  individuals.  Osswald  has  pointed  out  its  remarkable  frequency 
in  chlorotic  girls.  The  sym])toms  are  very  variable.  They  do  not,  as  a  rule, 
immediately  follow  the  ingestion  of  food,  but  occur  one  to  three  hours  later, 
at  the  height  of  digestion.  There  is  a  sense  of  weight  and  pressure,  some- 
times of  burning  in  the  epigastrium,  commonly  associated  with  acid  eructa- 
tions. If  vomiting  occurs,  the  pain  is  relieved.  The  ])atient  is  iisually  rela- 
tively well  nourished,  and  the  appetite  is  often  good,  though  the  sufferer 
may  be  afraid  to  eat  on  account  of  the  anticipated  pain.  Its  association 
with  ulcer  has  been  referred  to.    There  is  commonly  constipation. 

{h)  Supersecretion,  Intermittent  and  Continnous. — This  is  a  form  of  dys- 
pepsia which  has  been  long  recognized,  but  of  late  has  been  specially  studied 
by  Reichmann  and  others.  The  increased  flow  of  the  gastric  juice  may  bo 
intermittent  or  continuous.  The  secretion  under  such  circumstances  is 
usually  superacid,  though  this  is  not  always  the  case.  The  periodical  form — 
the  gastroxy.isis  of  Rossbach — may  be  quite  inde])endent  of  the  time  of 
digestion.  Great  quantities  of  highly  acid  gastric  juice  may  be  secreted 
in  a  very  small  space  of  time.  Such  cases  are  rare,  and  are  especially  asso- 
ciated either  wnth  profound  neurasthenia  or  with  locomotor  ataxia.  The 
attack  may  last  for  several  days.  It  usually  sets  in  with  a  gnawing,  unpleas- 
ant sensation  in  the  stomach,  severe  headache,  and  shortly  after  the  patient 
vomits  a  clear,  watery  secretion  of  such  acidity  that  the  throat  is  irritr'^ed 
and  made  raw  and  sore.  As  mentioned,  the  attacks  may  be  quite  inde- 
pendent of  food.  Continuous  supersecretion  is  more  common.  The  con- 
stant presence  of  fluid  in  the  stomach,  together  with  the  pyloric  spasm, 
which  commonly  results  from  the  irritation  of  the  overacid  gastric  juice, 


NEUIIOSKS  OP  TIIK  STOMACH. 


601 


lire  followed  liy  n  more  or  Icsh  extensive  dilatafioii.  Diffesticm  of  tlie  Hvarcheii 
JH  retarded,  and  there  are  eriietations  of  aeid  lliiid  and  j^nislrie  distress, 
'riiia  seeretion  of  lii^ddy  aeid  j^'astrie  juice  may  eonliniu'  wiien  the  stomach  is 
free  from  food.  Jn  these  eases  pain,  burning  neid  eructations,  and  even 
vomitinj;,  occurring  during  the  night  and  early  in  tlie  morning,  arc  rather 
charaeteristie, 

{(•)  Nt'rroiis  kSuhdcidity  or  hiacidHy;  Achijlia  (laslrica  Ncrrosa. — Lack  of 
the  nornud  amount  of  aeid  is  found  in  chronic  caturrii,  aiul  particuhirly  in 
cancer.  As  Leul)e  lias  shown,  a  reduction  in  tlie  normal  amount  of  acid 
may  exist  vith  the  most  pronounced  symptoms  of  nervous  dyspe|*ia  and 
yet  tlie  stomach  will  Ik(  free  from  food  within  the  regular  time.  A  condi- 
tion in  whi'.'h  free  acid  is  absent  in  the  gastric  juice  may  occur  in  cancer, 
in  extreme  sclerosis  of  the  mucous  memhrane,  as  a  nervous  manifestation  of 
hysteria,  and  occasionally  of  tahes.  In  most  of  these  cases,  though  there 
he  no  free  acid,  yet  the  other  digestive  ferments — pe|)sin  and  the  curdling 
ferments — or  their  zymogens  are  to  be  demonstrated  in  the  gastric  juice. 
There  may,  however,  be  a  complete  absence  of  the  gastric  secretion.  To 
these  canes  Kinhorn  has  given  the  name  of  (irhi/lia  (jastrica.  This  condition 
was  at  first  thought  to  occur  only  in  cases  of  total  atrophy  of  the  gastric 
mucosa,  but  recent  observations  have  shown  that  it  may  occur  as  a  neurosis. 
In  a  case  of  Einhorn's  the  gastric  secretions  returned  after  five  years  of  total 
achijlia  gaslrica. 

The  symptoms  of  subacidity,  or  even  of  arlnjUa  i/as(rirn,  vary  greatly 
in  intensity;  they  may  be  almost  or  (piite  al)sent  in  cases  of  advanced  atro- 
pliy  of  tlie  mucosa,  and,  as  a  rule,  are  not  marked  so  long  as  the  motor 
activity  of  the  stomach  remains  good.  Jf  atony,  however,  develop  and  ab- 
normal fermentative  processes  arise,  severe  gastric  and  intestinal  symptoms 
may  follow.  In  the  cases  associated  with  hysteria  and  neurasthenia,  even 
though  the  food  may  be  well  taken  care  of  l)y  the  intestines,  there  arc  very 
commonly  grave  sensory  disturbances  in  the  region  of  the  stomach,  in  ad- 
dition to  the  general  nervous  symptoms. 

III.  Sensory  Neuroses. — (a)  Hypem'sthnsin. — In  this  condition  the  pa- 
tients comiilain  of  fulness,  pressure,  weight,  burning,  and  so  forth,  during 
digestion,  just  such  symptoms  as  aecomi)any  a  variety  of  organic  diseases  of 
the  stomach,  and  yet  in  all  other  respects  the  gastric  functions  appear  quite 
normal.  Sometimes  these  distressing  sensations  are  present  even  when  the 
stomach  is  empty.  These  symptoms  are  usually  associated  with  other  mani- 
festations of  hysteria  and  neurasthenia.  The  jiain  often  follows  particular 
articles  of  food.  An  hysterical  patient  may  ai)i)arently  suffer  excruciating 
liain  after  taking  the  smallest  amount  of  food  of  any  sort,  while  anything 
l)rescribed  as  a  medicine  may  he  well  home.  In  severe  cases  the  patient 
may  he  .educed  to  an  extreme  degree  of  starvation. 

(h)  Gastrahjia;  Gastrodyma. — Severe  pains  in  the  epigastrium,  parox- 
ysmal in  character,  occur  (a)  as  a  manifestation  of  a  functional  neurosis, 
inde])endent  of  organic  disease,  and  usually  associated  with  other  nervous 
pymptoms  (it  is  this  form  which  will  here  he  descrihed);  {h)  in  chronic 
disease  of  the  nervous  system,  forming  the  so-called  gastric  crises;  and  (c) 
in  organic  disease  of  the  stomach,  such  as  ulcer  or  cancer. 


602 


DI.SKAHKS  OF  TIIK   DKJKSTIVP:  SYSTEM. 


■  I, 


; 


/' 


It: 


'Vhv  fimctioiuil  Dcuiosis  ((cciirH  cliiclly  in  wonicii,  vcit  cntiiiiioMly  in  con- 
nection with  (lihtiirltctl  iiiciistriiiil  t'linction  or  witli  itronoiinccd  liystcriciil 
ByniptoniH.  'I'lic  alTcction  niny  net  in  h.h  early  as  juiltcrty,  liut  it  irt  more 
common  at  the  m«'no|»aiiHc.  Ami'tnic,  conHtipatcd  women  wlio  liave  worries 
and  anxieties  at  home  are  most  prone  to  the  all'eetioti.  It  is  more  freciuent 
in  hnineltes  tiian  in  hloncU's.  Attacks  of  it  sometimes  occur  in  rohnst, 
iiealthy  men.  More  often  it  is  only  ono  fcntnre  in  a  condition  of  general 
nenrasthenia  or  a  niiinifestation  of  that  form  of  nervouH  dysjiepsia  in  which 
the  pistrie  juice  or  hydrochloric  acid  is  secreted  in  excess.  I  am  very 
scejitical  as  to  the  existence  of  a  <,'astnil;,'ia  of  purely  malarial  <tri<iin. 

The  symptoms  arc  very  cliaracl<'ristic;  the  patii'iit  is  suddenly  Hoiznl 
with  agonizing'  pains  in  the  epigastrium,  which  pass  toward  the  hack  and 
around  the  lower  rihs.  'V\\v.  attack  is  usually  independent  of  tlu?  taking 
of  food,  and  may  recur  at  delinite  intervals,  a  periodicity  which  has  given 
rise  to  the  supposition  in  some  cases  that  the  atl'ectiori  is  i\\\v  to  malaria. 
The  most  marked  periodicity,  however,  may  he  in  the  gastralgic  attacks  of 
ulcer.  They  fre(|uently  come  on  at  night.  Vomiting  is  rare;  more  com- 
moidy  the  taking  of  food  relieves  the  ])ain.  'I'o  this,  however,  there  are 
striking  exceptions.  Pressure  upon  the  e[)igastrium  commonly  gives  rclii'f, 
hut  deep  pressure  may  he  i)ainful.  It  seems  scarcely  necessary  to  separate 
the  forms,  as  some  have  done,  into  irritative  and  depressive,  as  the  cases 
insensihiy  merge  into  each  other.  Stress  has  heen  laid  upon  the  occurrence 
of  ])ainful  ])()ints,  ])ut  they  are  so  common  in  neurasthenia  that  very  little 
importance  can  he  attributed  to  them. 

The  didtjriosis  offers  many  dilVicuIties.  Organic  disease  either  of  the 
stomach  or  of  the  ner\'ons  system,  ])articularly  the  gastric  crises  of  loco- 
motor ataxia,  nr.ist  he  excluded.  In  the  case  of  idccr  or  cancer  this  is  not 
always  easy.  The  fact  that  the  pain  is  most  marktl  when  the  stomach  is 
empty  and  is  relieved  by  the  taking  of  food  is  sometimes  regarded  as  pathog- 
nomonic of  sim]>lc  gastralgia,  hut  to  this  there  are  many  exceptions,  and 
in  cancer  the  jmins  may  be  relieved  on  eating.  The  prolonged  intervals 
hctwcen  the  attacks  and  their  independence  of  diet  are  im])ortant  features 
in  sim])le  gastralgia;  hut  in  many  instances  it  is  less  the  local  than  the  gen- 
eral sym])toms  of  the  case  which  enahle  us  to  make  the  diagnosis.  It  is  to 
be  remembered  that  in  gall-stone  colic  jaundice  is  frequently  absent,  and  in 
any  long-standing  case  of  gastralgia,  in  which  the  attacks  recur  at  intervals 
for  years,  the  question  of  cholelithiasis  shoidd  be  considered. 

(c)  /  les  of  the  Sense  of  Hiinr/er  and  depletion;  Bulimia. — Ab- 

nori"' '  jssive  hunger  coming  on  often  in  paroxysmal  attacks,  which 

cf  ^-aticnt  to  commit  extraordinary  excesses  in  eating.     This  condi- 

ti  .y  occur  in  diabetes  niellitus  and  sometimes  in  gastric  disorders,  par- 

ticularly those  associated  with  su]iersccretion.  It  is,  however,  more  com- 
monly seen  in  hysteria  and  in  psychoses.  It  may  occur  in  cerebral  tumors, 
in  Graves'  disease,  and  in  epilepsy. 

The  attacks  often  begin  suddenly  at  night,  the  patient  waking  with  a 
feeling  of  faintness  and  pain,  and  an  uncontrollable  desire  for  food.  Some- 
times such  attacks  occur  immediately  after  a  large  meal.  The  attack  may 
be  relieved  by  a  small  quantity  of  food,  while  at  other  times  enormous  quan- 


NKl'UOSKS  OP  THE  STOMAC'U. 


503 


titles  iiiny  ho  tiikcii.     In  (ihntinnto  <s\m'^  pnstritU,  ntouy,  nnd  dilatation  fre- 
(jut'iitly  it'sult  fidiii  till'  alnirtc  of  the  btoniatli. 

Ahuria. — An  ahsi'iici'  of  the  hchho  of  natiety.  'I'hix  coiidition  i«  com- 
monly associated  with  huliniia  and  polyphagia,  hut  not  always.  The  jiatient 
always  feels  "  empty."  There  are  usually  other  well-marked  manifestations 
ui  hysteria  or  neiirasthen  a. 

Aiiiin'.ria  iXerrona. — This  eondition,  whieh  is  a  manifi-station  of  a 
neurotic  temperament,  is  (lisc'U,-se(l  suhseiiueiitly  under  the  general  head- 
ing of  Hysteria. 

'J'rcdhiiciit  of  Neiirnses  of  the  Slomnrh. — The  most  important  part  of  the 
treatment  of  nervous  dyspepsia  is  often  thai  directed  t  >ward  the  im[trnvc- 
ment  of  the  general  j)hysical  and  mental  condition  of  the  patient.  The 
possihility  that  the  symptoms  iiuiy  l)e  of  reilex  origin  should  he  l)orne  in 
mind.  A  large  ))r  /[lortion  of  cases  of  nervous  dyspepsia  are  dcpciKh-nt  upon 
mental  and  physical  e.\ha\istion  or  worry,  and  a  vacation  or  a  change  of 
scene  will  oftt'U  accomplish  what  years  of  treatment  at  home  have  failed 
to  do.  The  numner  of  life  of  the  patient  should  he  investigated  an.l  a 
l»roper  amount  of  ])hysical  exercise  in  the  open  air  insLmed  upon.  'I'his 
alone  will  in  some  cases  he  suilicieiit  to  cause  the  disappearaiu'e  of  the  symp- 
toms. 

IMnny  cases  of  nervous  dyspejisia  with  marked  neurasthenic  or  hysterical 
symptoms  do  well  on  the  Weir-Mitchell  treatment,  and  in  ohstinate  forms 
it  should  he  given  a  thorough  trial.  The  most  striking  results  are  perhaps 
seen  in  the  case  of  anorexia  nervo.'M,  which  will  he  nferred  to  suh.seipiently. 
It  is  also  of  value  in  nervous  vomiting. 

In  cardiac  spasm  care  should  he  taken  to  eat  slowly,  to  avoid  swallow- 
ing too  large  morsels  or  irritating  suhstanee.s.  The  methodical  introduction 
of  thick  sounds  may  he  of  value. 

The  treatment  in  atoin/  of  the  stomach  shoidd  he  similar  to  that  adopted 
in  moderate  dilatation — the  administration  of  small  quantities  of  food  at 
frequent  intervals;  the  limitation  of  tlie  fluids,  which  should  also  he  taken 
in  small  amounts  at  a  time;  lavage.  Strychnine  in  full  doses  may  he  of 
value. 

Tn  the  distressing  cases  of  liyperacidUy,  in  addition  to  the  treatment  of 
the  general  neurotic  condition,  alkalies  must  he  em]doyed  either  in  the 
form  of  magnesia  or  hicarhonate  of  soda.  These  shoidd  he  given  in  large 
doses  and  at  the  height  nf  difji'siion.  The  hurning  acid  eructations  may  he 
relieved  in  this  way.  The  diet  should  he  mainly  alhuminous,  and  should 
he  administered  in  a  non-irritating  form.  Stimulating  condiments  and 
alcohol  should  he  avoided.  Starches  should  he  s])aringly  allowed,  and  only 
in  most  digestihle  forms.    Fats  are  fairly  well  horno. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valua])le  procedure 
in  many  cases  of  dyspepsia  associated  with  hyperacidity.  The  meat  should 
he  taken  either  raw  or,  if  an  insuperahle  ohjection  exists  to  this,  very 
slightly  cooked.  It  is  hest  given  finely  minced  or  grated  on  stale  broad. 
An  ample  dietary  is  3^  ounces  (100  grammes)  of  moat,  two  medium  slices 
of  stale  hrcad,  and  an  ounce  (30  grammes)  of  butter.  This  may  1)0  taken 
three  times  a  day  with  a  glass  of  Apollinaris  water,  soda  water,  or,  what 


1 


504 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


.  \ 
/ 


is  just  as  satisfactory,  s|»rin;j;  water.  The  lliiid  should  not  l)e  taken  too  cold. 
Special  care  should  be  taken  in  the  examination  of  the  meat  to  guard  against 
tape-worm  infection,  hut  suitaljle  instructions  on  this  point  can  l)e  given. 
This  is  suflicient  for  an  adult  man,  and  numy  ohstinate  cases  yield  sitis- 
faetorily  to  a  nu)nth  or  six  weeks  of  this  treatment,  after  which  time  the 
less  readily  digested  articles  of  food  may  be  gradually  added  to  the  dietary. 

In  siipersecretiun  the  use  of  the  stomach-tube  is  of  the  greatest  value. 
In  the  ])eriodical  form  it  should  be  used  as  soon  as  the  attack  begins.  The 
stomach  may  be  washed  with  alkaline  solutions  or  solutions  of  nitrate  of 
silver,  1  to  1,000,  may  be  used.  Where  this  is  impracticable  the  taking  of 
albuminous  food  may  give  relief.  One  of  my  i)atients  used  to  have  two 
hard-l)oiled  eggs  by  his  bedside,  by  the  eating  of  which  nocturnal  attacks 
were  alleviated.    Alkalies  in  large  doses  are  also  indicated. 

In  cases  of  conlinued  sajwrserretion  there  is  usually  atony  and  dilata- 
tion. The  diet  hero  should  be  much  as  in  superacidity,  but  should  be 
adnn'nistered  in  smaller  ([uantities  at  frequent  intervals.  Lavage  with 
alkaline  solutions  or  with  nitrate  of  silver  is  of  great  value.  To  relieve  i)ain 
large  ([U-'ntities  of  bicarbonate  of  soda  or  magnesia  should  be  given  at  the 
height    -  digestion. 

In  suhacidilij  a  carefully  regulated,  easily  digestible  mixed  diet,  not  too 
rich  in  albuminoids,  is  advisable.  liitter  tonics  before  meals  are  sometimes 
of  value.  In  nrhj/lia  (/asfrica  the  use  of  predigested  foods  and  of  hydro- 
chloric acid  in  full  doses  may  be  of  assistance. 

In  marked  hi/pcncsllicsia,  beside  the  treatment  of  the  general  condition, 
nitrate  of  silver  in  doses  of  gr.  ^-^,  taken  in  5  iJj-o  i^  "^  water  on  an  emi)ty 
stomach,  is  advised  ])y  Rosenheim. 

In  some  instances  rectal  feeding  may  have  to  be  resorted  to. 

The  gastralgia,  if  very  severe,  requires  morphia,  which  is  best  admin- 
istered subcuianeously  in  eond)ination  A^ith  atropia.  In  the  milder  attacks 
tlie  combination  of  morphia  (gr.  -^)  with  cocaine  aiul  belladonna  is  ri'com- 
meiided  ])y  Kwald.  The  greatest  caution  should,  however,  be  exercised  in 
these  cases  in  the  use  of  the  hy])odermic  syringe.  It  is  preferable,  if  o])ium 
is  necessarA',  to  give  it  by  the  mouth,  and  not  to  let  the  patient  know  the 
character  of  the  drug.  Chloroform,  in  from  10-  to  20-drop  doses,  or  Ilolf- 
man's  anodyne  will  sometimes  allay  the  severe  pains.  The  general  condi- 
tion should  receive  careful  attention,  and  in  many  cases  the  attacks  recur 
until  the  health  is  restored  by  change  of  air  with  the  ]n'olonged  use  of 
arsenic.  If  there  is  ana'-mia  iron  may  be  given  freely.  Xitrate  of  silver  in 
doses  of  ^v.  I  to  ^  in  a  large  claret-glass  of  water  taken  on  an  em])ty  stomach 
is  useful  in  some  cases. 

There  are  forms  of  nervous  dyspe])sia  occurring  in  women  who  are  often 
well  nourished  and  with  a  good  color,  yet  who  suiter — ])articularly  at  night 
— with  flatulency  and  abdominal  distress.  The  sleep  may  be  quiet  and  un- 
disturbed for  two  or  three  hours,  after  which  they  are  aroused  with  ])ainrul 
sensations  in  the  abdomen  and  eructations.  The  ai)i)etite  and  digestion  may 
ai)iiear  to  be  normal.  Constipation  is,  however,  usually  present.  In  many 
of  these  patients  the  condition  seems  rather  intestinal  dyspepsia,  and  the 
distress  is  due  to  the  accumulation  of  gases,  the  result  of  excessive  putre- 


DISEASES   OF  THE   INTESTINES  ASSOCIATED   WITH   DIAKKHG^A.     5u5 

faction.  The  fats,  starches,  and  sugars  shoukl  be  restricted.  A  diastase 
iVrnu'iit  is  sonictinies  useful.  The  llatulency  may  he  treated  hy  tlie  methods 
altove  meiitione(h  Xaphthaliu,  salicylate  ot  hismuth,  and  saloi  have  heen 
recommended.  Some  of  these  cases  obtain  relief  i'rom  thorough  irrigation 
of  the  colon  at  bedtime. 

The  treatment  oi'  anorexia  nervosa  is  described  subsequently. 


YII.    DISEASES   OF  THE   INTESTINES. 


I.     DISEASES    OF 


THE     INTESTINES 
DIARRHCEA. 


ASSOCIATED    WITH 


CATARRHAL   ENTERITIS;   DIARRIKKA. 

In  tlie  classification  of  catarrhal  enteritis  the  anatomical  divisions  of 
the  bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejuniiis,  dei- 
tis,  ty])hlitis,  colitis,  and  ])roctitis  have  been  recognized;  whereas  in  a 
majority  of  cases  the  entire  intestinal  tract,  to  a  greater  or  lesser  "xtent,  is 
involved,  sometimes  the  small  most  intensely,  sometimes  the  large  bowel; 
but  during  life  it  may  be  quite  imj)ossible  to  say  which  })()rtion  is  specially 
ail'ected. 

Etiology. — 'V\\Q  causes  may  be  either  primnri/  or  scrnudarij.  Among 
the  causes  of  prhnanj  catarrhal  enteritis  are:  {a)  Improper  food,  one  of 
the  most"  fre(|uent,  especially  in  children,  in  whom  it  follows  overeating, 
or  the  ingestion  of  unri|)e  fruit.  In  some  individuals  special  articles  of 
diet  will  always  jjroduce  a  slight  diarrluea,  which  may  not  be  due  to  a 
catarrh  of  the  mucosa,  but  to  increased  peristalsis  induced  by  the  oll'ending 
material.  (/;)  Various  toxic  substances.  -Many  of  the  organic  ])oisons,  such 
as  those  produced  in  the  decomposition  of  milk  and  articles  of  food,  excite 
the  most  intense  intestinal  catarrh.  Certain  inorganic  substances,  as  arsenic 
and  mercury,  act  in  the  same  way.  {r)  Changes  in  the  weather.  A  fall  in 
the  tem])erature  of  from  twenty  to  thirty  degrees,  ])articularly  in  tlie  spring 
or  autunm,  nuiy  induce — ]u)W,  it  is  ditlicult  to  say — an  acute  diarrluea.  We 
speak  of  tliis  as  a  catarrhal  process,  the  result  of  cold  or  of  chill.  On  the 
other  hand,  the  diarrlm^al  diseases  of  children  are  associated  in  a  verj'  spe- 
cial way  with  the  excessive  heat  of  summer  months,  {d)  Changes  in  the 
constitution  of  the  intestinal  secretions.  We  know  too  little  about  the 
SHrru><  enterims  to  be  able  to  speak  of  influences  induced  by  change  in  its 
((uantity  or  quality.  It  has  long  been  held  that  an  increase  in  the  amount 
of  bile  poured  into  the  bowel  might  excite  a  diarrhnoa;  hence  the  term 
bilious  diarrlura,  so  frecpicntly  used  by  the  older  writers.  I'ossibly  there 
are  conditions  in  which  an  excessive  amount  of  bile  is  poured  into  the  intes- 
tine, increasing  the  peristalsis,  and  hurrying  on  the  contents:  but  the  oppo- 
site state,  a  scanty  secretion,  by  favoring  the  natural  fermentative  processes, 
much  more  commonly  causes  an  intestinal  catarrh.  Absence  of  the  y)an- 
creatic  secretion  from  the  intestine  has  been  associated  in  certain  cases  with 


506 


DISEASES  OF   THE   DIGESTIVE   SYSTEM. 


/ 


a  I'iilty  (lianiuoa.  (r)  Morvuu.s  iiilluciice.s.  It  is  by  iiu  incaiis  clear  how 
iiu'iital  .slates  act  upon  the  bowels,  and  yet  it  is  an  old  and  triistwoi'tliy  ob- 
servation, which  every-day  experience  coniirnis,  that  the  menial  slate  may 
Itrofonndly  all't'ct  tlie  intestinal  canal.  These  inliuences  should  not  prdp- 
erly  he  considered  nndci'  calarrhal  processes,  as  they  result  simply  from  in- 
creased peristalsis  or  increased  secretion,  and  are  usually  described  under 
the  heading'  iirrrotis  diarrliKd.  In  children  it  i'reipiently  ImIIows  i'l'ight. 
Jl  is  coniniDii,  too,  in  adults  as  a  I'csult  ol'  emotional  disluriiances.  Can- 
statt  mentions  a  surgeon  who  always  before  an  impoi'taiit  i)pei'ati(Ui  had 
watery  diarrho'a.  In  hysterical  women  it  is  seen  as  an  occasional  occu"- 
rence,  due  to  ti'ansient  excitement,  or  as  a  chronic,  jjrotracted  diarrlue.i, 
w  hicli  may  last  for  nioidhs  or  even  years. 

Amonti;  the  srcoinhiri/  causes  of  intestinal  catai'rh  may  be  mentioned: 
(d)  Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pyaunia.  sc])ti- 
ca'una,  tuberculosis,  and  pneumonia  are  occasionally  associated  with  intes- 
tinal catarrh.  Jn  dysentery  and  typhoid  fever  the  ulceration  is  in  part 
res[)onsil)le  for  the  catarrhal  condition,  but  in  cholera  it  is  ])robal)ly  a  direct 
influence  of  the  bacilli  or  of  the  toxic  materials  produced  by  them.  (/;) 
The  extension  of  inflammatory  processes  from  adjacent  ]iarts.  Thus,  in 
])eritonitis,  catarrhal  swelliuii'  fiud  increased  secretion  ai'c  always  present  in 
the  mucosa.  In  cases  of  invagination,  henna,  tuljcrcuhms  or  cancerous  ul- 
ceration, catarrhal  processes  arc  common,  (r)  Cii'culatory  disturbances 
cause  a  catarrhal  enteritis,  usually  of  a  very  chroinc  character.  This  is 
common  in  diseases  of  the  liver,  such  as  cirrhosis,  and  in  chronic  affections 
of  the  lieart  and  hmgs — all  conditions,  in  fact,  Mhich  ])roducc  engorgement 
of  the  terminal  l)ranches  of  the  ])ortal  vessels,  (d)  Jn  the  cachectic  condi- 
tions met  with  in  cancer,  })rpfound  ana'mia,  Addis(m's  disease,  and  liriglit's 
disease  intestinal  catarrh  may  develo]),  and  may  terminate  life. 

Morbid  Anatomy. — Changes  in  the  nuicous  membrane  are  not  al- 
ways visible,  and  in  cases  in  which,  during  life,  the  symptoms  of  intestinal 
catarrh  Imve  been  marked,  neither  redness,  swelling,  nor  increased  secre- 
tion— the  three  signs  usually  laid  down  as  characteristic  of  catarrhal  inflam- 
mation— may  be  present  ]iost  mortem.  It  is  rare  to  see  the  nuicous  mem- 
brane injected;  more  commonly  it  is  pale  and  C(jvered  with  mucus.  In 
the  upper  part  of  the  small  intestine  the  i\]n  of  the  valvula^  conniventes 
may  be  deeply  injected.  Even  in  extreme  grades  of  portal  obstruction  in- 
tense hyi)era^nna  is  not  often  seen.  The  entire  mucosa  may  ])e  softened  and 
infiltrated,  the  lining  epithelium  swollen,  or  even  shed,  and  ap])earing  as 
large  flakes  among  the  intestinal  contents.  This  is,  no  doubt,  a  ]iost-mor- 
tem  change.  The  lym])h  follicles  are  almost  always  swollen,  ])articularly 
in  children.  The  Peyer's  ]iatches  may  be  prominent  and  the  solitary  fol- 
licles in  the  large  and  small  bowel  may  stand  out  with  distinctness  and 
present  in  the  centres  little  erosions,  the  so-called  follicidar  ulcers.  This 
may  be  a  striking  feature  in  the  intestine  in  all  forms  of  catarrhal  enteritis 
in  children,  quite  irrespective  of  the  intensity  of  the  diarrhfoa. 

AAlien  the  process  is  more  chronic  the  mucosa  is  firmer,  in  some  instnnces 
thickened,  in  others  distinctly  thinned,  and  the  villi  and  follicles  present  a 
slaty  pigmentation. 


OISKA.SKS  OF  THE   INTESTINES   ASSOCIATED   WITH   DIAHKIKEA.     507 


Symptoms. — Acuto  .md  cliroiiic  forms  may  1)o  rcco^nii/i'd.  Tho  im- 
linrtaiil  >yiii[it()iii  of  Itotli  is  dianlio'ii,  which,  in  tiic  iiiajorily  of  instancos, 
is  tiic  solu  indication  of  this  condition.  It  is  not  to  he  supposed  tliat  diar- 
rlio'a  is  invariahly  t'auscd  hy,  or  associated  witli,  calai'rhal  entei'itis,  as  it 
may  l»e  pi'odiiced  hy  nervous  and  other  inthiences.  It  is  |tr()hal)le  that 
catarrh  of  the  jejunum  may  exist  without  any  diarriuea;  iniK'ed,  it  is  a 
very  common  cii'ciimstance  to  lind  post  mortem  a  catai'riial  state  of  the 
small  howel  in  persons  who  have  not  liad  diarriuea  (hiring'  life.  'Die  stools 
vary  extremely  in  ehai'acter.  Tlie  color  depends  upon  the  amount  of  hile 
with  which  they  are  nuxed,  and  tluy  may  lie  of  a  dark  or  hlackish  hrown, 
or  of  a  li^iit-yellow,  or  even  of  a  grayish-white  tint.  The  consistence  is 
usually  very  thin  and  watery,  Ijut  in  some  instances  the  stools  are  ])ultaceous 
like  thin  j^ruel.  I'ortions  of  nndi<iested  food  can  often  ho  seen  (lienterie 
diarrh(i'a),  and  flakes  of  yellowish-hrown  mucus.  .Microscopically  there 
are  innumeralile  niicro-ori:anisms,  epithelium  and  mucous  cells,  crystals  of 
l»hos|)hate  of  lime,  oxalate  of  lime,  and  occasionally  eholesterin  and  Char- 
cot "s  crystals. 

Pain  in  the  ahdomen  is  u>nally  present  in  the  acute  catarrhal  enteritis, 
particularly  when  due  to  food.  It  is  of  a  colicky  character,  and  when  the 
colon  is  involved  there  may  he  tenesmus.  More  or  less  tympanites  exists, 
and  there  are  gurgling  noises  or  horhorygmi,  due  to  the  ra])id  passage  of 
fluid  and  gas  from  one  ])art  to  anotlier.  In  the  veiy  acute  attacks  there 
may  he  vomiting.  Fever  is  not,  as  a  rule,  present,  hut  there  may  be  a 
slight  elevation  of  one  or  two  degrees.  The  appetite  is  lost,  there  is  intense 
thirst,  and  the  tongue  is  dry  and  coated.  In  very  acute  cases,  wlien  the 
(juantity  of  lluid  lost  is  great  and  the  ]iain  excessive,  there  may  be  collaj)se 
sym])toms.  The  number  of  evacuations  varies  from  four  or  iivc  to  twenty 
or  more  in  the  course  of  the  day.  The  attack  lasts  for  two  or  three  days, 
or  may  be  prolonged  for  a  week  or  ten  days. 

Chronic  catarrh  of  the  bowels  may  follow  tlie  acute  form,  or  may  de- 
velop gradually  as  an  inde])endent  affection  or  as  a  sequence  of  obstruction 
in  the  ])ortal  circulation.  Tt  is  characterized  by  diarrluea,  with  or  without 
colic.  The  dejections  vary:  when  the  snudl  Itowcl  is  chiefly  involved  the 
diarrluea  is  of  a  lienlei'ic  character,  and  when  the  colon  is  atfected  the 
stools  are  thin  and  mixed  with  much  mircus.  A  special  form  of  mucf)us 
diarrha'a  will  be  subsequently  described.  The  general  nutrition  in  these 
chronic  cases  is  greatly  disturbed;  there  may  l;e  nuu-li  loss  of  flesh  and 
great  pallor.  The  patients  are  inclined  to  sutler  from  low  spirits,  or  hypo- 
chondriasis may  develop. 

Diagnosis. — It  is  im])ortant,  in  tlu;  first  place,  to  determine,  if  pos- 
sible, whether  the  large  or  small  bowel  is  ciiietly  affected.  In  catarrh  of 
the  small  bowel  the  diarrluea  is  less  marked,  the  ]iains  are  of  a  colicky  char- 
acter, l)orbon-gmi  are  not  so  frequent,  the  fa>ces  usually  contain  portions 
of  food,  aiul  are  more  yellowish-trreen  or  grayish-yellow  and  flocculent  and 
do  not  contain  much  mucus.  "When  the  large  intestine  is  at  fault  there 
mav  be  no  pain  whatever,  as  in  tho  catarrh  of  the  large  intestine  associated 
with  tuberculosis  and  Bright's  disease.  When  present,  the  pains  are  most 
intense  and,  if  the  lower  portion  of  the  bowel  is  involved,  there  may  be 


508 


DISBLVSES  OP  THE  DIGESTIVE  SYSTEM. 


marked  tcncsinus.  Tlic  stools  liavc  a  iinif(jnn  soupy  consistence;  they  are 
grayish  in  color  and  granular  throughout,  with  here  and  there  flakes  of 
mucus,  or  they  may  contain  very  large  quantities  of  mucus. 

There  are  no  positive  symjitoms  l)y  whieii  the  diagnosis  of  duodenitis 
can  he  made.  Jt  is  usually  associated  with  acute  gastritis  and,  if  the  process 
extends  into  the  Ijile-duct,  with  Jaundice.  Neither  jejunitis  nor  ileitis  can 
be  separated  from  general  intestinal  catarrh. 


/ 


ENTERITIS  IN  CHILDREN. 

We  may  recognize  three  forms:  (1)  Tlie  acute  d3'speptic  diarrhcoa;  (2) 
cholera  infantum;  and  (;!)  acute  entero-colitis. 

General  Etiology  of  the  Diarrhoeas  of  Children. — The  dis- 
ease is  must  frequent  in  artilicially  fed  children,  and  the  greatest  number 
of  cases  occur  between  tiie  ages  of  six  and  eighteen  months.  A  })opular  and 
well-founded  belief  ascribes  special  danger  to  the  second  summer  of  the  in- 
fant. Infantile  diarrluea  is  very  prevalent  among  the  ])oorer  classes  in  the 
large  cities.  It  attacks,  however,  children  with  tlie  most  favorable  sur- 
roundings. Two  factors  inlhience  the  disease,  diet  and  temperature.  An 
immense  majority  of  all  fatal  cases  are  artificially  fed.  Of  1,943  fatal  cases 
in  Holt's  statistics,  only  three  per  cent  were  exclusively  breast  fed.  Among 
the  poor  the  bowel  complaint  in  children  begins  with  the  artificial  feeding. 
The  relation  of  temperature  to  the  ])revalence  of  diarrlueal  diseases  in  chil- 
dren has  long  been  recognized.  The  mortality  curve  begins  to  rise  in 
JMay,  increases  in  June,  reaches  the  maximum  in  July,  and  gradually  sinks 
through  August  and  Se])tember.  The  maximum  corresponds  closely  Avith 
the  higliest  mean  temperature;  yet  we  cannot  regard  the  heat  itself  as  the 
direct  agent,  but  only  as  one  of  several  factors.  Thus  the  mean  temper- 
ature of  Jime  is  only  four  or  five  degrees  lower  than  that  of  July,  and  yet 
the  mortality  is  not  more  than  one  third.  Seibert,  who  has  carefully  ana- 
lyzed the  mortality  and  the  tem]i"rature,  month  by  month,  in  Xew  York, 
for  ten  years,  fails  to  find  a  constant  relation  between  tlie  degree  of  heat 
and  the  number  of  cases  of  diarrhoea.  Neither  barometric  pressure  nor 
humidity  appears  to  have  any  influence. 

Relation  of  Bacteria. — The  healthy  faeces  of  sucklings  contain  a 
number  of  bacteria  and  micrococci,  the  most  im])ortant  of  which  are  the 
hacterium  lactis  aeroc/enes  and  the  harfenuiii  roll  conimuiic.  The  former  is 
only  present  in  the  intestine  after  a  milk  diet,  the  milk  sugar  a])pearing  to 
furnish  the  materials  necessary  for  its  growth.  It  occurs  rather  in  the 
u])]icr  ])ortion  of  the  bowel,  and  in  this  region  excites  the  fermentative 
])rocesses  in  the  milk.  The  hacterium  coli  commune  is  found  more  abun- 
dantly in  the  lower  portion  of  the  small  intestine  and  in  the  colon,  and  ex- 
cites fermentative  changes  which  are  probably  associated  with  certain  phases 
of  digestion.  The  ol)servations  of  Escherich  show  the  remarkable  simplic- 
ity of  this  bacterial  vegetation  in  the  healthy  fteccs  of  milk-fed  children,  as 
these  two  organisms  alone  develo])  and  are  constant.  In  infantile  diarrhwa 
the  number  of  bacteria  which  may  be  isolated  from  the  stools  is  remarkable. 
Booker  has  discriminated  forty  varieties,  the  greatest  number  of  which  were 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH   DIAKUIKEA.     Sgy 


found  in  tlie  cases  of  cholcni  infantiini.  The  two  constant  forms  noted 
aliove  do  not  disai)[)ear  in  tlu'  diarrlKeal  stools.  No  forms  have  heen  found 
to  hear  a  constant  or  s|iecilie  n-hition  to  the  diarrhu'al  fa'ces,  such  as  the 
two  ahove  mentioned  (h)  to  tiie  heahliy  milk  fieces.  'Vhc  hacteria  of 
the  ])rolcus  group  are  most  freijuent,  and  })ossess  ])athoj'enic  ])ro[)erties. 
All  the  varieties  develop  and  i)roduce  important  changes  in  the  milk,  which 
have  heen  dealt  with  very  fully  hy  Hooker  in  his  exhaustive  monograph 
(Johns  Jl()]>kins  Hospital  Ifejiorts,  vol.  vi).  This  author  concludes  that  in 
the  diarrhu'a  of  infants  "not  one  s])ecific  kind,  but  many  dilferent  kinds 
of  hacteria  are  concerned,  and  that  their  action  is  manifestiMl  more  in  the 
alteration  of  the  food  and  intestinal  contents  and  in  the  production  ol'  in- 
jurious ])roducts  than  in  a  direct  irritation  '])on  the  intestinal  wall."  With 
these  agree  the  conclusions  of  Jeffries  and  liaginsky  regarding  cholera  in- 
fantum. 

Morbid  Anatomy. — We  find  most  fre(piently  a  catarrhal  swelling 
of  the  mucosa  of  hoth  small  and  large  bowel  with  enlargement  of  the  lymph 
follicles.  In  more  chronic  cases  the  latter  show  small  erosions  or  follicular 
ulcers;  more  rarely  there  is  crouj)ous  enteritis  affecting  the  lower  part  of 
the  ileum  and  the  colon.  The  changes  in  the  other  organs  are  neither 
numerous  nor  characteristic.  r)r()ncho-])neum..nia  occurs  in  many  cases. 
The  spleen  may  be  swollen.  ]>rain  lesions  are  rare;  the  mend)rtines  and 
substance  are  often  anivmic,  but  meningitis  or  throndjosis  is  very  un- 
common. 

Clinical  Forms.— Acute  Dyspeptic  Diarrhoea. — The  child  nuiy  ap- 
])car  in  its  usual  health,  but  has  an  increase  in  the  niuuber  of  stools,  with- 
out fever  or  special  disturl)ance  exce])t  slight  restlessness  at  night.  After 
I)ersisting  for  a  day  or  two  the  stools  become  more  frequent  and  contain 
undigested  food  and  curds,  and  are  very  offensive.  In  other  cases  the  dis- 
ease sets  in  a1jru])tly  with  vomiting,  griping  ])ains,  and  fever,  which  may  rise 
rapidly  and  reach  10-1°  or  105°.  There  may  be  convulsions  at  the  outset. 
The  abdomen  is  sensitive,  and  the  child  lies  with  the  legs  drawn  up.  The 
stools  consist  of  grayish  or  greenish-yellow  faeces  mixed  with  gas,  curds,  and 
portions  of  food.  In  children  over  two  years  of  age  such  attacks  not  infre- 
quently follow  eating  freely  of  unripe  fruit  or  the  drinking  of  milk  which 
has  been  tainted.  With  judicious  treatment  the  children  improve  in  a  few 
days;  but  rela]ises  are  v^t  uncommon,  and  in  the  hot  weather  the  attack 
may  be  tbe  starting  ]ioiut  of  a  severe  cntcro-colitis.  In  a  del)ilitated  child 
a  mild  attack  may  ])rove  fatal.  This  dysjjcptic  diarrluea  is  distinguished 
sharply  from  cholera  infantum  by  the  character  of  the  stools,  which  never 
have  a  watery,  serous  character.  In  many  instances  this  form  ]H'ecedes  the 
onset  of  the  specific  fevers,  ])artic\darly  during  the  hot  weather. 

Cholera  Infantuin. — This  is  by  no  means  so  common  as  the  ordinary 
dys])e])tic  diarrhoea  of  children,  and,  according  to  Holt,  occurs  only  in  two 
or  three  per  cent  of  the  cases  of  summer  diarrluioa.  It  prevails  in  tbe  hot 
weather  and  in  children  artificially  fed  or  who  have  bad  previously  some 
slight  dyspeptic  derangement.  It  is  characterized  by  vomiting,  uncon- 
trollable diarrh(Pa,  and  collapse.  The  disease  sets  in  with  vomiting,  which 
is  incessant  and  is  excited  by  an  attempt  to  take  food  or  driidc.     The  stools 


510 


DISKASKS   OV  TllK    DIGESTIVK   SVSTKM. 


/ 


lire  pi'ol'iiSL'  iUid  ri('([ii(.'iit ;  at  i'lrst  la'cal  in  iluinicU'i',  lu'owii  nv  ycllnw  in 
color,  and  llnaliy  thin,  .-irons,  and  watery.  Tlii'  .-tools  lirsl  pas.-cd  aii'  wry 
oll'cnsiivo;  !?nlisi'([ncnlly  llicy  arc  odoilcss.  Tlio  thin,  scruns  stools  are  alka- 
line. There  is  lever,  lint  the  axillary  leinperatnie  may  re>,dster  three  or 
more  degrees  lielow  that  of  the  reetnm.  l''rom  the  outset  there  i.s  marked 
prostration;  the  eyes  are  sunken,  the  features  pinehed.  the  fontaiielle  de- 
jiressed,  and  the  skin  Juis  a  jieenliar  ashy  jiallor.  At  iirst  restless  and  e.\- 
eitt'd,  the  child  sul)se(iuently  becomes  heavy,  dull,  and  listless.  The  tongue 
is  coated  at  the  on.-et,  hut  suhseqiienlly  hecouics  red  ami  ilry.  As  in  all 
choleraie  conditions,  the  thirst  is  insatial)h';  the  pidse  is  rapid  and  feehle, 
and  towai'd  the  end  heconu's  i.regidar  and  inipt'rceplihle.  Death  may 
occur  within  twenty-four  hours,  with  symptoms  of  collapse  and  givat  eleva- 
ti<ni  of  the  internal  tejn[>erature.  JJcl'ore  the  eJid  the  diarrluea  and  vom- 
iting may  cease.  In  other  instances  the  intense  symptoms  sidiside,  hut  the 
child  remains  torpid  and  senu-conuitose  with  lingers  clutched,  and  thei'e 
may  he  convulsiotis.  The  head  may  ''■'  retracted  ami  the  respirations  in- 
terru])ted,  irregidar,  and  oi'  the  I'heyne-Stoki's  type.  The  child  may  re- 
main in  this  condition  for  some  days  without  any  signs  of  improvement. 
It  Avas  to  tJiis  groiijj  of  symptoms  in  infantile  diarrho-a  that  Marshall  Jlall 
gave  the  term  "  liydrencepJniloid  "'  or  spurious  hydrocei)halus.  xVs  a  rule, 
no  changes  in  the  hrain  or  other  organs  arc  found,  and  the  condition  is  no 
douht  caused  hy  the  to.vic  agents  ah-sorhed  from  the  intestine.  A  remark- 
ahle  condition  of  sclerema  is  described  as  a  setiuel  of  cholera  infantum. 
The  skin  and  subcntaneou.*  tissues  become  luird  and  lirni  and  the  appear- 
ance has  heen  com])ared  to  that  of  a  half-frozen  cadaver. 

No  constant  oi'ganism  has  heen  found  in  these  cases.  Baginsky  con- 
siders the  disease  the  result  of  the  action  on  the  system  of  the  poisonous 
products  of  decomposition  encouraged  by  the  various  bacteria  present — a 
Fit  111  n  if!  ft  disease.  'J'lie  clinical  picture  is  that  produced  by  an  acute  bac- 
terial infection,  as  in  Asiatic  cholera. 

The  (liai/iKiftis  is  readily  made.  There  is  no  other  intestinal  affection  in 
children  for  which  it  can  be  mistaken.  The  constant  vomitiiig,  the  fre- 
([uent  Avatery  discharges,  the  collapse  syni]»toms,  and  the  elevated  tem])er- 
ature  make  an  unmistakable  clinical  ])icture.  The  outlook  in  the  majority 
of  cases  is  liad,  particularly  in  children  artificially  fed.  Hyneqjyrexia,  ex- 
treme collai;se,  and  incessant  vomiting  are  the  most  serious  symptoms. 

Acute  Entero-COlitis. — In  this  form  the  ileum  and  colon  are  most  af- 
fected, chiefly  in  the  lym]ib  follicles,  hence  the  term  follicular  enteritis  or 
follicidar  dysentery.  Catarrhal  idccration  is  a  common  se(|uem-e.  \t  oc- 
curs most  fre(piently  in  warm  weather,  in  artificially  fed  children;  but  it 
may  set  in  at  any  season  of  the  year,  and  is  the  form  of  enteritis  most 
common  as  a  secondary  comjilication  in  the  s]iecific  fevers  of  childhood. 

The  attack  may  follow  the  ordinary  dysi)e])tic  diarrhoea.  The  temper- 
ature increases,  the  .stools  change  in  character  and  contain  races  of  blood 
and  mucus,  the  former  usually  only  in  streaks.  The  fa-ces  are  ])assed  with- 
out any  pain.  The  abdomen  is  distended  and  tender  along  the  line  of  the 
colon.  Vomiting  may  be  i»ro?ent  nt  the  outset,  but  is  not  a  characteristic 
feature,  as  in  cholera  infantum.     The  diarrluea  may  be  gradually  checked 


DISKASKS   OV   THP]   INTESTIXKS   ASSOflATKD   WITH    Dl AKUIKKA.     511 

iiiid  ((invaU'.sci'nce  \s  estublif-la'd  in  two  >n-  tlirt't'  wucks;  in  other  instances 
tliu  disoasf  Iji'conu's  sultaciitc,  tlio  i'uvcr  suhsidosi,  Itiit  tin-  diarrluL'u  persists 
iiiid  the  general  health  of  the  ehild  rapidly  deteriorates.  The  ease  may 
di'a;j;  on  I'or  five  or  six  weeks,  when  ini[irovt'nient  gradually  oceurs  or  the 
ehild  is  earried  olf  Ity  a  severe  intercnrrent  attack,  in  a  third  form  of 
acute  entero-colitis,  in  which  anatonucally  the  lesions  are  those  already 
mentioned — namely,  an  intcTise  follieidar  inllammation — tlii'  symptoms  are 
of  a  more  severe  character,  and  the  aU'eclion  is  sometimes  spoken  of  as  aciit(! 
dysentery.  It  attacks  children  n[)  to  the  third  or  fourth  year  or  even  older. 
'The  onset  is  sudden,  with  high  fever,  vomiting,  i'reiiuent  stools,  which  at 
lirst  contain  remnants  of  food  and  fa-ces  and  snl)se(|uently  much  mucus  and 
some  blood.  There  is  iiu-essant  pain,  wiiich  may  he  more  severe  than  in 
any  intestinal  all'ectiou  of  childhood.  The  prostration  is  very  great  and 
the  fatal  termination  may  occur  within  forty-eight  hours.  More  commonly 
the  case  lasts  for  a  week  or  longer. 

The  CoBliac  Affection. — Under  this  heading  (ieo  has  descrihi'd  an  intes- 
tinal disorder,  most  commonly  met  with  in  children  between  the  ages  of 
one  and  iive,  characterized  by  the  occurrence  of  [)ale,  loose  stools,  not  un- 
like gruel  or  oatmeal  porridge.  They  are  bulky,  not  watery,  yeasty,  frothy, 
and  extremely  olVensive.  The  atl'ection  has  received  various  names,  such  as 
iliarrlia'U  (illni  or  duirrliau  cliiflosd.  It  is  not  associated  with  tuberculous 
or  other  hereditary  disease.  It  begins  insidiously  and  there  are  progressive 
wasting,  weakness,  and  pallor.  The  belly  becomes  (h»ughy  and  inelastic. 
There  is  often  flatulency.  Fever  is  usually  absent.  The  disea.se  is  linger- 
ing and  a  fatal  termination  is  connnon.  So  far  nothing  is  kiu)wn  of  the 
pathology  of  the  disease.  L'lceration  of  the  intestines  has  been  met  with, 
but  it  is  not  constant. 

Sprue  or  Psilosis. — A  remarkalde  disease  of  the  tro|>ies,  character- 
ized by  "a  ])eculiar,  inflamed,  sui)erficially  idcerated,  exceedingly  sensitive 
condition  of  the  mucous  membrane  of  the  tongue  and  mouth;  great  wast- 
ing and  ana'uua;  jtale,  co])ious,  and  often  loose,  fre([nent,  and  frothy  fer- 
menting stools;  very  generally  by  nu)re  or  less  diarrlujea;  and  also  by  a 
marked  tendency  tf)  rehipse  "  (^[anson). 

It  is  very  ]»revalent  in  India,  China,  and  Java.  Xotliing  <h'fiiiite  is 
known  as  to  its  cause. 

When  fully  established  the  chief  symptoms  are  a  disturbed  condition  of 
the  bowels,  ])ale,  yeasty-looking  stools,  a  raw,  hare,  sore  condition  of  the 
tongue,  mouth,  and  gullet,  scmietimes  with  actual  superficial  ulceration. 
With  these  gastro-intestinal  symptoms  there  are  associated  anaemia  and 
general  wasting.  It  is  very  chronic,  with  numerous  relapses.  There  are 
no  characteristic  anatomical  changes.  There  are  usmilly  ulcc\i's  in  the 
(•(lion,  and  the  French  think  it  is  a  form  of  dysentery. 

^lanson  recommends  rest  and  a  nn'lk  diet  as  curative  in  a  large  ])ropor- 
tion  of  the  cases.  The  recent  mono<ira])h  hy  Thin  and  the  article  hy  Man- 
son  in  Allbutt's  System  give  very  full  descriptions  of  the  disease. 


32 


512 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


/ 


DIPIITIIElilTIC  OH  CROUPOUS  ENTERITIS. 

A  croii])niis  (ir  (liplitlu'ritio  inllaminatioii  of  the  nuicosii  of  tlie  small 
Hiul  lar^o  iiitt'htiiu's  occurs  (a)  niosl  frc(jiR'nlly  as  u  secondary  process  in  the 
infectious  diseases — i)neunionia,  pyivnda  in  its  various  forms,  and  ty[)hoid 
fever;  (b)  as  a  terndnal  ])rocess  in  many  chroiuc  all'ections,  such  as  IJrighfs 
disease,  cirrhosis  of  the  liver,  or  cancer;  and  (r)  as  an  elVect  of  certain  \ny\- 
sons — mercury,  lead,  and  arsenic. 

'J'liere  are  three  diifcrent  anatonncal  pictnies.  In  one  groui)  of  eases 
tilt!  mucosa  presents  on  the  top  of  Hie  folds  a  thin  grayish-yellow  di[)h- 
theritic  exudate  situated  uj)on  a  (lee])ly  congested  hase.  In  some  cases  all 
grades  may  he  seen  hetween  the  thinnest  film  of  sujjerlicial  necrosis  and  in- 
volvement of  the  entire  thickness  of  the  mucosa.  Jn  the  colon  similiir 
transver.sely  arranged  ai'eas  of  necrosis  are  seen  situated  upon  hypera'mic 
patches,  and  it  may  he  here  much  more  extensive  and  involve  a  large  ])i)r- 
tion  of  the  memhrane.  There  may  he  most  extensive  iidlammatioii  without 
any  involvement  of  the  solitary  follicles  of  the  large  or  small  bowel. 

In  a  second  grou])  of  cases  the  memhrane  has  rather  a  croupous  charactei'. 
It  is  grayish  white  in  color,  more  Ikke-likc  and  extensive,  limited,  perha])s, 
to  the  ca'cum  or  to  a  ])orti()n  of  the  colon;  thus, in  several  cases  of  pneumonia 
I  found  this  ilaky  adherent  false  menihrano,  in  one  instance  forming  patches 
1  to  !^  cm.  in  diameter,  which  were  iiot  uidike  in  form  to  ru[)ia  crusts. 

In  a  third  group  the  affection  is  really  a  follicular  enteritis,  involving 
the  solitary  glands,  which  arc  swollen  and  capped  with  an  area  of  diph- 
theritic necrosis  or  are  in  a  state  of  su])puration.  Follicular  ulcers  are  com- 
mon in  this  form.  The  disease  may  run  its  course  without  any  symjjtoms, 
and  the  condition  is  unexpectedly  met  with  post  mortem,  in  other  in- 
stances there  are  diarrha-a,  pain,  hut  not  often  tenesmus  or  the  ])assage  of 
hlood-stained  mucus.  In  the  toxic  cases  the  intestinal  symptoms  may  he 
very  marked,  l)ut  in  the  terminal  colitis  of  the  fevers  and  of  constitutional 
affections  the  sym])toms  are  often  trifling. 

The  ulcerative  colitis  of  chronic  disease  may  he  only  a  terminal  event 
in  these  diphtheritic  processes. 

PULEGMOXOUS  ENTERITIS. 

As  an  independent  affection  this  is  excessively  rare,  even  less  frequent 
than  its  counterjiart  in  the  stomach.  It  is  seen  occasionally  in  connection 
■with  intussusceiition,  strangulated  hernia,  and  chronic  ohstruction.  Apart 
from  these  conditions  it  occurs  most  frequently  in  the  duodenum,  and  leads 
to  suppuration  in  the  suhmucosa  and  ahscess  formation.  Exce])t  wlicn 
associated  with  hernia  or  intussusception  the  affection  cannot  he  diagnosed. 
The  symptoms  usually  rosemhlo  those  of  peritonitis. 

ULCERATIVE  ENTERITIS. 

In  addition  to  the  specific  ulcers  of  tuherculosis,  syphilis,  and  typhoid 
fever,  the  following  forms  of  ulceration  occur  in  the  liowels: 

(^r)  Follicular  Ulrcrafion. — As  previously  mentioned,  this  is  met  witli 
very  commonly  in  the  diarrhoeal  diseases  of  children,  and  also  in  the  sec- 
ondary or  terminal  inflammations  in  many  fevers  and  constitutional  disor- 


PISEASKS  OF   THE   INTESTINES  ASSOflATED   WrTFI    DIAIflilKKA.     5i;{ 


itional 


event 


leetinn 

Apart 

(1  loads 

when 

niosed. 


t  witli 
le  sec- 
disor- 


ders. 'I'lie  ulcers  are  small,  punched  oiil,  witli  sharply  cut  t'du'cs,  nnd  they 
are  usually  limited  to  the  I'ollieles.  With  this  I'orm  may  he  plact'd  the 
catarrhal  uli'crs  of  some  writers. 

(h)  Slnriinil  ulcers,  which  (tccur  in  lonj;  standing  eases  oC  constipation. 
\'cry  reiuarkahio  indeed  arc  the  cases  in  which  the  saceuli  of  thi'  colon  he- 
come  tilled  witli  rounded  snudl  scyhala,  some  of  which  produce  distinct 
ulcers  in  the  mucous  mendtraue.  The  ficcal  masses  may  have  lime  salts 
deposited  in  them,  and  thus  I'orm  little  enteroliths. 

{(•)  Simple  i'lreralive  ColHis. — 'J'his  ntreetion,  which  clinically  is  char- 
acterized hy  diarrlnea,  is  often  regarded  wrongly  as  a  form  of  dy.sentery. 
It  is  not  a  very  uncommon  all'ection,  and  is  most  fre(pient!y  met  witii  in 
men  ahove  the  middle  ])eriod  of  life.  'J'he  ulceration  may  he  very  exten- 
sive, so  that  a  large  pro])orti()n  of  the  niucosu  is  removed.  The  lumen  of 
the  colon  is  sometimes  greatly  increased,  and  the  muscular  walls  hy))er- 
trophied.  There  are  instances  in  which  the  howel  is  contracted.  Fre- 
(piently  the  remnants  of  the  mucosa  are  very  dark,. even  hiack,  and  there 
may  he  polypoid  outgrowths  hetween  the  idcers. 

These  cases  rarely  come  under  ohservation  at  the  outset,  and  it  is  dilli- 
cult  to  s[)oak  of  the  mode  of  origin.  They  are  characterized  hy  diarrluca 
of  a  lienteric  rather  than  of  a  dysenteric  character.  There  is  rarely  hlood  or 
]ius  in  the  stools.  Constipation  may  alternate  with  the  diarrlnea.  There 
is  usually  great  imi)airment  of  nutrition,  and  the  patients  get  weak  and 
sallow.     Perforation  occasionally  occurs. 

The  disease  may  prove  fatal,  or  it  may  pass  on  and  hocome  chronic. 
The  aU'ection  was  not  very  infrecpient  at  the  Philadelphia  Hospital,  and 
though  the  disease  hears  some  resemhlance  to  dysentery,  it  is  to  he  se[)a- 
rated  from  it.  Some  of  the  cases  which  wo  have  learned  to  recognize  as 
anuchic  dysentery  resemhle  this  form  very  closely.  An  excellent  descrij)- 
tion  of  it  is  given  hy  Hale  White  in  Allhutt's  System.  The  nlcerative 
colitis  met  with  in  institutions,  such  as  that  descriljed  hy  (Jemmel,  of  the 
Lancaster  Asylum,  in  a  recent  monograj)!!,  seems  to  he  a  true  dysentery. 
Dickinson  has  descrihed  what  he  calls  alhnminuric  ulceration  of  the  howels 
in  cases  of  contracted  kidney. 

(d)  Vlccralxon  from  Exlernal  Perforafion. — This  may  result  from  tlie 
erosion  of  new  growths  or,  more  commonly,  from  localized  i)eritonitis 
with  ahscess  formation  and  perforation  of  the  howel.  ^rhis  is  met  with 
most  frequently  in  tuhorculous  peritonitis,  hut  it  may  occur  in  the 
ahscess  Mdiich  follows  perforation  of  the  "n])endix  or  su]))iurative  or 
gangrenous  ])ancreatitis.  Fatal  ha-morrhage  may  result  from  the  ])crfora- 
tion.  % 

(c)  Caiirrrmis  Twicers. — Tn  very  rare  instances  of  multi]ile  cancer  o  sar- 
fouia  the  suhmucous  nodules  hreak  down  and  ulcerate.  Tn  one  case  the 
ileum  contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  extensive 
s^arcoma  in  the  neighhorliood  of  the  shoulder-joint. 

(f)  Occasionally  a  snlifari/  ulcor  is  met  with  in  the  ca"'cum  or  colon,  wliich 
may  lead  to  ]ierforation.  Two  instances  of  ulcer  of  the  caecum,  liotli  with 
|M'rforation,  have  come  under  my  ohservation,  and  in  one  instance  a  simple 
ulcer  of  the  colon  perforated  and  led  to  fatal  jieritonitis. 


511 


DISKASHS  (JF  TIIK   DKiKSTIVK  SYSTKM. 


•'3 


/ 


Diagnosis  of  Intestinal  Ulcers. — As  a  nilc.  diiurlm-ii  is  pivsont 
ill  iill  I'iisfs,  liiit  i'\cc|ili()iialiy  tlicic  iiiiiy  1)0  extensive  uleeratinn,  |tarlieii- 
larlv  ill  the  siiiall  Ixiwcl,  witlioiil  tlinrriiiea,  \'eiT  limited  ulceration  in  the 
colon  may  he  associated  witli  rre(|iient  stools.  The  character  of  the  dejee- 
lioiis  is  of  ^reat  imporlaiiee.  I'lis.  siireds  of  tissue,  and  Idood  are  the  ino.-t 
vaUiahle  indications.  I'lis  occurs  most  fre(|iientl_v  in  connection  with  ulcers 
in  the  larjic  inti'stinc,  hut  when  tlit;  howel  alone  is  involved  the  amount  is 
rarely  ;.'reat,  and  tln'  passafic  of  any  ((iiantity  of  |)ure  pus  is  an  indication 
that  it  has  come  I'roni  without,  most  commonly  from  the  rnpturc  of  a  peri- 
ctecal  ahsci'ss,  or  in  women  of  an  aljs(;ess  of  the  liroad  lijrameiit.  i'us  may 
also  he  present  in  cancel'  of  the  bowel,  or  it  may  be  due  to  local  disease  in 
the  rectum.  A  puriili'iit  mucus  Hiay  bo  present  in  the  stools  in  cases  of  ulcer, 
hut  it  luis  not  the  same  diiiffnostic;  value.  The  swollen,  saj^o-like  masst.'s 
oi'  niucus  which  are  believed  by  some  to  indicate  follicular  ulceration  are 
met  with  also  in  mucous  colitis.  Iliemorrha^e  is  an  importani  and  valn- 
jihle  symptfun  of  ulcer  of  the  bowel,  particularly  if  ]irofuse.  It  occurs 
(iiider  so  many  conditions  that  taken  alone  it  nuiy  not  be  specially  si<j:nili- 
cant,  but  with  other  coexisting'  circumstances  it  may  be  the  most  importani 
indication  of  all. 

I'ra^niicnts  of  tissue  are  occasionally  found  in  the  stools  in  ulcer,  |)ar- 
ticuUnly  in  the  extensive  and  rapid  slou^hin<i;  in  dysenteric  processes. 
Definite  portions  of  mucosa,  shreds  of  connective  tissue,  and  even  bits  of 
the  muscular  coat  may  be  found.  I'ain  occurs  in  many  casts,  either  of  a 
diffuse,  colicky  character,  or  sometimes,  in  the  ulcer  (jf  the  colon,  very  lim- 
ited and  well  defined. 

Perforation  is  an  accident  liable  to  happen  when  the  ulc.'cr  extends 
dee]ily.  In  the  small  bowel  it  leads  to  a  localized  or  general  |icritonitis. 
In  the  lari:H'  intestine,  too,  a  fatal  peritonitis  may  result,  or  if  perforation 
takes  ]»lace  in  the  posterior  wall  of  the  ascending;"  or  descend iiiij;  colon,  the 
production  of  a  larye  abscess  cavity  in  the  retro-peritoniiuim.  In  a  cast; 
at  the  I'niversity  Hospital,  Philadelphia,  there  was  a  perforation  at  tin; 
splenic  flexure  of  the  colon  with  an  abscess  containin<,'  air  and  pus — a  C(ni- 
dition  of  siibplirenic  iiyo-pneumotliorax. 

Treatment  of  the  Previous  Conditions. 

(a)  Acute  Dyspeptic  Diarrhoea. — All  solid  food  slionld  l)e  withheld.  If 
vomitinji:  is  present  ice  may  be  ^iven,  and  small  (piantities  of  milk  and  soda 
water  may  he  taken.  If  tlie  attack  has  followed  the  eatin.ir  of  larue  (|uan- 
tities  of  nndijiX'stible  material,  castor  oil  or  calomel  is  advisable,  but  is  not 
necessary  if  the  ])atient  has  been  freely  ])nrifed.  If  the  ])ain  is  severe,  '20 
diops  of  laudanum  and  a  drachm  of  s])irits  of  chloroform  may  be  uiven,  or. 
if  the  colic  is  very  intense,  a  hypodermic  of  a  (piarter  of  a  <rrain  of  n)()r])hia. 
It  is  not  well  to  check  the  diarrluca  unless  it  is  profuse,  as  it  usually  stops 
spontaneously  within  forty-eij>ht  hours.  If  jiersistent,  the  aromatic  chalk 
jiowder  or  lai'iic  doses  of  bismuth  (30  to  40  grains)  may  he  .niven.  A  .^mall 
eneum  of  starch  ('i  ounces)  with  20  drops  of  laud;inum,  every  six  lunirs.  is 
a  most  valuable  remedy. 

(h)  Chronic  diarrhoea,  inchulincr  chronic  catarrh  and  ulcerative  enter- 
itis.    It  is  im])ortant,  in  the  first  ])lacc,  to  ascertain,  if  ])ossible,  the  cause 


)vati')n 
)!!,  tlio 
a  (.'iist; 
iit  tho 
—a  C()ii- 


■1(1.      If 

11(1  soda 

(|uan- 

t  is  not 


/(TC, 


•l\) 


\C11,  ol', 

iMrj»hia. 
ly  stops 
ic  clialk 
A  .qiiall 
Kiiirs,  is 


DISEASES  OF  THE   IXTESTIXES  ASSOCIATEK   WJT  I    DIAliKlKKA.     5ir, 

and  ulictlicr  ulccnitioii  is  present  or  not.  So  nineli  in  treatment  depenili* 
upon  tlie  eiirel'ul  exandiiiit ioii  of  the  ftool.s — as  to  the  anionnl  of  miieiis, 
the  |iresenee  of  |Mis,  the  oeenrrenee  of  parasites,  and,  ahove  all,  the  state  of 
dii^e^tion  (d'  the  food — that  the  praetiti(»ner  shonid  piy  special  attention 
lo  t'leni.  .Many  eases  simply  retpiire  rest  in  lied  and  a  restricted  diet. 
Chronie  diarrluea  of  many  UKmth.s'  or  even  of  several  years'  duration  may 
lie  sometimes  cnred  hy  strict  cotirmement  to  hed  and  a  diet  of  hoilcd  milk 
;ind  alliiinicn  water. 

In  that  form  in  which  imnudiately  after  eating;  llioro  is  u  teiideney  to 
l(»o.<e  evacuations  it  is  usually  found  that  some  one  article  of  diet  is  at 
liiidt.  The  patient  should  rest  I'or  an  hour  or  more  after  meals.  Some- 
linics  this  alone  is  sullieient  to  jtrevent  the  occurrence  of  the  diarrlnea. 
Ill  those  forms  which  depend  upon  ahnormal  conditions  in  the  small  intes- 
liiic.  cither  too  nipid  peristalsis  or  faulty  i'ermentutive  ])rocesses,  hismutU 
is  indicated.  It  must  he  jriven  in  larj^o  doses — from  half  a  drachm  to  a 
drachm  three  times  a  day.  The  smaller  doses  are  of  little  u^v.  Naphthidiiv 
preparations  here  do  much  ^'oo(l,  ^nvcii  in  doses  of  from  lit  to  1")  j^rains  (in 
(apsulc)  four  or  five  times  a  day.  Larj^'er  doses  may  he  needed.  Salol  and 
the  salicylate  of  hismuth  may  he  tried. 

An  extremely  ohstinate  and  intractahle  form  is  the  diarrlnea  of  hyster- 
ical women.  A  systematic  rest  cure  will  he  found  most  ad\antai;eous,  and 
if  a  milk  diet  is  not  well  home  the  patient  may  he  fed  exclusively  on  v^'^ 
iilhumen.  The  condition  ,«eems  to  he  assoc'iate(l  in  some  cases  with  in- 
creased i)eristalsis,  and  in  such  the  hroinides  may  do  ^'ood,  or  jjreparations 
of  o])inm  may  he  necessary.  There  are  instances  which  ])rove  most  ohsti- 
nate and  resist  all  forms  of  treatment,  and  the  patient  may  he  ^xrcatly  re- 
duced.    A  chanffc  of  air  and  surroundinj^s  may  do  more  than  medicines. 

In  a  lar^'e  "^roiip  (d'  the  chronic  diarrlucas  the  mischief  is  seated  in  the 
colon  and  is  due  to  ulceration.  Medicines  liy  th(>  mouth  are  here  of  little- 
value.  The  stools  should  he  carefully  watched  and  a  diet  arranjicd  which 
shall  leave  the  smallest  ])ossil)le  residue.  Uoiled  or  ])eptoni/ed  milk  may 
l)c  ;iiveii,  hut  the  stools  should  he  examined  to  see  whether  tlicr(  is  an 
excess  of  food  or  of  curds.  Meat  is,  as  a  rule,  l)adly  home  in  the.se  cases. 
The  diarrlnea  is  hest  treated  hy  encmata.  HMie  starch  and  laudanum  should 
lie  tried,  hut  wlu'ii  ulceration  is  ])rescnt  it  is  hetter  to  use  aslriii,i:cnt  injec- 
tions. From  '^  to  1  pints  of  warm  water,  containing'  from  half  a  drachm 
to  a  drachm  of  nitrate  of  silver,  may  he  used.  In  the  chronic  diar- 
rlKca  which  follows  dysentery  this  is  particularly  advanta.iieous.  In  ^livinir 
liirire  injections  the  ])ntient  .«liould  he  in  the  dorsal  ])osition,  with  the  hips 
elevated,  and  it  is  hest  to  allow  the  injection  to  flow  in  iiradiially  from  a 
>iplion  hair,  lu  t.iis  way  the  entire  colon  can  lie  irripited  and  the  ])ati('iit 
(•;in  retain  the  injection  for  some  time.  '^I'he  silver  injections  may  he  very 
pniiifnl.  hut  they  are  invaluahle  in  all  forms  of  ulcerative  colitis.  Acetate 
>>\  lead,  horacic  acid,  siiljihate  of  copper,  sulphate  of  zinc,  and  salicylic  acid 
may  he  used  in  l-per-cent  solution?. 

Tn  the  intense  forms  of  choleraic  diarrlnea  in  adults  associated  with 
constant  vomit in<i  and  fre(pient  watery  discharge's  the  ])atient  should  ho 
.iiivcn  at  once  a  hypodermic  of  a  (piartcr  of  a  frrain  of  morithia.  which  should 


r)U) 


DISKAM'IS  OK  TIIK   lUdllSTlVK  SVSTKM. 


/ 


1)0  n'|H>jit('(l  ill  DM  liitiir  il'  tlic  |)iiins  icliirri  or  tlic  piir^riiij,'  juTsists.  TliU 
^'ivcs  |tiuiii|)l  rclid',  mill  is  (»ricii  tlic  only  iin'<li(iiif  ih'ciIimI  in  tlu'  iiltack. 
The  |iiili»'iil  hIiouM  lie  jfivt'ii  Htiniiiliints,  ami,  wlitii  the  voniitiiiK  Ih  allayi'd 
liy  Huital)l(>  rciiii'dics,  Hiiiall  (|iiiiiilitii'H  «>!'  milk  and  lime  water. 

((■)  The  Diarrhooa  of  Children.-  ////'//'•// /V  iiKtninintinil  U  of  tlio  liivt 
iiiiliortanci'.  Tlu'  I'll'cct  of  a  (■haii;;('  Iroiii  tlic  hot,  j^liiliii^'  atinosplu'rc  of  a 
town  to  till'  inoiintains  or  the  nca  in  ol'ti'ii  hci-ii  at  oiict'  in  a  reduction  in 
the  iiiinilier  of  stooln  and  a  rapid  iniproveineiit  in  the  pliynical  condition, 
i'ivi'ii  in  fitii'H  iniicli  may  he  done  !»v  Hcndiii;,'  the  child  into  the  parks  or 
for  daily  excursions  on  the  water.  However  extreme  the  comlitinii.  fresh 
air  is  indicated.  The  child  should  not  he  too  thickly  clad.  Many  niothers, 
even  in  the  warm  weather,  clothe  their  children  too  heavily.  Uatliin^'  is 
of  value  in  infantile  diarr'iiea,  and  when  the  fever  rises  ahove  lii'^..")"  the 
child  should  he  placed  in  a  warm  hath,  the  temperature  of  which  may  he 
^M-adiially  rcdiici'd,  or  the  child  is  kept  in  the  hath  for  twenty  niiniites,  hy 
which  time  the  water  is  suilicieiitly  cooled.  Much  relief  is  ohtniiicil  hy 
the  application  of  ice-cold  cloths  or  of  the  ice-cap  to  the  head.  Irripition 
of  the  colon  with  ice-cold  water  is  sometimes  favorahle,  liut  it  has  not  the 
a(lvanta«.'e  of  the  /^'cneral  hath,  the  heiielicial  clfcct  of  which  is  seen,  not  only 
in  the  reduction  of  the  temperature,  hut  in  a  general  stimulation  of  the 
nervous  system  of  the  child. 

Divd'iic  Trvnlmvnl. — Jn  the  <-aHo  of  n  hand-fed  child  it  is  important,  if 
])ossihle,  to  <ret  a  wet-nurse.  While  fever  is  present,  di<:estion  is  sure  to  he 
much  disturhed,  and  the  amount  of  food  should  he  restricted.  If  water 
or  harley  water  he  ^dven  the  child  will  not  feel  the  de|)rivation  of  food  so 
much.  Wlu'ii  the  vomitinj?  is  incessant  it  is  much  hetter  not  to  attempt 
to  ^dve  milk  or  other  articles  of  food,  hut  let  the  child  take  the  water  when- 
ever it  will. 

In  the  dysjieptic  diarrli(ea>-  of  infants,  practically  the  whole  treatment 
is  a  matter  of  artificial  feedinji,  and  there  i.s  no  suhject  in  medicine  on 
which  it  is  more  ditlicult  to  lay  down  satisfactory  rules.  The  studies  of 
Iiotch  on  modified  milk  have  revolutionized  the  artificial  fecdin;:'  of  infants, 
and  the  estahlishiiieiit  of  the  \Valker-(i(»rdon  lahoratories  in  various  cities 
jiiis  hi'cn  a  <freat  hoon  to  the  ])nhlic  and  the  jirofi'ssion.  Xo  douht  within 
a  U'W  years  the  study  of  the  bacterial  ])roce.«.ses  p>in}i;  on  in  the  intestines 
of  the  child  will  ^nve  us  most  important  su<i:jrestions.  From  his  ohserva- 
tions  I'^schcrich  lavs  down  the  followin<i  rules.  reco<rnizin<;'  two  well-defined 
forms  of  intestinal  ft'rmentation — the  acid  and  the  alkaline:  If  there  is 
much  decomposition,  with  foul,  oifensivo  stools,  the  albuminous  articles 
sluuild  he  withheld  from  the  diet  and  the  carbohydrates  given,  such  as  dex- 
trin foods,  sutrar.  and  milk,  which,  on  account  of  its  sugar,  ranks  with  the 
carhohydrates.  If  there  is  acid  fermentation,  with  sour  but  not  fetid  stools, 
an  albuminous  diet  is  given,  snch  as  broths  and  q»^  albumen.  It  is, 
however,  by  no  means  certain  whether  the  reaction  of  the  stools,  nj^m 
which  this  author  relies,  is  a  sufhcient  te.et  of  tii'e  nature  of  the  intestinal 
fermentation.  Tn  the  dvsiioptic  diarrlueas  of  artificially  fed  infants  it  is 
l)est,  as  a  rule,  to  withhold  milk  and  to  feed  the  child,  for  the  time  at  least, 
on  egg  albumen,  broths,  and  beef  juices.     To  prepare  the  g^^  albumen,  the 


DISKASKS  OF  Til  10   INTKSTINKS  ASSOCIATKD   WITH    DIAIUUKKA.     01 7 


wliifcs  (if  two  or  tliiTc  (•f:^'j«  iniiy  Itc  stiri('(l  in  a  jdiil  of  wnfcr  mid  a  toii- 
>|ii)()Mriil  of  Itnindy  iiiiil  n  littlt-  salt  mixed  with  it.  Tlic  child  will  usually 
taki'  this  I'rccly,  and  it  is  hoth  stiMiulatin^'  and  iinui'isliiM<r.  It  is  suiiic- 
litni'ri  rcinarlsnhic  with  uhat  rapidity  a  child  which  has  lu'cii  iVd  on  artificial 
liHid  and  iinlk  will  pick  up  and  improve  on  this  diet  alone.  Heer-juiee  is. 
nhtained  hy  pressing:  with  a  h'mon-s»pieezcr  Fresh  steak,  previously  minced 
iind  either  uncookccl  or  sli<,ditly  hroiled.  This  may  he  ;:iven  alternately 
with  the  van  alhumcii  or  it  nuiy  he  j.Mven  alone.  .Mutton  or  chicken  hrotli 
will  he  ''"und  (Mpially  serviceahle,  hut  it  Ih  propart'd  with  greater  dilliculty 
iind  contains  iimre  fat.  In  the  preparation,  a  pound  of  mutton,  chicken,  or 
liect",  carefully  i'recd  from  I'at,  is  minci'd  and  ])laccd  in  a  pint  ol'  cold  water 
Iind  allowed  to  stand  in  a  ^dass  jar  on  ice  t'ur  three  or  four  hours.  U  should 
then  he  cooked  over  a  slow  lire  for  at  least  three  liours,  and,  after  hein^' 
strained,  allowed  to  cool;  the  fat  i.s  then  skimnu'd  oil*  and  sullicient  salt 
iid(lc<";  it  may  then  he  ^iven  either  warm  or  cold.  These  naturally  prepared 
idhumin  foods  are  very  much  to  he  preferre(|  to  the  various  artilicial  sui)- 
>^tancea.  There  is  no  form  of  nourisliment  so  readily  assimilated  ami  ajjt  to 
lU-ic  80  little  disturhanec  as  ofTR  nlhunien  or  the  simple  heef  juices.  The 
child  should  he  fed  every  two  hours,  and  in  the  inter' als  water  may  be  freely 
^iven.  It  cannot  he  expected  that,  with  the  dij^cstion  seriously  impaired, 
as  much  fo'>d  can  be  taken  as  in  health,  and  in  many  instances  we  see  the 
diarrluea  a^'<,'ravated  by  persistent  over  feedin;  When  the  child's  stomach 
is  ([uieted  and  the  diarrluea  checked  there  nuiy  be  a  ^M'adual  return  to  the 
milk  diet.  The  milk  should  be  sterilized,  and  in  institutions  and  in  cities 
this  simple  ])rophylactic  measure  is  of  the  very  first  importance  and  is 
readily  carried  out  by  means  of  the  Arnold  steam  sterilizer.  The  milk 
shonld  be  at  first  freely  diluted — four  parts  of  water  to  one  of  milk,  which 
is  perhaps  the  preferable  way — or  it  nuiy  be  peptonized.  The  stools  should 
be  examined  daily,  as  important  indications  may  be  obtained  from  them. 
Milk-whey  and  forms  of  fermented  milk  are  .sometimes  useful  and  may  be 
employed  when  the  stomach  is  very  irritable.  These  general  directions  as 
to  food  also  hold  ji-ood  in  cholera  infantum. 

Mnllriiial  'J'iraliiinif. — The  first  indication  in  the  dyspeptic  diarrluea 
of  children  is  to  jret  rid  of  the  decomposing'  matter  in  the  stomach  and  in- 
testines. The  diarrluea  and  voniitinj,'  i)artially  ell'ect  this,  but  it  may  be 
more  thoronjjjhly  aceom])lished,  so  far  as  the  stomach  is  concerned,  by  irri- 
gation. It  may  seem  a  harsh  ])rocedure  in  the  case  of  youn<,'  infants.  l)ut  in 
reality,  with  a  lar<,n'-sized  soft-rubber  catlu'ter,  it  is  ])ractiscd  without  any 
ililliculty.  V>y  means  of  a  funnel,  lukewarm  water  is  allowed  to  pass  in  and 
out  until  it  comes  away  quite  clear.  I  can  speak  in  the  very  warmest  man- 
ner of  the  fjood  resulth  obtaini'd  by  this  sim])le  i)rocedure  in  cases  of  the 
most  obstinate  frastro-intestinal  catarrh  in  children.  Tn  most  cases  the 
warm  water  is  sufhcienr.  In  some  hands  this  method  has  ])robably  l)een 
oarried  to  excess,  hut  that  does  not  detract  from  its  preat  value  in  suitable 
cases.  To  remove  the  fermentinfj  substances  from  the  intestines,  doses  of 
calomel  or  <rray  powder  may  be  administered.  The  castor  oil  is  equally 
efficacious,  hut  is  more  ajit  to  be  vomited.  Trrifjation  of  the  larfre  bowel  is 
useful,  and  not  only  thoroughly  removes  fermenting  sub.stauces,  hut  cleanses 


518 


DISEASES  OF  THE   DIGESTiVE  SYSTEM. 


/' 


the  iiiiu-dsa.  'J'Jk'  fliild  s^liould  lit-  iilaet'd  on  tlic  biuk  with  the  hi|)S  ele- 
vatt'ih  A  Ik'xihlo  catheter  is  passed  for  I'rom  (i  to  8  inches  and  from 
a  pint  to  2  \un[6  of  water  aHoweil  to  How  in  from  a  fountain  .syringe. 
A  pint  will  tlioroughly  irrigate  the  colon  of  a  child  of  six  months  and  a 
(piart  that  of  a  child  of  two  years.  The  water  may  be  lukewarm,  but  when 
there  is  high  fever  ice-cold  water  may  be  used.  Ju  cases  of  entero-colitis 
there  may  be  injections  with  borax,  a  drachm  to  the  jtint,  or  dihito  nitrate 
of  silver,  which  may  be  either  given  in  large  injections,  as  in  the  adult,  or 
in  injections  of  ;5  or  -1  ounces  with  'A  grains  of  nitrate  of  silver  to  the  ounce. 
These  often  cause  very  great  pain,  and  it  is  well  in  such  cases  to  follow  the 
silver  injection  with  irrigations  of  salt  solution,  a  drachm  to  a  pint. 

We  are  still  without  a  reliable  intestiJuU  antisei»tic.  Xeither  najjlitha- 
lin,  sal(»l,  resorcin,  the  salicylates,  nor  mercury  meets  the  indications.  As 
in  the  diarrluca  of  adults,  bismuth  in  large  dos(>s  is  often  very  cU'ective, 
but  })ractitioners  are  in  the  habit  of  giving  it  in  doses  which  are  quite  in- 
sulHcient.  To  be  of  any  service  it  must  be  nscd  in  large  doses,  so  that  an 
infant  a  year  old  will  take  as  iiiuch  as  2  drachms  in  the  day.  The  gray 
])owder  has  long  l)een  a  favorite  in  tliis  condition  and  may  be  given  in 
half-grain  doses  every  liour.  It  is  perhai)s  i)referable  to  calomel,  whicli 
may  be  used  in  snutll  doses  of  from  one  tenth  to  one  fourth  of  a  grain  every 
hour  at  the  onset  of  tlie  troid)le.  The  sodium  salicylate  (in  doses  of  2  or 
3  grains  every  two  hours  to  a  child  a  year  old)  has  been  recommended. 

]n  cholera  infantum  serious  symptoms  may  develop  with  great  ra])idity. 
and  liere  the  incessant  vomiting  and  the  frequent  i)urging  render  tlie  ad- 
ministration of  remedies  extremely  diHicult.  Irrigation  of  the  stomach 
and  large  bowel  is  of  great  service,  and  when  the  fever  is  high  ice-water 
injections  may  ]»e  nsed  or  a  graduated  bath.  As  in  the  acute  choleraic 
diarrluea  of  adults,  morpjiia  hypodermically  is  the  remedy  which  gives 
greatest  relief,  and  in  the  conditions  of  extreme  vomiting  and  ])nrging,  with 
restlessness  and  colla])se  symi)t()ms,  this  drug  alone  commands  the  situation. 
A  child  of  one  year  may  be  given  from  f-jy^to  -^^^  of  a  grain,  to  l)c  re])eated: 
in  an  hour,  and  again  if  not  better.  AViicn  the  vomiting  is  allayed,  at- 
tem])ts  may  be  made  to  give  gray  ])owder  in  half-grain  doses  with  y'-jj 
of  Dover's  powder.  >Starch  (,3  ij)  and  laudanum  (HI  ij-iij)  injections,  if  re- 
tained, are  soothing  and  beneficial.  The  combination  of  bismuth  with 
Dover's  ]towder  will  also  be  found  beneficial.  Xo  attem])t  should  be  made 
to  give  food.  AVater  may  be  allowed  freely,  even  when  ejected  at  once  In- 
vomiting.  Small  doses  of  brandy  or  champagne,  frequently  re])eated  and 
given  cold,  are  sometimes  retained.  AVlien  the  colla])se  is  extreme,  hyjx)- 
dermic  injections  of  1-per-cent  saline  solution  nuiy  be  used  as  recomraeiuled 
in  Asiatic  cholera,  and  hypodermic  injections  of  ether  ami  brandy  may  be 
tried.  The  convalescence  requires  very  careful  management,  as  many  cases 
]tass  on  into  the  condition  of  entero-colitis.  "When  tlie  intense  symptoms 
have  sultsided,  tlie  food  should  l)e  gradually  given,  l)eginning  with  tea- 
sitoonfid  doses  of  egg  ^ilbumen  or  beef-juice.  It  is  best  to  withhold  milk 
for  several  days,  and  wlu'u  used  it  should  Ije  at  first  completely  peptonized 
or  diluted  with  gruel.  A  tcaspoonful  of  raw,  scraped  meat  three  or  four 
times  a  dav  is  often  well  liorne. 


APPENDICITIS. 


519 


II.     APPENDICITIS. 


Inflinninalioh  of  the  viTiniionn  npiu'iulix  is  tlu'  most  ini])ortant  of  acuto 
intt'stinal  disorders.  Formerly  the  '*  iliae  ))liiegmoii  ""  was  tlioujrlit  to  l)e 
due  to  disease  of  the  ca>eiim — lijphHHs — and  of  the  peritona'um  coverin^f 
it — pcrihiiilililis;  Ijiit  we  ]io\v  know  that  witii  rare  exeeptions  tiie  ca'cuni 
itself  is  not  aU'ected,  and  even  the  condition  formerly  deseribed  as  stercoral 
typhlitis  is  in  reality  ap])endieitis.  The  recojinition  of  the  imjjortance  of 
a])]»endieitis  is  duo  larfrely  to  the  woi'k  of  tlie  Anu'rican  ]»hysic'ians  and  sur- 
geons— to  l'ep])er,  \vho  descril)ed  in  1883  the  reiapsin*,'  form;  to  J''itz. 
wliose  exhanstive  article  in  188(5  served  to  put  the  whole  (piestion  on  a 
rational  basis;  to  AVillard  Parker,  wiio  was  the  first  to  advocate  early  o]ier- 
ation;  and  to  Sands,  Bull,  ]\lei)urney.  Weir,  .Morton,  Keen,  Senn,  .1.  Wil- 
liam Wiiite,  Deaver,  and  others,  who  have  done  so  mucli  to  improve  tiie  op- 
erative measures  for  its  re!  '.  Treves,  of  JiOiuhm,  has  been  foremost  in 
advocating.',  the  ])roper  sm-gieal  treatment  of  the  disease.  ^Piie  interest  at- 
taclied  to  the  subject  is  manifest  from  the  ai)i)earance  within  a  few  years  of 
a  number  of  s])eeial  mono<rra,  hs  by  Kelynack,  Talanjon,  Fowler,  Sonnen- 
berg,  Hawkins,  Deaver,  and  Mynter. 

Anatomy. — The  ap})endix  veriformis  is  a  functionloss  relic  of  a  largo 
ancestral  ca?cum.  It  measures  usually  about  3  inches  in  lengtii,  but 
it  may  be  scarcely  an  inch.  The  diameter  is  about  one  fourth  of  an  inch. 
In  a  majority  of  instances  it  has  a  triangular-shaped  meso-ai)pendix,  iisually 
shorter  than  the  tube,  which  thus  becomes  a  little  curled  or  Ijcnt  upon 
itself,  '^^rhere  is  often  a  snuill  lymph-gland  just  at  the  root  of  its  mesentery. 
The  jiosition  of  the  ap])endix  is  very  variable.  The  most  common  direc- 
tion it  assumes  is  upward  and  inward,  the  tij)  pointing  toward  the  spleen. 
The  position  next  in  frequency  is  behind  the  ciecum,  and  next  passing  over 
the  i)elvic  brim.  It  may  ])e  met  with,  however,  in  almost  every  region  of 
the  abdomen,  and  adherent  to  almost  every  organ  in  it.  I  have  seen  it  in 
close  contact  with  the  bladder,  adherent  to  one  ovary  and  the  broad  liga- 
ment; in  the  central  ]iortion  of  the  abdomen  close  to  the  navel;  in  contact 
with  the  gall-bladder,  passing  out  at  right  angles  ami  adiierent  to  the  sig- 
moid flexure  to  the  left  of  the  middle  line  of  the  abdomen;  and  in  one  case 
it  entered  with  the  caecum  the  inguinal  canal,  curved  upon  itself,  re-cntoied 
the  abdomen,  and  was  adherent  to  the  wall  of  an  abscess  cavity  just  to  the 
right  of  the  ]n-omontory  of  the  sacrum.  The  structuiv  of  the  ap])endix  is 
almost  identical  with  that  of  the  caecum;  it  is  particuhwly  rich  in  ]ymi)hoid 
tissue.  The  blood  su])ply  is  derived  from  a  small  artery  which  |)asses 
along  the  fr(>e  edge  of  its  niesentcrv. 

Morbid  Anatomy  and  Etiology.— The  following  are  the  most 
common  morbid  conditions: 

((()  Faecal  Coueretions. — The  lumen  of  the  appendix  may  contain  a 
mould  of  faeces,  which  can  readily  be  S(|ueezed  out.  I'^ven  while  soft  the 
c(»ntents  of  the  tube  may  be  moulded  in  two  or  three  sections  with  rounded 
ends.  CVmcrction'^  ^iteroliths,  cojiroliths — are  also  cfunuum.  The  mode 
of  formation  is  not  very  clear.     Possibly,  as  with  gall-stones,  the  micro- 


520 


DISEASES  OF  THE  UIGPISTIVE  SYSTEM. 


/ 


organisms  may  have  a  favoring  influence.  They  were  jjresent  in  38  cases 
ill  400  autoi)sies  (Ribbert),  and  in  179  of  4oU  autopsies  in  perityphlitis 
(•(jlh'cted  by  Kenvers.  The  enteroHtbs  often  reseniljle  in  sluqie  date- 
stones.  The  importance  of  tliese  concretions  is  sliown  l)y  the  great  fre- 
(piency  witli  MJiich  tliey  are  found  in  all  acute  inflammations  of  the  ap- 
])eii(lix. 

(h)  Foreign  bodies  are  l)y  no  means  so  fre(|ucntly  met  with — only  13 
]K'Y  cent  in  lo'^  cases  of  ajipendicitis  collected  by  Fitz.  Only  two  instances 
came  under  my  o])servation  in  ten  years'  jiathological  work  in  Montreal;  in 
one  there  were  eight  snipe-shot  and  in  another  Ave  ajiple-pits.  The  stones 
and  seeds  of  various  fruits,  bits  of  bone,  and  i)ins  have  been  found.  It  is 
well  to  bear  in  mind  tliat  some  of  the  concretions  bear  a  very  striking  re- 
seml)lance  to  clierry  and  date  stones. 

{(■)  Obliterative  Appendicitis. — The  entire  tube  is  thickened,  tlie  peri- 
toneal surface  smooth  or  injected,  and  either  with  adhesions  from  sliglit 
circumscribed  peritonitis,  or  perfectly  free.  The  mucosa  may  sliow  noth- 
ing more  than  a  shedding  of  epithelium  with  infiltration  of  leucocytes  in 
the  submucosa,  while  in  more  chronic  cases  there  is  almost  com])lete  den- 
lulation  of  the  mucosa,  which  is  replaced  by  granulation  tissue.  The  mus- 
cular coats  are  thickened  throughout,  and  the  entire  tube  is  firm  and  stilf, 
as  if  in  a  state  of  erection.  When  laid  o])en  longitudinally  it  at  once  as- 
sumes a  rolled  form  in  the  reverse  direction. 

The  term  catarrhal,  which  has  been  a]iplied  to  this  condition,  is  scarcely 
appropriate,  since  the  changes  are  diffuse  throughout  the  whole  tube.  In 
the  majority  of  instances  the  term  appendicitis  ohliterans,  used  by  Senn, 
is  in  reality  more  a])propriate.  As  Hawkins  remarks,  this  condition  is 
])robably  a  fertile  source  of  local  peritonitis,  and  one  may  see  in  this  stage 
fresh  adhesions  on  the  peritoneal  surface  or  more  extensive  circumscribed 
peritonitis.  It  may,  however,  be,  as  he  says,  the  precursor  of  complete  im- 
munity from  such  attacks.  "  For  if  by  the  pressure  of  the  surrounding 
l)arts  the  o])posed  granulating  surfaces  are  brought  into  contact,  and  if  the 
whole  organ  remains  at  rest,  union  may  take  ])lace,  and  the  appendix  as  a 
source  of  disease  then  ceases  to  exist.  In  other  cases  obliteration  of  the 
lumen  cannot  take  place  on  account  of  the  rigid  incollapsible  character  of 
the  walls,  and  it  is  this  condition  of  chronic  ap]iendicitis  which  may  lead 
to  recurrences  of  attacks  of  olic  and  local  symptoms  in  the  right  iliac 
fossa." 

]\rcBurney  lays  great  stress  upon  the  narrowing  of  the  lumen  as  pre- 
venting normal  drainage  of  the  tube  and  establishing  conditions  favorable 
for  the  develojmient  of  septic  processes. 

Olditerative  appendicitis  is  met  with  in  about  S  per  cent  of  all  sub- 
jects. When  the  stricture  occurs  at  the  ca'cal  end  of  the  tube  the  lumen 
may  become  greatly  dilated,  forming  a  cystic  aiipendix  wdiich  may  reach 
the  size  of  tlie  tliuml),  or  even  tliat  of  an  ordinary  sausage.  The  con- 
Tents  of  the  cyst  are  either  clear  fluid  or  pus.  Ulceration  and  perforation 
are  very  apt  to  occur.  Obliterative  appendicitis  may  go  on  as  an  ordinary 
involution  process  without  causinsr  any  symptoms,  but  in  many  instances 
there  are  attacks  of  pain — appendicular  colic;  in  others,  exacerbations  of 


APPENDICITIS. 


521 


fever  with  pain  and  swelling;  while  in  others  again  ulceration  and  perfora- 
tion may  take  place. 

((/)  Ulcerative  Appendicitis. — Local  ulceration  in  the  ajjpendix  is  met 
with  as  a  result  of  the  i)resence  of  concretions  or  of  foreign  hodies,  or  as 
the  result  of  the  action  of  certain  micro-organisms,  eitiier  those  noruially 
inhabiting  the  civcum  or,  under  certain  circuuistances,  tlie  typiu)id  and 
tubercle  liacilli.  I'lecal  concretions  and  foreign  bodies  are  met  with  in  the 
appendix  without  apparently  causing  the  sligiitest  abrasion  of  its  mucosa. 
In  other  cases  the  enterolith  has  caused  atroi)iiy  of  the  mucous  meml)rane 
with  which  it  is  in  contact.  In  other  cases  again,  the  concretion  or  foreign 
body  may  be  jjocketed  in  an  ulcer  at  the  tij)  of  the  ai)pemlix,  from  which 
it  nuiy  be  shelled  out.  These  conditions  may  ])e  ])resent  without  adhe- 
sions and  without  reddening  of  the  serous  surface,  but  one  not  infrequently 
sees  thickening  of  the  ])eritona'um  with  adhesions  to  the  adjacent  parts  in 
ulcerative  ap[)endicitis. 

Tuberculosis  of  the  apjjcndix  is  by  no  means  uncommon.  Ulceration 
in  ty})hoid  fever  is  also  frequently  met  with;  in  a  series  of  80  auto})sies 
there  were  3  instances  of  perforation  of  the  ap[)endix  by  a  typhoid  ulcer. 
An  actinomycotic  ulcer  has  also  been  described. 

(c)  Necrosis  and  Sloughing  of  the  Appendix — Acute  Infective  Appendi- 
citis.— Following  upon  the  conditions  described  under  (c)  and  (d),  necrosis 
and  sloughing  may  take  i)lace  either  in  a  limited  })ortion  of  the  appendix 
with  perforation,  or  en  masse  without  ]ierf oration,  in  both  cases  leading  to 
the  most  intense  peritonitis,  localized  or  general.  Most  commonly  the  gan- 
grene is  localized  to  one  spot,  either  at  the  tip  or  in  some  portion  of  the 
tube.  Usually  the  organ  is  swollen;  the  color  may  be  reddish  brown,  black, 
or  greenish  yellow.  Xecrosis  may  occur  en  masse,  and  the  entire  appendix 
may  indeed  slough  off  from  the  caecum  and  lie  free  in  an  abscess  cavity. 
In  one  remarkable  case  operated  u])on  Ijy  my  colleague,  Halsted,  tlie  appen- 
dix, l)etween  4  and  5  inclies  in  length,  was  shrunken,  blackish  brown  in 
color,  sphacelated  throughout,  and  looked  like  a  desiccated  earthworm. 

These  active  ]irocesses  leading  to  ulceration  and  necrosis  are  due  to  the 
action  of  micro-organisms,  and  much  work  has  been  done  to  determine 
their  character.  no(len])yl  showed  that  the  bacillus  coli  cummunis  was 
present  in  a  very  large  number  of  cases  of  a])pendicitis.  In  (M  cases  of 
peritoneal  inflammation  consequent  ui)on  disease  of  the  a])])endix  the  ba- 
cillus coli  communis  was  found  in  57,  and  in  50  of  these  it  was  tlie  only 
organism  present.  The  streptococcus  pyogenes  and  tlie  sta])hylococcus 
]\vogenes  aureus,  the  proteus  and  bacillus  ])yocyaneus  have  also  been  found. 
The  streptococcus  infection  is  the  most  virulent.  Probably  too  much  stress 
has  been  laid  upon  the  bacillus  coli  communis  as  a  cause  of  infective  pro- 
cesses in  and  about  the  appendix.  In  many  cases,  with  slight  fresh  adlie- 
sion  and  a  little  sero-fibrin,  the  cultures  are  negative.  As  Welch  renuirks," 
"There  is  reason  to  believe  that  the  highly  resistant  colon  bacillus  may 
survive  in  an  inflamed  ])art  after  the  ])rimary  organism  which  started  the 
trouble  has  died  out,  or  has  been  crowded  out  by  the  invader."  The  prone- 
ness  of  the  appendix  to  infective  inflammation  of  this  sort  lies  "in  that 
subtle  structure  which  determines  the  degree  of  resistance  of  a  tissue  to  dis- 


522 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


.  \ 
/ 


ease.  One  man  diU'ors  from  anotlicr  in  liis  ])n\vc'r  of  resistance;  the  more 
(It'f^encrate  the  iiian  the  k'ss  resistance  can  he  exert.  Jm  like  manner,  one 
orpin  in  a  man  diifers  from  another.  And  in  tlie  apjjendix  \vc  are  dealing 
with  an  or«:an  which  is  de<,a'nerate  and  fiinctionless  from  first  to  last,  and 
its  scanty  ])Ower  of  resistance  to  bacterial  invasion  is  but  another  way  of 
ex])ressin<,'  tliis  fact"  (Jlawkins). 

It  has  been  urffcd  that  the  anatomical  relations  of  the  me.so-a])])endix 
and  the  adjacent  peritoneal  folds  are  such  that  distention  of  the  ca>cum, 
or  of  tiie  lower  ])ortion  of  the  ileum,  may  cause  draji'fjjing  with  torsion  and  in- 
tei'fere  seriously  with  the  blood  su])i)ly  of  the  tube.  The  swelling  of  ihe 
mucosa  so  induced  may  be  an  important  factor  in  the  infection  of  its  tissues. 

Fowler  suggests,  and  brings  a  case  in  sujjport,  that  in  some  of  these 
cases  the  necrosis  is  due  to  the  thrombosis  of  a  large  arterial  branch. 

Immediate  EflFects  of  the  Perforation,  (a)  Acute  General  Peritonitis.— 
If  the  ap])endix  is  free,  withouc  adhesions,  the  perforation  may  lead  at  once 
to  a  widespread  ])eritonitis.  The  inflammation  vanes  much  in  virulence, 
depending  ajjparently  U])on  the  infecting  organism.  The  worst  cases  are 
those  in  which  the  streptococcus  ])yogenes  is  ])resent.  A  general  peritonitis 
is  more  common  in  the  acute  infective  ai)i)endieitis  than  in  the  other  forms. 
It  probably  results  less  frequently  from  direct  perfom  ion,  or  sloughing  of 
the  a])pendix,  than  from  extension  of  inllanunation  from  a  local  peri-aj)- 
])endicular  abscess. 

(/>)  Localized  Peritonitis,  with  Abscess. — Perforation  leads  usually  to 
the  formation  of  a  circumscribed  intra-i)eritoneal  abscess  cavity,  which 
A'aries  in  sitnation  with  the  position  of  the  api)endix,  and  in  size  from  a 
walnut  to  a  cocoanut.  Perhai)s  the  most  common  sitiuition  is  on  the  psoas 
muscle,  just  at  the  angle  ])etween  the  ileum  and  the  ca}cum.  The  ])erfo- 
rated  api)endix,  however,  may  be  within  tlie  pelvis,  or  ui)on  the  promontory 
of  the  sacrum,  or  lie  between  the  coils  of  small  bowel  in  the  neighborhood 
of  the  undjilicus.  A  common  situation  for  the  large  circnmscril)ed  intra- 
])eritoneal  abscess  is  in  the  iliac  region  midway  between  the  navel  and  the 
anterior  sn])erior  s])ine.  Perforation,  adhesive  peritonitis,  and  the  produc- 
tion of  a  localized  abscess  may  proceed  without  causing  any  serious  symp- 
toms, and  the  condition  may  be  foimd  when  death  has  resulted  from  acci- 
dent or  from  some  intercurrent  aifection.  The  contents  of  the  abscess 
may  be  a  grayish  yellow,  thick  ])ns,  usually  with  a  strong  fjrcal  odor;  Ijut 
in  the  old,  limited,  small  abscesses  it  is  usually  dark  gray  in  color,  and  hor- 
riljly  offensive.  The  apjicndix  may  be  found  free  in  the  localized  al)SCoss; 
in  other  instances  it  is  so  covered  with  pus  and  inflammatory  exudate  that 
it  is  impossible  to  find  it.  While  in  a  majority  of  all  instances  the  abscess 
cavity,  even  when  large,  is  intra-peritoneal,  there  may  be — 

(r)  Extensive  Extra-Peritoneal  Suppuration. — When  an  apjiendix  perfo- 
rates, it  lies,  of  course,  in  immediate  contact  with  the  peritonanim;  if  on 
the  iliac  fascia,  or  the  wall  of  the  pelvis,  or  behind  the  cannim,  the  adhesion 
may  take  place  in  such  a  way  that  the  perforation  occurs  into  the  retro- 
]ieritoneal  tissue.  In  these  days  of  operation  we  do  not  so  often  see  the  ex- 
tensive retro-]ieritoneal  absce.«ses  due  to  appendix  disease.  The  inis  may 
pass  beneath  the  iliac  fascia  and  appear  at  Poupart's  ligament,  in  which 


APPENDICITIS. 


523 


iiitiiation  oxtcnial  pcri'Dratinn  may  occur  and  recovery  take  place.  The 
piiri  may  be  cliiclly  in  the  ictro-peritoiical  tissue  in  tiie  llank,  I'orniiii",'  a 
lar<,a'  perinepliritic  abscess.  Jn  a.  case  under  tiie  care  of  Ciardner,  of  Mont- 
real, an  enonnouri  al)sces.s  cavity  developed  in  this  situation,  which  con- 
tained air,  i)ushed  up  the  diaphragm  nearly  to  the  second  rib,  and  produced 
the  symptoms  of  ])ni'umothorax.  Perforation  of  the  pleura  may  occur  in 
the  '  cases,  forming  a  fa'cal  pleural  listula.  The  i)us  may  exteiul  along 
the  ^,soas  muscle  and  may  perforate  the  hip  joint,  or  pass  to  the  neighbor- 
hoocl  of  the  rectum,  or  produce  niulti])le  abscesses  of  the  scrotum;  or,  pass- 
ing through  the  ol)turator  foramen,  form  a  large  gluteal  al)scess.  Jioth  the 
intra-  and  extra-peritoneal  appendix  abscess  iiuiy  perforate  into  the  bladder 
or  into  the  bowel,  and  recovery  may  follow,  though  there  is  greater  danger 
in   perforation   into  the  latter.     The  appendix   has   been  discharged   per 

Remote  Effects. — The  remote  effects  of  perforative  ap))endicitis  arc  in- 
teresting, lljcmorrhage  nuiy  occur,  in  one  of  niy  cases  tiie  appendix  was 
adherent  to  the  prouu)ntory  of  the  sacrum,  and  the  abscess  cavity  had  per- 
forated in  two  i)laces  into  the  ileum.  Death  resulted  from  profuse  luvmor- 
rhage.  Cases  are  on  record  in  which  the  internal  iliac  artery  or  the  deep 
circundlex  iliac  artery  has  been  opened.  Suppurative  ])ylephlebitis  nuiy 
result  from  inllammation  of  the  mesenteric  veins  near  the  ])erforate(l  ap- 
]iendix.  Two  instances  of  it  have  come  uiuler  my  notice;  in  one  there 
was  a  small  localized  abscess  which  had  resulted  from  the  perforation  of  a 
ty])hoid  ulcer  of  the  appendix.  In  the  other  case,  which  1  saw  with  ^la- 
chell,  of  Toronto,  the  symptoms  were  those  of  septic;enua  and  of  suppura- 
tion of  the  liver.  The  al)scess  of  the  ap])endix  was  small  and  had  not  ])ro- 
duced  symjitoms.  In  the  healing  of  extensive  intlammation  about  the  mar- 
gin of  the  ])elvis  the  iliac  veins  nuiy  be  greatly  compressed,  and  one  of  my 
})atients  had  for  months  u'dema  of  the  right  leg,  which  is  now  permanently 
enlarged. 

The  appendix  may  perforate  in  a  hernial  sac.  Several  instances  of  this 
have  been  recorded.  In  a  case  which  came  under  my  care  at  the  Uni- 
versity Hospital,  Philadelphia,  there  was  a  hernia  of  the  ca'cum  in  the 
inguinal  canal.  The  pidximal  orifice  of  the  ap])endix  was  at  the  extreme 
end  of  the  hernia  in  the  inguinal  canal.  The  tulje  then  curved  upon  itself, 
])asscd  into  the  abdomen,  and  the  terminal  three  foiu'ths  of  an  inch  had 
sloughed  in  a  small  circumscriljcd  sac  situated  close  to  the  promontory  of 
the  sacrum. 

The  following  additional  facts  may  be  mentioned,  bearing  on  the  eti- 
ology : 

Age. — A]ipendicitis  is  a  disease  of  young  persons.  According  to  Fitz's 
statistics,  more  than  .50  ]ier  cent  of  the  cases  occur  l)efore  the  twentieth 
year;  according  to  Einhorirs,  (10  i^cr  cent  between  the  sixteenth  and  thir- 
tieth years.  It  has  been  met  with  as  early  as  the  seventh  week,  but  it  is 
rarely  seen  prior  to  the  third  year. 

Sex. — It  is  much  more  common  in  males  than  in  females,  80  per  cent 
of  the  former  in  the  table  of  Fitz.  In  Hawkins'  series,  Ifil  were  males 
and  03  females.     Contrary  to  the  general  experience,  the  ^Munich  figures 


524 


DISKASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


^fivcii  liy  I']iiili(irn  iiidicatc  n  ri'lativcly  greater  iiiiiiilier  of  women  at- 
tacked. 

Occupation. — l'er.>;oiis  whose  woik  necessitates  the  lifting  of  lieavy 
weigiits  seem  more  prone  to  the  disease,  '^rraiima  |)hiys  a  very  definite  rnlr, 
and  in  a  niiiidxT  of  cases  the  .symptoms  iiave  fojlowi'd  very  closely  a  fall  or 
a  hlow. 

Indiscretions  in  diet  are  very  prone  to  hriiig  on  an  attack,  ])articularly 
in  the  recnrring  form  of  tiie  disease,  in  which  ])ain  in  the  appendi.x  region 
not  infrtMpiently  follows  tln'  eating  (d'  indigestihie  articles  of  food.  1  have 
heen  im])ri'ssed,  too,  with  tiie  mnnher  of  cases  in  hoys  in  wiiicli  there  has 
heen  a  history  of  gorging  with  ])eanuts. 

Symptoms. — in  a  large  pro])ortion  of  all  cases  of  acnte  a])iicndicitis 
the  following  symptoms  are  present:  (1)  Sndden  ])ain  in  the  alxlomen,  usn- 
ally  I'eferred  to  the  right  iliac  fossa;  {2)  fever,  often  of  moilerate  grade; 
(;i)  gastro-intestinal  disturhance — nansea,  vomiting,  and  fre(piently  consti- 
l)ation;  (4)  tenderness  or  ])ain  on  jiressnre  in  the  a[)pendix  region. 

Sncli  a  gronp  of  symi)toms  in  a  yonng  person,  ])articnlarly  following  an 
indiscretion  in  diet  or  an  injnry  or  strain,  in  the  ahsence  of  signs  of  hernia, 
indicate  the  existence  of  appendicitis;  they  do  not  snggest  in  any  way  the 
natnre  of  the  lesion,  whether  ohl iterative,  nlcerative,  or  an  acute  necrotic 
appendicitis.  "We  may  first  consider  more  fully  these  general  symjjtoms  of 
the  disease. 

Pain. — A  sudden,  violent  ])ain  in  the  abdomen  is,  according  to  Fitz, 
the  most  constant,  first,  decided  symptom  of  ])erforating  inllamniation  of 
the  a])i)endix,  and  occurred  in  S-t  i)er  cent  of  the  cases  analyzed  hy  hiii\ 
In  fully  half  of  the  cases  it  is  localized  in  the  right  iliac  fossa,  but 
it  may  he  central,  diffuse,  or  iiuleed  in  almost  any  region  of  the  abdo- 
men. Even  in  the  cases  in  which  the  ])ain  is  at  first  not  in  the  a])pendix 
region,  it  is  usually  felt  here  within  thirty-six  or  forty-eight  hours.  It 
may  extend  toward  the  ])erina'um  or  testicle.  It  is  sometimes  very  shar]) 
and  colic-like,  and  cases  have  been  mistaken  for  ne]ihritic  or  for  biliary 
colic.  Some  ])atients  speak  of  it  as  a  sharp,  intense  ])ain — serous-mem- 
brane ])ain;  others  as  a  dull  ache — connective-tissue  i)ain.  "While  a  very 
valuable  symptom,  pain  is  at  the  same  time  one  of  the  most  misleading. 
Some  of  the  forms  of  recurring  ])ain  in  the  appendix  region  Talamon 
has  called  aiijiendicular  colic.  The  condition  is  believed  to  be  due  to 
partial  occlusion  of  the  lumen,  leading  to  violent  and  irregular  ])eristal- 
tic  action  of  the  circular  and  longitudinal  muscles  in  the  expulsion  of  the 
mucus. 

Fever. — A  rise  in  the  temperature  follows  rajiidly  upon  the  pain,  and  is 
one  of  the  most  valuable  of  the  symptoms  of  the  early  stage  of  ap])cndi- 
citis.  An  initial  chill  is  very  rare.  The  fever  may  be  moderate,  from 
100°  to  10"-^°;  sometimes  in  children  at  the  very  outset  the  thermometer 
may  register  above  103. .5°.  The  thermometer  is  one  of  the  most  trust- 
worthy guides  in  the  diagnosis  of  ac;ite  a]>pendicitis.  Ap]iendicular  colic 
of  great  severity  may  occur  without  fever.  "When  a  localized  abscess  has 
formed,  and  in  some  very  virulent  cases  of  general  ])eritouitis,  the  tempera- 
ture may  be  normal,  but  at  this  stage  there  are  other  symptoms  which  in- 


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APPENDICITIS. 


525 


dicalt'  the  gravity  of  the  situation.  The  i)iilse  is  (juickeiu'd  in  proportion 
to  the  lever. 

Gastro-intestinal  Disturbance. — The  tongue  is  usually  furred  and  moist, 
seldom  dry.  iS'aiisea  and  vonuting  are  symptouis  whieh  may  he  al)sent, 
])ut  which  are  connnonly  present  in  the  aeute  perforative  eases.  The  vom- 
iting rarely  jjorsists  heyond  the  seeond  day  in  i'avorahle  cases.  Constipa- 
tion is  the  rule,  hut  the  attack  may  set  in  with  diarrhcea.  particularly  in 
children. 

Local  Signs. — Inspection  of  the  ahdomen  is  at  first  negative;  there  is  no 
distention,  and  the  iliac  fossiv  look  alike.  On  palpation  there  are  usually 
from  the  outset  two  important  signs — namely,  great  tension  of  the  right 
rectus  muscle,  and  tenderness  or  actual  pain  on  deep  pressure.  The  mus- 
cular rigidity  may  be  so  great  that  a  satisfactory  exannnation  cannot  he 
nuule  without  an  antvsthetie.  ^IcBurney  lias  called  attention  to  the  value 
of  a  localized  point  of  tenderness  on  deep  i)ressure,  wliich  is  situated  at  the 
intersection  of  a  line  drawn  from  the  navel  to  the  anterior  superior  spine 
of  the  ilium,  Mith  a  second,  vertically  jilaced,  corresponding  to  the  outer 
edge  of  the  right  rectus  muscle.  Firm,  dee]),  continuous  pressure  with 
one  finger  at  this  sjjot  causes  pain,  often  of  the  most  exquisite  character. 
In  addition  to  the  teiulerness,  rigidity,  and  actual  pain  on  deep  |)rcssure, 
there  is  to  be  felt,  in  a  majority  of  the  cases,  an  induration  or  swelling. 
In  some  ca.ses  this  is  a  boggy,  ill-defined  mass  in  the  situation  of  the 
ca'cum;  more  commonly  tlie  swelling  is  circumscribed  and  definite,  situated 
in  the  iliac  fossa,  two  or  three  fingers'  breadth  al)ove  Poupart's  ligament. 
Some  have  been  able  to  feel  and  roll  beneath  tlu'  fingers  the  thickened  ap- 
])endix.  The  later  the  case  comes  under  observation  the  greater  the  ])roba- 
hility  of  the  existence  of  a  Avell-marked  tumor  mass.  It  is  not  to  be  for- 
gotten that  there  may  be  neither  tumor  mass  nor  induration  to  be  felt  in 
some  of  the  most  intensely  virulent  cases  of  perforative  api)endieitis. 

In  addition  may  be  mentioned  great  irritability  of  the  Idadder,  which 
1  have  known  to  lead  to  the  diagnosis  of  cystitis.  It  may  be  a  very  early 
symptom.  The  urine  is  scanty  and  often  contains  albumin  and  indiean. 
re])tonuria  is  of  no  moment.  The  attitude  is  somewhat  suggestive,  the 
(lecubitis  is  dorsal,  and  the  right  leg  is  semi-flexed.  Examination  prr 
rcrhim  in  the  early  stages  rarely  gives  any  information  of  value,  uidess  the 
appendix  lies  well  over  the  brim  of  the  pelvis,  or  unless  there  is  a  large  ab- 
scess cavity. 

There  are  three  possibilities  in  any  case  of  appendicitis  presenting  the 
above  symptoms:  (1)  Gradual  recovery,  (2)  the  formation  of  a  local  abscess, 
and  (3)  the  development  of  a  general  peritonitis.       X 

Recovery  is  the  rule.  Ont  of  204  cases  at  St.  Tlmmas's  Hospital  with 
the  above-mentioned  clinical  characters,  190  recovered.  In  one  instance 
the  appendix  was  removed,  and  in  two,  attempts  were  made  to  remove  it 
(Hawkins).  There  are  surgeons  who  claim  that  the  getting  well  in  these 
cases  does  not  mean  much;  that  the  patients  have  recurrences  and  are  con- 
stantly liable  to  the  graver  accidents  of  the  disease.  This,  I  feel  sure,  is 
an  unduly  dark  picture. 

In  a  case  which  is  j^rocecding  to  recovery  the  pain  lessens  at  the  end  of 


Ill 


520 


DISKASKS  OK  TIIK   DKJKSTIVK  SYSTKM. 


.  \ 
/ 


llir  third  or  roiirtli  dny,  ilic  t(  iii|i«'nitiin'  ImIIs,  ilic  t()ii>,Mi(>  hccomcs  cleaner, 
tlic  viiiiiitiM;,^  ccasr,-,  the  loc'il  triidcnirss  is  h'ss  iimi'i<t'd,  iiiid  I  lie  Ixjweld 
lire  moved.  I'.y  the  end  ul'  n  week  the  iieiite  syiii[it(»ins  hiivo  subsided.  Tho 
entire  attiiek  nuiy  not  hist  more  thnti  ten  ihiys.  In  other  instances  slight 
fever  persists,  and  it  may  \)v  two  or  three  weei<s  helon;  convalescenco  id 
establisiied.  An  induration  or  an  actual  small  tumor  mass  from  tho  size 
of  a  walnut  to  that  of  an  e.Lr<i'  uiay  persist — a  condition  which  leaves  the 
patients  very  liahle  to  a  rectirreiice. 

fn  these  cases  there  is  either  a  chronic  ap|)en(licitis  without  perforation 
or  involvement  of  the  serous  surface,  or  there  is  involvement  of  the  j)eri- 
toneal  surface,  usually  from  i)erforation,  with  a  sero-llbrinous  exudate 
and  an  ajrglutination  of  tiio  contiguous  parts^.  In  the  cases  with  a  weli- 
delined  tumor,  whether  large  or  small,  there  is  ahnost  always  pus  forma- 
tion. 

Local  Abscess  Formation. — As  a  result  of  ulceration  and  perforation, 
sometimes  following  the  necrosis,  rarely  as  a  seciuence  of  the  dill'uso  ap- 
pendicitis, the  ])atient  has  the  train  of  symptoms  above  described;  hut  at 
the  end  of  the  lirst  week  the  local  features  persist  or  become  aggravated. 
The  course  of  the  disease  may  be  indeed  so  acute  that  by  the  end  of  the 
fourth  or  fifth  day  there  is  an  extensive  area  of  induration  in  the  right 
iliac  fossa,  with  great  tenderness,  and  operations  have  shown  that  even  at 
this  very  early  date  an  abscess  cavity  may  have  formed,  'i'hough  as  a  rule 
the  fever  becomes  aggravated  with  the  onset  of  su[)puration,  this  is  iu)t 
always  the  case.  The  two  most  ini|)ortant  elements  in  the  diagno.sis  of 
abscess  formation  are  the  gradual  increase  of  the  local  tumor  and  the  aggra- 
vation of  the  general  symptoms.  Xowadays,  when  operation  is  so  fretjuent, 
we  have  o])])ortunities  of  seeing  the  abscess  in  various  stages  of  develop- 
ment. (^)uite  early  the  ])us  may  lie  between  the  ciocuni  and  the  coils  of 
the  ileum,  with  the  general  peritonanim  shut  off  by  fibrin,  or  there  is  a  sero- 
fibrinous exudate  with  a  slight  amount  of  pus  hetween  the  lower  coils  of  the 
ileum.  The  al)scess  cavity  may  be  small  and  lie  on  the  psoas  muscle,  or 
at  the  o(]go  of  the  promontory  of  the  sacrum,  and  never  reach  a  ])alpable 
size.  The  sac,  when  larger,  may  he  roofed  in  by  the  small  bowel  and  pre- 
sent irregular  jirocesses  and  ])ockets  leading  in  dill'erent  directions.  In 
larger  collections  in  the  iliac  fossa  the  roof  is  generally  formed  ])y  the  ab- 
dominal wall.  Some  of  the  most  important  of  the  localized  abscesses  are 
tliose  whicli  are  situated  entirely  within  the  pelvis.  The  various  directions 
and  jiositions  into  which  the  abscess  nuiy  ])ass  or  perforate  have  already 
been  referred  to  under  morbid  anatomy,  hut  it  may  be  here  mentioned 
again  that,  left  alone,  they  may  discharge  externally,  or  burrow  in  various 
directions,  or  discliarge  through  tlie  rectum,  vagina,  or  l)ladder.  Death 
luay  be  caused  by  septicaemia,  by  perforation  into  an  artery  or  vein,  or  by 
pylephlebitis. 

General  Peritonitis. — Tliis  may  be  caused  by  direct  perforation  of  tho 
appendix  and  general  infection  of  the  ])eritona>um  before  any  delimiting 
inflammation  is  excited.  Tn  a  second  group  of  cases  there  has  been  an  at- 
tem])t  at  localizing  tlie  infective  process,  but  it  fails,  and  the  general  peri- 
tona}um  becomes  involved.     In  a  third  group  of  cases  a  localized  focus  of 


API'KNDIcrnS. 


r.27 


sii|»|tm'iil  ion  exists  iiboiil  iiii  inlliinicil  ii|>|icii(li\,  n  d  rrmii  lliis  lu'iTonition 
l;iki's  pliicc. 

Dt'iilli  ill  ii|i|M'ii(licil  is  is  due  iisiiiilly  to  ^■(•iicriil  |ii'iit(iiiit  is. 

We  sec  !it  (i|ici'iiti()iis  ill!  ^'radcs  ol'  the  jill'rctiun,  I'loiii  llic  niildol,  in 
wliich  t lie  serous  siirfiiee  is  injected,  tiifliid,  mid  sticl<y,  iiiit  without  lyiii|iii 
or  ell'iisioii,  c\cc|tt  ill  the  iiiiiiie(li;ite  iieij:hltorliood  of  the  perl'onited  iip- 
peiidix.  Ill  olher  ejises  thiTe  is  ii  liiii'iiioiis  exiKhitc  ^liiinL;'  the  coils  to- 
j.'ether  !ind  a  variiilth'  Miiioiint  of  liiriiid  serous  lliiid.  In  other  iiisluiurs, 
as  liic  ahdoiiieii  is  o|)eiied,  pus  wells  ont,  and  tlieif  is  a  dilViise  pnriilelit  ili- 
llaniinat  ion  (d'  the  peritoineiini.  Il  is  interest  iiiu',  however,  to  note  the  coni- 
parative  rarity  of  fatal  peritonitis  from  ap|ieiidix  disea>e  in  i^cneral  inetlical 
work.  In  loH  consecutive  autopsies  on  |)atieiits  dead  in  my  wards  there 
was  not  a  single  instance  of  ^■eiieral  peritonitis  IVoni  appendix  disease.  On 
the  siir<i;ical  side  tliero  have  heeii  admitted  during'  the  same  period  jo  eases 
of  diU'Msc  peritonitis  fiwnn  this  cause.  I'liyht  were  operatc(|  up(tn;  all  died. 
In  !»  casi's  there  was  found  a  perforati'd  and  more  or  less  <raii;irenous  ap- 
pendix, with  little  or  no  atleinpt  at  localization;  in  1  case  iiiptiire  of 
an  ahsccss  caused  the  {general  peritonitis. 

The  i/nirili/  of  (i/i/irinli.r  (lisrtisr  I  Irs  in  the  far!  Ilia  I  fraiii  llir  vrnj  oiilsrt 
llir  pcrilniKntiii  iikii/  he  iiifrcird;  Ihc  inilial  siiiuplniiix  of  pniii,  irilh  luiiisra 
(iiiil  rniiiiliiiii,  fcj'rr,  a  ml  lonil  Irndcrin'ss,  prrsenl  in  all  nisrs,  )iiiii/  imlirdlr  a 
iridcspri'dd  infccliiin  nf  llils  nirndininc  The  onset  is  usually  sudden,  the 
pain  did'use,  not  always  localized  in  the  ri<,dit  iliac  I'ossa,  but  it  is  not  so 
much  the  character  as  tlii'  <ireater  intensity  of  the  symptoms  from  the  out- 
set that  makes  one  suspicious  of  a  <i('iieral  jieritonitis.  iMxIoininal  disten- 
tion, dilTuse  tenderness,  and  ahseiice  of  ahdominal  movements  are  the  most 
triistwoi'thy  local  si,<ins,  l)\it  they  are  not  really  so  trustworthy  as  the  jj,'en- 
eral  symptoms.  The  initial  nausea  and  voinitin«;f  iiersist,  the  i)ulse  l)e- 
comcs  more  rapid,  the  toii;^iie  is  dry,  the  urine  scanty.  In  very  acute 
cases,  l)y  the  end  of  twenty-four  hours  the  abdomen  may  be  distended.  \\y 
the  third  and  fourth  days  the  classical  jiicture  of  a  jicneral  peritonitis  is 
well  established — a  distended  and  motionless  abdomen,  a  ra])id  pulse,  a  dry 
tonirne,  dorsal  decubitus  with  the  knees  drawn  u[),  and  an  anxious,  pinched, 
llippocratic  facies. 

J'\'ver  is  an  nncertain  element.  It  is  nsually  ]»!'esent  at  first,  but  if  the 
physician  does  not  see  the  case  until  the  third  or  f(Uirtli  day  he  should 
not  be  deceived  by  a  temperature  Ijclow  l(l()..")°.  The  i)ulse  is  really  a 
better  indication  than  the  tempi'rature.  One  rarely  has  any  doubt  on  t1ie 
tiiii'd  or  fonrth  day  whether  or  not  ])eritonitis  exists,  but  it  must  be  ac- 
knowled^icd  that  there  are  exceptions  which  trouble  tlie  jiidiiiiu'iit  not  a 
little.  Wliile  on  the  one  hand,  without  suii'^'cstive  sym|>toms,  a  Iji])arotoiny 
has  dis(dosed  an  nnex])ected  iicncral  ix'ritonit is.  on  the  other,  with  severe 
constitutional  symptoms  and  apparently  characteristic  local  siyiis,  the  peri- 
tonanim  has  been  found  smooth. 

Relapsing  Appendicitis. — Tejipcr,  in  1SS;5,  called  attention  to  the  re- 
mark.ible  liability  to  relapse  in  p(M-ity]»hlitis.  The  jiatient  .acts  well  and 
all  trace  of  induration  and  tenderness  disa])pears:  then  in  three  or  four 
iiHMiths,  or  earlier,  he  again  has  fever,  pain,  and  local  signs  of  trouble. 

no  I 


S'JS 


DISKASKS  OV  TUK   DUiKSTlVK  SYSTKM. 


/ 


'riic  iittiicks  niiiy  recur  fur  yciirs.  'I'lic  cases  wliicli  recover  witli  tlio  pcr- 
Hisleiici'  (tl  ill)  iiidiirnlion  (»r  liiiiinr  muss  are  in(»sl  prone  to  relapse.  'I'liere 
are  more  severe  cases  in  wliicli  I  lie  intervals  ix'tweeii  the  attacks  are  very 
short,  and  the  patient  hecomes  a  chronic  invalitl.  After  repeated  attack-^, 
however,  recovery  may  he  perlVct.  'I'he  rretpiency  of  recurrence  is  diHiciill 
to  estimate.  Kitz  places  it  at  I  I  per  cent,  llawkinn  at  )i'.\A>  per  cent.  Tiie 
recent  statistics  of  operations  f^iven  l)y  Deaver,  Murphy,  and  others  indi- 
cate how  common  must  he  this  type?  of  the  disease.  Mull  has  colle<'ted 
•I !»'  operations  in  chronic  relapsing,'  appendicitis  Ity  eighty  sui';;eons,  with 
a  mortality  of  l.H  per  cent,  hut  he  tliinks  that  5  or  (5  per  cent  would  be  a 
fairer  estimate. 

The  moritid  condition  in  this  form  is  either  a  simple  olditerativc  ap- 
pendicitis with  or  without  adhesions,' or  an  adherent,  perhaps  perforated 
appcndi.v  with  a  suuiU  localized  abscess  eircumscrihed  hy  dense  iihroi<l 
tissue. 

Diagnosis. — Apjx'ndicitis  is  by  far  the  most  common  inllammatory 
condition,  not  only  in  the  cu'cal  region,  hut  in  the  abdomen  generally  in 
persons  under  thirty,  ^i'he  surgeons  have  taught  us  that,  almost  without 
e.\ce|)tion,  sudden  pain  in  the  right  iliac  fossa,  with  fever  and  localized  ten- 
derness, with  or  without  tumor,  means  appendix  ilisease.  There  are  cer- 
tain diseases  of  the  abdomiiiiil  organs  characterized  hy  paiu  which  are  apt 
to  be  confounded  with  appendicitis.  iJiliary  colic,  kidney  colic,  and  the 
colicky  ])ains  at  the  menstrual  period  in  women  have  in  some  cases  to  be 
most  carefully  considered.  J  have  not  met  with  an  instance  of  either  renal 
or  hepatic  calculus  causing  any  dilliculty  in  diagnosis,  but  n  patient  was 
admittt'd  to  my  wards  with  a  history  of  very  snd(b'n  onset  of  severe  pain 
three  days  jireviously  in  the  right  side  of  the  abdomen,  and  with  an  ill- 
delined  tumor  mass  low  in  the  right  flank.  Fortunately,  she  was  trans- 
ferred at  once  to  the  surgical  side  for  operation,  and  the  condition  jiroved 
to  bo  an  acutely  distended  and  inllamed  gall-bladder  almost  on  the  i)oini 
of  ])erforating.     A  second  very  similar  case  has  since  occurred. 

Diseases  of  the  tubes  and  pelvic  ])eritonitis  may  simulate  appendicitis 
very  closely,  but  the  history  and  the  local  exannnation  under  ether  should 
in  most  cases  enabl(>  the  ])ractitioner  to  reach  a  diagnosis.  I  have  seen 
several  cases  su])])osed  to  be  recurring  a})pendicitis  which  j)roved  to  be  tnbo- 
ovarian  disease. 

The  Dietl's  crises  in  floating  kidney  have  been  mistaken  for  appendi- 
citis. 

Both  intnssusce])tion  and  internal  strangulation  may  present  very  sim- 
ilar sym])toms,  and  if  the  ])atient  is  only  seen  at  the  later  stages,  when 
there  is  dilfuse  ])erit()nitis  and  great  tym])any,  the  features  may  be  almost 
identical.  Faecal  vomiting,  which  is  common  In  obstruction,  is  never  seen 
in  ajipendicitis,  ami  in  children  the  marked  tenesmus  and  bloody  stools 
are  im])ortnnt  signs  of  intussusce])tion.  Tt  is  not  often  diffieult  to  dccidi* 
when  the  cases  are  seen  early  and  when  the  history  is  clear,  but  mistakes 
have  been  made  by  surgeons  of  the  first  raidc. 

Acute  ha^morrhagic  ])ancrcatitis  may  also  jiroduce  symptoms  very  like 
those  of  appendicitis  with  general  peritonitis.     Typhoid  fever  has  been 


AI'I'KNDIC'ITI.S. 


529 


TIh 


I'o  1)11  in 

an  ill- 

trnns- 

point. 

(Ileitis 

sliould 

!  seen 

tuho- 

jpendi- 

ry  pini- 

almost 

.'!•  seen 

stools 

dccidt.' 

listaki's 

ry  like 
s  been 


iiiistukcn  for  ii|iitciidifitiM.  I  was  (old  of  u  cano  recently  in  one  of  the  lar;,'e 
hospitals  of  this  country  in  \shich  the  IVvcr,  the  presence  of  a  tender  indu- 
ration in  the  ri^ht  iliac  fossa,  seemed  to  iiulicate  so  clearly  appendix  dis- 
ease that  an  operation  was  perfornu'd,  hut  the  induration  was  found  to  ho 
the  s\V(dlen  ileum  and  adjacent  ^dands.  In  a  pcismi  wlm  had  had  previous 
appendicitis  the  (lia;;nosis  mi^^ht  he  extremely  dillicidt,  as  in  a  ease  men- 
tioned hy  Da  Costa,  iiate  in  the  convali'scence  of  typhoid  fever  symptoms 
of  appendicitis  may  develop,  due  to  the  perforation  of  an  unhealed  idi  er. 

There  is  a  well-nuirked  appendicular  hypochondriasis,  'i'hrou^di  the 
pernicious  inlluence  (d'  the  daily  press,  .ippemlieitis  has  hecome  a  sort  of 
fad,  and  (he  physician  has  often  (o  deal  \\i(h  pa(ien(s  who  have  a  sort 
of  lixed  idea  that  (hey  have  (he  disease.  The  worst  cases  of  this  class 
which  1  have  seen  have  been  in  nu^nhers  of  our  profession,  and  I  know  of 
at  least  one  instance  in  which  a  perfecdy  normal  appendix  was  removed. 
The  (piesdon  really  has  its  ludicrous  side.  A  well-known  physician  in  a 
Western  city  havin.u  one  ni;;ht  a  hellyache,  and  leelin<,'  convinced  that  his 
appendix  had  perforated,  summoned  a  surgeon,  who  (piickly  removed  the 
supposed  oil'ender! 

Hysteria  may  of  course  simulate  appendicitis  very  closely,  and  it  may 
re(pnre  a  very  keen  jud<:inent  to  make  a  diagnosis. 

.Mucous  colitis  with  enteralgia  in  ni'rvous  women  is  sometimes  mi^i- 
takeii  for  appendicitis.  In  two  instances  of  the  kind  I  have  pn-vented 
proposed  o|)eration,  and  1  have  heard  of  cases  in  which  (he  appendix  has 
been  removed. 

Perinephritic  and  perica-cal  altscess  from  ]terfora(ion  of  ulcer,  either 
simple  or  cancerous,  and  circumscrihcil  peritonitis  in  (his  I'egion  from  other 
causes,  can  rarely  be  differentiated  until  an  exploratory  incision  is  made. 

Chronic  obliterative  ai)pendiciti8  cannot  always  he  ditl'erentiated  from 
the  i)erforative  form,  and  in  intensity  of  pain,  severity  of  symptoms,  and,  in 
rare  instances,  even  in  the  production  of  peritonitis,  the  two  may  be  iden- 
tical. 

IJriefly  stated,  localized  pain  in  the  right  iliac  fossa,  with  or  without 
induration  or  tumor,  the  existence  of  ^IcUurney's  tender  ])oint,  fever, 
furred  tongue,  vomiting,  with  constipation  or  diarrluea,  indicate  appendi- 
citis. The  occurreiu'c  of  general  peritonitis  is  suggested  I»y  increase  and 
did'usion  of  the  abdominal  pain,  tymi)auitefl  (as  a  rule),  marked  aggrava- 
tion of  the  constitutional  symptoms,  ])articularly  elevation  of  fever  and  in- 
creased rajjidity  of  the  ])ulse.  Obliteration  of  hepatic  dulness  is  rarely 
prcs(>nt,  as  the  ])eritona'um  in  these  cases  does  not  often  contain  gas. 

Prognosis. — Whib;  we  cannot  overestimate  the  gravity  of  certain 
forms  of  a]i])endicitis,  it  is  avcII  to  recognize  that  a  largo  proportion  of  all 
cases  recover.  It  is  the  element  of  iincprldinh/  in  individual  cases  which 
has  given  such  an  impetus  to  the  surgical  treatment  of  the  disease.  Th'at 
an  inflamed  ajjpendix  may  heal  ])erfectly,  even  after  ])erforation,  is  shown 
by  instances  (post  mortem)  of  obliterated  tubes  firndy  ind)edded  in  old 
scar  tissue.  Formerly  we  had  not  a  full  knowledge  of  the  natural  history  of 
the  disease.  As  J.  William  "White  remarked  in  an  address  at  the  Collcire 
of  Physicians,  rhiladelj)hia,  "We  are  in  special  need  of  reliable  medical 


I!. 


fi.'W) 


DISKASKH  OP  THE  DIOKSTIVK  SYSTKM, 


/ 


clatihtics  iiH  to  till-  |H)iiil."  'riit'M'  liii\t'  imu  Imi'm  sii|i|ili('i|  in  ihc  iiiliiii- 
riil)l(>  in)>ii();;i'ii|ili  i>r  llnwkiiis  (Lniiilun,  Is'i.'i),  in  wliicli  lif  liiis  niialy/.cd  tliu 
t'HMi'K  at  St.  'riioniiiH's  lluspitiil,  »'»li  in  nnMiliti'.  The  wurk  is  tu  lie  coin- 
incMtlcd  |i;irticnliirl_v  In  Mirjicnns,  sincf,  while  wiiltcn  I'l'iini  llic  stinidpoint 
(if  tilt'  |ili\>i('iiiii  iind  |iatliii|(i;:i>t,  tlic  tuitlmr  is  lullv  idivc  to  llic  siir^^ical 
nspccts  of  tlit<  dist'iisc,  niiil  t\*)\'!i  iini|)l('  jnslicc  to  the  work  nf  Anicricmi 
<»|i('riitors.  Mis  lij.Miri'S  iirc  iis  inlJnwH:  {a)  I'lTJlnnitis,  liniilrd  in  the  ii;;lii 
iliiic  I'dssti  iind  not  iirucccdinii;  to  tlic  I'nnniitioii  nl'  \n\-,  !!•()  ciiscs,  no 
dentils;  (/>  peritmiilis,  ^inlillll•ly  Ineidi/.ed,  luit  eiidin;;'  in  the  rnrniidion 
t»l'  [Ills  (|ieiil_v|ilili(ic  idtseess),  IIS  ciiscs,  with  Id  deaths;  (r)  g-eiicral  peri- 
tointJH,  ;i(l  cases,  with  '.'T  deaths.  This  <:ives  a  total  innrtalily  ol'  1  1  per 
cent.  I''il'l y-nine  <d'  the  ".'fll  patit'iits  had  had  nne  nr  ninre  previous  at- 
tacks; |.'»  of  these  had  simple  "  perityphlitis,""  and  all  recovered;  (d'  7  with 
aliscess  rorniatioM,  ;{  died;  oi  '  with  e^ncral  peritonitis,  .'{  died,  'riicsc  11^^- 
iircs  compare  \cry  I'avorahly  with  those  collected  hy  Porter:  Kemoval  of 
appendix  dnriii^^  the  attack,  P.'.i  per  cent  mortality;  incision  and  draiii- 
a;;e  of  ahscess,  IS. IS  per  cent  of  deaths.  The  slutistics  of  individual  opera- 
li)i'<  ;;i\('  a  miieli  inofe  favorahlc  showinu'.  and  we  may  say  that  in  acute 
casi'S  without  ^•ciieralized  peritonitis,  and  in  the  Jocalizcd  ap|)ciidicidar  al)- 
wcss,  the  pi'rceiitagt'  of  doullis  in  the  hands  of  good  surgeons  is  now  \t'iy 
much  lower. 

Treatment. — So  jmpn'sscd  am  1  by  the  fact  that  we  physicians  los(^ 
lives  hy  temporizing  with  certain  cases  of  appendicitis,  that  I  prefer,  in 
liospital  work,  to  havi'  the  suspected  cases  admitted  diri'ctly  to  the  surgical 
PJdc.  The  general  practitioner  does  well  to  rememlier— wlietlier  his  lean- 
ings b«  toward  the  conservat  ivt'  or  the  I'adical  methods  of  treatiniMit — thai 
the  sui'geon  is  often  called  too  late,  never  too  early. 

'{'here  is  no  nieilicinal  treatment  of  appendicitis.  There  are  I'emcdics 
which  will  allay  the  pain,  hut  there  are  none  capahle  in  any  way  of  con- 
trolling the  course  of  the  disease.  K'est  in  l>ed,  a  light  diet,  measures  di- 
rcctetl  to  allay  the  vonuting — upon  these  all  are  agrci'd.  There  are  two 
])oints  on  which  the  profession  is  very  much  dividi'd,  namely,  the  use  of 
(ipium  and  of  salint'  purges.  The  practice  of  giving  opium  in  .some  form 
in  apjiendicitis  and  peritonitis  is  almost  universal  with  physicians.  Sur- 
geons, on  the  fither  hand,  almost  nnainmously  condemn  the  practice,  as 
ohscuring  the  cliidcal  picture  and  tending  to  give  a  false  sense  of  security; 
and  since  they  coidrol  the  situati(»n,  I  think  we  shonld — did'erring  in  this 
matter  to  their  judgment — give  less  opium,  and  trust  to  the  jiersistent  use 
of  ice  locally  to  relieve  the  pain. 

'i'he  use  of  .saline  ])urges  early  in  the  disease,  which  is  advocated  hy 
some  surgeons,  is,  I  helieve,  a  most  injui'ious  ]tractice.  In  any  given  case 
the  ]iain  and  tenderness  at  the  outset  may  mean  ])erforation  of  the  appen- 
dix, and  the  life  of  the  ])atii'nt  may  depend  upon  whether  a  llnnling  adhe- 
sive inllamniatioii  is  set  up.  Undei'  these  ciieumstances,  anything  that 
Avill  stimulate  active  pei'istalsis  of  the  howel  wall  throughout  its  extent  is 
certainly  contra-indicated.  Suigery,  too,  has  taught  us  that  the  caecum  is 
rarely,  if  ever,  filled  with  hardened  faves,  so  that  it  is  really  on  theoretical 
grounds  that  a  saline  is  urged  to  clear  this  part  of  the  howel.     I  am  glad 


INTKSTIN'AL  onSTIU'CTIoy. 


Ml 


to    H'C,    Imm.    tliilt    SDlllt'    silf;ii<)lls    of    llic    liir;;t'>l    fSltriicilct',    lis    Me  MliriH'V, 
^tllt('  tllilt   tllfV  IM'Vrl'  cliililoy   |illl';^ilti\rs.       'I'llcV  lire  illso  (i  Hit  lll-ill(licillfti.    I 


lliiiik,  wlii'ii 


tlu'i 


0  aro  si; 


I'lis  ol'  till'  riiniiiitiiiii  III'  ii  jiM'jil  ali.<- 


ii'i 


liil 


tit  all,  it   is  wlu'ii  j^ciicriil  iirritiiiiilis  lias  lircii  (-<lalili»li('»l,  Imt   tluii,  as  u 
lull',  iIk'  iiiiscliicr  is  (June,  anil  |Mir;.'ativi's  caiiiiut  iiilliiriici'  tin-  ri'.-iilt. 

Uj»"mtiiMi  is  iiidiriitril  ill  ill!  cai-i's  nl'  ariilr  iiilluiiiiiiiildiT  liDiilili'  in  tin' 
lii'cal  iv^^ion,  wlu'tluT  tiiniur  is  incscnt  or  nut,  wlini  the  ;,'t'ni'ial  fyniptoiiis 
lire  severe,  ami  ifhrii  hi/  Ilic  llilnl  dm/  llir  frdliiirs  of  llir  rtisr  jmliil  hi  n  pru- 
i/irssirc  /c.s/'o//.     The  iiiurtiilit}'  irom  early  ()|ieralii)ii  iiiuler  these  cireiim- 


.•.taiiecH  IS  very  sli< 


:ht. 


In  I'linirrin;;  apiKMidicitis,  when  the  attacks  are  i)\'  >\\t\\  severity  ainl 
l're(iiieney  as  seriously  to  interrii|i|  the  |iatient\s  oeeiipatioii,  the  li;^iii'i's  al- 
reiiily  ^'iven  show  how  sli;;lil  the  inortality  is  in  the  lianils  of  eiipaltle  o|iei'- 
ators.     riifortiiiiiitely,  in  hospital  practice  too  many  cases  are  l»nui«rht 


with  general  peritonitis — a  condition  in  which  operation  is  rarely  siiccessrul. 
I'dsl-opcrodri'  Fciihiirs  in  AjijifiuHrilitt. — rnfortunately,  the  operation 


does  not  alwavs  fiiusli  the  victim's  Ironldi 


I   have  heeli  consulted   liV  sev- 


eral patii'iits  with  severe  pain  followin^i'  the  operation,  and  the  literature  con- 
tains a  niimlier  of  reports  of  recurrence  of  the  pain  in  the  ii;,dit  iliac  fossa, 
'riicrc  lia\('  hceii  instances,  indi'cd,  in  which  an  indni'atcd  coi'd  has  hccii 
J'elt.  and  mi^lit  have  ri'adily  heeii  mistaken  for  the  appendix  had  it  not  heeii 
1.      In  some  instances  a  second  operation  has  been  iiic- 


i)revioiislv  rcmovei 


cessrul  ill  I'lveing  the  adhesions  which  havo  caused  the  pain. 


III.     INTESTINAL  OBSTRUCTION. 

Intestinal  ohstructioii  may  he  cansed  hy  stran<,ndation,  intussusception, 
twists  and  knots,  strictures  and  tumors,  and  hy  ahnormal  contents. 

Etiology  and  Pathology.— (rO  Strangulation. — This  is  the  most 
freiiiii'iit  cause  of  acute  ohsti'iict  ion,  und  occurred  in  lU  per  cent  of  the  'i\^Ti 
eases  analyzed  hy  Fitz,*  and  in  3.j  per  cent  of  the  1,131  eases  of  [..eichten- 
stern.f  Of  the  101  cases  of  stran<ridation  in  Fitz's  tahle,  which  has  the  spe- 
cial vahie  of  having  been  carefully  selected  from  the  literature  since  jsso, 
the  followiii'i'  were  the  causes:  Adhesions,  fi.'V,  vitelline  remains,  "^1;  adher- 
ent ap|)i'iidix,  ('■>;  mesenteric  and  omental  slits,  (i;  peritoiie;d  pouches  and 
openings,  3;  adherent  tube,  1;  peduncular  tumor,  1.  The  bands  and  adhe- 
sions resnlt,  in  a  majority  of  cases,  from  former  ])eritonitis.  A  number 
of  instances  have  been  re])orted  following  o])erations  ni)on  the  ))elvic  or- 
igans in  Avomen.  Tlie  strangulation  may  l)e  recent  and  due  to  adhesion  of 
the  bowel  to  the  abdominal  wound  or  a  coil  may  be  caught  between  the 
pedicle  of  a  tnmor  and  the  ])elvic  wall.  Such  cases  are  only  too  common. 
Kate  occlusion  after  recovery  from  the  operation  is  due  to  bands  and  ad- 
hesions. 


*  Transactions  of  tho  ronnrress  of  Amorican  Pliysicinns  and  Surgeons,  vol.  i,  ISSft 
The  percentages  of  liis  tables  aro  useil  throughout  tliis  section. 
f  Yon  Ziemsscn's  p]ncyclopa<dia  of  Practical  Medicine. 


532 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


The  vilc'lliiK'  rciimiiiri  arc  iriu'esL'utL'J  by  Mockers  divorticiiluin,  which 
forms  a  liii<,a'r-liko  i)rojocti()ii  Irom  f  e  ileum,  usually  within  eighteen 
inches  of  the  ileo-ca'cal  valve.  Jt  is  a  remnant  of  the  omi)hal()-mesenteric 
duct,  through  which,  in  the  early  embryo,  the  intestine  communicated  with 
the  yolk-sac.  The  end,  though  commonly  free,  may  be  attached  to  tho 
abdoiuinal  wall  near  the  navel,  or  to  the  mesentery,  and  a  ring  is  thus 
formed  through  which  the  gut  may  pass. 

Seventy  per  cent  of  the  cases  of  ol)struction  from  strangulation  occur 
in  males;  -K)  jier  cent  of  all  the  cases  occur  between  the  ages  of  lifteen  aud 
thirty  years.  Jn  iK)  per  cent  of  the  cases  of  obstruction  from  these  causes 
the  site  of  tlic  trouble  is  in  the  small  bowel;  tho  position  of  the  strangidated 
])ortion  was  in  the  right  iliac  fossa  in  G7  })er  cent  of  the  cases,  and  in  the 
lower  abdomen  in  S3  ))er  cent. 

{!))  Intussusception. — In  this  condition  one  portion  of  the  intestine  slips 
into  an  adjaceut  [jortion,  forming  an  invagination  or  intussuscei)tion.  The 
two  ])ortions  make  a  cylindrical  tumor,  which  varies  m  length  from  a  half- 
inch  to  a  foot  or  more.  The  condition  is  always  a  descending  intussusce})- 
tion,  and  as  the  process  proceeds,  the  middle  and  inner  layers  increase  at 
the  expense  of  tho  outer  layer.  An  intussusception  consists  of  three  layers 
of  bowel:  the  outermost,  known  as  the  intnssuscipiens,  or  receiving  layer; 
a  middle  or  returning  layer;  and  the  innermost  or  entering  layer.  Tho 
student  can  obtain  a  clear  idea  of  the  arrangement  by  making  the  end  of  a 
glove-finger  pass  into  the  lower  portion.  Tho  actual  condition  can  be  very 
clearly  studied  in  the  i)ost-mortem  invaginations  which  are  so  common  in 
the  suiall  bowel  of  children.  In  the  statistics  of  Fitz.  93  of  ^95  cases 
of  acute  intestinal  obstruction  were  due  to  this  cause.  Of  these,  52  Avere  in 
males  and  2?  in  females.  The  cases  are  most  common  in  early  life,  34 
per  cent  under  one  year  and  50  )or  cent  under  the  tenth  year.  Of  103 
cases  in  children,  nearly  50  per  cent  occurred  in  the  fourth,  fifth,  and  sixth 
months  (Wiggin).  Xo  definite  causes  could  bti/^assigned  in  4"-3  of  the  cases; 
in  the  others  diarrluea  or  habitual  constipation  had  existed. 

The  site  of  the  invagination  varies.  We  may  recognize  (1)  an  ikn-civcal, 
wlien  the  ileo-ca-cal  valve  descends  into  the  colon.  There  are  cases  in 
which  this  is  so  extensive  that  the  valve  has  been  felt  ])er  rectum.  This 
form  occurred  in  75  jjor  cent  of  the  cases;  in  89  per  cent  of  Wiggin's  col- 
lected cases.  In  the  ilcn-rnlic  the  lower  ])art  of  the  ileum  ]iasses  through 
the  ileo-ca'cal  valve.  {2)  The  (7m/,  in  which  the  .iCum  is  alone  involved. 
(3)  The  colic,  in  which  it  is  confined  to  the  large  intestine.  And  (i)  coUco- 
rcciol,  in  which  the  colon  and  rectum  are  involved. 

Irregular  peristalsis  is  the  essential  cause  of  intussusception.  Xoth- 
nagel  found  in  the  localized  peristalsis  caused  by  the  faradic  current  that 
it  was  not  f^  descent  of  one  ])ortion  into  the  other,  hut  the  drawing  up 
of  the  receiving  layer  by  contraction  of  the  longitudinal  coat.  Invagina- 
tion may  follow  any  limited,  sudden,  and  severe  peristalsis. 

In  the  ]io;-.t-moneui  jxamination,  in  a  case  of  death  from  intussuscep- 
tion, the  condition  is  very  characteristic,  reritonitis  may  be  present  or 
an  acute  injection  of  the  serous  membrane.  When  doatii  occurs  early,  as 
it  may  do  from  shock,  there  is  little  to  he  seen.     The  portion  of  bowel 


INTESTINAL  OBSTRUCTION. 


533 


cases; 


nll'cctcd  is  lar<fc  and  thick,  and  forms  an  clonj^atcd  tumor  with  a  curved 
(iiilline.  The  parts  are  swollen  and  congested,  owing  to  the  constriction 
of  tlie  mesentfry  hetween  the  layers.  The  entire  mass  may  he  of  a 
(li'ep  livid-red  color.  In  vciy  recent  i)rocesses  there  is  only  congestion,  and 
perliaps  a  thin  layer  (d"  lymph,  and  the  intussusception  can  he-  reduced, 
liiit  when  it  has  histed  I'or  a  lew  days,  lymph  is  thrown  out,  the  layers 
are  glued  together,  and  the  entering  jjortion  of  the  gut  cannot  he^with- 
<lrawn. 

The  anatomical  condition  nccounts  for  the  presence  of  the  tumor,  which 
exists  in  two  thirds  of  all  cases;  and  the  engorgement,  which  results  from 
the  compression  of  the  mesenteric  vessels,  explains  the  fre([nent  occurrence 
(  f  blood  in  the  discharges,  which  has  so  important  a  diagnostic  value.  If 
the  j)atient  survives,  necrosis  and  sloughing  of  the  invaginated  portion  may 
occur,  and  if  union  luis  taken  jdace  between  the  middle  and  outer  layer, 
til  '  calibre  of  the  gut  may  be  restored  and  a  cure  in  this  way  eU'ected. 
Many  cases  of  the  kind  are  on  record.  In  the  .'Museum  of  the  ]\ie(lical  Fac- 
ulty of  ^IcCJill  University  are  17  inches  of  small  intestine,  which  were 
passed  by  a  lad  who  had  had  symptoms  of  internal  strangulation,  and  who 
made  a  complete  recovery. 

{(■)  Twists  and  Knots, — V(dvulus  or  twist  occurred  in  12  of  the  295 
cases.  Sixty-eight  i)er  cent  were  in  nuiles.  It  is  most  frequent  between 
the  ages  of  thirty  and  forty.  In  the  great  majority  of  all  cases  the  twist 
is  axial  and  associated  with  an  unusually  long  mesentery.  In  50  per  cent 
of  the  cases  it  was  in  the  sigmoid  Hexure.  The  next  most  common  situa- 
tion is  about  the  ca'cum,  which  may  be  twisted  u])on  its  axis  or  bent  upon 
itself.  As  a  rule,  in  volvulus  the  loop  of  bowel  is  simply  twisted  upon  its 
long  axis,  and  the  portions  at  the  end  of  the  loop  cross  each  other  and  so 
cause  the  strangidation.  It  occasionally  hajjpens  that  one  ])ortion  of  the 
liowel  is  twisted  about  another. 

{(I)  Strictures  and  Tumors. — These  are  very  much  less  important  causes 
of  acute  obstruction,  as  may  be  judged  by  the  fact  that  there  are  only  15 
iii>.ances  out  of  the  2i)5  cases,  in  l-t  of  which  the  obstruction  occurred  in 
the  large  intestine.  On  the  other  hand,  they  are  common  causes  of  chroiirc 
obstruction. 

The  ol)struction  may  result  from:  (1)  C()H(/niiltil  xirichtrr.  These  are 
exceedingly  rare.  ^luch  more  commonly  the  condition  is  that  of  complete 
occlusion,  either  forming  the  im])erforate  anus  or  the  congenital  defect  by 
which  the  duodenum  is  not  united  to  the  ])ylorus.  (<;)  Siiii/ilr  cicdfririal 
siriiosis,  which  results  from  idceration,  tuberculous  or  syphilitic,  more 
liirely  fro'n  \vsentery,  and  most  rarely  of  all  from  ty])hoid  ulceration.  {'■)) 
Xrtr  growths.  The  malignant  strictures  are  due  chiefly  to  cylindrical  cjii- 
tlielioma,  which  forms  an  annular  tumor,  most  commonly  met  with  in  the 
large  howel,  about  the  sigmoid  flexure,  or  the  descending  colon.  Of  be- 
nign growths,  pi.pillomata,  adenomata,  lipon^  ■  and  filiromata  occasion- 
ally induce  obstruction.  (4)  Compression  anc  ion.  Tumors  of  neigh- 
boring organs,  particularly  of  the  ])elvic  vis'^era,  may  cause  obstruction  by 
iidhesion  and  traction;  more  rarely,  a  coil,  such  as  the  sigu'.oid  flexure, 
flded  with  fp^ce  ■,  compresses  and  obstructs  a  neighboring  coil.     In  the  heal- 


■t 


i: 


/ 


534 


DISEASES  OP  THE  DIGESTIVE  SYSTEM, 


inn'  of  t u1)crculoii,s  in'ritoiiitis  the  coiitractidii  of  llio  thick  exialutu  nu\y 
cause  coiiiprcssioii  iiiid  iiai'i'owiiig  of  the  euils. 

(>')  Abnormal  Contents. —  l'"(irei>iii  hoilics,  such  a.<  I'ruit  stones,  coins,  pins, 
needles,  or  I'aise  teeth,  ai'e  oeeasionally  swaUowed  accidentally,  or  Ijy  luna- 
tics on  |)iir|)ose.  Iioiind  woinis  may  become  rolled  into  a  tangled  mass 
and  cause  obstrueticm.  In  reality,  however,  the  majoi'ity  oi'  foreign  bodies, 
such  as  coins,  buttons,  and  pins,  swallowed  l)y  childi'en,  cause  no  incon- 
venience whatever,  but  in  a  day  or  two  are  found  in  the  stools.  Occasion- 
ally such  a  foreign  body  as  a  |)in  will  pass  through  the  tcso]thagus  and  will 
be  found  loflge<l  in  some  adjacent  orgaji,  as  in  the  heart  (i'eabody),  or  a 
Ijarley  ear  niay  reach  the  liver  (Dock). 

^ledicines,  .such  as  nmgiu'sia  or  bismuth,  have  Ijeen  known  to  accumu- 
late in  the  bowels  and  ])roduce  obstruction,  Ijut  in  the  great  majority  of 
the  cases  the  condition  is  caused  by  fiuccs,  gall-stones,  or  enteroliths.  Of 
4-i  cases,  in  '^;3  the  obstruction  was  by  gall-stones,  in  11)  by  ficces,  and  in  2 
by  enteroliths.  ()I)struction  by  IVeces  may  hai)pen  at  any  })eriod  of  life. 
As  mentioned  when  s})eaking  of  dilatation  of  the  colon,  it  may  occnr  in 
young  children  an'd  persist  for  Aveeks.  In  ficeal  accumulation  the  large 
howel  may  reach  an  enormous  size  and  the  contents  become  very  hard. 
The  retained  masses  nuiy  lie  channeled,  and  small  (iuantities  of  f;ecal  nuitter 
are  ])assed  until  a  mass  too  large  enters  the  lumen  and  causes  obstruction. 
There  may  be  very  few  symptoms,  as  the  condition  may  be  borne  for  weeks 
or  even  for  months. 

Obstrnction  by  gall-stones  is  not  very  infrequent,  as  may  be  gathered 
from  the  fact  that  ^3  cases  -were  reported  in  tlie  literature  in  eight  years. 
Eighteen  of  these  were  in  women  and  5  in  men.  In  six  sevenths  of  the 
cases  it  occurred  after  the  fiftieth  year.  The  obstruction  is  usually  in  the 
ileo-CKcal  region,  Ijut  it  may  be  in  the  duodenum.  These  large  solitary 
gall-stones  ulcerate  through  the  gall-bladder,  usually  into  the  small  intes- 
tine, occasi(mally  into  the  colon,  in  the  latter  case  they  rarely  cause  ob- 
struction.     Courvoisier  has  collected  131  cases  in  the  literature. 

Enteroliths  may  be  formed  of  masses  of  hair,  more  commonly  of  the 
phos])hates  of  lime  and  magnesia,  with  a  nucleus  formed  of  a  foreign  body 
or  of  hardened  fa'ces.  Xearly  every  museum  ])Ossesses  specimens  of  this 
kind.  They  are  not  so  common  in  men  as  in  ruminants,  and,  as  indicated 
in  Fitz's  statistics,  are  very  rare  causes  of  obstruction. 

Symptoms. — (a)  Acute  Obstruction. — Constipation,  ])ain  in  the  abdo- 
men, and  vomiting  are  tlie  three  important  symptoms.  Pain  sets  in  early 
and  may  come  on  abruptly  while  the  patient  is  walking  or,  niou  com- 
moidy,  during  the  perfoi'mance  of  some  action.  It  is  at  first  coli*  ky  in 
character,  but  subsequently  it  becomes  continuous  and  very  intense.  Vom- 
iting follows  (|uickly  and  is  a  constant  and  most  distressing  symptom.  At 
first  the  contents  of  the  stonuich  are  voided,  and  tiien  greenish,  bile- 
stained  material,  and  soon,  in  cases  of  acute  and  ])ermanent  obstruction, 
the  material  vomited  is  a  brownish-black  liquid,  wlih  a  distinctly  ftecal 
odor.  This  sequence  of  gastric,  bilious,  and,  finally,  stercoraceous  vomit- 
ing is  ]X'rhaps  the  most  important  diagnostic  feature  of  acute  obstruction. 
The  constipation  may  be  absolute,  without  the  discharge  of  either  freces 


INTKSTI X AL   OUST UUCTK  )y. 


535 


or  ^^as.  A'cry  ol'teii  the  cniitcnls  of  llir  Ixiui'l  hclow  i\\v  stridiiri'  iirc  (\\>i- 
cli  a  !•;:■(■(  1.  I  )ist('iit  idii  oi  the  ahiioiiifn  usually  occurs,  and  w  lnii  tlic  [ai',i:c 
lidwcl  is  iiiv(il\c(l  it  is  c.\t  I'cnic.  On  llic  olliri'  hand,  it'  the  olisti'uct  ion  is 
high  n|)  in  the  small  intestine,  iIittc  may  he  very  slighl  tympany.  At 
lirst  the  ahdomeJi  is  not  painful,  hut  suhst'ijui'ntly  it  may  hec(une  acutely 
tender. 

T|ic'  constitutional  sympt(uns  from  the  (lutset  are  severe.  'I'he  face  is 
pallid  and  anxious,  ami  linally  collapse  symptoms  sn|)ervene.  The  eyes 
hecome  sunken,  the  features  i)inehed,  and  the  skin  is  covered  with  a  cold, 
clammy  sweat.  The  i)u]se  l)econie.s  rapid  and  feeble.  'J'liere  may  he  no 
fever;  the  axillary  temperature  is  often  suhnormal.  The  tongue  is  dry 
and  parched  and  the  thirst  is  incessant.  The  urine  is  high-colored,  scanty, 
and  there  may  he  sup[)ression,  i)artieularly  when  the  olistruction  is  high 
u|)  in  the  ])owel.  This  is  pr()l)al)ly  due  to  tlie  constant  vomiting  and  the 
small  amount  of  liquid  wliicli  is  absorbed.  The  case  ternnnates  as  a  rule 
in  from  three  to  six  davs.  In  some  instances  the  patient  dies  from  shock 
or  sinks  into  coma. 

(b)  Symptoms  of  Chronic  Obstruction. — Wlieu  du(>  to  fivcal  impaction, 
there  is  a  history  of  long-standing  constipation.  There  may  have  been 
discharge  of  mucus,  or  in  some  instances  the  fa'cal  masses  have  been  chan- 
neled, and  so  have  allowed  tiie  contents  of  the  ujjjjcr  })()rtion  of  the  bowel 
to  pass  throi'gh.  In  elderly  jjcrsons  this  is  not  infrequent;  but  examina- 
tion, cither  per  rccluni  or  externally,  in  tlie  course  of  the  colon,  will  reveal 
the  i)resence  of  hard  scyljalous  masses.  There  may  be  retention  of  fivces 
for  weeks  without  exciting  serious  symptoms,  in  other  instances  there  are 
vomiting,  ])ain  in  the  abdomen,  gradual  distention,  and  finally  the  ejecta 
hecome  fivcal.  The  hardened  masses  may  excite  an  intense  colitis  or  even 
peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  of  ol)struc- 
tion  are  very  diverse.  Constipation  gradually  comes  on,  is  extremely  vari- 
al)le,  and  it  may  he  months  or  even  years  before  there  is  eomi)lete  obstruc- 
tion. There  are  transient  attacks,  in  which  from  some  cause  the  faeces 
accumulate  ahove  the  stricture,  the  intestine  becomes  greatly  distendcil, 
and  in  the  swollen  abdomen  the  coils  can  he  seen  in  active  peristalsis.  In 
such  attacks  there  may  be  vomiting,  but  it  is  very  rarely  of  a  fa,'cal  charac- 
ter. In  the  majority  of  these  cases  the  general  health  is  seriously  im- 
])aired;  the  patient  gradually  becomes  amemic  and  emaciated,  and  finally, 
in  an  attack  in  which  the  obstruction  is  com[)lete,  death  occurs  with  all 
the  features  of  acute  occlusion  or  the  case  may  be  prolonged  for  ten  or 
twelve  days. 

Diagnosis. — (a)  The  Situation  of  the  Obstruction. — Hernia  must 
be  excluded,  which  is  by  no  means  always  easy,  as  fatal  ol)struction  may 
occur  from  the  involvement  of  a  very  limited  portion  of  the  giit  in  the 
external  rin^:^  or  in  tlie  obturator  foramen.  ^Mistakes  from  both  of  these 
causes  ha\'e  come  under  my  observation;  they  were  cases  in  which  it  was 
impossible  to  make  a  diagnosis  other  than  acute  obstruction.  Timely  op- 
eration would  have  saved  both  lives.  A  thorough  rectal  and,  in  women,  a 
vaginal  examination  should  be  made,  Avhicli  will  give  important  information 


/s;:^^ 


536 


DISEASES  OF   THE    DKJESTIVE  SYSTEM. 


/ 


as  to  tlio  condition  of  the  pelvic  and  rectal  contents,  particularly  in  cases  of 
intiisfe'iisce])tion,  in  w  iiich  tlie  descending  bowel  can  sometimes  be  felt.  Jn 
cases  of  obstruction  lii^^ii  ti[)  tlie  empty  coils  sink  into  tlie  pelvis  and  can 
there  be  (U-tectcd.  Kectal  exploration  Nvilh  the  entire  luuul-is  of  doubtful 
value.  In  the  insi)ection  of  the  abdomen  there  are  important  indications,  as 
the  special  prominence  in  certain  regions,  the  occurrence  of  indetinite,  wcll- 
tU'fiiu'd  masses,  and  the  presence  oi!  hypertroi)]iied  coils  in  active  peristalsis. 
Joim  Wyilie  has  recently  called  attention  to  tlu}  great  value  in  diagnosis  of 
tiie  "  jKitterns  of  abdominal  tumidity."  *  In  obstruction  of  the  lower  end 
of  tlie  large  intestine  not  only  may  the  horseshoe  of  the  colon  stand  out 
plainly,  when  tiie  bowel  is  in  rigid  spasm,  but  even  the  pouches  of  the  gut 
may  l)e  seen.  Wlien  tlie  cacum  or  lower  end  of  the  ileum  is  ol)structed 
the  tumidity  is  in  the  lower  central  region,  and  during  sjmsm  the  coils  of 
the  small  bowel  may  stand  out  i)rominently,  one  a1)ove  the  other,  either 
obliquely  or  transversely  placed — the  so-called  "'  ladder  pattern."  in  ob- 
struction of  the  duodenum  or  jejunum  there  may  oidy  be  slight  distention 
of  the  upper  part  of  the  abdomen,  associated  usually  with  rapid  collapse 
and  anuria. 

In  the  ileum  and  caecum  the  distention  is  more  in  the  central  portion 
of  the  abdomen;  the  vomiting  is  distinctly  fiecal  and  occurs  early.  In 
obstruction  of  the  colon,  tympanites  is  much  more  extensive  and  general. 
Tenesmus  is  more  common,  with  the  passage  of  mucus  and  blood.  The 
course  is  not  so  quick,  the  eolla])se  does  not  supervene  so  rapidly,  and  the 
urinary  secretion  is  not  so  much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  some  cases 
be  accurately  localized,  but  in  others  it  is  very  ditlicult.  Digital  examina- 
tion of  the  rectum  should  first  be  made.  The  rectal  tube  may  then  be 
passed,  but  it  is  impossible  to  get  beyond  the  sigmoid  flexure.  In  the  use 
of  the  rigid  tube  there  is  danger  of  perforation  of  the  bowel  in  the  neigh- 
borhood of  a  stricture.  The  quantity  of  fluid  which  can  be  passed  into 
the  large  intestine  should  be  estimated.  The  capacity  of  the  large  bowel  is 
about  six  quarts.  Wiggin  advises  about  a  pint  and  a  half  from  a  height  of 
three  feet  for  an  infant.  To  thoroughly  irrigate  the  bowel  the  patic  it 
should  be  chloroformed  and  should  lie  on  the  back  or  on  the  side — best  on 
the  l)ack,  with  the  hi])s  elevated.  Treves  suggests  that  the  ca-cal  region 
should  1)0  auscultated  during  the  passage  of  the  fluid.  For  diagnostic  pur- 
poses the  rectum  may  be  inflated,  either  by  the  bellows  or  by  the  use  of 
bicarbonate  of  soda  and  tartaric  acid.  In  certain  cases  these  measures  give 
im]iortant  indications  as  to  the  situation  of  the  obstruction  in  the  large 
bowel. 

(h)  Nature  of  the  Obstruction. — This  is  often  dilTicult,  not  infrequently 
impossible,  to  determine.  Siraugvlatinn  is  not  common  in  very  early  life. 
In  many  instances  there  have  lieen  previous  attacks  of  abdominal  pain,  or 
tliero  are  etiological  factors  which  give  a  clew,  such  as  old  peritonitis  or 
operation  on  the  pelvic  viscera.  Neither  the  onset  nor  the  character  of  the 
pain  gives  lis  any  information.     In  rare  instances  nausea  and  vomiting 


*  Edinburgh  ITospital  Reports,  vol.  ii. 


INTESTINAL  OHSTllUCTION. 


537 


may  1)0  absent,  Tlic  vomiting  usually  l)ccouios  fii'cal  from  the  third  to  the 
liith  (lay.  A  tumor  iri  not  comiuou  in  .strauj^Milation,  and  was  pri'st'iit  in 
only  one  liftli  oi'  the  eases.     Fever  is  not  of  dia<,niostie  value. 

Inliissiisccplioit  is  an  alfection  of  childhood,  and  is  of  all  forms  of  in- 
ternal ohstruetion  the  one  most  readily  diagnosi'd.  The  presi'iiee  (tf  tumor, 
liloody  stools,  and  teni'smus  are  the  important  factors.  The  tumor  is 
usually  sausage-shaped  and  felt  in  the  region  of  the  transverse  colon.  Jt; 
existed  in  GO  of  1)3  cases.  It  was  present  on  the  first  day  in  more  than  onel 
third  of  the  cases,  on  the  second  day  in  more  than  one  fourth,  and  on  the 
third  day  in  more  than  one  fifth.  JUood  in  the  stools  occurs  in  at  least 
three  fifths  of  the  cases,  either  spontaneously  or  following  the  use  of  an 
enema.  The  blood  nuiy  be  mixed  with  mucus.  Tenesmus  is  i>resent  in 
one  third  of  the  cases.  Fiecal  vomiting  is  iu)t  very  common  and  was  pres- 
ent in  only  13  of  the  93  instances.  Abdominal  tym|)any  is  a  symptom  of 
slight  im])ortance,  occurring  in  only  one  third  of  the  cases. 

Volruliis  can  rarely  be  diagnosed.  The  freciuency  with  which  it  in- 
volves the  sigmoid  flexure  is  to  l)e  borne  in  mind.  The  passage  of  a  flex- 
ible tube  or  injecting  fluids  might  in  these  cases  give  valuable  indica- 
tions. An  absolute  diagnosis  can  probably  be  made  only  by  an  abdominal 
section. 

In  fa'cal  obslniction  the  condition  is  usually  clear,  as  the  faeces  can  he 
felt  per  rectimi  and  also  in  the  distended  colon.  Fa'cal  vomiting,  tym- 
]»any,  abdominal  ])ain,  nausea,  and  vomiting  are  late  and  are  not  so  con- 
i-tant.  In  ol)struction  by  gall-stone  a  few  of  the  cases  gave  a  previous  his- 
tory of  gall-stone  colic.  Jaundice  was  ])resent  in  only  8  of  the  23  cases. 
I'ain  and  vomiting,  as  a  rule,  occur  early  and  are  severe,  and  faecal  vomit- 
ing is  ])resent  in  two  thirds  of  the  cases.     A  tumor  is  rarely  evident. 

(r)  Diagnosis  from  other  Conditions. — Acute  enteritis  witli,.  great  re- 
laxation of  the  intestinal  coils,  vomiting,  and  i)ain  may  be  mistaken  for 
obstruction.  In  an  autopsy  on  a  case  of  this  kind  the  small  and  large 
bowels  were  intensely  inflamed,  relaxed,  sodden,  and  enormously  distended. 
The  symptoms  were  those  of  acute  obstruction,  but  the  intestine  was  free 
from  duodenum  to  rectum.  Of  late  years  many  instances  have  been  re- 
ported in  which  peritonitis  following  disease  of  the  a})pendix  has  been 
mistaken  for  acute  obstruction.  The  intense  vomiting,  the  general  tyni- 
]iany  and  abdominal  tenderness,  and  in  some  instances  the  suddenness  of 
the  onset  are  very  decei)tive,  and  in  two  cases  which  have  come  under  my 
notice  the  symptoms  pointed  very  strongly  to  internal  strangulation.  In 
a])pendix  disease  the  temperature  is  more  frequently  elevated,  the  vomit- 
ing is  never  faecal,  and  in  many  cases  there  is  a  history  of  previous  attacks 
in  the  ca^cal  region.  Acute  hiemorrhagic  ]iancreatitis  niay  produce  symp- 
toms which  simulate  closely  intestinal  obstruction.  A  lioy  was  admitted 
to  the  Johns  no])kins  IIos])ital  with  a  history  of  obstinate  vomiting,  in- 
tense abdominal  pain,  gradually  increasing  tympany,  and  no  ]iassage  for 
several  days.  His  condition  seemed  serious  and  he  was  transferred  at  once 
to  the  surgical  wards.  At  the  ojieration  tlie  coils  were  found  uniformly 
distended  and  covered  in  ])l;ices  with  the  thinnest  film  of  lymph.  Ts^o  ob- 
struction existed,  but  there  was  a  tumor-like  mass  surrounding  the  pan- 


i 


538 


DISKASKS  OF   TIIK   J)l(i  KS'l'lVK   SVSTKM. 


.  \ 


creas.  (iiiii,  Inird,  niid  (Iccply  iiillltratcd  with  Mood.  Tht'  ji.iticiit  iiii|)n)V(-d 
at'tcr  tlic  ()|u'rati()ii  and  rccuvci'cd  compU'ti'ly. 

Treatment. — I'lir^atiNcs  should  not  he  <iiv(Mi.  For  tho  pain  hypo- 
di'i'inic  iiijc'itidiis  of  morphia  arc  iiidicalcd.  'J'o  aUay  the  distrc's.siM<f  voiiiil- 
in^f,  llic  stomacli  should  ho  washed  out.  Not  only  is  this  dirt'ctly  bunL'ticial. 
hut  Kussniaul  chiiiiis  that  the  ah(|(»niiiial  distention  is  I'elicvcd,  the  pivs- 
suiv  in  the  howcd  ahove  the  seat  of  ohstniclion  is  lessened,  and  the  violent 
peristalsis  is  dinunislied.  It  may  l)e  ])i'aetised  three  or  I'our  times  a  day, 
and  in  some  instances  has  proved  IxMieficial;  in  others  curative.  Thor- 
ou;^h  irri<i'ation  ol'  the  lai'<re  bowel  with  injections  should  he  practised,  tlie 
warm  lluid  l)eiii<;-  allowed  to  How  ill  J'rom  a  fountain  syringe,  and  the 
amount  cai'i'fully  estimated.  Jonathan  Hutchinson  recommends  that  the 
l)atient  he  j)laced  under  an  ana'sthelic,  the  ahtlomen  thoroughly  kneaded, 
and  a  co|)ious  enenui  j^'iven  while  in  ihe  inverted  ])osition.  Then,  with  the 
aid  of  three  or  four  strong  men,  tlu'  patient  is  to  he  thorou{j;hly  shaken, 
iirst  with  the  alxlomcn  held  downward,  and  subsequently  in  the  inverted 
})osition. 

Inflation  may  also  be  tried,  by  forcinji'  the  air  into  the  rectum  with  the 
hellows  or  with  a  Davidson's  syrinj;-e.  It  is  a  measure  not  without  risk, 
as  instances  of  rupture  of  the  bowel  have  been  reimrted.  Fitz's  figures 
show  that  in  the  iirst  eight  years  of  the  last  decade  there  wi're  313  cases  of 
recovery  after  injection  or  inflation  in  cases  of  certain  or  jjrobable  intussus- 
ception, and  11  deaths.  Of  3'J  cases  in  children  treated  by  inilation  or  eno- 
niata  l(i  recovered  (Wiggin).  In  cases  of  acute  obstruction,  if  tliese  means 
do  not  i)rove  successful  by  the  third  day,  surgical  measures  should  bo  re- 
sorted to,  and  when  the  ol)struction  seems  i)ersistent  and  the  condition 
serious,  lai)arotomy  should  he  performed  at  once.  Of  04  cases  in  which 
laparotomy  was  performed,  21  recovered.  The  youngest  case  operated  upon 
was  only  three  days  old. 

For  the  tympanites  tur|)entine  stupes  and  hot  applications  may  be  ap- 
])licd;  if  extreme,  the  bowel  may  be  punctured  with  a  small  aspirator  needle. 
In  cases  of  chronic  obstruction  the  diet  must  be  carefully  regulated,  and 
o])iuin  and  belladonna  are  useful  for  the  paroxysmal  pains.  Enemata 
should  he  employed,  and  if  the  obstruction  becomes  complete,  resort  must 
be  had  to  surgical  measures. 


IV.    CONSTIPATION  (Costiveness). 

Definition. — Tfetention  of  fivces  from  any  cause. 

Constipation  in  Adults, — The  causes  are  varied  and  may  be  classed  as 
general  and  local. 

General  Causes. — (a)  Constitutional  peculiarities:  Torpidity  of  the 
bowels  is  often  a  fann'ly  complaint  and  is  found  more  often  in  dark  than 
in  fair  persons,  (h)  Sedentary  habits,  particularly  in  persons  who  eat  too 
nmcli  and  neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  aua.>- 
mia,  neurasthenia  and  hystcrir  chronic  affections  of  the  liver,  stomach, 
and  intestines,  and  the  acute        lTs.     Under  this  heading  may  appropri- 


the 
tlian 
t  too 
aiuv- 
lachj 
■opr:- 


att'ly  be  placed  that   iiinst 


COXSTIPATIOX. 


')39 


injurious  ol'  all  hal)its,  ilnKj-lnl-lnij.     (il)  Kithcr 


a  coarse  diet,  which  h'aves  too  luiich  residue,  ur  a  dii't  whit'h  leaves  too 
little,  may  l)e  a  cause  of  costiveness. 

Liicdl  Cdiiscs.- — \\ Cakiic-s  of  the  JilHlouii ii.il  niu>(lcs  in  olicsilv  or  lioiu 
overdistiMilion  in  repealed  ju'e;;- nancies.  Atony  of  the  lar;^('  howci  from 
clironic  disease  ol.'  the  mucosa;  the  presence  of  luniors,  physiological  or 
|iatholo^ital,    pressin<r    upon    the    bowel;    enteritis;    foreign    hodies,    larjic 


masses  oi'  scyhala,  and  strictures  (d'  a! 


;inds.     An   important    local  cause 
useles  of  the  si'nnoid  llexure  bv 


is  atony  of  the  colon,  particularly  oi'  the  in 
which  tlie  licces  are  propelled  into  the  rectum.  15y  far  the  most  obstinate 
form  is  that  associated  with  a  contracted  state  of  the  bowel,  which  is 
sometimes  spoken  of  as  spasmodic  constipation.  'I'his  may  be  nu't  with 
in  three  conditions:   i'^irst,  as  a  se(pience  of  chronic  dysentery  or  ulcerative 


CO 


\{\> 


secondly,  in  protracti'd  cases  of  hysteria  and  neurasthenia  in  women, 


particu 


larly 


in  association  with  uterine  disease;  an( 


thin 


in   very  old 


■j'sons  often   without   any   delinite   cause.     It  may   be  that   the   sijiinoid 


lexure  and  lower 


Ion  are  in  a  condition  of  contraction  ant 


lasm,  Willie 

the  transverse  and  ascending  parts  are  in  a  slate  of  atony  and  dilatation. 
The  most  chai'acleristic  sign  of  this  variety  is  the  presence  of  hard,  gloliulai' 
masses,  or  more  rai'cly  small  and  sausage-like  fa-ces. 

Symptoms. — The  most  persistent  constipation  for  weeks  or  even 
months  may  exist  with  fair  liealth.  All  kinds  of  evils  ha\e  been  attributed 
to  poisoinng  by  the  resorption  of  noxious  matters  from  the  retained  i'leces 
— co[)ra'mia — hut  it  is  not  likely  that  this  takes  place  to  any  extent,  ('hlo- 
rosis,  which  Sir  Andrew  Clai'k  attributes  to  fa'cal  poisoning,  is  not  always 
associated  with  consti])atioii,  and  if  due  to  this  cause  should  be  in  men, 
women,  and  childri'n  the  most  c(jmmon  of  all  disordei's.  Debility,  lassi- 
tude, and  a  mental  depression  are  frequent  symptoms  in  couslipation, 
particidarly  in  persons  of  a  nervous  tempci'anient.  Headache,  loss  of  appe- 
tite, and  a  furred  tongue  may  also  occur.  Individuals  dill'er  extraoidina- 
rily  in  this  matter:  one  feels  wretched  all  day  without  the  accustomed 
evacuation;  another  is  eonifortalde  all  the  wet'k  except  on  the  day  on 
which  1)y  ])urge  or  enema  the  bowels  are  relieved. 

^\'hen  i)ersistent,  the  accumulation  of  fieees  leads  to  un])lea<aid,  sonie- 
iimes  serious  symidoms,  such  as  ])iles,  ideeration  of  the  colon,  distention 
of  the  saceuli,  ])eri'oratiou,  enteritis,  and  occlusion.  \n  women,  pressure 
may  cause  i)ain  at  the  time  of  menstruation  and  a  sensation  of  fulness  and 
distention  in  the  ])clvie  organs.  Neuralgia  of  the  sacral  nerves  nury  be 
caused  by  an  overloaded  sigmoid  flexure.  The  fa>ces  collect  chielly  in  the 
colon.  Kven  in  extreme  tirades  of  constipation  it  is  rare  to  iind  drv  ftoces 
in  the  caecum.  The  fieccs  nuiy  form  large  tumors  at  the  hepatic  or  splenic 
llexures,  or  a  sausage-like,  doughy  mass  above  the  navel,  or  an  irrcgidar 
lumpy  tumor  in  the  left  inguinal  region.  In  old  ])ersons  the  saceuli  of  the 
colon  become  distended  and  the  scvbala  may  remain  in  them  and  undergo 
calcification,  forming  enteroliths. 

In  cases  with  ])rolonged  retention  the  fa'cal  masses  become  channelled 
and  diarrhd'a  may  occur  for  days  before  the  true  condition  is  discovered 
by  rectal  or  external  examination.     In  women  who  have  been  habitually 


540 


DISEASES  OF  THE   DIOESTIVE  SYSTEM. 


/ 


coiLstiiHiti'd,  nttiicks  of  diarrluni  with  luiiisni  iiiul  vomiting  should  excite 
Biispicioii  and  h'ad  to  a  tlioroiigh  t'xaniination  of  tho  hirge  IjowcI.  Fever 
may  occur  in  these  cases,  and  .M('i<,'s  has  reported  an  instance  in  which 
tlic  condition  siniuii.tcd  typhoid  fever. 

Constipation  in  infants  is  a  conunon  and  troul)losome  disorder.  The 
causes  are  congenital,  dietetic,  and  local.  ^J'here  are  instances  in  wliich 
the  child  is  constipated  from  hirtli  and  may  not  have  a  natural  nu)vement 
for  years  and  yet  tiirive  and  develop.  An  instance  of  the  kind  was  in  my 
ward  recently  in  which  a  hahy  of  seven  months  had  never  had  a  movement 
■without  })reliminary  injections.  The  ahdomcn  hecame  swollen  every  day, 
hut  suhsided  after  an  injection  and  the  passage  of  a  long  catheter.  No 
stricture  could  he  felt.  There  are  cases  of  enormous  dilatation  of  the  large 
howel  with  persistent  consti|)ati()n.  The  condition  ai)pears  sometimes  to 
be  a  congenital  defect.  In  some  of  these  i)atients  there  uuiy  be  constrictiiig 
bands,  or,  as  in  a  case  of  Cheever's,  a  congenital  stricture. 

Dietetic  causes  arc  more  common.  In  sucklings  it  often  arises  from 
an  unnatural  dryness  of  the  small  residue  which  ])asses  into  the  colon,  and 
it  may  he  very  dillicult  to  decitle  whether  the  fault  is  in  the  nu)ther's  milk 
or  in  the  digestion  of  the  child.  Most  probably  it  is  in  the  latter,  as  some 
babies  may  l)e  i)ersistently  costive  on  natural  or  artificial  foods.  Deli- 
t-ifmcy  of  fat  in  the  milk  is  believed  by  some  writers  to  be  the  cause.  In 
older  children  it  is  of  the  greatest  importance  that  regular  habits  should 
be  enjoined.  Carelessness  on  the  })art  of  the  mother  in  this  nuittc'  ofti'U 
lays  the  foundation  of  troublesome  constipation  in  after  life.  Impairment 
of  the  contractility  of  the  intestinal  wall  in  consequence  of  inflammation, 
disturbance  in  the  iu)rmal  intestinal  secretions,  and  mechanical  obstruc- 
tion by  tumors,  twists,  and  intussusception  are  the  chief  local  causes. 

Treatment. — ^fuch  may  be  done  by  systematic  habits,  particularly 
in  the  young.  The  desire  to  go  to  stool  should  always  be  granted.  Exer- 
cise in  moderation  is  heljifnl.  In  stout  persons  and  in  women  with  ])end- 
nlous  a])doniens  the  muscles  should  have  the  su])port  of  a  bandage.  Fric- 
tion or  regularly  api)lied  massage  i*:  invaluable  in  the  more  chronic  cases. 
A  good  substitute  is  a  metal  ball  weighing  from  four  to  six  pounds,  which 
may  be  rolled  over  the  abdomen  every  morning  for  five  or  ten  minutes. 
The  diet  should  be  light,  with  ])lenty  of  fruit  and  vegetables,  ])articularly 
salads  and  tomatoes.  Oatmeal  is  usually  laxative,  though  not  to  all;  brown 
bread  is  better  than  that  made  from  fine  white  fiour.  Of  liquids,  water 
and  aerated  mineral  waters  nuiy  be  taken  freely.  A  tumblerful  of  cold 
water  on  rising,  taken  slowly,  is  efhcacious  in  many  cases.  A  glass  of  hot 
water  at  night  may  also  be  tried  alone.  A  i)ipe  or  a  cigar  after  breakfast 
is  with  many  men  an  infallible  remedy. 

"When  the  condition  is  not  very  ol)stinate  it  is  well  to  try  to  relievo  it 
by  hygienic  and  dietetic  measures.  If  drugs  must  be  used  they  should  be 
the  milder  saline  laxatives  or  the  compound  liquorice  powder.  Enemata 
are  often  necessary,  and  it  is  much  perferable  to  em])loy  them  early  than 
to  constantly  use  purgative  pills.  Glycerin  either  in  the  form  of  su])- 
pository  or  as  a  small  injection  is  very  valuable.  TLilf  a  drachm  of  boric 
acid  placed  within  the  rectum  is  sometimes  efficacious.     The  injections  of 


ExXTEUOPTOSIS. 


541 


tepid  water,  with  or  without  mi\\),  may  he  used  for  n  jjrohxi^'cd  period  witli 
good  ellVet  and  without  damage.  Tlie  patient  siiould  he  in  tlie  dorsal 
position  with  the  liips  elevated,  aiul  it  its  hest  to  let  the  lluid  How  in  blow  ly 
I'rom  a  fountain  syringe. 

The  usual  remedies  emph)yed  are  often  useless  in  the  eonsti}>ation  asso- 
eiated  with  contracted  howd.  A  very  satisfactory  measure  is  the  olive-oil 
injection  as  recommended  hy  Kussnuiul.  The  patient  lies  on  llie  hack  with 
the  hips  elevated,  and  with  a  cannula  and  tuhe  from  15  to  '^()  ouiu-is 
of  pure  oil  are  allowed  to  How  slowly  (or  are  injected)  into  the  howel.  The 
oj)eration  should  take  at  least  lifteen  nunutes.  This  nuiy  he  repeated  every 
day  until  the  intestine  is  cleared,  and  suhseciuently  a  smaller  inji'ction  every 
few  days  will  sullice. 

There  are  various  drugs  which  are  of  special  service,  particularly  the 
cond)ination  of  i})ecacuanha,  nux  vomica,  or  helladoniui,  with  aloes,  rhu- 
harh,  colocynth,  or  podophyllin.  ^leigs  recomnu'uds  particularly  the  com- 
hination  of  extract  of  helladonna  (gr.  -,V),  extract  of  nux  vomica  (gr.  .} ), 
and  extract  of  colocynth  (gr.  ij),  one  pill  to  he  taken  tlin-e  times  a  day. 
in  ana'Uiia  and  chlorosis,  a  sulphur  confection  taken  in  the  nu)rning,. 
and  a  pill  of  iron,  rhuharh,  and  aloes  throughout  tlie  day,  are  very  serviee- 
ahle. 

In  children  the  indications  should  he  met,  as  far  as  possihle,  hy  hygiciuc- 
and  dietetic  measures.  In  the  constijjation  of  sucklings  a  change  in  the 
diet  of  the  mother  may  he  tried,  or  from  one  to  three  teaspoon i'uls  oi'  crean* 
may  he  given  hefore  each  nursing.  In  artificially  fed  children  the  top 
milk  with  the  cream  should  he  used.  Driiddng  of  water,  harley  water,  or 
oatnu'al  water  will  sometimes  ohviale  the  diiliculty.  If  laxaiives  are  re- 
(pured,  simi)le  syrup,  nuuina,  or  olive  oil  may  he  sufficient.  The  conical 
piece  of  soaj),  so  often  seen  in  nurseries,  is  sometimes  elFicacious.  ^lassage- 
along  the  colon  may  l)c  tried.  Small  ir  jections  of  cold  water  may  Ijc  nsed. 
Large  injections  should  he  avoided,  if  ])ossihle.  If  it  is  necessary  to  give 
a  laxative  hy  the  month,  castor  oil  or  the  fluid  magnesia  is  the  hest.  If 
there  are  signs  of  gastro-intestinal  irrivation,  rhuharh  and  soda  or  gray 
powder  may  he  given.     In  older  children  the  diet  should   he  carefully 


regulated. 


V.     ENTEROPTOSIS  (OJhmrd's  Disease). 


Definition. — "  Drop]iing  of  the  viscera,"  visceroptosis,  is  not  a  disease,, 
hut  a  symptom  group  characterized  hy  looseness  of  the  mesenteric  and  peri-* 
toneal  attachments,  so  that  the  stomach,  the  intestines,  ])articularly  the 
Transverse  colon,  the  liver,  the  kidneys,  and  the  spleen  occupy  an  ahnor- 
mally  low  position  in  tlie  ahdominal  cavity. 

Sjnnptoms  and  Physical  Signs. — It  is  im])ortant  to  recognize  two 
grou])s  of  cases.  In  one  the  s])lanclmo]itosis  follows  tlie  loss  of  normal  siip- 
]iort  of  the  ahdominal  wall  in  consequence  of  repented  pregnancies  or  re- 
curring ascites.  The  condition  .may  he  extreme  without  the  slightest  dis- 
tress on  the  ]iart  of  the  ])atient. 

Tiie  second  and  most. important  group  occurs  iisually  in  young  persons,. 


542 


DISEASES  (»F  Till-;    DKHCSTIVK  SVSTKM. 


wild  |ii'('siiil,  with  splaiicliiiopttisis,  the  IVatiiri's  of  iiioix'  w  lu«8  iimrlaHl  nv 
I'ustliciiia. 

Ill  the  first  ^'r()ii[t  iii^iH'ctioii  of  tlic  iiImIomicm  Hlir)\vs(  a  very  relaxed  ab- 
ilniiiiiial  Willi,  ami  as  a  rule  the  iiiii'a'  alhicaiiles  of  ri'i'iirriii;^  [irc^iiaiicies. 
I'eristiilsis  ((f  the  iiilesliiies  may  he  sei-ii,  and  in  exlreme  eases  the  oiilliiies  of 
the  stoimieh  it>elf  with  its  waves  of  peristalsis.  On  inllaliii^  the  Htoiiiaeh 
uilli  ( iii'huiiic-acid  ,i;as  the  or;:an  stands  out  with  ;:reat  promilieiiee,  and 
till'  lesser  and  ^iicater  ciirvalnres  are  sei'ii,  the  latter  extending,'  perhaps  a 
hand's  hreadth  helow  the  level  of  the  navel.  The  waves  of  peristalsis  are 
fecMc  and  without  the  vi^^)r  and  force  of  those  seen  in  the  stomach  dilated 
fi'(nii  siricttire  of  the  pylorus.  The  condition  of  descensus  \('iit  liciili  with 
atony  is  hest  studied  in  this  ^roup  of  casi's.  An  iinpoi'tani  point  to  icimiii- 
her  is  that  it  may  exist  in  an  extreme  jrrade  without  symptoms. 

In  the  other  f^i'oup  is  einhraced  a  somewhat  motley  series  of  cases,  in 
which,  with  a  proiioiiiiced  nei'vous,  or,  as  we  call  it  now,  neurasthenic  hasi^, 
there  are  dis[)lacemi'nts  of  the  visci'ra  /r/7/t  ftyniiihinis.  The  patients  are 
usually  youn<r,  more  fre([uently  women  than  men,  and  of  spai'e  liahit.  The 
condition  may  follow  an  acute  illness  with  wasting'.  'J'liey  complain,  as  a 
rule,  of  dyspepsia,  throhhin-j;  in  the  ahdonu'ii,  and  dra^'^dn;,''  pains  or  weak- 
ness ill  the  hack,  and  inahility  to  ])erfonii  the  usual  duties  of  life.  .\  very 
considerahle  pi'oportion  of  all  the  cases  of  neurasthenia  ]iresent  the  local 
I'l'atures  of  eiiteroptosis.  When  preparing,'  for  the  examination  one  notices 
nsually  an  erytheiuatoiis  lliishin;:;-  (d'  the  skin;  the  scratch  of  the  nail  is  fol- 
lowed instantly  hy  a  line  (d'  hypera'iiiia,  less  often  of  marked  pallor.  The 
])ulsation  of  the  ahdonumil  aorta  is  readily  seen. 

(.)n  examination  «\'  the  viscera  one  finds  the  following?:  The  stomach  is 
helow  the  normal  level,  and  in  women  who  have  laced  it  may  he  vertically 
])laced.  The  s[)lasliing  or  elapota;,a'  is  nnusually  distinct.  After  inllation 
with  carhonic-acid  jjas  the  outlines  of  the  stomach  are  seen  throu;j;h  the 
thin  ahdominal  walls.  In  extreme  cases  there  may  he  •i'reat  dilatation  of 
the  stomach,  in  conse([nence  oi'  ohsl ruction  of  the  jjylorus  hy  pressure  ui'  the 
displaced  rii,dit  kidney. 

Xephrojitosis,  or  disiilacemcnt  of  the  kidney,  is  one  of  the  most  constant 
phenomena  in  enteroplosis.  It  is  well,  perhaps,  to  distin<;nish  between 
the  kidney  which  one  can  just  touch  on  dee[)  inspiration — palpable  kidney, 
one  v/liich  is  freely  movable,  and  wliich  on  dee})  inspiration  descends  so  that 
one  can  put  the  fin<;ers  of  the  palpatinfj  hand  above  it  and  hold  it  down, 
and,  thirdly,  a  floating  kidney,  which  is  entirely  outside  the  costal  arch, 
is  easily  ,<:ras])ed  in  the  hand,  readily  moved  to  the  middle  line,  and  low- 
down  toward  the  riuht  iliac  fossa.  It  is  held  hy  some  that  the  desi<:na- 
tion  float inff  kidney  should  he  restricted  to  the  cases  in  wliich  there  is  a 
meso-nephron,  hut  this  is  excessively  rare,  while  extreme  grades  of  renal 
mobility  are  common.  Some  of  the  more  serious  sequences  of  movabh; 
kidney,  namely,  Pietl's  ci'ises  and  intermittent  liydronei)hrosis,  will  he  con- 
sidered with  diseases  of  the  kidney. 

Displacement  of  the  liver  is  very  much  less  common.  In  thin  women 
who  have  laced  the  organ  is  often  tilt(>d  forward,  so  that  a  very  large  sur- 
face of  the  lobes  comes  in  contact  with  the  ahdominal  AvaU;  it  is  a  very 


ENTKUOI'TUSIS. 


543 


idiiiiiion  !nistaki*  undi'i'  these  t'iri'iiiiistiiiiees  to  think  thnt  the  orpin  is  en- 
lirpM.      hisliiiiitinn  of  tiie  livt'r  itself  will  he  euiisidered  Inter. 

Mohility  iti  llie  spleen  is  smnelinies  \v\\  marked  in  enleri)|>tn>is.  In 
;iu  extri'nie  tirade  it  iniiy  he  I'mind  in  almost  any  ren;i(m  nl'  ihe  ahdonien.  It 
is  very  l"re(|nently  ndstaken  lor  a  liiirnid  nr  nvnriiin  lumnr.  A  ennsiderahie 
iiro|i(>rtiun  nf  the  eases  enme  lirsl   under  the  eare  oj'  ihe  ^'yneeolo^^isl. 

There  is  iisnally  much  relaxation  ol'  the  mesentery  and  nl'  the  pi'riloneal 
I'lilds  which  sn|i|iort  the  intestines.  'The  colon  is  di.>.|)|;ieed  downward  (eo- 
l()|itosis),  with  eoiiseiinent  kinkinj-' at  the  lii-xures.  The  descent  may  he  so 
\nw  that  the  transverse  colon  Ih  at  the  hrim  of  tlu'  pelvis.  It  may  indud 
lie  fixed  or  hcnt  in  the  form  td"  a  \'.  It  is  freiinenlly  to  he  felt,  as  (ilenard 
."tates,  as  a  lirm  cord  crossinir  the  ahdonien  at  or  helow  the  level  of  the 
navel.  This  kinkiiiji:  may  take  place  not  only  in  tlie  colnn,  hut  at  the 
pylorus,  where  the  duodenum  pa.->e<  into  the  jejunum,  and  whciv  the  ileum 
(liters  the  ca'cum. 

'J'lie  explanation  of  the  |)lienoiiiciia  accompaiiyin;.;'  eiiteroptosis  is  hy  no 
means  easy.  It  has  heeii  sujz'^'estetl  hy  (ilenard  and  others  that  the  vascular 
(li^turhanccs  in  the  ahdominal  viscera  in  conseipieiiee  of  displacements 
and  kinking'  aci'onnt  J'or  the  feelin^^s  of  exhaustion  and  general  nervous- 
ness, in  a  lar.iic  proportion  of  the  cases,  however,  no  symptoms  di'velop 
until  after  an  illness  ov  some  proti'acte(l  nervous  strain. 

Treatment. — In  a  majority  of  all  cases  four  indications  ai'c  i)rest'nt: 
T(t  tri'at  the  e.xistinjr  neurasthenia,  to  relieve  the  nervous  dyspepsia,  to 
uNcrcome  the  constipation,  and  to  alVord  nu'chaiiical  support  to  the  orjxans. 
Three  of  these  are  considered  under  their  appropriate  sections.  Jn  cast's  in 
which  the  eiiteroptosis  has  followed  loss  in  weij.dit  after  an  acute  illness  or 
wuri'ies  and  cares,  an  iinportant   indication  is  to  fatten  the  ]mlient. 

A  well  adapted  ah(h)ininal  haiida^'e  is  one  of  the  most  important  meas- 
ures in  eiiteroptosis.  In  many  of  the  milder  irrades  it  alone  sullices.  I 
know  of  no  siuiiie  simple  measure  which  all'ords  relief  to  distre>siii<^  syinp- 
iniiis  in  so  many  cases  as  the  ahdominal  handaj-e.  It  is  hest  iiia<le  of  linen, 
should  lit  snuu'ly,  and  should  he  arran^^'d  with  straps  so  that  it  cannot  rido 
up  over  the  hips.  A  special  form  must  he  used,  as  will  he  mentioned  later, 
for  movahle  kidney.  Some  of  the  more  a.n'uravatecl  tyjies  of  eiitei'oplosis  are 
enmhiiied  with  sucli  features  of  neurasthenia  tjiat  a  ri;.;id  Weir  .Mitchell 
treatiiK'iit  is  indicated.  In  a  few  very  refraetoiT  cases  surirical  interference 
may  ho  called  for.  Treves,  in  Allhutt".s  System,  records  two  cases,  one  in 
which  the  lajiarotomy  was  resorted  to  as  a  medical  measure  with  ])erfect 
results.  In  the  other  the  liver  was  stitched  in  place,  aiul  cuiii[»lete  recovery 
I'nllowed. 

And  lastly,  the  ])liysician  must  he  careful  in  dealin,<jf  with  the  suhjecls 
of  eiiteroptosis  not  to  lay  too  much  stress  on  the  disorder.  It  is  well  never 
10  tell  the  ])atient  that  a  kidney  is  mo\'ahle;  the  symptoms  may  date  from 
a  knowledge  of  the  e-vis-tencc  of  the  condition. 


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23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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544 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


VI.    MISCELLANEOUS  AFFECTIONS. 

I.    MUCOUS  COLITIS. 

This  affection  is  known  by  various  names,  such  as  memhranous  enteritis, 
tubular  diarrha'a,  and  mucous  colic.  It  is  a  remarkable  disease,  to  whieli 
much  attention  has  been  paid  for  several  centuries.  An  exhaustive  de- 
scrii)tion  of  it  is  given  by  "Woodward,  in  vol.  ii  of  the  Medical  and  Surgical 
Ik'ports  of  the  Civil  War.  It  is  an  affection  of  the  large  bowel,  character- 
ized by  the  production  of  a  very  tenacious  adherent  mucus,  which  may  be 
passed  in  long  strings  or  as  a  continuous,  tul)ular  membrane.  I  hh-c.  twice 
had  opportunities  of  seeing  this  membrane  in  situ,  closely  adherent  ^o  the 
mucosa  of  the  colon,  but  capable  of  sejjaration  without  any  lesion  of  the 
surface.  Judging  from  the  statement  of  English  authors  as  to  its  rarity, 
it  would  appear  to  be  a  more  frequent  disease  in  this  country,  in  which  it 
has  been  carefully  studied  by  Da  Costa,  Edwards,  and  others.  According 
to  Edwards,  80  per  cent  of  the  recorded  adult  cases  have  been  in  women. 
It  occurs  occasionally  in  children.  Of  111  cases  6  were  under  the  age  of 
ten.  The  cases  are  almost  invariably  seen  in  nervous  or  hysterical  women 
or  in  men  with  neurasthenia.  All  grades  of  the  affection  occur,  from  the 
passage  of  a  slimy  mucus,  like  frog-spawn,  to  large  tubular  casts  a  foot  or 
more  in  length.  Microscopically  the  casts  are,  as  shown  by  Sir  Andrew 
Clark,  not  fibrinous,  but  mucoid,  and  even  tlie  firmest  consisi  of  dense, 
opaque,  transformed  mucus.  The  nature  of  the  disease  has  been  mucli 
discussed.  It  is  probably  not  an  enteritis,  but  a  secretion  neurosis.  In 
favor  of  this  view  is  the  large  proportion  of  cases  in  neurotic  women. 

Symptoms. — The  disease  persists  for  years,  varying  extremely  from 
time  to  time,  and  is  characterized  by  paroxysms  of  pain  in  the  abdomen, 
tenderness,  occasionally  tenesmus,  and  the  passage  of  flakes  or  long  string:? 
of  mucus,  sometimes  of  definite  casts  of  the  bowel.  There  is  frequently 
a  spot  of  great  tenderness  just  between  the  navel  and  the  left  costal  border. 
The  attacks  last  for  a  day  or,  in  some  instances,  for  ten  days  or  two  weeks. 
Mental  emotions  and  worry  of  any  sort  seem  particularly  apt  to  bring  on 
an  attack.  Occasionally  errors  in  diet  or  dyspepsia  precede  an  outbreak. 
Membranes  are  not  passed  with  every  paroxysm,  even  wdien  the  pains  and 
cramps  are  severe.  There  are  instances  in  which  the  morphia  habit  has 
been  contracted  on  account  of  the  severity  of  the  pain.  There  may  bo 
nuirked  nervous  symptoms,  and  authors  mention  hysterical  outbreaks,  hy])o- 
chondriasis,  and  melancholia.  Blood  may  be  passed  in  rare  instances.  The 
condition  may  persist  for  years  and  lead  to  great  emaciation  and  chronic 
invalidism.  Constipation  is  a  special  feature  in  many  cases.  Ilerringliam 
states  that  he  knew  of  three  cases  of  mucous  colitis  in  which  death  had  sud- 
denly occurred,  in  all  with  great  pain  in  the  left  side  of  the  abdomen.  In 
another  case  there  was  an  abscess  in  the  region  of  the  descending  colon. 

The  (tiagnosis  is  rarely  doubtful,  but  it  is  important  not  to  mistake  tlic 
membranes  for  other  substances;  thus,  the  external  cuticle  of  asparagus 
and  unrligested  portions  of  meat  or  sausage-skins  sometimes  assume  forms 
not  unlike  mucous  casts,  but  the  microscopical  examination  will  quickly 


'.nterilis, 
0  which 
tive  de- 
Surgical 
laractor- 
may  Ijc 
,v\?  twice 
it  ;o  the 
n  of  the 
:s  rarity, 
which  it 
ccording 
.  women, 
le  age  of 
il  women 
from  the 
a  foot  or 
Andrew 
of  denize, 
en  much 
[•osis.     In 
1. 

ely  from 
ibdomen, 
g  strings 
-equently 
1  border. 
0  weeks, 
bring  on 
)utbreak. 
ains  and 
uibit  has 
may  ho 
vs,  hv])o- 
cs.    The 
chronic 
•ringhaiii 
had  snd- 
iien.     In 
olon. 
take  the 
isparagns 
le  forms 
quickly 


MISCELLANEOUS  AFFECTIONS. 


545 


difTcrcntiate  them.     Twice  I  have  known  mucous  colitis  with  severe  pain 
to  be  mistaken  for  appendicitis. 

The  treatment  is  very  unsatisfactory.  Drugs  arc  of  doubtful  benefit. 
^Measures  directed  to  the  nervous  condition  are  perhaps  most  imi)()rtant. 
Sometimes  local  treatment  with  Kelly's  long  rectal  tubes  is  bcnelicial. 
Hale  White  recommends  in  very  obstinate  cases  in  which  life  is  a  l)ur(len 
right  inguinal  colotomy.  This  has  been  performed  with  success  now  in 
several  cases.     The  artificial  anus  should  remain  open  for  some  time. 

II.    DILATATION  OF  THE  COLON. 

Hale  "White,  in  AUbutt's  System,  recognizes  four  groups  of  cases. 
In  the  first  the  distention  is  entirely  gaseous,  and  occurs  not  infrequently 
as  a  transient  condition.  In  many  cases  it  has  an  important  influence,  inas- 
much as  it  may  be  extreme,  pusiiing  up  the  diaphragm  and  seriously  im- 
pairing the  action  of  the  heavt  and  lungs.  II.  Fenwick  has  called  attention 
to  this  as  occasionally  a  cause  of  sudden  heart-failure. 

In  the  second  group  are  the  cases  in  which  the  distention  of  the  cob  . 
is  caused  by  solid  substances,  as  ixeal  matter,  occasionally  l)y  foreign  jjodios 
introduced  from  without,  and  more  rarely  by  gall-stones. 

In  a  third  group  are  embraced  the  cases  in  which  tlie  dilatation  is  duo 
to  an  organic  obstruction  in  front  of  tlie  dilated  gut.  Under  these  circum- 
stances the  colon  may  reach  a  very  large  size.  These  cases  are  common 
enough  in  malignant  tumors  and  sometimes  in  volvulus.  Dilatation  of  the 
sigmoid  flexure  occurs  particularly  when  this  portion  of  the  bowel  is  con- 
gcuitally  very  long.  In  such  cases  the  bowel  may  be  so  distended  that  it 
occupies  the  greater  part  of  the  abdomen,  pushing  up  the  liver  and  the 
diaphragm.  An  acute  condition  is  sometimes  caused  by  a  twist  in  the 
meso-colon. 

Fourthly,  there  are  the  cases  of  so-called  idiopathic  dilatation  of  the 
colon.  The  condition  has  been  very  carefully  studied  by  Rolleston,  C.  F. 
j\Iartin,  and  others.  I  have  had  four  well-marked  instances  under  my  care. 
Treves  suggests  that  the  condition  is  always  due  to  a  narrowing  low  down  in 
the  colon.  This  proved  to  be  true  in  Case  II  of  my  series,  a  boy  who  died 
at  the  age  of  about  two  and  a  half  years.  There  was  a  distinct  stricture  in 
the  sigmoid  flexure.  In  the  idiopathic  chronic  form  tlie  gut  reaches  an 
enormous  size.  The  coats  may  be  hypertrophied  without  evidence  of  any 
special  organic  change  in  the  mucosa.  The  most  remarkable  instance  has 
been  reported  by  Formad.  The  patient,  known  as  the  "  balloon-man,"  aged 
twenty-three  years  at  the  time  of  his  death,  had  had  a  distended  abdomen 
from  infancy.  Post  mortem  the  colon  was  found  as  large  as  that  of  an  ox, 
the  circumference  ranging  from  15  to  30  inches.  The  weight  with  the  con- 
tents was  47  pounds.  The  condition  is  incural)le,  and  surgical  interference 
should  be  probably  the  only  measure.  In  one  of  my  cases  good  results  fol- 
lowed the  establishment  of  an  artificial  anus,  1)ut  the  most  brilliant  case 
is  that  reported  recently  by  Treves,  who  excised  the  greater  part  of  the 
colon,  with  recovery. 


iiG 


DISEASES   OF  THE   DIGESTIVE  SYSTEM. 


/ 


III.     INTESTINAL  SAND. 

"  Sahlr  InlpfiHiKil." — Miliary  gravel  may  be  passed  in  larfro  nmount,  and 
tlie  iiCL'ilri  <)i  raspljpvrie?,  etc.,  may  occur  in  tlie  foccs  in  cxtrno.dinary  num- 
bers. Delepine,  Sliattock,  and  others  liave  described  in  tbe  feces  sal)urrous 
matter  coiisistin^i;  ol'  sjiheroidal  a«rji're;:ati()ns  of  veizctable  sclereiichymatous 
ci'lls.  sucli  as  occur  in  i)ears.  In  Sliattock"s  patient  the  (liscl)ar<>c  was  in- 
termittent, l)nt  it  couUl  always  be  broiiirht  away  by  an  aperient.  1  have  re- 
cently seen  a  case  in  wliich  the  patient  on  two  occasions  passed  a  consider- 
ahk'  (plant ity  of  sand.  The  sample  which  he  broni^ht  consisted  of  small 
giains,  some  of  a  beautiful  garnet  color.  They  proved  to  bo  vegetable 
matter. 

IV.     AFFECTIONS  OF   THE   JIESENTKRY. 

There  arc  various  diseases  of  tlie  structure  emhraced  in  the  nu'sentory, 
which  are  of  nuire  or  less  importance. 

(1)  HiBhiOTThdigQ  (iKi'inatoma). — instances  in  which  the  bleeding  is  con- 
fined to  the  mesenteric  tissues  are  rare;  more  connnonly  the  condition  is 
associated  with  ha'inorrhagic  infiltration  of  the  pancreas  and  with  retro- 
lierit.iiieal  luemorrhage.  It  occurs  in  rui)tures  of  aneurisms,  either  of  the 
abdominal  aorta  or  of  the  sn})erior  mesenteric  artery,  in  malignant  forms 
of  the  infectious  fevers,  as  snuill-])ox,  and,  lastly,  in  individuals  in  whom 
110  jiredisposing  conditions  exist.  In  1887,  at  the  Philadelpbia  Hospital, 
there  was  a  ])atient  in  the  ward  of  my  colleague,  lirucn,  wlio  had  o])scurc 
abdominal  symptoms  for  several  days  with  great  i)ain  and  })rostration.  I 
found  at  the  post  mortem  the  greater  ])ortion  of  the  mesentery  and  the 
retro-peritoneal  tissues  intiltrated  with  large  blood-clots.  There  was  no 
disease  of  the  aorta  or  of  the  branches  of  the  cceliac  axis  or  of  the  mesen- 
teric vessels.  Isamljard  Owen  bas  reported  a  case  of  sudden  death  in  a 
woman  aged  sixty-seven  from  ha-morrhage  in  tbe  transverse  meso-colon. 

(•2)  Affections  of  the  Mesenteric  Arteries. — (a)  Aneurism  (see  under 

Arteries). 

(li)  J'JntholisDi  and  Tlironihusis — Infnnliun  of  the  Bowel. — When  the 
mesenteric  vessels  are  blocked  by  emboli  or  throndn  the  condition  of  in- 
farction follows  in  tbe  territory  su])])lied.  Probably  the  occlusion  of  small 
vessels  does  not  produce  any  symjitoms,  and  the  circulation  may  be  re- 
established. If  the  superior  mesenteric  artery  is  blocked,  a  serious  and  fatal 
condition  follows.  Three  instances  have  come  under  my  observation.  In 
one.  a  woman  aged  fifty-fivo  was  seized  with  nausea  and  vomiting,  Avhich 
])crsisteil  b)r  more  than  a  week.  There  was  ]iain  in  the  abdomen,  tym- 
panites, and  toward  the  close  the  vomiting  was  incessant  and  fa'cal.  The 
autopsy  showed  great  congestion,  with  swelling  and  infiltration  of  the  jeju- 
num and  ileum.  The  superior  mesenteric  artery  was  blocked  at  its  orifice 
by  a  firm  thrombus.  In  the  second  case,  a  woman  aged  seventy-five  was 
seized  with  severe  abdominal  pain  and  fretpK.iit  vomiting.  At  first  there 
was  diarrhoea;  subsecpiently  the  symptoms  pointed  to  obstruction,  with 
great  distention  of  the  abdomen.  The  post  mortem  showed  the  small 
bowel,  with  the  exception  of  the  first  foot  of  the  jejunum  and  the  last  six 


MISCELLANEOUS  AFFECTIONS. 


54T 


inches  of  llic  ileum,  greatly  distended  and  deeijly  infiltrated  with  blood. 
The  mesentery  was  also  cim^icslcd  and  iidiltratcd.  The  superior  mesen- 
teric artery  contained  a  firm  brownish-yellow  clot.  There  were  many  re- 
cent warty  vcfietations  on  the  mitral  valve.  In  the  third  case,  a  man  a^ied 
forty  was  sud(h'n]y  seized  with  intense  pain  in  tiie  abdomen,  became  faint, 
tell  to  tile  ground,  and  vomited.  Tor  a  week  he  had  persistent  vomiting, 
severe  diarrluea,  tympanites,  and  great  pain  in  the  abdomen.  The  stools 
were  thin  and  at  times  blood-tinged.  'JMie  autoi)sy  showed  an  aneurism 
involving  the  aorta  at  the  diaphragm.  The  superior  mesenteric  artery,  half 
an  inch  I'rom  its  origin  on  tlie  sac,  was  l)locke(l  by  a  ])ortion  of  the  librincnis 
clot  of  the  aneurism.  Watson  has  analyzed  the  symptoms  in  'iH  cases;  in 
LS  there  was  pain,  usually  colicky  and  violent;  diarrha>a  occurred  in  11; 
vonnting  in  1-1;  and  abdominal  distention  in  1'.'.  In  a  majority  of  the 
cases  the  heart  or  the  abdominal  aorta  was  diseased.  In  one  sixth  of  the 
cases  the  lesion  was  limited  enough  to  have  ])ermilted  the  successful  re- 
section of  the  bowel.  J.  AY.  Elliot  has  operated  upon  two  cases  of  in- 
farction of  the  bowel,  in  one  of  which  (throndjosis  of  the  mesenteric 
veins)  he  successfully  resected  forty-eight  inches,  hi  the  horse,  infarction 
of  the  intestine  is  extremely  common  in  connection  with  the  verminous 
aneurisms  of  the  mesenteric  arteries,  and  is  the  usual  cause  of  colic  in  this 
animal. 

(3)  Diseases  of  the  Mesenteric  Veins. — Dilatation  and  sclerosis  occur  in 
cirrhosis  of  the  liver.  Jn  instances  of  pndonged  obstruction  there  may 
lie  large  saccular  dilatations  with  calcillcal-ion  of  the  intinia,  as  in  a  case  of 
obliteration  of  the  vena  i)orta^  described  by  me.  Sup])uration  of  the  mes- 
enteric veins  is  not  rare,  and  occurs  usuall}'  i!i  conni'ction  w  ith  pyle|)hlebitis. 
The  mesi'iitery  may  be  much  swollen  and  is  like  a  bag  of  ])u^,  and  it  is  only 
on  careful  dissection  that  one  sees  that  the  pus  is  really  within  channels 
]e))rcsenting  extremely  dilated  mesenteric  veins.  Two  of  the  three  eases 
J  have  seen  were  in  connection  with  local  appendix  abscess. 

(I)  Disorders  of  the  Chyle  Vessels. — A'aricose,  cave-nous,  and  cystic 
chylangionuda  are  met  with  in  the  miu'osa  and  submuc(jsa  of  the  small  in- 
tci-tine,  occasionally  of  the  stomach.  Mxtravasation  of  chyle  into  the  mes- 
enteric tissue  is  sometimes  seen.  Chylous  cysts  are  found.  I  saw  one  the 
size  of  an  eg;;  at  the  root  of  the  mesentery.  Bramann  rec()r(l,-f  a  case  in 
a  man  aged  sixty-three,  in  which  a  cyst  of  this  kind  the  size  of  a  child's 
head  was  healed  by  operation.  There  is  an  instance  on  record  of  a  con- 
genital malformation  of  the  thoracic  duct,  in  which  the  receptaculuni 
formed  a  flattened  cyst  which  discharged  into  the  peritonanim,  and  a  ^-hylous 
ascitic  fluid  was  withdrawn  on  several  occasions.  Ilonians,  of  Boston,  re- 
ports an  extraordinary  case  of  a  girl,  who  from  the  third  to  the  thirteenth 
year  had  an  enlarged  abdomen.  Laparotomy  showed  a  series  of  cysts  con- 
taining cknr  fluid.  They  were  sui)posed  to  be  dilated  lymph  vessels  con- 
nected with  ihe  intestines. 

(5)  Cysts  of  the  Mesentery. — :\ru(h  attention  has  l)een  directed  of  lato 
years  to  the  occurrence  of  mesenteric  cysts,  and  the  literature  which  is 
fully  given  by  Delmez  (Paris  Thesis,  1891)  is  already  extensive.  They 
may  be  either  dermoid,  hydatid,  serous,  sanguineous,  or  chylous.     They 


548 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


occur  at  nny  iiortion  of  tlio  mcscntor}',  and  ranfjo  from  a  few  indies  in 
diameter  to  lai>;e  masses  occupying  the  entire  abdomen.  They  are  fre- 
quently adiierent  to  tlie  neighboring  organs,  to  the  liver,  spleen,  uterus,  and 
sigmoid  llexure. 

The  symj)toms  usually  arc  those  of  a  progressively  enlarging  tumor  in 
the  abdomen.  Sometimes  a  mass  develops  rajjidly,  ])artieularly  in  the 
luemorrhagic  forms.  Colic  and  constipation  arc  i)resent  in  some  cases. 
The  general  health,  as  a  rule,  is  well  maintained  in  spite  of  the  progres- 
sive enlargement  of  the  abdomen,  which  is  most  prominent  in  the  um- 
hilical  region.  Mesenteric  cysts  may  persist  for  many  years,  even  ten  or 
twenty. 

The  diagnosis  is  extremely  uncertain,  and  no  single  feature  is  in  any 
■way  distinctive,  Augagneur  gives  three  important  signs:  the  great  mo- 
bility, the  situation  in  the  middle  line,  and  the  zone  of  tympany  in  front 
of  the  tumor.  Of  these,  the  second  is  the  only  one  which  is  at  all  con- 
stant, as  Mhen  the  tumors  are  large  the  mobility  disappears,  and  at  this 
stage  the  intestines,  too,  are  pushed  to  one  side.  It  is  most  frequently  mis- 
taken for  ovarian  tumor.  Movable  kidney,  hydronephrosis,  and  cysts  of 
the  omentum  have  also  been  confused  with  it.  In  certain  instances  ])unc- 
turc  may  be  made  for  diagnostic  purposes,  but  it  is  better  to  advise  lapa- 
rotomy for  the  purpose  of  drainage,  or,  if  possible,  enucleation  may  be  prac- 
tised. 


VIII.    DISEASES  OF  THE   LITER. 

I.     JAUNDICE  (Icterus). 

Definition. — Jaundice  or  icterus  is  a  condition  characterized  by  col- 
oration of  the  skin,  mucous  membranes,  and  fluids  of  the  body  by  the  bile- 
])igment. 

For  a  full  consideration  of  the  theories  of  jaundice  the  reader  is  referred 
to  "William  Hunter's  article  in  Allbutt's  System  of  Medicine.  The  cases 
with  icterus  may  be  divided  into  two  great  groups. 


1.  Obstructive  Jaundice, 

The  following  classification  of  the  causes  of  obstructive  jaundice  is  given 
by  Murchison:  (1)  Obstruction  by  foreign  bodies  within  the  ducts,  as  gall- 
stones and  parasites;  (2)  by  inflammatory  tumefaction  of  the  duodenum  or 
of  the  lining  membrane  of  the  duct;  (3)  by  stricture  or  obliteration  of  the 
duct;  (4)  by  tumors  closing  the  orifice  of  the  duct  or  growing  in  its  inte- 
rior; (5)  by  pressure  on  the  duct  from  without,  as  by  tumors  of  the  liver 
itself,  of  the  stomach,  pancreas,  kidney,  or  omentum;  by  pressure  of  en- 
larged glands  in  the  fissures  of  the  liver,  and,  more  rarely,  of  abdominal 
aneurism,  faecal  accumulation,  or  the  pregnant  uterus. 

To  these  causes  some  add  lowering  of  the  blood  pressure  in  the  portal 
system  so  that  the  tension  in  the  smaller  bile-ducts  is  greater  than  in  the 
blood-vessels.    For  this  view,  however,  there  is  no  positive  evidence.     In 


JAUNDICE. 


549 


tliis  class  niny  perhaps  bo  placed  the  cases  of  jaundice  from  mental  shock 
or  depresssed  emotions,  which  *'  may  conceival)ly  cuiis-e  spasm  and  reversed 
peristalsis  of  the  bile-duct  "  (W.  Hunter). 

(iciicral  ISi/iiij)loins  of  Obstniclirc  Jaundice. — (1)  Icterus,  or  tintiiit;  of 
the  skin  and  conjunctiva".  The  color  ranges  from  a  lemon-yellow  in  catar- 
rhal jaundice  to  a  deep  olive-green  or  bronzed  hue  in  permanent  obstruc- 
tion. In  some  instances  the  color  of  the  skin  is  greenish  black,  the  so- 
called  "  black  jaundice.'' 

{'i)  Of  the  other  cutaneous  symptoms,  pruritus  in  the  more  ciironic  forms 
may  be  intense  and  cause  the  greatest  distress.  It  \\\\\y  precede  the  onset 
<d'  the  jaundice,  but  as  a  rule  it  is  not  very  nuirked  excei)t  in  cases  of  pro- 
longed obstruction.  Sweating  is  common,  and  may  be  curiously  localized 
to  the  abdomen  or  to  the  palms  of  the  hands.  Lichen,  urticaria,  and  boils 
may  develop,  and  the  skin  disease  known  as  xanthelasnui  or  vitiligoidea. 
'J'he  jaundice  may  be  due  to  the  extension  of  the  xantbonuita  to  tlie  bile- 
jtas-sages.  The  visceral  localization  of  this  disorder  has  been  ehielly  ob- 
f^erved  when  there  are  numerous  punctate  tubercles  on  the  lind)S  (Ilallo- 
])cau).  In  very  chronic  cases  telangiectases  develop  in  the  skin,  sometimes 
in  large  numbers  over  the  body  and  face,  occasionally  on  the  mucous  mem- 
l)rane  of  the  tongue  and  lips,  forming  patches  of  a  bright  red  color  from 
1  to  2  cm.  in  breadth. 

(3)  The  secretions  are  colored  with  bile-pigment.  The  sweat  tinges 
the  linen;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  expectora- 
tion is  not  often  tinted  unless  there  is  inflammation,  as  when  pneumonia 
coexists  with  jaundice.  The  urine  may  contain  the  pigment  before  it  is 
a])parcn^  in  the  skin  or  conjunctiva.  The  color  varies  from  light  greenish 
yellow  to  a  deep  black-green.  Gmelin's  test  is  made  by  allowing  five  or 
six  drops  of  urine  and  a  similar  amount  of  common  nitric  acid  to  flow 
together  slowly  on  the  fiat  surface  of  a  white  plate.  A  play  of  colors  is 
produced — various  shades  of  green,  yellow,  violet,  and  red.  In  cases  of 
jaundice  of  long  standing  or  great  intensity  the  urine  usually  contains 
all)umin  and  always  bile-stained  tube-casts. 

(4)  No  bile  passes  into  the  intestine.  The  stools  therefore  are  of  a 
])ale  drab  or  slate-gray  color,  and  usually  very  fetid  and  pasty.  There 
may  be  constipation;  in  many  instances,  owing  to  decomposition,  there  is 
diarrhoea. 

(5)  Slow  pulse.  The  heart's  action  may  fall  to  40,  30,  or  even  to  20 
per  minute.  It  is  particularly  noticeable  in  the  cases  of  catarrhal  jaundv  -. 
and  is  not  as  a  rule  an  unfavorable  symptom.  The  respirations  nuiy  fail 
to  10  or  even  to  7  per  minute. 

(fi)  IIa>morrhage.  The  tendency  to  bleeding  in  chronic  icterus  is  a  se- 
rious feature  in  some  cases.  It  has  been  shown  that  the  Idood  coagulation 
time  may  be  much  retarded,  and  instead  of  from  three  minutes  and  a  half 
to  four  minutes  and  a  half  we  have  found  it  in  some  cases  as  late  as  eleven 
or  twelve  minutes.  This  is  a  point  which  should  be  taken  account  of  by 
surgeons,  inasmuch  as  incontrollable  hajmorrhage  is  a  well-recognized  acci- 
dent in  operating  upon  patients  with  chronic  obstructive  jaundice.  Pur- 
pura, large  subcutaneous  extravasations,  more  rarely  hremorrhagos  from  the 


550 


DISKASRS  OF  THE  DTOESTIVR  SYSTEM. 


/ 


iniicoiis  iiR'mbraiU's,  occur  in  protracted  jaiimlicc,  and  in  tlic  luorc  aovcre 
I'ui  iii.s. 

(I)  Corubral  syiii[)toiiis.  Irritaldlity,  great  depression  of  spirits,  or  even 
meiiiiH'liolia  may  he  present.  In  any  case  of  persistent  jmiiidice  special 
iieivoiis  plieiioiuena  may  develop  and  rapidly  piove  fatal — sucli  as  sudden 
coma,  acute  delirii.m,  or  convulsions.  I'sually  the  patient  has  a  rapid 
pulse,  sli<ilit  fever,  and  a  dry  tongue,  and  he  })asses  int(j  the  so-called  "  ty- 
jdioid  state."  'J'heso  features  are  not  neui'ly  so  common  in  ohstructive  as 
in  fehrile  jnniulice,  hut  th<\y  not  int'reipient ly  tei'ininate  a  chronic  icterus 
in  whatever  way  i)roduced.  The  group  of  symi)toms  has  heen  termed 
(■li(il(('inla  or,  on  the  supposition  that  cliolesterin  is  the  jioison,  cholvslvr- 
IV  lit  id  :  hut  its  true  nature  has  mjt  yet  heen  determined.  In  some  of  the 
cases  the  symptoms  nuiy  he  due  to  nra-mia. 

2.  Toxj;.Mic  J-vrxDicE. 

In  this  form  there  is  no  ohstrnction  in  tlu'  l)ile-|)assages,  liut  the  jaundice 
is  associated  with  to.xic  states  of  the  hlood,  dependent  njion  various  [joisons 
Avhich  either  act  directly  on  the  hlood  itself  or  in  some  cases  on  the  liver- 
cells  as  well,  "^^rhe  term  luenuitogenous  jaundice  was  former!,  a])plied  to 
this  group  in  contradistinction  to  the  he])atogenous  jaundice,  associated 
with  ohstructive  changes  in  the  hile-passages.  Hunter  groups  tho  causes 
as  follows: 

1.  Jaundice  ])roduccd  hy  the  action  of  poisons,  such  as  toluylendiamin, 
])hosphorus,  arsenic,  snake-venom. 

'i.  Jaundice  met  with  in  A'arious  s])ecific  fevers  and  conditions,  such  as 
A'cllow  fever,  nuddria  (renuttent  and  interniittent),  pyivmia,  relapsing  fever, 
tyi)hus,  enteric  fever,  scarlatina. 

3.  Jaundice  met  with  in  various  conditions  of  unknown  hut  more  or 
less  ohscure  infective  nature,  and  variously  designated  as  ei)idennc,  infec- 
tious, fehrile,  malignant  jaundice,  icterus  gravis,  AVeil's  disease,  acute  yel- 
low atroi)hy. 

The  syni])tonis  of  toxic  jaundice  are  not  nearly  so  striking  as  in  the  ol)- 
structive  variety.  The  hile  is  usually  jiresent  in  the  stools,  sometimes  in 
excess,  causing  very  dark  movements.  The  skin  has  in  many  cases  only  a 
light  lemon  tint.  Tn  the  severer  forms,  as  in  acute  yellow  atro})hv,  the 
color  nuiy  he  more  intense,  hut  in  malaria  and  pernicious  anaunia  the  tint 
is  usually  light.  In  these  mild  eases  the  urine  may  contain  little  or  no  Ijile- 
pigment,  hut  the  uriimry  ])igments  are  considerahly  increased.  In  many 
Cases  of  the  toxic  variety  the  constituticmal  disturhance  is  very  profcnind, 
and  there  are  high  fever,  delirium,  convulsions,  sujjpression  of  urine,  hlack 
vomit,  and  cutaneous  haunorrhages. 

Tn  connection  M'ith  the  various  fevers,  malaria,  yelloAv  fever,  and  "Weil's 
disease  jaundice  has  heen  descrihed.  Two  special  afl'ections  may  here  re- 
ceive consideration,  the  icterus  of  the  new-horn  and  acute  yellow  atrophy. 


ACUTK  YELLOW  ATIIOI'IIY. 


661 


II.    ICTERUS   NEONATORUM. 

Nc\v-l)orn  infniits  nw  liiihlo  to  jiUiiKlico,  wliicli  in  sonic  instani-cs  riipidly 
proves  ralal.     A  mild  and  a  st'Vcri'  foiin  may  l)i'  rcco-^iii/i'd. 

The  ntild  or  physioloijical  iclerua  of  llic  new-horn  is  a  common  disense 
in  f()un<llin^'  hospitals,  and  is  not  very  int'rc(picnt  in  private  practice.  Jn 
!)0()  consecutive  hii'ths  at  the  Sloane  Maternity,  icterns  was  noted  in  300 
cases  (Holt).  The  discoloration  appears  early,  usually  on  the  lirst  or  sec- 
ond day,  and  is  of  moderate  intensity.  The  urine  nniy  bo  ))ile-staine<l  and 
the  fteces  colorless.  The  nutrition  of  the  child  is  not  usually  disturlied, 
and  in  the  majority  of  cases  the  jaundice  disappears  within  two  weeks. 
This  foi'in  is  never  fatal.  'J'he  cause  of  this  jaundice  is  not  at  all  clear. 
.Some  have  attributed  it  to  stasis  in  the  smaller  bile-diuts,  which  are  com- 
])resscd  by  the  distended  radicals  of  the  portal  vein.  Others  hold  that  the 
jaundice  is  due  to  the  destruction  of  a  large  nund)tr  of  red  blood-coi'pusclcs 
during  the  first  fi'w  days  after  birth. 

The  scrrre  form  of  icterus  in  the  new-born  iiiay  dc[>cnd  upon  (»/)  con- 
genital absence  of  the  common  or  he])atic  duct,  of  which  there  are  sevci'al 
instances  on  record;  (h)  congenital  syphilitic  he])atitis;  and  (c)  septic  poi- 
soning, associated  with  phlebitis  of  the  nnd)ilical  vein.  This  is  a  severe 
and  fatal  form,  in  which  also  hieniorrluige  from  the  coid  niny  occur. 


he  ob- 

mes  in 
inly  a 

ly,  the 
tint 

10  bile- 
many 
"ound, 
black 

AYcil's 
?rc  re- 
phv. 


III.     ACUTE    YELLOW    ATROPHY  {.m>Ii,/nani  Juu ml ivr ,-  IvIvrnH  OraviH). 

Definition. — Jaundice  associated  with  ma^l^";'d  cercbi'al  symptoms  and 
characterized  anatomically  by  extensive  necrosis  of  the  liver-cells  with  re- 
duction in  vf)lnnio  of  the  organ. 

Etiology. — This  is  a  rare  disease.  Xo  case  has  been  admitted  to  the 
Johns  Hopkins  llos])ital  in  the  niiie  years  of  its  work.  Hunter  has  col- 
lected only  50  cases  between  1880  and  I8i)4  (inclusive),  which  brings  \\\) 
the  total  number  of  recorded  eases  to  about  250.  In  a  soinewh.it  varied 
]iost-mortem  and  clinical  experience  no  instance  has  fallen  under  my  ob- 
servation. On  the  other  hand,  a  physician  may  see  several  cases  within  a 
few  -ears,  or  even  within  a  few  months,  as  hap])ened  to  lieiss,  who  saw  live 
ea.vs  within  three  months  at  the  Charite,  in  IJerlin.  'J'lie  disease  seems 
to  be  rare  in  this  country.  It  is  more  common  in  women  than  in  men.  Of 
the  100  cases  collected  l)y  Legg,  GO  M'cre  in  females:  and  (d'  'I'hierfelder's 
1  t:i  cases,  88  were  in  women.  There  is  a  remai'kable  association  between 
the  disease  and  pregnancy,  which  was  ))resent  in  25  of  the  GO  women  in 
Legg's  statistics,  and  in  ;};5  of  the  88  women  in  Thierfelder's  collection. 
ft  is  most  common  between  the  ages  of  twenty  and  thirty,  but  has  been  met 
with  as  early  as  the  fourth  day  and  the  tenth  month.  It  has  followed 
flight  or  profound  mental  eniotion.  In  hypertrophic  cirrhosis  the  sym]i- 
tnms  of  a  profound  icterus  gravis  may  develoji,  with  all  the  clinical  features 
of  acute  yellow  atrophy,  including  the  presence  of  leucin  and  tyrosin  in  the 
urine,  and  convulsions.     I  have  seen  two  such  cases;  in  both  there  were 


552 


DISEASES  OP  THE  DIOKSTIVR  SYSTEM. 


/ 


^'xtcnsive  necroses  in  the  liver-colls,  TIi<)ii<,'h  the  symptoms  i)n)(lucccl  by 
l)lio8j)lionKs  jjoisoning  closely  simulato  those  of  acute  yellow  atrophy,  the 
two  (•(•nditioiis  are  not  ich-ntical. 

Morbid  Anatomy. — 'Vhv.  liver  is  greatly  rctliued  in  size,  looks  thin 
and  IhittLnc'cl,  and  sometimes  does  not  reach  more  than  one  halt'  or  even 
one  third  of  its  normal  weight.  It  is  llahby  and  the  capsule  is  wrinkled. 
On  section  the  color  is  of  a  yellowish  brown,  yellowish  red,  or  mottled,  and 
the  outlines  of  the  lobuh'S  are  indistinct.  'JMie  yellow  and  dark-red  \h)V- 
tions  represent  dill'erent  stages  of  the  same  jiroccss — the  yellow  an  earlier, 
the  red  a  more  advanced  stage.  The  organ  may  cut  with  considerable  lirni- 
ness.  Micro8co])ieally  the  liver-cells  are  seen  in  all  stages  of  necrosis,  and 
in  spots  ap])ear  to  have  undergone  complete  destruction,  leaving  a  fatty, 
granular  (Ifbris  with  ])ignu'nt  grains  and  crystals  of  leucin  and  tyrosin. 
The  bile-ducts  and  gall-bladder  are  empty.  Hunter  concludes  that  it  is  a 
toxicmic  catarrh  of  the  finer  bile-ducts,  similar  to  that  which  is  found  after 
poisoning  by  toluylendiamin  or  phosphorus. 

The  other  organs  show  extensive  l)ile-staining,  and  there  are  numerous 
luiMuorrhages,  The  kidneys  may  show  marked  granular  degeneration  of 
the  ej)ithelium,  and  usually  there  is  fatty  degeneration  of  the  heart.  In  a 
majority  of  the  cases  the  sideen  is  enlarged. 

Symptoms. — In  the  initial  stage  there  is  a  gastro-duodenal  catarrh, 
and  at  first  the  Jaundice  is  thought  to  b*^  of  a  simple  nature.  In  some  in- 
stances this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then 
severe  symptoms  set  in — headache,  delirium,  trembling  of  the  muscles,  and, 
in  some  instances,  convulsions.  Vomiting  ;-  a  constant  symptom,  and  blood 
nuiy  be  brought  up.  Haemorrhages  occur  into  the  skin  or  from  the  mucous 
•surfaces;  in  jiregnant  women  abortion  may  occur.  With  the  development 
of  the  liead  symptoms  the  jaundice  usually  increases.  Coma  sets  in  and 
gradually  deepens  until  death.  The  body  temperature  is  variable;  in  a 
majority  of  the  cases  the  disease  runs  an  afebrile  course,  though  sometimes 
just  before  death  there  is  an  elevation.  In  some  instances,  however,  there 
has  been  marked  pyrexia.  The  pulse  is  usually  rapid,  the  tongue  coated 
and  dry,  and  the  patient  is  in  a  "  typhoid  state." 

The  urine  is  bile-stained  and  often  contains  tube-casts.  Leucin  and 
tyrosin  are  not  constantly  ])resent;  of  23  recent  cases  collected  by  Hunter, 
in  !)  neither  was  found;  in  10  both  were  ])resent;  in  3  tyrosin  only;  in  1 
leucin  only.  The  leucin  occurs  as  rounded  disks,  the  tyrosin  in  needle- 
shaped  crystals,  arranged  either  in  bundles  or  in  groups.  The  tyrosin  may 
sometimes  be  seen  in  the  urine  sediment,  but  it  is  best  first  to  evaporate  a 
few  drops  of  urine  on  a  cover-glass.  In  the  majority  of  cases  no  bile  enters 
the  intestines,  and  the  stools  are  clay-colored.  The  disease  is  almost  in- 
variably fatal.  In  a  few  instances  recovery  has  been  noted.  I  saw  in 
Leube's  clinic,  at  Wiirzburg,  a  case  which  was  convalescent. 

Diagnosis. — Jaundice  with  vomiting,  diminution  of  the  liver  volume, 
delirium,  and  the  ])rcsence  of  leucin  and  tryosin  in  the  iirine,  form  a  char- 
acteristic and  unmistakable  group  of  symptoms.  Leucin  and  tyrosin  are 
not,  however,  distinctive.  They  may  be  present  in  cases  of  afebrile  jaun- 
dice with  slight  enlargement  of  the  liver. 


AFFECTIONS  OF  TIIH   HLOOD-VESSELS  OF  TIIH   LIVKIl. 


553 


It  is  not  to  1)0  f(iri,'()ttL'ii  that  any  severe  jaiiiitlicx'  may  be  nssociatod  with 
intense  cerebral  symptoms.  The  clinical  features  in  certain  cases  of  liyper- 
trM|iliic  cirrhdsis  arc  almost  icK'ntical,  but  the  ciilarj^'cmcnt  of  the  liver,  the 
more  constant  occurrence  of  fever,  and  the  absence  of  leucin  and  tyrosin 
are  (listin<iuishui<.'  si^nis.  I'hosjthorus  i»()is<tnin<(  may  closely  simulate  acute 
yellow  atrophy,  partieidarly  in  the  ha'nu)rrha^'es,  jaundice,  and  llic  diminu- 
tion in  the  liver  volume,  but  the  <;astric  symptoms  arc  usually  mori'  marked, 
4ind  leucin  and  tyrosin  arc  stated  not  to  occur  in  the  urine. 

is'o  known  remedies  have  any  inlluence  on  the  course  of  the  disease. 


l)ment 

in  and 

in  a 

nctimes 

there 

coated 

in  and 
unter, 
in  1 
needle- 
in  may 
orate  a 
enters 
est  in- 
saw  in 


IV.    AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE 

LIVER. 

(1)  AnsBinia. — On  the  post-mortem  table,  vhen  the  liver  looks  nnivmic, 
iis  in  the  fatty  or  amyloid  orjran,  the  blood-vessels,  which  duriiij;  life  were 
])robal)ly  well  filled,  can  be  readily  injected.  There  are  no  symptoms  in- 
<licativc  of  this  condition. 

{2)  Hyperaemia. — This  occurs  in  two  forms,  (a)  Aclire  In/pcnvmia. 
After  each  meal  the  rapid  absorption  by  the  portal  vessels  induces  transient 
<'ongestion  of  the  or<;an,  which,  however,  is  entirely  ])hysiolo<jical;  but  it 
is  ((uite  jjossible  that  in  i)ersons  who  persistently  eat  and  drink  too  much 
this  active  hypericmia  may  lead  to  functional  disturbance  or,  in  the  ease 
of  drinkini^  too  freely  of  alcohol,  to  organic  change.  In  the  acute  fevers 
an  acute  hyperemia  may  be  present. 

The  symploms  of  active  hyperu'mia  are  indefinite.  Possibly  the  sense 
of  distress  or  fulness  in  the  right  hypochondrium,  so  often  mentioned  by 
dyspeptics  and  by  those  who  eat  and  drink  freely,  may  be  due  to  this  cause. 
There  arc  probably  diurnal  variations  in  the  volume  of  the  liver.  In  cir- 
rhosis with  enlargemeT>t  the  rai)id  reduction  in  volume  after  a  copious 
luvmorrhage  indicates  the  important  })art  which  hypera'mia  i)lays  even  in 
■organic  troubles.  It  is  stated  that  suppression  of  the  menses  or  sup])rcssion 
of  a  ha^morrhoidal  flow  is  followed  by  hypera'mia  of  the  liver.  Andrew  11. 
Smith  has  described  a  case  of  periodical  enlargement  of  the  liver. 

(h)  Passive  Coiu/estion. — This  is  much  more  common  and  results  from 
an  increase  of  pressure  in  the  efferent  vessels  or  sub-lobular  branches  of  the 
hepatic  veins.  Every  condition  leading  to  venous  stasis  in  the  right  heart 
at  once  affects  these  veins. 

In  chronic  valvular  disease,  i  mphyscma,  cirrhosis  of  the  lung,  and 
in  intrathoracic  tumors  mechani(  x  congestion  occurs* and  finally  leads  to 
very  definite  changes.  The  liver  is  enlarged,  firm,  and  of  a  dee])-red  ccdor; 
the  he])atic  vessels  are  greatly  engorged,  particularly  the  central  vein  in 
each  lobule  and  its  adjacent  ca]iillaric3.  On  section  the  organ  presents  a 
peculiar  mottled  appearance,  owing  to  the  deeply  congested  hepatic  and 
the  anaemic  portal  territories;  hence  the  term  niilmcij  which  has  been  given 
to  this  condition.  Gradually  the  distention  of  the  central  capillaries  reaches 
such  a  grade  that  atrophy  of  the  intervening  liver-cells  is  induced.  Brown 
pigment  is  deposited  about  the  centre  of  the  lobules  and  the  connective 


554 


DISEASES  OP  THE   DIGESTIVE  SYSTP:i.I. 


/ 


tisHUO  is  ^'icntly  iiicrciisi'd.  In  this  cyniiotic  iiidiiratiuii  or  fiirdiac  liver  the 
orj^'im  i.'i  larjrc  in  tlu;  early  sta^fc,  but  latiT  it  may  l)ee()iiie  contructed.  Ueea- 
sionally  in  tliiH  t"t)nii  the  connective  tisniie  is  increased  about  the  lubulos  as 
uell,  but  the  process  usually  extends  Troni  the  sublobular  and  central  veins. 

The  symptoms  of  this  form  are  not  always  to  be  separated  I'rom  those 
of  the  associated  c(Uiditions.  (iastro-intestinal  catarrh  is  usually  presi'Ut 
and  ha'Uiatemcsis  may  occur.  The  portal  oltstructiou  in  iidvanccd  cases 
leads  to  ascites,  which  may  precede  the  developuieiit  (d'  ^icncral  dropsy. 
There  is  (d't  Ml  sli^dit  jaundice,  the  stools  may  be  clay-cidorcd,  and  the  urine 
coidaius  bile-pi-irucut. 

On  exannnation  the  or;^iin  is  found  to  be  inciciiscd  in  siz".  Il  may  be 
a  full  haiuTs  breadth  bidow  the  costal  nunyiu  and  tender  on  pressure.  It 
is  in  this  coruliliiui  particularly  that  we  'lu'ct  with  |)ulsation  of  the  liver. 
"We  must  distinguish  the  conimunicated  •.hrobbiui;  of  the  heait,  wh.ich  is 
A'ery  <'<>uiinon,  from  tlu;  lic!iviu<r,  <lill'usi'  impulse  due  to  re;.fiu'j,ntati()u  into 
the  hepatic  veins,  in  which,  when  oiu'  hand  is  upon  the  ensiform  cartila^ro 
ami  the  other  upon  the  rij^lit  side  at  the  margin  of  the  ribs,  the  whoh' 
liver  can  be  felt  to  dilate  with  each  impulse. 

'i'he  indications  for  lirdliiinil  in  passive  liypera'Uiia  are  to  restore  the 
l)alance  of  the  circulation  and  to  unload  the  en<rov<fe<|  ])ortal  ves.sels.  In 
cases  of  intense  hyperaunia  IS  ov  ".Ml  ounces  of  blood  may  be  directly 
aspirated  from  the  liver,  as  advised  by  (Icor^ic  Ilarlcy  and  practised  by 
immy  .\n,<,do- Indian  physicians.  (Jood  results  souu'tinu's  J'ollow  this  hc- 
pato-])hlebotomy.  The  prompt  relief  and  marked  reduction  in  the  voliuue 
of  the  or,i;an  w  liicli  follow  an  attack  of  lucmntemesis  or  bleeding.;;  I'rom  piles 
8U<r^ests  this  ])ractice.  Salts  adnunistered  by  ^latthew  (lay's  method  de- 
])lete  the  portal  system  freely  an<l  thoroii^ddy.  As  a  rnle,  tlu^  treatment 
must  be  that  id'  the  condition  with  which  it  is  associated. 

(;5)  Diseases  of  the  Portal  Vein. — {n)  Tliminhnsis;  A(1lir:<!re  Pijlc- 
phlchilix. — ( 'oatrulaticui  of  blood  in  the  portal  vein  is  met  with  in  ciri'liosis, 
in  syphili'^'  (d'  the  liver,  imasion  of  the  vein  by  caiU'cr,  pi'olib'rat  i\('  perito- 
nitis involvino-  the  ^^astro-hepatic  omentum,  ])ei'foration  of  the  vein  by  j,''all- 
stom^s,  and  occasionally  follows  sclerosis  of  the  walls  of  the  ]iortal  vein  or 
of  its  branches  (I'orrmann).  In  rare  instances  a  complete  collateral  circula- 
tion is  established,  the  thrond)US  iinder<,n)es  the  iisual  chan^'cs,  and  ulti- 
mately the  vein  is  rc])resented  by  a  fi])rous  cord,  a  condiliim  which  has  been 
called  pi/h'plih'hUis  adhcsiva.  In  a  case  of  this  kind  which  I  dissected  the 
portal  vein  was  re]iresentc(l  by  a  narrow  (ibrous  cord;  the  collateial  circiUa- 
tif-n.  which  mnst  have  been  com])lctoly  establislicd  for  3'ears,  nltimately 
failed,  ascites  and  hannatcmesis  su])ervened  and  ra])idly  proved  fatal.*  T\w 
dia<inosis  of  obstruction  of  the  portal  vein  can  rarely  be  made.  X  su,l^- 
gestive  pym])tom,  however,  is  a  siKhlcn  onset  of  the  most  intense  cnp-orgc- 
ment  of  the  branches  of  the  portal  system,  leading  to  licTmatemcsis,  mchvna. 
ascites,  and  swelling  of  the  spleen. 

End)oli  in  the  branches  of  the  portal  vein  do  not.  as  a  rule,  produce 
infarction,  for  blood  reaches  the  lobular  capillary  plexus,  as  shown  by 

*  Journal  of  Anatomy  and  Physiology,  vol.  xvii. 


Iiuent 

J'ljJr- 
•liosis, 
)i'rit()- 

,U-al]- 

in  or 
niila- 

iilti- 

'   1)C'(']1 

1  llio 
rciila- 
natcly 

?l!vna. 

rodiice 
,vn  by 


t'( 


DISEASES  OF  TIIK   I'lLK-I'ASSAGPJS  AN'D  (JALL-IiLADDFIl.        555 

('(iliiilu'iiii  and  I^ittrii,  tlir()iij;li  tlu'  tri'i'  a.iastoniosi.s  with  u  lu'itatic  ai'lcry. 
In  rare  insstanii's,  liuwcvcr,  a  fuiidition  rt'^cniljling  iiil'arctinn  docs  occur, 
.<(iiiic'tinu's  ill  small  areas,  at  otluTs  in  (|iiiti'  cxtt'n.-ivu  t('rrit.>ricrf.  Si'ptic 
milinli,  on  tlu'  otiicr  hand,  may  induce  su|)|)urati(in. 

{h)  t^iipiiiirntirc.  iii/lrj)hlihilis  will  he  I'oiisidercd  in  the  scctiini  on  ahscesd. 

(4)  Attoctions  of  the  hepatic  vein  ait-  extremely  rare.  J)ilatati(m  oc- 
curs in  cases  of  chronic  enlargement  of  the  ri^dit  heart,  from  whati'Ver  cause 
produced,  i'lmholi  occasionally  pass  from  the  ri^ht  auricle  into  the  hepatic 
\eins.  A  rare  and  unusual  event  is  stenosis  of  the  orilii'cs  of  the  lie|iatic 
veins,  which  1  met  in  a  case  of  iihroid  ohliteration  of  the  infericn*  venu  cava 
and  which  was  associated  with  a  .irreatly  enlarjred  and  indurated  liver.* 

(.'))  Hopatic  Artory. — !']iilar,i:t'meiit  of  this  vessel  is  seen  in  cases  of  cir- 
rhosis of  till'  livir.  Jt  may  be  the  seat  of  extensive  sclerosis.  Aiu'urism 
of  the  hepatic  artery  is  rare,  hut  instances  are  ou  record,  and  will  be  re- 
ferred to  in  the  section  on  arteries. 


V.    DISEASES    OF    THE    BILE-PASSAGES    AND 
GALL-BLADDER. 

(a)  AcuTK  Cat.vuimi  ui"  thk  Bm^k-olcts  {Catarrhal  Jaundice). 

Definition. — daundiee  duo  to  swelliiiji:  and  olistruction  of  the  leriuinal 
portion  of  the  coinnion  duct. 

Etiology. — (Jeneral  catarrlial  iidlaniuiation  of  the  hile-ducts  is  usu- 
ally a.-sociated  with  ^all-stones,  'riie  catarrhal  process  now  under  consid- 
eration is  prohahly  always  an  extension  of  a  <,'astro-dnodenal  catarrh,  and 
the  ))rocess  is  most  intense  in  the  para  inli's/iiiali!i  of  the  duct,  which  jiro- 
jects  into  the  duodenum.  The  mucous  nieiiihraiie  is  swcdien,  and  a  jiluj,' 
of  inspissated  mucus  tills  the  divcrtic\ilum  of  \'att'r,  and  the  narrower  por- 
tion just  at  the  oriiice,  completely  obstrnctinjx  the  ontllovv  of  bile.  It  is  not 
known  how  vvides|)read  this  catarrh  is  in  the  bilc-iiassaj/es,  and  whether 
it  really  ]iasscs  up  the  ducts.  Jt  would,  of  course,  be  ]tossible  to  have  a 
catarrh  of  the  finer  duc*^s  within  the  liver,  which  some  French  writers  think 
may  iuiliate  the  attack,  but  the  evidence  for  this  is  not  stronjx,  and  it  seems 
niiu'c  likely  that  the  terminal  ])ortif)n  of  the  duct  is  always  first  involved. 
In  the  only  instance  which  I  have  had  an  o]ii)ortunity  to  examine  post 
mortem  the  oridco  was  plu<r,ired  with  inspissated  mucus,  the  common  and 
lioi)atic  ducts  were  sli.i;htly  distended  and  contained  a  hile-tinjred,  not  a 
clear,  mucus,  and  there  were  no  observal)le  chan.i^'es  in  the  mucosa  of  the 
ducts. 

This  catarrhal  or  «im[do  jaundice  results  from  the  i'ollowin,ir  causes: 
(1)  Duodenal  catarrh,  in  whatever  way  produced,  most  commonly  follow- 
inj;  an  attack  of  indigestion.  It  is  most  firquontly  met  witli  in  youn.c; 
persons,  but  may  occur  at  any  au'o,  and  may  follow  not  only  errors  in  diet, 
hut  also  cold,  ex])osnro,  and  malaria,  as  avoII  as  the  conditions  associated 
with  portal  obstruction,  chronic  heart-disease,  and  Bright's  disease.     (2) 


*  Journal  of  Anatomy  and  Physiology,  vol.  xvi. 


656 


DISEASES  OP  TnE  DIGESTIVE  SYSTEM. 


.  \ 
/ 


Emotional  disturbances  may  be  followed  by  jaundice,  wJiieh  is  believed  to 
be  due  to  catarrhal  swelling.  Cases  of  this  kind  are  rare  and  the  anatom- 
ical condition  is  unknown.  (3)  Simple  or  catarrhal  jaundice  may  occur 
in  epidemic  form.  (4)  Catarrhal  jaundice  is  occasionally  seen  in  the  in- 
fectious fevers,  such  as  pneumonia,  and  typhoid  fever.  The  nature  of  acute 
catarrhal  jaundice  is  still  unknown.  It  may  possibly  be  an  acute  infection. 
In  favor  of  this  view  are  the  occurrence  in  epidemic  form  and  the  presence 
of  slight  fever.  The  spleen,  however,  is  not  often  enlarged.  In  only  4 
out  of  ^3  cases  was  it  palpable. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  the  pa- 
tient's friends  may  first  notice  the  yellow  tint,  or  the  patient  himself  may 
observe  it  in  the  looking-glass.  In  other  instances  there  are  dyspeptic 
symptoms  and  uneasy  sensations  in  the  hei)atic  region  or  pains  in  the  back 
and  lindjs.  In  the  epidemic  form,  the  onset  may  be  more  severe,  with 
headache,  chill,  and  vomiting.  Fever  is  rarely  present,  though  the  tem- 
l)erature  may  reach  101°,  sometimes  102°,  All  the  signs  of  obstructive 
jaundice  already  mentioned  are  present,  the  stools  are  clay-colored,  and 
the  urine  contains  bile-pigment.  The  jaundice  has  a  bright-yellow  tiut^ 
the  greenish,  bronzed  color  is  never  seen  in  the  simple  form.  The  pulse 
may  be  normal,  but  occasionally  it  is  remarkably  slow,  and  may  fall  to  40 
or  30  beats  in  the  minute,  and  the  resi)irations  to  as  low  as  8  per  minute. 
Sleepiness,  too,  may  be  present.  The  liver  may  be  normal  in  size,  but  is 
usually  slightly  enlarged,  and  the  edge  can  be  felt  below  the  costal  margin. 
Occasionally  the  enlargement  is  more  marked.  As  a  rule  the  gall-bladder 
cannot  be  felt.  The  spleen  may  be  increased  in  size.  The  duration  of  the 
disease  is  from  four  to  eight  weeks.  There  are  mild  eases  in  which  the 
jaundice  disappears  within  two  weeks;  on  the  other  hand,  it  may  persist 
for  three  months.  The  stools  should  be  carefully  watched,  for  they  give 
the  first  intimation  of  removal  of  the  obstruction. 

The  diagnosis  is  rarely  difficult.  The  onset  in  young,  comparatively 
healthy  persons,  the  moderate  grade  of  icterus,  the  absence  of  emaciation 
or  of  evidences  of  cirrhosis  or  cancer,  iisually  make  the  diagnosis  easy. 
Cases  which  persist  for  two  or  three  months  cause  uneasiness,  as  the  sus- 
picion is  aroused  that  it  may  be  more  than  simple  catarrh.  The  absence 
of  pain,  the  negative  character  of  the  physical  examination,  and  the  main- 
tenance of  the  general  nutrition  are  the  points  in  favor  of  simple  jaundice. 
There  are  instances  in  which  time  alone  can  determine  the  true  nature  of 
the  case.  The  possibility  of  Weil's  disease  must  be  borne  in  mind  in  anom- 
alous types. 

Treatm.eilt. — As  a  rule  the  patient  can  keep  on  his  feet  from  the  out- 
set. ]\Ieasures  should  be  used  to  allay  the  gastric  catarrh,  if  it  is  present. 
A  dose  of  calomel  may  be  given,  and  the  bowels  kept  open  subsequently 
by  salines.  The  patient  should  not  be  violently  purged.  Bismuth  and 
bicarbonate  of  soda  may  be  given,  and  the  patient  should  drink  freely  of  the 
alkaline  mineral  waters,  of  which  Vichy  is  the  best.  Irrigation  of  the 
large  bowel  with  cold  water  may  be  practised.  The  cold  is  supposed  to  ex- 
cite peristalsis  of  the  gall-bladder  and  ducts,  and  thus  aid  in  the  expulsion' 
of  the  mucus. 


DISEASES  OP  THE  BILE-PASSAGES  AND  GALL-BLADDER.        557 


ieved  to 
aiiutoin- 
ly  occur 
the  iu- 
of  acute 
iifoction. 
pi'csouce 
1  only  4 

the  pa- 
self  may 
lyspeptie 
the  back 
!rc,  with 
the  toiu- 
structive 
red,  and 
iow  tint;. 
he  pulse 
all  to  40 
•  minute. 
;e,  but  is 
.  margin. 
l-]jladdcr 

n  of  the 
the 
persist 

ley  give 


lliich 


iratively 
laciation 
ns  easy. 
I  the  sus- 
absence 
le  main- 
jaundice, 
jature  of 
In  anom- 

Ithe  out- 
present, 
jquently 
lith  and 
ly  of  the 
of  the 
Id  to  ex- 
mulsion 


(b)  Chronic  Catauuiial  Angiociiolitis. 

This  may  possibly  occur  also  as  a  sequel  of  the  acute  catarrh.  I  have 
never  met  with  an  instance,  however,  in  which  a  chronic,  persistent  jaundice 
could  be  attributed  to  this  cause.  A  chronic  catarrh  always  accomi)anies 
obstruction  in  the  connnon  duct,  whether  by  gall-stones,  malignant  disease^ 
stricture,  '  r  external  pressure.     There  are  two  groups  of  cases: 

(1)  Willi  Complete  Obslrudion  of  the  Common  Dud. — In  this  form  the 
bile-passages  arc  greatly  dilated,  the  common  duct  may  reach  the  size  of 
the  tlunnl)  or  larger,  there  is  usually  dilatation  of  the  gall-bladder  and  of 
the  ducts  within  ';lie  liver.  The  contents  of  the  ducts  and  of  the  gall- 
bladder are  a  clear,  colorless  mucus.  The  mucosa  may  be  everywhere 
"-mooth  and  not  swollen.  The  clear  mucus  is  usually  sterile.  The  patients 
are  the  subjects  of  chronic  jaundice,  usually  without  fever. 

(2)  With  Incomplete  Obstruction  of  the  Duct. — There  is  pressure  on  the 
duct  or  there  are  gall-stones,  single  or  multii)le,  in  the  common  duct  or  in 
the  diverticulum  of  Vater.  The  bile-passages  are  not  so  much  dilated,  and 
the  contents  are  a  bile-stained,  turbid  mucus.  The  gall-bladder  is  rarely 
much  dilated.     In  a  majority  of  all  cases  stones  are  found  in  it. 

The  symptoms  of  this  type  of  catarrhal  angiociiolitis  are  sometimes  very 
distinctive.  With  it  is  associated  most  frequently  tl.'e  so-called  hepatic  in- 
termittent fever,  recurring  attacks  of  chills,  fever,  and  sweats.  We  need 
still  further  information  about  the  bacteriology  of  these  eases.  In  all  prob- 
al)ility  the  febrile  attacks  are  due  distinctly  to  infection.  I  cannot  too 
strongly  emphasize  the  point  that  the  recurring  attacks  of  intermittent 
fever  do  not  necessarily  mean  suppurative  angiociiolitis.  The  question  will 
be  referred  to  again  under  gall-stones. 

(c)  Suppurative  and  Ulcerative  Angiocholitis. 

The  condition  is  a  diffuse,  purulent  angiocholitis  involving  the  larger 
and  smaller  ducts.  In  a  large  proportion  of  all  cases  there  is  associated 
^suppurative  disease  of  the  gall-bladder. 

Etiology. — It  is  the  most  serious  of  the  sequels  of  gall-stones.  Occa- 
sionally a  diffuse  suppurative  angiocholitis  follows  the  acute  infectious 
cholecystitis;  this,  however,  is  rare,  since  fortunately  in  the  latter  condi- 
tion the  cystic  duct  is  usually  occluded.  Cancer  of  the  duct,  foreign  bodies, 
such  as  lumbricoids  or  fish  bones,  are  occasional  causes.  And  lastly  there 
may  be  extension  from  a  suppurative  pylephlebitis. 

The  common  duct  is  greatly  dilated  and  may  reach  the  size  of  the  index 
finger  or  the  thumb;  the  walls  are  thickened,  and  there  may  be  fistulous 
communications  with  the  stomach,  colon,  or  duodenum.  The  hepatic  ducts 
and  their  extensions  in  the  liver  are  dilated  and  contain  pus  mixed  with  bile. 
On  section  of  the  liver  small  abscesses  are  seen,  which  correspond  to  the  di- 
lated suppurating  ducts.  The  gall-bladder  is  usually  distended,  full  of 
pus,  and  with  adhesions  to  the  neighboring  parts,  or  it  may  have  perfo- 
rated. 

Symptoms. — The  symptoms  of  suppurative  cholangitis  are  usually 
very  severe.     A  previous  history  of  gall-stones,  the  development-  of  a  septic 


558 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


fever,  the  swell in<j:  and  tenderness  of  the  liver,  the  enlargement  of  the  gall- 
bladder, and  tlie  leiicocytosiri  are  suggestive  features.  Jaundice  is  always 
l)re.sent,  but  is  variable.  Jn  some  eases  it  is  very  intense,  in  others  it  is 
slight.  'J'lierc  may  be  very  little  pain.  There  is  })rogressive  emaciation 
and  loss  of  strength.  In  a  receut  case  parotitis  developed  on  the  left  side, 
which  subsided  without  sui)})uratiom 

L'lceration,  stric.ure,  perforation,  and  listului  of  the  bile-passages  will 
be  considered  with  gall-stones. 


.  \ 
/ 


u> 


(d)  Acute  Infectious  Cholecystitis. 

Etiology. — Acute  intlammation  of  the  gall-bladder  is  usually  due  to 
bacterial  invasion,  with  or  without  the  presence  of  gall-stones.  Three  vari- 
eties or  grades  may  be  recognized:  The  catarrhal,  tiie  su])])urative,  and  the 
phlegmonous.  The  condition  is  very  serious,  dilUcuIt  to  diagnose,  often 
fatal,  and  may  re(iuirc  for  its  relief  prompt  surgical  inter-  ention.  The 
cases  associated  with  gall-stones  have  of  course  long  been  recognized,  but 
we  now  know  that  an  acute  infection  of  the  gall-bladder  leading  to  suppura- 
tion, gangrene,  or  ])erforation  is  by  no  means  infrecjucnt.  For  an  interest- 
ing series  of  cases  the  reader  is  referred  to  a  paper  by  Maurice  11.  Kichard- 
son  in  the  American  Journal  of  the  Medical  Sciences,  1898,  I.  In  10  of 
his  59  operations  upon  the  gall-bladder  acute  cholecystitis  was  present  with- 
out known  ])re-exi sting  disease! 

Acute  non-calculus  cholecystitis  is  a  result  of  bacterial  invasion.  The 
colon  bacillus,  the  typhoid  bacillus,  the  pneumococcus  and  stai)hylococci 
and  streptococci  have  been  the  organisms  most  often  found.  The  fre- 
quency of  gall-bladder  infection  in  the  fevers  is  a  point  already  referred  to, 
])articularly  in  ty])hoid  fever.  Two  instances  of  acute  cholecystitis  have 
occurred  within  the  ])ast  year  at  the  Johns  IFopkins  Hospital  in  which 
typhoid  bacilli  were  isolated  from  pure  culture,  and  the  Widal  reaction  was 
present  in  the  patient's  b.lood,  without,  so  far  as  could  be  ascertained,  any 
history  of  tyidioid  fever  (see  Gushing,  Typhoid  Cliolec3-stitis,  J.  II.  11.  Bul- 
letin, ".May, 'l898). 

Condition  of  the  Gall-bladder. — The  organ  is  usually  distended  aiul  the 
walls  tense.  Adhesions  may  have  formed  with  the  colon  or  the  omentum. 
In  other  instances  perforation  has  taken  place  and  there  is  a  localized  ab- 
scess, or  in  the  more  fulminant  forms  general  peritonitis.  The  contents  of 
the  organ  are  usually  dark  in  color,  muco-purulent,  i)urulent,or  hannorrhagic. 
In  the  cases  with  acute  phlegmonous  intlammation  there  may  be  a  very  foul 
odor.  As  Eichardson  remarks,  the  cystic  duct  is  often  found  closed  even 
when  no  stone  is  impacted.  It  should  be  borne  in  mind  that  in  the  acutely 
distended  gall-bladder  the  elongation  and  enlargement  may  take  ])lace 
chiefly  ^'Dward  and  inward,  toward  the  foramen  of  Winslow. 

Symptoms. — Severe  paroxysmal  pain  is,  as  a  rule,  the  first  indication, 
most  commonly  in  the  right  side  of  the  abdomen  in  the  region  of  the  liver. 
It  may  be  in  the  epigastrium  or  low  down  in  the  region  of  the  ai)pendix. 
"  Xausea,  vomiting,  rise  of  pulse  and  temperature,  prostration,  distention  of 
the  abdomcii,  rigidity,  general  tenderness  becoming  localized  "  usually  fol- 


DISEASES   01^    THE   BILE-PASSAOES   AND  (i ALIi-IU.ADDKIl.        r>od 


will 


Tlu 


low  (Ricliardsoii).  In  tins  rorm,  witlioiit  gall-stones,  jaiiiKlicc  is  not  ol'lcn 
lirt'scnt.  ^.i'lie  local  ti'iidonicss  is  I'xtrt'iiii',  l»iit  it  may  bu  (lect'[)tivf  in  its 
.-ituation.  Associated  |)rol)al)ly  witli  the  adiicsioii  and  indaniinatoi y  pro- 
cesses between  the  gall-bladder  and  the  bowel  are  tlu'  intestinal  syni|ttonis, 
and  there  may  be  complete  stoppage  of  gas  and  Fa'ces;  indeed,  the  opera- 
limi  for  acute  obstruction  has  been  perfoi'mcd  in  sevei'al  eases,  'riie  dis- 
tended gall-bladder  may  sonu'times  be  i'elt. 

The  dUiijiuisis  is  by  no  means  easy.  The  symptoms  may  not  indicate 
the  section  of  the  al)donien  involved.  In  two  of  our  cases  and  in  three  of 
h'ichardson's  ajjpendicitis  was  diagnosed;  in  two  of  his  cases  acute  intes- 
liiial  obstruction  was  suspected.  This^  was  the  diagnosis  in  a  case  of  acute 
phlegmonous  cholecystitis  which  I  reitortcd  in  1881.  The  history  of  the 
eases  is  often  a  valuable  guide.  Occurring  during  the  convalescence  from 
typhoid  I'evcr,  after  pneumonia,  or  in  a  [tatient  with  previous  cholecystitis, 
such  a  group  of  symptoms  as  mentioned  would  be  highly  suggestive.  The 
dill'erentiation  of  the  variety  of  the  cho'ecystitis  cannot  be  made.  In  the 
acute  sup])urative  and  phlegmonous  forms  the  symptoms  are  usually  more 
severe,  perforation  is  very  apt  to  occur,  with  local  or  general  peritonitis, 
and  unless  operated  ujjou  death  ensues. 

There  is  an  acute  cholecystitis,  prol)ably  an  infective  form,  in  which 
the  ])atient  has  recurring  attacks  of  pain  in  the  region  of  the  gall-bladder. 
The  diagnosis  of  gall-stones  is  made,  but  an  operation  shows  simply  an  en- 
larged gall-l)ladder  fdled  with  mlicus  and  bile,  and  the  mucous  membrane 
])erhaps  swollen  and  inflamed.  In  some  of  these  cases  gall-stones  may  have 
l)een  present  and  have  passed  before  the  operation. 


)lace 


(e)  Cancer  of  the  Bile-passages. 

The  subject  has  been  very  thoroughly  studied  of  late  years  by  Zenker, 
Musser,  Ames,  liolleston,  and  Kelynack.  Females  suffer  in  the  projjor- 
tion  of  3  to  1  (Alusser),  or  4  to  1  (ximes).  In  cases  of  prinuiry  cancer  of 
the  bile-duct,  on  the  other  hand,  men  and  women  appear  to  bo  about 
eipially  affected.  In  ilusser's  series  Go  per  cent  of  the  cases  occurred  be- 
tween the  ages  of  forty  and  seventy.  The  association  of  malignant  disease 
of  the  gall-l)ladder  with  gall-stones  I  as  long  bei'U  recogiuzed.  ^J'he  fact  is 
M'ell  ])ut  by  Kelynack  as  follows:  "  While  gall-stones  are  found  in  from  G 
to  I'i  ]ier  cent  of  all  general  cases  (that  is,  coming  to  autopsy),  they  occur  in 
association  with  cancer  of  the  gall-bladder  in  from  !)0  to  100  per  cent." 

The  exact  nature  of  the  association  is  not  very  clear,  but  it  is  usually  re- 
garded as  an  effect  of  the  chronic  irritation.  On  the  other  hand,  it  is  urged 
that  the  presence  of  the  malignant  disease  may  itself  favor  the  ])roduction 
of  gall-stones.  Histologically,  "  carcinoma  of  the  gall-bladder  varies  much, 
both  in  the  form  of  the  cells  and  in  their  structural  arrangement;  it  may 
be  either  colum^^ar  or  s])heroidal-celled  "  (RoUeston).  The  fundus  is  usu- 
ally first  involved  in  the  gall-bladder,  and  in  the  ducts  the  duct\is  communis 
choledochus. 

When  the  disease  involves  the  fiall-hhuhhr,  a  tumor  can  be  detected  ex- 
tending diagonally  downward  and  inward  toward  the  navel,  variable  in 


■  «^- 


560 


DTSKASES  OF  THE  DIGESTIVE  SYSTEM. 


.  \ 
/ 


pizo,  nocapinnally  very  liirjio,  duo  cither  to  groat  clistontion  of  tlio  gall- 
l)la(l(lor  or  to  iiivolvomont  of  contiguous  i)arts.  It  is  usually  very  lirm  amf 
hard. 

Among  tho  important  symptoms  aro  jaundico,  whicli  was  prosont  in  (!I> 
pi'r  oont  of  Mussor's  oasos;  j)ain,  ofton  of  groat  sovority  and  j)aro.\ysnial  in 
oharactor.  'J'iio  pain  and  tondornoss  on  pressure  i)orsist  in  the  intervals- 
l)etween  tho  paroxysmal  attacks.  In  one  of  my  throe  cases,  which  Ame* 
roportofl,  there  was  a  very  profound  anaemia,  hut  an  absence  of  jaundice 
tliroughout.  (iall-stones  wore  ])rosont  in  two  of  the  cases,  and  a  history  of 
gall-stone  attacks  was  obtained  from  the  third. 

Primary  malignant  disease  in  the  hik-ducls  is  less  common,  and  rarely 
forms  tumors  that  can  be  felt  externally.  Kelynack  (Medical  Chronicle, 
November,  181)7)  gives  very  fully  a  number  of  important  i)oints  in  the  dif- 
ferential dii. gnosis  between  tumors  in  the  duct  and  tumors  in  the  gall- 
bladder. There  is  usually  an  early,  intense,  and  persistent  jaundico.  Tho 
gall-bladder  is  much  dilated.  At  best  the  diagnosis  is  very  doul)tful,  unless 
cleared  up  by  an  ex])loratory  ojjoration.  A  very  interesting  form  of  malig- 
nant disease  of  tho  ducts  is  that  which  involves  tho  diverticulum  of  Yater. 
lUisson  has  coUoctod  eleven  cases.  A  few  months  ago  an  chlerly  woman 
was  admitted  under  my  care  with  jaundice  of  some  months  duration,  with- 
out pain,  with  ])rogrcssive  emaciation,  and  a  greatly  enlarged  gall-bladder. 
My  colleague,  Ilalstod,  operated  and  found  obstruction  at  the  orifice  of  tho 
common  duct.  lie  opened  tho  duodenum,  removed  a  cylindrical-celled 
epithelioma  of  the  ampulla  of  Yater,  and  stitched  the  common  duct  to  an- 
other portion  of  tho  cluodonum.  The  patient  made  an  uninterrupted  re- 
covery, and  now,  fourteen  weeks  after  the  operation,  has  gained  twenty- 
five  pounds  in  weight  and  is  passing  bile  with  the  fivces. 


(/)  Stenosis  and  Obstruction  of  the  Bile-ducts. 

Stenosis  or  com]ileto  occlusion  may  follow  ulceration,  most  commonly 
after  tho  passage  of  a  gall-stone.  In  these  instances  the  obstruction  is 
usually  situated  low  down  in  the  common  duct.  Instances  are  extremely 
rare.  Foreign  Mes,  such  as  the  seeds  of  various  fruits,  may  enter  the 
duct,  and  occasionally  round  worms  crawl  into  it.  In  the  Wistar-IIornor 
Museum  of  the  University  of  Pennsylvania  there  is  a  remarkable  specimen 
showing  tho  common  and  hepatic  duets  enormously  distended  and  densely 
packed  with  a  dozen  or  more  lumbricoid  worms.  Similar  specimens  exist 
in  one  of  the  Paris  museums,  and  at  the  Hoyal  Yictoria  Hospital,  Netloy. 
Liver-flukes  and  ochinocoeci  are  rare  causes  of  obstruction  in  man. 

Obstruction  by  pressure  from  without  is  more  frequent.  Cancer  of  the 
head  of  the  pancreas,  less  often  a  chronic  interstitial  inflammation,  may 
compress  tho  terminal  portion  of  the  duct;  rarely,  cancer  of  the  pylorus. 
Secondary  involvement  of  the  lymph-glands  of  the  liver  is  a  common  cause 
of  occlusion  of  tho  duct,  and  is  met  with  in  many  cases  of  cancer  of  the 
stomach  and  other  abdominal  organs.  Rare  causes  of  obstruction  are  aneu- 
rism of  a  I-  anch  of  the  coeliac  axis  of  the  aorta,  and  pressure  of  very  large 
abdominal  tumors. 


: 


CnOLELITHTASIS. 


501 


ho  gall- 
liriii  aiuf 

lit  in  (il> 
ysinal  in 
intorvaU 

jaundice 
istory  ol 

1(1  rarely 
hroniclo, 
the  dif- 
llie  gall- 
cc.  The 
\\,  unless 
if  nialig- 
3f  Vater. 
f  woman 
an,  with- 
-bladdor. 
ce  of  the 
cal-cellod 
ct  to  an- 
[iptcd  re- 
;\venty- 


iinmonly 
iction  is 
;remely 
ter  the 
Horner 
)ecimcn 
densely 
ns  exist 
Netley. 

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)n,  may 

lylorus. 
)n  cause 
'  of  the 

e  anen- 
ry  large 


I 


The  symiitoms  produced  are  those  of  chronic  ohstructivc  jaundice.  At 
first,  the  liver  is  usually  enlarged,  hut  in  chronic  cases  it  may  he  reduciMl  in 
t^ize,  and  be  found  of  a  deeply  hronzcd  color.  The  hepatic  intermittent  fever 
is  not  often  associated  with  coiii]»l('te  occlusion  of  the  <luct  from  any  cause, 
hut  it  is  most  frciiuently  nu't  with  in  chronic  ohstruction  hy  gall-stDiics. 
iVrmanent  occlusion  of  the  duct  terminates  in  death.  In  a  majority  (it  ilic 
cases  the  conditions  which  lead  to  the  ohstruction  arc  in  themselves  fatal. 
'I'lie  liver,  which  is  not  nci-cssarily  (Milargcd,  presents  a  moderate  grade  of 
cirrhosis.  Cases  of  cicatricial  occlusion  may  last  for  years.  A  i)alieiit  under 
my  care,  who  was  ])ermanently  jaundiced  for  nearly  three  years,  had  a 
lihroid  occlusion  of  the  duct. 

The  diaijiiosis  of  the  nature  of  the  occlusion  is  often  very  diflicult.  A 
history  of  colic,  jaundice  of  varying  intensity,  ])aroxysms  of  ])ain,  and  in- 
termittent fever  point  to  gall-stones.  In  cancerous  obstruction  the  tumor 
mass  can  sometimes  he  felt  in  the  epigastric  region.  In  cases  in  which 
the  lymph-glands  in  the  transverse  fissure  are  cancerous,  the  primary  dis- 
ease may  he  in  the  ])clvic  organs  or  the  rectum,  or  there  nuiy  be  a  limited 
cancer  of  the  stomach,  which  has  not  given  any  sym])toms.  In  these  cases 
the  examination  of  the  other  lymphatic  glands  may  be  of  value.  In  a  case 
wlio  came  under  ohservation  with  a  jaundice  of  seven  weeks'  duration, 
believed  to  be  catarrhal  (as  the  patient's  general  condition  was  good  and 
he  was  not  said  to  have  lost  flesh),  a  small  nodular  mass  was  detected 
at  the  navel,  which  on  removal  proved  to  he  scirrhus.  Involvement  of  the 
clavicular  groups  of  lymph-glands  may  also  be  serviceable  in  diagnosis. 
Tlie  gall-bladder  is  usually  enlarged  in  obstruction  of  the  common  duct, 
except  in  the  cases  of  gall-stones  (Courvoisier's  law).  Great  and  progressive 
enlargement  of  the  liver  with  jaundice  and  moderate  continued  fever  is  more 
commonly  met  with  in  cancer. 

Congenital  ohliferalion  of  the  civcfs  is  an  interesting  condition,  of  which 
there  are  some  GO  or  70  cases  on  record.  It  may  occur  in  several  meiul)ers 
of  one  family.  Spontaneous  hamiorrhages  are  frequent,  ])articularly  from 
the  navel.  The  subjects  may  live  for  three  or  even  eight  weeks.  For  a 
recent  careful  consideration  of  the  subject,  see  John  Thomson's  article  in 
Allbutt's  System  of  Medicine. 


VI.    CHOLELITHIASIS. 

No  chapter  in  medicine  is  more  interesting  than  that  which  deals  with  the 
question  of  gall-stones.  Few  affections  present  so  many  points  for  study — 
cliemical,  bacteriological,  pathological,  and  clinical.  The  past  few  years 
have  seen  a  great  advance  in  our  knowledge  in  two  directions:  First,  as  to  the 
mode  of  formation  of  the  stones,  and,  secondly,  as  to  the  surgical  treatment 
of  the  cases.  The  recent  study  of  the  origin  of  stones  dates  from  Xaunyn's 
work  in  ISOl.  ^Marion  Sims's  suggestion  that  gall-stones  came  within  the 
sitliero  of  the  surgeon  has  been  most  fruitful.  Lawson  Tait,  Langenbuch, 
^layo  Robson,  Riedel,  Kehr,  and  in, this  country  Keen,  Fenger,  ^lurphy. 
Lange,  and  Halsted  have  no+  onlv  revolutionized  the  treatment  of  chole- 


562 


I)ISI-]ASKS  OP  TIIK  J)l(;i       .VK  SVSTKM. 


/ 


litliiiisis,  lint    from  tlicir  M'orl<   wo  itliysicimis  linvc  <:ntlu'rc'(l  iiiiuli  oT  tlic 
^fi'ciitcst  iiHiiiH'iit   ill  syiii[)t()iii;it(»l(ii:T  mid  diii^fiiosis. 

Origin  of  Gall-stones. — 'I'wo  iiii|iortiiMt  points  with  ivl'crcncc  to  ty*;  for- 
iiiiitioii  of  ciiliiili  in  tlif  l)ik'-i)nssnj,'t'.s  were  l)roii,L:lit  out  liy  Xaimvn:  (</) 
'riic  oi'i^^in  of  I  he  cliolcstcrin  of  tlic  hilc,  ;is  well  iis  of  tlic  lime  suits  I'roni  the 
iniicoiis  iiifiiiliriinc  of  llic  hiliiiry  ])!issii«:(s.  |)iirti(iiliirly  when  inlliiincd;  iiiid 
[h)  llic  rciiiiirkiilik'  iissutiation  oT  micTo-()i';^aiiisnis  with  j^iill-stoius.  it  is 
stal('(l  thai  I'.ristowf  lirst  noticed  tlie  ori^nn  of  cliolcstcrin  in  the  <fall-blad- 
dci"  itscir.  I)iit  Xaiinyirs  observations  showed  that  both  the  eholesterin  and 
the  lime  were  in  ^reat  part  a  production  of  the  mucosa  ot  the  ji:all-b!adder 
and  of  the  bile-diiets,  particularly  when  in  a  condition  of  catarrhal  inllam- 
jiialion  e.\cite(l  by  the  presence  of  microbes.  According  tu  the  views  of  this 
antlior,  the  lilho^'ciious  calarrh  (which,  by  the  way,  is  qiiitt'  an  old  idea) 
niodilies  materially  the  cliemical  constitution  of  the  bile  and  I'avors  the  de- 
position about  epitbelial  drhris  and  bacteria  of  the  insoluble  salts  of  lime 
ill  coinl)ination  with  the  bilirnbin.  Welch  and  others  have  demonstrated 
the  presence  of  ndcro-orti.inisnis  in  tlio  centre  of  gall-stones.  Three  addi- 
tional points  oi'  interest  may  be  referred  to: 

First,  the  demonstration  that  the  gall-lHadder  is  a  i)eoiiliarly  favoraldo 
liabitat  for  micro-organisms.  The  colon  Ijacilli,  staphylococci,  str(>ptococci, 
jineumococci,  and  the  typhoid  bacilli  have  all  been  J'ound  here  under  varying 
conditions  of  the  l)ile.  A  remarkable  fact  is  the  length  of  time  wbich  they 
may  live  in  the  gall-bladder,  as  was  first  demonstrated  by  Blaclistcin  in 
AVelch's  laboratory.  '^Ihe  iyjtlioid  bacillus  has  been  isolated  in  pure  culture 
seven  years  after  an  attack. 

Secondly,  the  ex])erimental  production  of  gall-stones  has  been  success- 
fully accomplished  by  (iilbert  and  Fournier  by  injecting  micro-organi.snis 
into  the  gall-bladder  of  animals. 

Thirdly,  the  association  of  gall-stones  with  the  s])ccific  fevers.  T'ern- 
lieini,  in  JSSi),  first  called  attention  to  the  frecpiency  of  gall-stcme  attacks 
after  ty])hoid.  Since  that  time  Dufort  has  collected  a  scries  of  cases,  and 
Chiari,  Mason,  and  Osier  have  called  attention  to  the  great  frequency  of  gall- 
bladder complications  during  and  after  this  disease. 

AVhile  it  is  j)robable  that  a  lithogenous  catarrh,  induced  by  micro-organ- 
isms, is  the  most  imjjortant  single  factor,  there  are  other  accessory  causes  of 
great  moment. 

Age. — Xearly  50  per  cent  of  all  the  cases  occur  in  persons  ahove  forty 
years  of  age.  They  are  rare  under  twenty-five.  They  have  been  met  with 
in  the  new-horn,  and  in  infants  (John  '^^Fhomson). 

Sex. — Three  fourths  of  the  cases  occur  in  women.  Pregnancy  has  an 
im]iortant  influence.  Naunyn  states  that  DO  ])er  cent  of  women  with 
gall-stones  have  borne  children. 

All  conditions  which  favor  siagiindon  of  hile  in  the  gall-bladder  predis- 
pose to  the  formation  of  stones.  Among  these  may  he  mentioned  corsot- 
Avearing,  enteroptosis,  nephroptosis,  and  occupations  requiring  a  "  leaning 
forward"  position.  Tiack  of  exercise,  sedentary  occupations,  particularly 
when  combined  with  over-indulgence  in  food,  constipation,  depressing  men- 
tal emotions  are  also  to  he  regarded  as  favoring  circumstances.     The  belief 


h   oj    tlio 

)  ll^e  for- 
iiiyii:  (ii) 
I'roiii  the 
iiu'd;  iiiiil 
I'S.  It  is 
urnll-l.lii.l- 
li'i'in  iiiid 
ll-l.l,i<l<l.'r 
<\  iiillain- 
kvs  ol'  this 
old  iih'ii) 
I'S  the  (K'- 
s  of  liiiic 
lonstratcd 
ireo  iuhli- 

t'avorahle 
e])tococt'i, 
T  varviiii,' 
hicii  tiu'V 
hstoin  ill 
I'O  culture 

I  succef-s- 


prganij^nis 


P)Crn- 
e  attacks 
ases,  and 
■y  of  gall- 

ro-orj^au- 
causes  of 

ove  forty 
met  with 

y  lias  an 
len   with 

r  predis- 
d  corsct- 
"  leauin.c 
■ticularly 
\r\g  men- 
he  belief 


CIlOLKLrTIIIASIS. 


603 


prevailed  formerly  that  there  was  a  lithiae  diathesis  closely  allied  to  that 
of  gout. 

Physical  Characters  of  Gall-stones.— They  may  he  single,  in  which  caso 
the  stone  is  usually  ovoid  and  may  attain  a  very  large  size.  Instances  are 
on  record  of  gall-stoiu's  measuring  more  than  o  inches  in  length.  They  may 
be  extremely  numerous,  ranging  from  a  score  to  several  hundreds  or  even 
M'veral  thousands,  in  which  case  the  stones  are  very  small.  When  moderately 
iiiinierous,  they  show  signs  of  mutual  jire.ssure  and  have  a  polygonal  form, 
with  smooth  facets;  occasionally,  however,  live  or  six  gall-stones  of  medium 
si/i'  are  met  with  in  the  hladder  which  are  round  or  ovoid  and  without 
facets.  They  are  sometimes  nuilherry-shaped  and  very  dark,  consisting 
largely  of  hile-pigments.  Again  there  are  small,  hiack  calculi,  rough  and 
irregular  in  shape,  and  varying  in  size  from  grains  of  sand  to  sm.dl  shot. 
'J'liese  are  sometimes  known  as  gall-sand.  On  s(>ction,  a  calculus  contains 
a  nucleus,  which  consists  of  hile-pigment,  rarely  a  foreign  hody.  The 
greater  jiortion  of  the  stone  is  made  up  of  cholesterin,  which  may  form 
tlu'  entire  calculus  and  is  arranged  in  concentric  lamina;  showing  also  radi- 
ating lines.  Salts  of  lime  and  magnesia,  hile  acids,  fatty  acid.s,  and  traces 
of  iron  and  copper  arc  also  found  in  them.  A  majority  of  gall-stones  con- 
sist of  from  7U  to  SO  per  cent  of  cholesterin,  in  either  the  amorphous  or  the 
crystalline  form.  As  ahove  stated,  it  is  sometinu'S  pure,  hut  more  commonly 
it  is  nuxed  with  the  hile-|)ignient.  The  outer  layer  of  the  stone  is  usually 
harder  and  brownish  in  color,  and  contains  a  larger  projiortion  of  lime  salts. 

The  Scat  of  Formal  ion. — "Within  the  liver  itself  calculi  are  occasionally 
found,  hut  are  here  usually  small  and  not  abundant,  and  in  the  form  of 
iivoid,  greenish-black  grains.  A  large  majority  of  all  calculi  are  formc(l 
within  the  gall-hladder.  The  stones  in  the  larger  ducts  have  usually  luub 
their  origin  in  the  gall-l)ladder. 

Symptoms. — In  a  majority  of  the  cases,  gall-stones  cause  no  symp- 
tonis.  The  gall-hladder  will  tolerate  the  presence  of  large  numhi'i's  for  an 
iiub'tinite  period  of  time,  and  ])ost-morteni  examinations  show  that  they 
are  present  in  25  per  cent  of  all  women  over  sixty  years  of  age  (Xaunyn). 

The  French  writers  have  suggested  recently  a  useful  division  of  the 
sym])toms  of  cliolelithiasis  into  (1)  the  aseptic,  mechanical  accidents  in  eon- 
seiiuence  of  migration  of  the  stone  or  of  obstruction,  either  in  the  ducts  or 
in  the  intestines;  (2)  the  se])tie,  infectious  accidents,  either  local  (the  angio- 
cliolitis  and  cholecystitis  Avith  empyema  of  the  gall-bladder,  and  the  listulaj 
and  abscess  of  the  liver  and  infection  of  the  neighboring  ]»arts)  or  general, 
the  biliary  fever  aiul  the  secondary  visceral  lesions. 

It  will  be  better,  perhaps,  to  consider  cholelithiasis  under  the  following 
lieadiugs:  The  symptoms  ])roduced  by  the  ]iassage  of  a  stone  through  the 
duets — biliary  colic;  the  elTects  of  ])ermanent  ])lugging  of  the  cystic  duct; 
of  the  stone  in  the  common  dxict;  and  the  more  remote  effects,  due  to  ulcera- 
iion,  perforation,  and  the  establislnnent  of  fistuhu. 

1.  Biliary  Colic. — Ciall-stones  may  become  engaged  in  the  cystic  or  the 
common  duct  without  producing  pain  or  severe  symptoms,  ^fore  com- 
iiinnly  the  passage  of  a  stone  excites  the  violent  symjitoms  known  as  l)iliary 
colic.     The  attack  sets  in     Sruptly  with  agonizing  pain  in  the  right  hypo- 


504 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


.  \ 
/ 


clioiidriiic  rc^^ion,  uliith  nidiatoH  lo  (he  siuiuldcr,  or  is  very  iiili'iisc  ii)  tho 
('l)i;^Mstri('  and  in  liie  lower  tiioraoic;  r('<j;ioiis.  Jt  is  often  associated  with  ii 
ri<,M)r  and  a  rise  in  leniperaturo  from  lU;;i°  to  103°.  'I'iie  pain  is  nsually  so 
intense  that  tliu  jiatient  rolls  ahont  in  nj^'ony.  There  arc  vomiting,  pro- 
fnse  s\veatin<r,  and  great  depression  of  tlie  eircidation.  There  may  ho 
marked  tenderness  in  tho  region  of  tho  liver,  which  may  he  enlarged,  and 
the  gall-hladder  may  bocome  palpahlo  and  very  tender.  Jn  other  oases  the 
fever  is  more  marked.  The  spleen  is  enlarged  (Xaunyn)  and  the  rrine  con- 
tains alhnmin  with  red  hlood-eorpuscles.  Ortner  holds  that  rholeri/slilis 
ocuUi,  occnrring  in  connection  with  gall-stones,  is  a  septic  (hacterial)  in- 
fection of  the  hile-passages.  The  symptoms  of  acute  infectious  cholecystitis 
«nd  those  of  what  we  call  gall-stone  colic  are  very  similar,  and  surgeons  have 
frecpiently  ])erformed  cholecystotomy  for  the  former  condition,  believing 
calculi  were  ])resent.  In  a  large  number  of  the  cases  jaundice  develo])s,  but 
it  is  not  a  necessary  symptom.  Of  course  it  does  not  occur  during  tho  pas- 
sage of  the  stone  through  the  cystic  duct,  but  only  when  it  becomes 
hxlged  in  the  common  duct.  The  pain  is  due  (o)  to  the  slow  progress  in 
the  cystic  duct,  in  which  the  stone  takes  a  rotary  course  owing  to  the  ar- 
rangement of  the  Ileisterian  valve;  {h)  to  the  acute  inllammation  which 
usually  accompanies  an  attack;  and  {c)  to  the  stretching  and  distention  of 
the  gall-bladder  by  retained  secretions. 

The  attack  varies  in  duration.  It  may  last  for  a  few  hours,  several 
days,  or  even  a  week  or  more.  If  the  stone  becomes  impacted  in  the  orifice 
of  the  common  duct,  the  jaundice  becomes  intense;  much  more  commonly 
it  is  a  slight  transient  icterus.  The  attack  of  colic  may  be  repeated  at  in- 
tervals for  some  time,  but  finally  the  stone  passes  and  the  symptoms  rapidly 
disappear. 

Occasionally  accidents  occur,  such  as  ru})ture  of  the  duct  with  fatal 
peritonitis.  Fatal  syncope  during  an  attack,  and  the  occurrence  of  re- 
])eated  convulsive  seizures  have  come  under  my  observation.  These  are, 
however,  rare  events.  Pal])itation  and  distress  about  the  heart  may  be 
])resent,  and  occasionally  a  mitral  murmur  develops  during  tho  paroxysm; 
but  the  cardiac  conditions  described  by  some  writers  as  coming  on  acutely 
in  biliary  colic  are  possibly  pro-existent  in  these  patients. 

The  diagnosis  of  acute  hepatic  colic  is  generally  easy.  Tho  pain  is  in 
the  U])]K'r  abdominal  and  thoracic  regions,  whereas  the  pain  in  nephritic 
colic  is  in  the  lower  abdomen.  A  chill,  with  fever,  is  much  more  frequent 
in  biliary  colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  bo 
confounded.  A  history  of  previous  attacks  is  an  important  guide,  and  the 
occurrence  of  jaundice,  however  slight,  determines  the  diagnosis.  To  look 
for  the  gall-stones,  the  stools  should  be  thoroughly  mixed  with  water  and 
carefully  fdtercd  through  a  narrow-meshed  sieve.  Pseudo-biliary  colic  is  not 
infrequently  met  with  in  nervous  women,  and  the  diagnosis  of  gall-stones 
made.  This  nervous  hepatic  colic  may  be  periodical;  the  pain  may  be  in  the 
right  side  and  radiating;  sometimes  associated  with  other  nervous  phenom- 
ena, often  excited  by  emotion,  tire,  or  excesses.  The  liver  may  be  tender, 
but  there  are  neither  icterus  nor  inflammatory  conditions.  The  combina- 
tion of  colic  and  jaundice,  so  distinctive  of  gall-stones,  is  not  always  present. 


CIIOLKLITIIIASIS. 


505 


80  in  till" 
(I  witli  a 
isiially  so 

111  ay  1)0 
•^'0(1,  niul 
(;a.st'S3  tliu 
rino  c'oii- 
oleri/slitis 
erial)  in- 
)lec'ystiti.s 
Mills  havo 
lielioving 
ilops,  Init 
f  the  pas- 

bc'cuiiics 
•ogress  in 
o  the  ar- 
3n  wliic'h 
ention  of 

s,  several 
lie  orifice 
ommonly 
;ecl  at  in- 
is  rapidly 

th  fatal 

:'e  of  re- 

lese  are, 

may  be 

iiroxysm ; 

acutely 

a  in  is  in 
iophritic 

'rcquent 
cp,  to  be 

and  tbc 

To  look 
ater  and 

ic  is  not 
ill-stones 
)e  in  the 
})lienom- 
tender, 
;ombina- 

present. 


'i'he  pains  may  be  not  (olicky,  Imt  imtre  constant  and  drag,i,nng  in  cliarnc- 
iir.  (M'  50  cases  operated  upon  by  Uiedel,  10  had  not  had  colic,  only  11 
nix'scntcd  a  <,MlI-bladdcr  tiinior,  whih'  a  majority  had  not  iiad  jaundice,  A 
!•(  iiiarl<al)k'  \antlionia  of  the  bile-passages  has  been  found  in  association  with 
hepatic  colic.  1  have  already  spoken  of  tiic  diagnosis  of  acute  choh'cystitis 
from  ai)pendicitis  and  olistruction  of  the  bowels.  Kecurring  attacks  of  pain 
ill  the  region  of  the  liver  may  follow  adhesions  between  the  gall-bladder 
and  adjacent  parts. 

)i.  Obstruction  of  the  Cystic  Duct. — The  ell'ecls  may  be  thus  cnumer- 
i.ted: 

(a)  Dilatation  of  the  gall-bladder — liydroj)s  vesica;  fellete.     In  acute  ob- 
truction  the  contents  are  bile  mixed  with  much  mucous  or  muco-puruleiit 

material.  In  chronic  obstruction  the  bile  is  rcphiced  by  a  clear  lluid  mucus. 
This  is  an  important  point  in  diagnosis,  particularly  as  a  dropsical  gall- 
hhidder  may  form  a  very  large  tumor.  The  reaction  is  not  always  con- 
stant. It  is  either  alkaline  or  neutral;  the  consistence  is  thin  and  mucoid. 
Albumin  is  usually  present.  A  dilated  gall-bladder  may  reach  an  enormous 
size,  and  in  one  instance  Tait  found  it  occupying  the  greater  part  of  the 
ahdomen.  In  such  cases,  as  is  not  unnatural,  it  has  been  mistaken  for  an 
ovarian  tumor.  I  have  described  a  case  in  which  it  was  attached  to  the 
light  broad  ligament.  The  dilated  gall-bladder  can  usually  be  felt  below 
the  edge  of  <he  liver,  and  in  many  instances  it  has  a  characteristic  outline 
hke  a  gourd.  An  enlarged  and  relaxed  organ  may  not  be  ])alpable,  and  in 
nciite  cases  the  distention  may  be  upward  toward  the  hilus  of  the  liver. 
The  dilated  gall-bladder  usually  projects  directly  downward,  rarely  to  one 
side  or  the  other,  though  occasionally  tow.,  d  the  middle  line.  It  may 
reach  below  the  navel,  and  in  persons  with  thin  walls  the  outline  can  lie 
accurately  defined.  I{iedel  has  called  attention  to  a  tongue-like  projection 
of  the  anterior  margin  of  the  right  lobe  in  connection  with  enlarged  gall- 
hlndder.  It  is  to  b.  '  omembered  that  distention  of  the  gall-bladder  may 
octur  without  jaundice;  indeed,  the  greatest  enlargement  has  been  met  with 
ill  such  cases. 

Gall-stone  crepitus  may  be  felt  when  the  bladder  is  very  full  of  stones 
and  its  walls  not  very  tense.  It  is  rarely  well  felt  unless  the  abdominal  walls 
are  much  relaxed.  It  may  be  found  in  patients  who  have  never  had  any 
.'-\iii])toms  of  cholelithiasis. 

(b)  Acute  cholecystitis.  The  simple  form  is  common,  and  to  it  are  duo 
probably  very  many  of  the  symptoms  of  the  gallstone  attack.  Phleg- 
monous cholecystitis  is  rare;  only  seven  instances  are  found  in  the  enor- 
mous statistics  of  C'ourvoisier.  It  is,  however,  much  more  common  than 
these  figures  indicate.     Perforation  may  occur  with  fatal  ])eritonitis. 

(r)  Suppurative  cholecystitis,  empyema  of  the  gall-bladder,  is  much 
more  common,  and  in  the  great  majority  of  cases  is  associated  with  gall- 
stones— 41  in  5.5  cases  (Courvoisier).  There  may  be  enormous  dilatation, 
iiiul  over  a  litre  of  ]ms  has  been  found.  Perforation  and  tlie  formation  of 
ahseesses  in  the  neighborhood  are  not  uncommon. 

{(1)  Calcification  of  the  gall-bladder  is  commonly  a  termination  of  the 
jnx'vious  condition.     There  are  two   separate   forms:  incrustation   of  the 


■ 


500 


DISKASKS  OP  TIIK   DIOKSTIVK  SVSTKM. 


.  \ 
/ 


miicnsii  with  lime  suits  mid  the  true  infill  nit  ion  of  the  wnll  with  liino,  Hk^ 
s<i-ciillt'(l  ossiliciitioii.  A  rcniiiri\iil)l('  ('\!ini|>l('  nf  tiic  Inllcr,  sent  to  mo  hy 
(irovcs,  of  ('iii'p,  is  now  in  llic  Mcdill  Mrdicnl  Miiscuni. 

(r)  Atro|tli_v  of  I  he  <^uil-lilii(l(lcr.  This  is  l>y  no  means  uncomnKH.  Tin,' 
or^jin  shrinks  into  a  small  liliroid  mass,  not  lar^fcr,  pcrliaps,  than  a  ^^ood- 
si/cd  pea  or  walnut,  or  even  has  the  I'orm  of  a  narrow  lihrous  strin;.'';  more 
commonly  the  ^all-hladdcr  ti^ililly  cmliraci-.s  a  slonc,  Tiiis  condition  is 
usually  preceded  l»y  hydrops  ol"  the  l)ladder. 

Occ-asionally  the  pdl-hladder  presents  diverticnla,  which  nniy  be  cut  olf 
from  the  main  poi'tion.  and  usually  contain  calculi. 

(."!)  Obstruction  of  the  Common  Duct. — There  may  be  a  sin-ilo  stone 
tightly  w('(|^('(l  in  the  duct  in  any  part  of  its  course,  or  a  series  (»l'  stones, 
sometimes  extendin;^  i'df)  both  hepatic  and  cystic  ducts,  or  a  stono  lies  in 
the  divertieulum  ol'  N'ater.  There  are  three  t^roups  of  cases:  (a)  In  rare 
instances  a  stone  tifzhtly  corks  the  common  duct,  causing  /icniKinciit  orrln- 
.sioii ;  or  it  may  partly  rest  in  the  cystic  duct,  and  may  have  caused  tliicken- 
in<,'  of  the  junction  of  the  ducts;  or  a  bif^  stone  may  compress  the  hepatic 
or  upjicr  part  (d'  the  common  duct.  The  jaundice  is  deep  and  enduring', 
and  there  are  no  septic  features.  Tlu'  pains,  the  ])revious  attacks  of  colic, 
and  the  absence  of  enlarj^ed  ;^a  11-1  (ladder  help  to  separate  the  condition  from 
obstruction  by  new  ^n-owths,  although  it  cannot  be  dilTcrentiated  with  cer- 
tainty. The  ducts  aro  usually  much  dilated  and  everywiu're  contain  a  clear 
mucoid  lluid. 

(h)  Iiiroiii/ilrlr  iilislnirllo)},  villi  iiifcrHrc  chnhiiKiith. 

There  may  be  a  .series  of  stones  in  the  common  duct,  a  sinj^le  stone  wliirli 
is  freely  movable,  or  a  stone  (hall-valve  stone)  in  the  diverticulum  of  N'ater. 
Those  conditions  may  be  met  with  at  autopsy,  without  the  subjects  baviuL:' 
liad  symptoms  ])ointin^  to  gall-stones;  hul  in  a  majority  (d'  cases  there  are 
very  charactei'istic  features. 

'V\w  common  diu-t  may  be  as  lar,i;e  as  the  tliniid);  the  lie|)atic  duct  and 
its  branches  through  the  liver  may  be  gi'catly  dilated,  and  the  distention  may 
even  be  apparent  beneath  the  liver  capsule.  (Jreat  enlargement  of  the 
gall-bladder  is  rare.  The  mucous  mend)rane  of  the  ducts  is  usually  smooth 
and  clear,  and  the  contents  consist  of  a  thin,  slightly  turbid  bile-stained 
mucus. 

Naunyn  has  given  the  following  as  the  distinguishing  signs  of  stone  in 
tlio  common  duct:  "(1)  The  continuous  or  occasional  presonce  of  bile  in 
the  fa'ces;  {'I)  distinct  variations  in  the  intensity  of  the  jaundice:  (.']) 
normal  size  or  only  slight  eidargement  of  the  liver;  (-1)  absem-e  of  disten- 
tion of  the  gall-bladder:  (T))  enlargement  of  the  s])leen:  ((!)  absence  of 
ascites;  (T)  ])resenco  of  febrile  disturbance;  and  (S)  duration  of  the  jaun- 
clico  for  nu)re  than  a  year."' 

In  connection  with  the  ball-valve  stone,  which  is  most  commonly  found 
in  the  diverticulum  of  Vater,  though  it  may  bo  in  the  common  duct  itself. 
I  have  tried  to  se])arate  a  special  symjitom  grou]):  {a)  Ague-like  paroxysms, 
chills,  fever,  and  sweating;  the  Jirjndtc  iiifrrniillcut  fever  of  Charcot;  {h) 
jaundice  of  varying  intensity,  which  ]'.ersists  for  months  or  even  years,  and 
deepens  after  each  paro.xysni;  (r)  at  the  time  of  the  paroxysms,  pains  in  the 


rnorjOMTiiiASis. 


507 


ri';.finii  (if  tlic  liver  witli  pistric  •listurbiuicc.  Tlios(»  syjiii>toins  miiy  rontimio 
oil  mill  oil*  I'll'  tlircc  (ir  I'mir  yciirs,  willimil  the  (l('\c|ii|iiiii'iit  (if  sii|i|iiiriitivi> 
clioliinj^itis.  Ill  one  ol'  my  ciiscs  the  Jiiiiii(lici'  niul  rcnirriii;,'  Ir'imtic  iiitcr- 
mitlciit  IVvcr  existed  Irom  .Inly,  IS*;),  until  Aii;:iist,  ls,s-.»;  tlie  |iiitieiit  rc- 
(•ii\ere(l  iiiKJ  still  lives.  'V\h\  eomlition  liiis  lusted  i'nnii  ei;;lil  iiioiitlis  to 
three  yeiirs.  The  rigors  arc  of  iiiteiiHe  severity,  and  the  teiiiitenitiire  rises 
to  lti;i '  (ir  lO.')".  'riic  chills  may  rocur  daily  for  weeks,  aiul  present  a  tertian 
or  t|iuirliin  type,  so  that  they  are  often  attrihiiled  to  ninhiria,  with  which, 
however,  tlii'y  have  no  eoiiiieetion.  T\w  jaiiiidieu  is  variable,  and  di'cpeiis 
after  cueli  paruxysiii.  The  ifehiiijf  may  bu  most  intense.  I'aiii,  wliieh  is 
somc'timt'S  Hcvoro  and  colicky,  does  not  always  occur,  'i'here  niay  be  marked 
voinitin<,'  and  nausea.  As  a  rule  there  is  no  pro^M'essive  deterioration  of 
health,      in  the  intervals  between  the  attacks  the  temperature  is  normal. 

'I'he  clinical  history  and  the  post-mortem  examinations  in  my  cases  show 
conclusively  that  this  condition  may  ])crsist  for  years  without  a  trace  of 
suppuration  within  the  ducts.  There  must,  however,  be  an  infection,  siicli 
as  may  exist  for  years  in  the  jfall-ldadder,  without  causing''  suppuration. 
Jt  is  probable  that  the  toxic  symptoms  only  dcNcloj)  when  a  certain  ^^rade 
of  tension  is  reached. 

An  interest in^f  and  valuable  dia<jjnostie  point  is  the  absence  of  dilataticm 
of  the  ;,^•dl-bladdcr  in  cases  of  obstruction  from  ,'tone — ( 'ourvoisier's  rule, 
lu'klin,  who  has  recently  reviewed  this  point,  liiids  that  of  It'i  cast's  of  ob- 
i-truction  of  the  coinnion  duct  by  calculus  in  'A  1  the  <iall-bladder  was  normal, 
ill  110  it  wjis  contracted,  and  in  "-.'S  it  was  dilated.  Of  1;!!)  cases  of  occlusion 
of  the  common  duct  from  other  causes  the  <:all-bladder  was  normal  in  1>, 
^liniiiken  in  !),  and  dilated  in  l'.M. 

{(■)  I iicdiiiplric  uhslriiclidii,  irilli  siippiinilirc  cliohnij/ilis. 

"When  SI  |)})urative  cholan^iitis  exists  the  mucosa  is  thickened,  often 
eroded  or  ulcerated;  there  may  be  extensive  suppuration  in  the  ducts 
tlirou<;liout  the  liver,  and  even  em])yenia  of  the  jfall-bladder.  Occasionally 
the  su|)pnration  extends  l)eyond  the  ducts,  and  there  is  l()calize(1  liver  al)- 
scess,  or  there  is  ])ei'foration  of  the  <iall-bla<ldcr  with  the  formation  of  ab- 
scess between  the  liver  and  stomach. 

Clinically  it  is  characterized  by  a  fever  which  may  be  intermittent,  hut 
more  commonly  is  remittent  and  without  ])rolon,<;cd  intervals  of  apyri'xia. 
The  jaundice  is  rarely  so  intense,  nor  do  we  see  the  dcepeiiin;^'  of  Ww  color 
after  the  paroxysms.  There  is  nsnally  <]^reater  cnlar^icment  of  the  liver 
and  tenderness  and  more  definite  si<ins  of  sei)tica}mia.  The  cases  run  a 
sliorter  course,  and  recovery  never  takes  place. 

(-1)  The  More  Remote  Effects  of  Gall-stones. — (a)  Jiilinrii  FishiUv. 
These  are  not  nncommon.  There  may,  for  instance,  be  abnormal  coinmu- 
nication  between  the  ^rail-bladder  and  the  lu'iiatie  duct  or  the  pill-ljladdcr 
and  '1  cavity  in  the  liver  itself.  ^Fore  rarely  perforation  occurs  between 
the  common  duct  and  the  ])ortal  vein.  Of  this  there  are  at  least  four  in- 
stances on  record,  amonp:  them  the  celebrated  case  of  Tunatius  Loyola. 
Perforation  into  the  abdominal  cavity  is  not  uncommon;  11!)  cases  exist 
in  the  literature  (Courvoisier),  in  70  of  whidi  tlie  ru])ture  occurred  directly 
into  the  peritoneal  cavity;  in  -19  there  was  an  encapsulated  al^scess.     Per- 


MS 


DISK  ASKS  OF  TIIK  DinFSTIVK  SVSTKM. 


/ 


fonilinii  tuny  inkc  placi'  Iroiii  iiri  iiilnili*'|iiitit'  Imincli  or  fi'iti  tlu'  lH'|)iiti(.', 
coiiiiiioii,  or  ('}'Htic  iluctH.  IVrronitioii  Trom  llio  gall-hladdcr  in  tliu  inutit 
coinnioi). 

Fistulous  (•(iiiiiiitmicatiojis  between  the  bile-passa^jes  and  tlu;  gastro-in- 
testinal  eaiial  are  lre(|iieiit.  ()|)i'niri<,'s  into  the  .stninaeli  arc;  rare.  IJetweeii 
the  (juotleninn  ami  ltiie-iiassa;;es  tliey  are  nuuli  more  coiiiinon.  Cour- 
voisicr  han  eoiU'eted  10  instanees  of  coinniunieatioii  l)t'tween  the  ductiw 
<'onununis  and  the  duoch-nuin,  and  '!'>)  caseH  between  the  gall-l)hidder  and 
tile  diio(h'iiiini.  ('oniiiiui)i(  ntion  will)  tlie  ileum  and  jejunum  is  extremely 
rare.  Of  (istidoiis  opening  into  the  colon  IVJ  eases  are  on  record.  'J'heso 
communications  can  rarely  be  diagnosed;  they  nuiy  be  present  without  any 
symptoms  whatever.  It  is  probably  by  ulceration  into  the  duodenum  or 
colon  that  the  large  gull-stones  escape. 

Occasionally  the  urinary  passage.'^  nuiy  be  ojiencd  into  and  the  stones 
nuiy  be  found  in  the  bladder.  Many  instances  are  on  record  of  listuhe  be- 
tween the  bile-passages  ind  the  lungs.  Courvoisier  has  collected  24:  cmcs, 
to  which  list  J.  E.  (Jraham  has  added  10,  including  !<.  .-aseH  of  liis  own. 
(Trans,  of  Assoc,  of  Am.  Physicians,  xiii.)  I'ile  may  b  )Ughed  up  with 
the  expectoration,  sometimes  in  consi(leral)Ie  (juantities. 

Of  all  fistulous  communications  the  exteriuil  or  cutaneous  is  the  most 
•connnon.  Courvoisier's  statistics  number  ISl  cases,  in  oO  per  cent  of 
Avhich  the  jjcrforation  took  ]ilaco  in  tiie  right  liy])()chondrium;  in  2^.)  per 
■cent  in  the  region  of  the  luivel.  T  nund)er  of  stones  discharged  varied 
from  one  or  two  to  many  hundreds.  Itecovery  took  place  in  '8  eases;  some 
Avith,  some  without  opcu-ation. 

(h)  Ohslntcliun  of  the  Jiuwcl  by  Gall-slones. — Reference  has  already  been 
made  to  this;  its  freipiency  apjiears  from  the  fact  that  of  21)5  cases  of 
obstruction,  occurring  during  eight  years,  analyzed  l)y  Fitz,  ^3  were  by 
^\  M-stone.  Courvoisier's  statistics  give  a  total  number  of  l.'U  cases,  in  6 
of  which  tlie  calculi  had  a  peculiar  situation,  as  in  a  diverticulum  or  in  the 
api)endix.  Of  the  renuiining  125  cases,  in  70  the  stone  was  s|)()ntaneously 
passed,  usually  wiiii  severe  sym])toms.  The  post-mortem  reports  show  that 
in  some  of  these  cases  even  very  large  stones  have  passed  per  viain  ludanihm, 
lis  the  gall-duct  has  been  enormously  distended,  its  orifice  admitting  the 
finger  freely.  This,  however,  is  extremely  rare.  The  stones  have  been 
found  most  commonly  in  the  ileum. 

Treatment  of  (Gl^all-stones  and  their  Effects. — In  an  attack  of 
biliary  colic  t'e  patient  should  be  kept  under  mori)hia,  given  hypodermie- 
ally,  in  quarter-grain  doses.  In  an  agonizing  paroxysm  it  is  well  to  give 
a  whiff  or  two  of  chloroform  until  the  morpliia  has  had  time  to  act.  Great 
relief  is  ex]ierienced  froiu  the  hot  bath  and  from  fomentations  in  the  region 
of  the  liver.  '^Phe  ])atieut  should  be  given  laxatives  and  shoidd  drink  co- 
piously of  alkaline  mineral  waters.  Olive  oil  has  proved  useless  in  my 
hands.  When  taken  in  large  quantities,  fatty  concretions  are  passed  with 
the  stools,  which  have  been  regarded  as  calcidi;  and  concretions  due  to 
eating  pears  have  been  also  mistaken,  particularly  when  associated  with 
colic  attacks.  Since  the  days  of  Durande,  Avhose  mixture  of  ether  and 
turpentine  is  still  largely  used  in  France,  various  remedies  have  been  ad- 


tiick  of 
idcrinic- 
lo  give 
Great 


region 


(1  with 

duo  to 

}d  with 

lor  and 

ocn  ad- 


TIIE   CIUKIIOSKS   OF  TIIK    MVKU. 


509 


vJKt'd  to  (iJHHolvo  tho  HtoiU'S  williiii  (lie  ^'iill-hhidder,  noiu«  of  which  aw 
vllicacioiis. 

The  diet  hhoidd  he  regidaled,  the  pnlieiit  should  lake  regular  exercise 
and  avoid,  an  much  an  |iossihle,  the  Klarcliy  and  faccharine  too  Is.  The 
soda  naltri  reeoiiiineiKh'd  l)y  I'rout  are  helievcd  to  |ircvcM(  tho  ciiieeiit ra- 
tion of  the  hilo  and  the  fornuition  (d"  gall-stones.  Mither  tho  sul|)liate  <tr 
the  phosphate  may  Ih'  taken  in  doses  of  from  1  to  2  drachms  daily. 
I'or  the  intoh-rahle  itching  .McCall  .Vnderson's  dusting  powder  nwiy  he  used; 
starch,  an  omiico;  camphor,  a  drachm  ami  a  half;  and  8ul[ihato  uf  zinc,  half 
an  ounce,  homo  of  this  should  ho  linely  dusted  ovor  tho  skin  with  a  powder- 
|iuir.  I'owdering  with  starch,  strong  alkaline  haths  (hot),  pilocarpin  liypo- 
dermically  (gr.  i-ji),  and  antipyrin  (gr.  viij),  may  he  tried.  Ichtliyol  and 
lanolin  ointment  somelimes  gives  relii-f. 

J'lxploratory  puncture,  as  practised  hy  tho  elder  l*ep|)er,  in  \x'u,  in  a 
case  of  onipyoma  of  tho  gall-hladder,  and  hy  Ihirtholow  in  1818  is  not 
now  (d'ten  done.  Aspiration  is  usually  a  m''  procedure,  tlu.ugh  a  fatal 
result  has  followed. 

Tho  surgical  troatnu'ut  of  gall-stones  luis  oi  late  years  nuule  rapi<I 
|trogress.  Tho  operation  of  choleeystotomy,  or  opening  the  gall-hladder 
and  removing  the  stoiu's,  \,hich  was  advised  hy  Sims,  has  heen  remark- 
ahly  successful.  The  removal  of  the  gall-hladder,  cholecystectomy,  has  also 
heen  practised  wiCi  success.  The  indications  for  operation  are:  (a)  J{e- 
peatod  attacks  of  gall-stone  colic.  Tho  operation  is  iu)w  attended  with  such 
slight  risk  that  the  jjationt  is  much  safer  in  tho  hands  of  a  surgeon  than 
when  left  to  Nature,  with  the  feehle  assistance  of  drugs  and  mineral  waters. 
(//)  The  presence  of  a  distended  gall-hladder,  associat''<l  with  attacks  of  pain 
or  with  fever,  (r)  AVhen  a  gall-stone  is  pernumently  lodged  in  the  common 
duct,  and  the  group  of  symptoms  ahovo  descrihod  are  present,  the  ques- 
tion, then,  of  advising  operation  depends  largely  upon  the  i)ersonal  niethodj 
imd  success  of  the  surgeon  who  is  availahle.  Tho  o{)eration,  necessarily 
much  more  serious  and  dilllcult  than  that  ujjon  the  gall-hladdor,  is  now 
remarkably  successful  oven  in  desi)eiuto  cases  of  years'  duration. 


VII.     THE    CIRRHOSES    OF   THE    LIVER. 

General  Oonsiderations. — The  many  forms  of  cirrhoses  of  the 
liver  have  ono  feature  in  common — an  increase  in  the  connective  tissue  of 
the  organ.  Tn  fact,  we  use  the  term  cirrhosis  (hy  which  Lannec  character- 
ized the  tawny,  yellow  color  of  the  connnon  atroidiic  form)  to  indicate  simi- 
lar changes  in  other  organs. 

The  cirrhoses  may  be  classified,  etiologically,  according  to  the  supposed 
causation;  anatomically,  according  to  tho  structure  primarily  involved;  or 
clinically,  according  to  certain  special  symptoms. 

Etiological  Classification.— 1.  Toxic  Cirrlwxcs. — Alcohol  is  the  chief 
cause  of  cirrhosis  of  the  liver.  Other  poisons,  such  as  lead  and  the  toxic 
products  of  faulty  metabolism  in  gout,  diabetes,  rickets,  and  indigestion, 
jday  a  minor  rule. 


570 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


2.  Infcrlums  Cirrlnu^es. — With  iiiaiiy  of  the  s[)('c'ijlc  fevers  necrotic 
(•liiuiffes  occur  in  the  liver  which,  when  widespread,  may  be  foHowcd  by 
cirrho-sis.  Possibly  tlie  liy])ertrophic  cirrhosis  oi"  Hanoi  and  other  forms 
met  with  in  earlv  life  are  due  to  infection.  The  malarial  cirrhosis  is  a  well- 
reco<Tnized  variety.  'J'he  syphilitic  ])ois()n  jtroduces  a  very  characteristic 
form. 

.'3.  Cirrhosis  from  chronic  congestion  of  (he  hlood-vcssels  in  heart-disease 
— the  cardiac  liver. 

4.  Cirrhosis  from  citron ir  ohslniclion  of  the  liilc-ducts,  a  form  of  very 
slight  clinical  interest.  In  anthracosis  the  carbon  pigment  may  reach  the 
liver  in  large  quantities  and  be  de])Osited  in  the  connective  tissue  about  the 
portal  canal,  leading  to  cirrhosis  (Welch). 

Anatomical  Classiflcation. — 1.  Vascutar  cirrhoses,  in  which  the  new 
growth  of  connective  tissue  has  its  starting  point  about  the  finer  branches 
the  ])()rtal  or  hei)atic  veins. 

2.  Bitiary  cirrhoses,  in  which  the  ])roccss  is  snpposed  to  begin  about 
the  liner  bile-ducts,  as  in  the  hyj)ertro[)hic  cirrhosis  of  llanot  and  in  the 
form  from  obstruction  of  the  larger  ducts. 

3.  Capsular  cirrhoses,  a  perihej)atitis  leading  to  great  thickening  of  the 
capsule  and  reduction  in  the  volunu'  of  the  liver. 

Clinical  Classification. — For  practical  ]Hiri)oses  we  may  recognize  the  fol- 
lowing varieties  of  cirrhosis  of  the  liver: 

1.  Tlie  alcoholic  c'l-rhosis  of  Laennec,  including  with  this  the  fatty  cir- 
rhotic liver. 

2.  The  hypcrtro])hic  cirriiosis  of  Ifanot. 

3.  Syphilitic  cirrhosis. 

4.  Capsidar  cirrhosis — chronic  ptrihc])atitis. 

Other  forms,  of  slight  cliincal  interest,  are  considered  elsewhere  under 
diabetes,  malaria,  tubeixulosis,  and  heart-disease.  The  cirrhosis  from  ma- 
laria, upon  winch  the  French  writers  lay  so  much  stress  (one  describes  thir- 
teen varieties!),  is  excessively  rare.  In  our  large  experience  with  malaria 
during  the  past  nine  years  not  a  single  case  of  advanced  cirrhosis  due  to 
this  cause  bas  been  seen  in  the  wards  or  autopsy-room  of  the  Johns  Hop- 
kins Hospital. 

T.     ALCOHOLIC  CIURIIOSIS. 

Etiology.— The  disease  occurs  most  frequently  in  middle-aged  males 
who  have  been  addicted  to  drink.  Whiskey,  gin,  and  brandy  are  more  po- 
tent to  cause  cirrhoses  than  beer.  It  is  more  common  in  countries  in  which 
strong  spirits  are  used  than  in  those  in  which  malt  liquors  are  taken.  Among 
1,000  autopsies  in  my  colleague  Welch's  de])artment  of  the  Johns  Hopkins 
Hospital  there  were  G3  cases  of  small  atrophic  liver,  and  8  cases  of  the  fatty 
cirrhotic  organ.  Lancereaux  claims  that  the  vin  ordinaire  of  France  is  a 
common  cause  of  cirrhosis.  Of  210  cases,  excess  in  wine  alone  was  present 
in  (IS  cases.  He  thinks  it  is  the  sulphate  of  potash  in  tlie  plaster  of  Paris 
used  to  give  tlie  "  dry"  flavor  which  damages  the  liver. 

Cir  'losis  of  the  liver  in  young  children  is  not  very  rare.  Palmer  How- 
ard collected  G3  cases,  to  which  Hatfield  added  93.      In  a  certain  num- 


THE   rilMMlOSES  OF   THE   LIVER. 


671 


litT  of  llio  cases  tluTc  is  an  alcoholic  history,  in  others  syphilis  has  hccii  pres- 
ent, while  a  third  <:roiip,  dne  to  the  poisons  of  the  infectious  diseases,  eni- 
liraces  a  cei'tain  nund)er  of  the  cases  of  llanot's  hypertrophic  cirrhosis. 

Morbid  Anatomy.  —  Practically  on  the  i)ost-niorl(Mu  tahlu  we  sec 
alcoholic  ciri'hosis  in  two  well-characterized  forms: 

21ic  Alroiihic  Ciriiidsis  nf  Ldnnicr. — The,  or^an  is  j;reatly  reduced  in 
size  and  may  he  defornuMl.  '{'he  weij;ht  is  sometimes  not  more  than  a 
pound  or  a  pound  and  a  half,  it  proents  numerous  <j:ranulations  on  the 
>url'ace;  is  iirm,  hard,  and  cuts  with  ;^reat  resistance.  The  substance  is 
seen  to  he  made  up  of  greenish-yellow  islands,  surrounded  hy  grayish-white 
ciiiinective  tissue.  This  yellow  appearance  (jf  the  liver  induced  Laeiuu'c  to 
give  to  the  condition  the  name  of  cirrho.>-is. 

'I'lio  Falhj  Cirrholic  Jjirer. — J'^ven  in  the  atn)[)liic  form  the  fat  is  in- 
cri'ased,  hut  in  typical  examples  of  this  variety  the  organ  is  not  reduced  in 
size,  hut  is  enlarged,  smooth  or  very  slightly  granular,  ana'uiic,  ytdlowish 
white  in  color,  and  resend)les  an  ordinary  fatty  liver,  it  is,  however,  iirm, 
cut^  with  resistance,  and  microscopically  shows  a  great  increase  in  the  con- 
nective tissue.     This  form  occurs  must  frequently  in  heer-drinkers. 

The  two  essential  elements  in  cirrhosis  are  destruction  of  liver-cells  and 
obstruction  to  the  portal  circulation. 

In  an  aulo])sy  on  a  case  of  atroi)hic  cirrhosis  the  ])eriton,Tnm  is  usually 
lound  to  contain  a  large  ((uantity  of  lluid,  the  mendirane  is  opaijue,  and 
there  is  chronic  catarrh  of  the  stomach  and  of  the  small  intestines.  '^J'he 
spleen  is  enlarged,  in  part,  at  least,  from  the  clironic  congestion,  ])ossil)ly 
due  in  part  to  a  "  vital  reaction,"  to  a  toxic  iniluencc  (Parkes  Weber).  The 
kidneys  are  sometimes  cirrliotic,  the  l)ases  of  the  lungs  may  he  much  com- 
[iressed  by  the  ascitic  fluid,  the  heart  often  shows  marked  degeneration, 
and  arterio-sclerosis  is  usually  present.  A  remarkable  feature  is  the  asso- 
ciation of  acute  tuberculosis  with  cirrhosis.  In  seven  cases  of  my  series 
ilie  ]iatients  died  with  either  acute  tuberculous  ])eritonitis  or  acute  tuber- 
culous ])leurisy.  ]Mtt  states  that  2'2-h  per  cent  of  the  cases  of  cirrhosis  dying 
in  Ciuy's  TIosi)ital  during  twelve  years  had  acute  tuberculosis.  Of  l.'l 
auto])sies  at  the  ]\[anchester  lioyal  Infirmary  in  cirrhosis,  ahout  23  per  cent 
gave  evidence  of  tuherculous  infection.  Twelve  of  these  had  tuherculosis 
of  the  ])eritonannn,  and  1"3  died  directly  fi'oin  the  tuberculous  infection 
(Ivelynack). 

The  compensatory  circulation  is  usually  reaslilv  demonstrated.  Tt  is 
carried  out  by  the  following  si't  of  vessei>:  (1)  Tlie  accessory  portal  system 
of  Sap])ey,  of  which  inii)ortant  branches  pass  in  the  round  and  suspensory 
ligaments  and  unite  with  the  epigastric  and  mammary  systems.  These  ves- 
sels are  numerous  and  small.  Occasionally  a  huge  single  vein,  which  may 
attain  the  size  of  the  little  finger,  passes  from  the  hilus  of  the  liver,  follows 
the  round  ligament,  and  joins  the  ejngastric  veins  at  the  navel.  Although 
this  has  the  position  of  the  innbilical  vein,  it  is  usually,  as  Sappey  showe(l, 
a  para-und)ilical  vein — that  is,  an  enlarged  vein  hy  tlie  side  of  the  obliter- 
ated und)ilical  vessel.  There  may  he  ])roduced  ahout  the  navel  a  larsro 
hunch  of  A'arices,  the  so-called  ca]int  Mcdusa\  Other  branches  of  this 
system  occur  in  the  gastro-epiploic  omentum,  about  the  gall-hladder,  and, 


572 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


m 


most  important  of  all,  in  the  suspensory  lij^amcnt.  These  latter  form  large- 
branches,  which  anastomose  freely  with  the  diaphragmatic  veins,  and  so 
unite  with  the  vena  azygos.  ['I)  J5y  the  anastomosis  between  the  oesoph- 
ageal and  gastric  veins.  The  veins  at  the  lower  end  of  the  a'sophagus  may 
be  enormously  enlarged,  i)ro(lucing  varices  which  ])roject  on  the  mucous 
membrane.  (;5)  The  communications  between  the  luumorrhoidal  and  the  in- 
ferior mesenteric  veins.  The  freedom  of  communication  in  this  direction 
is  very  varial)le,  and  in  some  instances  the  ha'morrhoidal  veins  are  not  much 
enlarged.  (1)  The  veins  of  Ketzius,  which  unite  the  radicles  of  the  portal 
brandies  in  the  intestines  and  mesentery  with  the  inferior  vena  cava  and 
its  branches.  To  this  system  belong  the  whole  group  of  retroj)eritoneal 
veins,  which  are  in  most  instances  enormously  enlarged,  ])articularly  about 
the  kidneys,  and  which  serve  to  carry  off  a  considerable  proportion  of  the 
portal  blood. 

Symptoms. — 'I'he  most  extreme  grade  of  atro])liic  cirrhosis  may  exist 
without  symptoms.  »S'o  lung  as  the  compensalury  circulation  is  maintained' 
the  patient  may  sufTer  little  or  no  inconvenience.  The  remarkable  e(H- 
ciency  of  this  collateral  circulation  is  well  seen  in  those  rare  instances  of 
permanent  obliteration  of  the  portal  vein.  The  symptoms  ^^ny  be  divided 
into  two  groups — obstructive  and  toxic. 

Obstruct  ire. — The  overfilling  of  the  blood-vessels  of  lu^  stomach  and 
intestine  lead  to  chronic  catarrh,  and  the  patients  suffer  with  nausea  and 
vomiting,  particidarly  in  the  morning;  the  tongue  is  furred  and  the  bowels 
are  irregular.  Ifivmorrhage  from  the  stomach  may  be  an  early  symptom; 
it  is  often  jn-ofuse  and  liable  to  recur.  It  seldom  proves  fatal.  The  amount 
vomited  may  be  remarkable,  as  in  a  case  already  referred  to,  in  which  ten 
pounds  were  ejected  in  seven  days.  Following  the  luumatemesis  melivna 
is  common;  but  ha}morrhages  from  the  bowels  may  occur  for  several  years 
without  lurmatemesis.  The  bleeding  very  often  comes  from  the  (esopha- 
geal varices  already  described  (p.  459).  Enlargement  of  the  s|)leen,  usu- 
ally regarded  as  a  sign  of  the  passive  congestion,  may,  as  Parkes  Weber  sug- 
gests, be  due  to  a  toxemia.  The  organ  can  usually  be  felt.  Evidences  of 
the  establishment  of  tlie  collateral  circulation  are  seen  in  the  enlarged  epi- 
gastric and  mammary  veins,  more  rarely  in  the  presence  of  the  caput  ]\Ie- 
dusffi  and  in  the  development  of  haemorrhoids.  The  distended  venules  in 
the  lower  thoracic  zone  along  the  line  of  attachment  of  the  diajihragm  are 
not  specially  marked  in  cirrhosis.  The  most  striking  feature  of  failure  in 
the  compensatory  circulation  is  ascites,  the  elfusion  of  serous  fluid  into  the 
peritoneal  cavity.  The  conditions  under  which  this  occurs  are  still  ob- 
scure. The  abdomen  gradually  distends,  may  reach  a  large  size,  and  con- 
tain as  much  as  15  or  20  litres.  (Edema  of  the  feet  may  precede  or  develop 
with  the  ascites.     The  drojisy  rarely  becomes  general. 

Jaundice  is  usually  slight,  and  was  present  in  only  35  of  130  cases  of 
cirrhosis  reported  by  Fagge.  The  skin  has  frequently  a  sallow,  slightly 
icteroid  tint.  The  urine  is  often  reduced  in  amount,  contains  urates  in 
abundance,  often  a  slight  amount  of  albumin,  and,  if  jaundice  is  intense, 
tube-casts.  The  disease  may  he  afebrile  throughout,  but  in  many  cases, 
as  shown  by  Carrington,  there  is  slight  fever,  from  100°  to  102.5°. 


THE  CIIIIIIIOSES   OF  TOE   LIVER. 


578 


rm  large 
,  and  so 
i  oesoph- 
igus  may 
mucous 
d  the  in- 
direction 
lot  much 
he  portal 
cava  and 
jcritoncal 
rly  about 
HI  of  the 

may  exist 
aintained' 
:a])le  elli- 
;tances  of 
le  divided 

nacli  and 
lusea  and 
he  bowels 
Bymptoni; 
e  amount 
hich  ten 
s  mela.>na 
eral  years 
(Ksopha- 
een,  usu- 
ebcr  sug- 
dences  of 
rged  epi- 
aput  ]\Ie- 
cnules  in 
ragm  are 
failure  in 
into  the 
still  ob- 
land  con- 
develop 

cases  of 

slightly 

Inrates  in 

intense, 

ly  cases. 


Examination  at  an  early  stage  of  the  disease  may  show  an  enlarged  and 
painful  liver.  Drcschfeld,  Foxwell,  and  -jtliers  in  I'highind  have  of  late 
years  called  particular  attention  to  tlio  fact  that  in  very  many  of  the  cases 
of  alcoliolic  cirrhosis  the  organ  is  "•  enlarged  at  all  stages  of  the  disease,  and 
tliat  whether  enlarged  or  contracted  the  clinical  symptoms  and  course  are 
much  the  same"  (Foxwell).  The  patient  nuly  first  come  under  observa- 
tion for  dyspepsia,  lui'matemesis,  slight  jaundice,  or  nervous  symi)tonis. 
Later  in  the  disease,  the  patient  has  an  unmistakable  hepatic  facies;  he  is 
thin,  the  eyes  are  sunken,  the  c()nju]u;tivie  watery,  the  nose  and  cheeks 
show  distended  venules,  and  the  complexion  is  muddy  or  icteroid.  On  the 
enlarged  abdomen  the  vessels  are  distended,  and  a  bunch  of  dilated  veins 
may  surround  the  navel.  When  much  iluid  is  in  the  ])eritonivum  it  is 
impossible  to  make  a  satisfactory  examination,  but  after  withdrawal  tiie 
area  of  liver  dulness  is  fouml  to  be  diminished,  particularly  in  the  middle 
line,  and  on  deep  pressure  the  edge  of  the  liver  can  be  detected,  and  occa- 
sionally the  hard,  firm,  and  even  granular  surface.  The  si)leen  can  be  felt 
in  the  left  hypochondriac  region.  Examination  of  the  anus  nuiy  reveal 
the  presence  of  hajmorrhoids. 
Il  Toxic  Symptoms. — At  any  stage  of  atrophic  cirrhosis  the  patient  may 

develop  cerebral  symptoms,  either  a  noisy,  joyous  delirium,  or  stupor, 
coma,  or  even  convulsions.  The  condition  is  not  infreciuently  mistaken  for 
ura>mia.  The  nature  of  the  toxic  agent  is  not  yet  settled.  The  symptom* 
may  develop  without  jaundice,  and  cannot  be  attri!)uted  to  chohvmia,  and 
tliey  may  come  on  in  hospital  when  the  patient  has  not  had  alcohol  for 
weeks. 

The  fatty  cirrhotic  liver  may  jiroduce  symptoms  similar  to  those  of  the 
atro])hic  form,  but  it  more  frequently  is  latent  and  is  found  accidentally  in 
topers  who  have  died  from  various  diseases.  The  greater  number  of  the  cases 
clinically  diagnosed  as  cirrhosis  with  enlargement  come  in  this  division. 

Diagnosis. — With  ascites,  a  well-marked  history  of  alcoholism,  the- 
hepatic  facies,  and  ha>morrhage  from  the  stomach  or  bowels,  the  diagnosis- 
is  rarely  doubtful.  If,  after  withdrawal  of  the  fluid,  the  spleen  is  fouml 
to  be  enlarged  and  the  liver  cither  not  palpable  or,  if  it  is  enlarged,  liard 
and  regular,  the  probabilities  in  favor  of  cirrhosis  are  very  great.  In  the 
early  stages  of  the  disease,  when  the  liver  is  increased  in  size,  it  may  be 
impossible  to  say  whether  it  is  a  cirrhotic  or  a  fatty  liver.  The  dilferential' 
diagnosis  between  common  and  syphilitic  cirrhosis  can  sometimes  be  made. 
A  marked  history  of  syphilis  or  the  existence  of  other  syphilitic  lesions,  with 
groat  irregularity  in  the  surface  or  at  the  edge  of  the  liver,  are  the  points' 
in  favor  of  the  latter.  Thrombosis  or  obliteration  of  the  ])ortal  vein  can 
rarely  be  differentiated.  In  a  case  of  fibroid  transformation  of  the  ])ortal 
vein  which  came  under  my  observation,  the  collateral  circulation  had  been 
established  for  years,  and  the  symptoms  w«-re  simply  those  of  extreme  por- 
tal obstruction,  such  as  occur  in  cirrhosis.  Thrombosis  of  the  portal  vein 
is  frequent  in  cirrhosis  and  may  be  characterized  by  a  rapidly  developing 
ascites. 

Prognosis. — The  prognosis  is  bad.  When  the  collateral  circulation 
is  fully  established  the  patient  may  have  no  symptoms  wdiatever.     Three 


574 


DISEASES  OF  THE  DIOEbTIVE  SYSTEM. 


.  \ 
/ 


cast's  of  ii(lviincr<l  iitrophic  cirrliosis  luivo  died  uiidi'i'  my  oljscrvalioii  of 
other  aU'eflioiis  \vitli(nit  prcsejiliii^^  diiiniiy  lil'c  any  syiupUtius  jioiiiting  to 
disease  of  tlie  liver.  TJiere  are  iiistaiiees,  too,  of  euiargemeiit  of  tiie  liver, 
slight  jaundice,  (■erel)ral  syiiiptoiiis,  and  evi'ii  h.i'inatemesis,  in  which  the 
liver  becniues  reduced  in  size,  the  syin])tonis  disappear,  and  the  patient  may 
live  in  comparative  comfort  fur  many  years.  There  are  eases,  too,  possildy 
.'•yphilitic,  in  which,  after  one  or  two  tappings,  the  synii)toms  have  disap- 
jjcared  and  the  patients  have  apjiarentiy  recovered.  Ascites  is  a  very  serious 
eve]it  in  oidiiuii'y  cirrhosis.  Of  of  cases  with  ascites  10  died  hefore  tap- 
ping was  necessaiy;  If  were  tapped,  and  the  average  duration  of  life  after 
tlie  swelling  was  iirst  noticed  was  only  eight  weeks;  of  10  cases  the  diag- 
imsis  was  wrong  in  4,  and  in  the  remaining  (5,  who  were  tai)|)ed  oftener 
than  once,  chronic  jieritonitis  and  ])erihepatitis  wei'e  ])resent  (Hale  \\'hite). 

II.     IIVPKRTROPIIIC   CIRRHOSIS  (Tranot). 

This  well-characteiMzed  form  was  iirst  descrihed  hy  lieqiun  in  1S4(!, 
hut  our  accurate  knowledge  of  the  condition  dates  from  the  work  of 
the  lamented  llanot  (l.STT)),  whose  name  in  France  it  hears — maladie  de 
llaiiot. 

Cirrhosis  with  enlargement  occurs  in  the  early  stage  of  atrophic  cirrho- 
sis; there  is  an  enlarged  fatty  and  cirrhotic  liver  of  alcoholics,  a  pigmentary 
form  in  diabetes  has  been  do-vrihed,  and  in  association  with  syphilis  the 
organ  is  often  very  large.  The  hypertro])hic  cirrhosis  of  llanot  is  easily 
distingnished  from  these  forms. 

Etiology. — ^'ales  are  more  often  alTected  than  females — in  2'i 
of  Schachmann's  2G  cases.  The  subjects  are  young;  some  of  the  cases 
in  children  ])rol)ahly  belong  to  this  form.  Of  four  recent  cases  under  my 
care  the  ages  were  from  twenty  to  thirty-five.  Two  were  brothers.  Alco- 
hol ])lays  a  minor  ])art.  Not  one  of  the  four  cases  referred  to  had  been  a 
heavy  drinker.  The  abst'uce  of  all  known  etiological  factors  is  a  remark- 
al)le  feature  in  a  majority  of  the  cases. 

Morbid  Anatomy. — The  organ  is  enlarged,  weighing  from  2.000  to 
4,000  grammes.  The  form  is  maintained,  the  surface  is  smooth,  or  presents 
small  granulations;  the  color  in  advanced  cases  is  of  a  dark  olive  green; 
the  consistence  is  greatly  increased.  The  section  is  uniform,  greenish  yel- 
low in  color,  and  the  liver  lobules  may  he  seen  separated  1)y  connective 
tissue.  The  l)ile-])assages  ]u'esent  nothing  ahnornial.  In  a  case  without 
much  jaundice  ex])loratory  operation  showed  a  very  large  red  organ,  with 
a  slightly  roughened  surface,  ^ficroscopically  the  following  characteris- 
tics are  described  hy  French  writers:  The  cirrhosis  is  mono-  or  multilobular, 
with  a  connective  tissue  rich  in  round  cells.  The  bile-vessels  are  the  seat  of 
an  angiocholitis,  catarrhal  and  ])roductive.  and  there  is  an  extraordinary 
development  of  new  biliary  canaliculi.  The  liver-cells  are  neitber  fatty 
nor  ])igraented,  and  may  be  increased  in  size  and  show  karyokinetic  figures, 
l-'rom  the  su])i)osed  origin  about  the  bile-vessels  it  has  been  called  biliary  cir- 
rhosis, but  the  histological  details  have  not  yot  been  worked  out  fully,  and 
the  separation  of  this  as  a  distinct  form  should,  for  the  present  at  least,  rest 


THE   CIKKIIOSKS  OF  TIIK    LIVKR. 


575 


itioii  Oi 
iting  to 
le  liver, 
licli  the 
L'lit  may 
pobriiltly 
e  disap- 
y  suriuus 
ore  ta|)- 
U'e  after 
he  dhVfi- 
.  ol'teiier 
^Vllite). 


ill  ISKi, 
work  of 
aladic  dn 

0  cirrlio- 

finentai'V 

)liili,s  tlio 

is  easily 

-in    tl 

he   cases 

luler  my 

Alco- 

il  1)cen  a 

remark- 

'>.0()0  to 

presents 
•e  <zreen; 
nish  yel- 
)nnective 

without 
;an,  with 
iraeteris- 
lilot)ular, 
le  scat  of 
lordinary 

ler  fatty 

fi»iures. 

iary  cir- 

lly,  and 

oast,  rest 


upon  clinical  rallier  than  anatonucal  grounds,     'i'he  spleen  is  greatly  en- 
huj^icd  and  may  weigh  (iOl)  or  more  grammes. 

Symptoms. — iianot's  liypertrophic  eirrliosis  i)resonts  the  following 
\ery  eharaclerislic  group  ol  symptoms.  As  [)reviou.'~ly  stated,  tiie  eases 
occur  in  young  persons;  there  is  not,  as  a  rule,  an  alcoholic  Jiistory,  and 
males  are  usually  all'ected:  («)  A  remarkaldy  chroidc  course  of  from  four 
lo  six,  or  even  ten  years,  {h)  Jaundice,  usually  slight,  often  not  more  than 
a  lemon  tint,  or  a  tinging  of  the  conjunctiva'.  At  any  time  during  the 
course  an  icieriis  (jrarifi,  with  high  fevr-r  and  delirium,  may  deveh^i).  There 
is  hilo  in  the  urine;  the  stools  are  not  clay-colored  as  in  obstructive  jaundice, 
liut  may  be  very  dark  and  "■  bilious."  (c)  Attacks  of  pain  in  the  region  of  the 
liver,  which  may  be  severe  ami  associated  with  nausea  and  vomiting.  The 
|iain  may  be  slight  and  dragging,  and  in  some  cases  is  lujt  at  all  a  prom- 
inent symjitom.  The  jaundice  may  deei)en  after  attacks  of  i)ain.  (</) 
I'lnlarged  liver.  A  fulness  in  the  upper  abdonunal  zone  may  be  the  first 
complaint.  On  inspection  the  enlargement  may  bo  very  marlscd.  in  one 
of  my  cases  the  left  lobe  was  unusually  |)rominent  and  stood  out  almost 
like  a  tumor.  An  oxi)loratory  o])eration  showed  oidy  an  enlarged,  smooth 
organ  without  adhesions.  On  palpation  the  hypertrophy  is  uniform,  the 
( (insistence  is  increased,  and  the  edge  distinct  and  hanl.  The  gall-bladdor 
i>  not  enlarged.  '^Phe  vertical  flatness  is  much  increased  and  may  extend 
fi'om  the  sixth  rib  to  the  level  of  the  navel,  (r)  The  spleen  is  enlarged,  eas- 
ily palpable,  and  very  hard.  (/)  Certain  negative  features  arc  of  moment— - 
ibsence  of  ascites  and  of  dilatation  of  the  subcutaneous  veins  of  the  abdo- 
men. Among  other  syni])toms  may  be  mentioned  ha'inorrhages.  One  of 
my  cases  had  blooding  at  the  gums  for  a  year;  another  had  had  for  years 
most  remarkable  attacks  of  i)uri)ura  with  urticaria.  Pruritus,  xanthoma, 
lichen,  and  tolangicctasics  may  be  present  in  the  skin.  In  one  of  my  cases 
the  skin  became  very  bronzed,  almost  as  deeply  as  in  Addison's  disease. 
Slight  fever  may  be  present,  which  increases  during  the  crises  of  pain. 
There  may  be  a  marked  loucocytosis.  A  curious  attitude  of  the  body  has 
heen  seen,  in  which  the  right  shoulder  and  right  side  look  dragged  down. 
The  patients  die  with  the  symptoms  of  icterus  gravis,  from  htomorrhage, 
from  an  intercurrent  infection,  or  in  a  ])Tofound  cachexia,  rertain  of  the 
cases  of  cirrhosis  of  the  liver  in  children  are  of  this  type;  the  enlargement 
•  >f  the  spleen  may  be  very  pronounced. 

III.    SYPHILITIC   CIRRIIOSIS. 

This  has  already  been  considered  in  the  section  on  sy])hilis  (]i.  '249).  T 
rt'fer  to  it  again  to  emphasize  (1)  its  frequency;  ('I)  the  great  importance  of 
its  differentiation  from  tlu'  alcoholic  form;  (;?)  its  curability  in  many  cases; 
and  (4)  the  tumor  fornuitions  in  connection  with  it. 

IV.    CAPSULAR  CinRIIOSTS— PERIHEPATITIS. 

Local  capsulitis  is  common  in  many  conditions  of  the  liver.     The  form 
fif  disease  here  described  is  characterized  by  an  enormous  thickening  of  the 
entire  capsule,  with  great  contraction  of  the  liver,  but  not  necessarily  with 
36 


570 


DISEASES  OF  THE  1>^}KSTIVE  SYSTEM. 


/ 


spociiil  iiuTCiisu  in  tlic  conia'ctive  tiissiie  ol'  tlio  or<,Mn  itsoll".  Our  cliiui" 
kiiowk'dgo  ol'  the  disoaso  wo  owe  to  tho  Uuy's  Hospital  })liysicMaus,  paiticu- 
lurly  to  Hilton  i-'ajigo  and  to  llalu  White,  who  has  colloctt'd  from  tho  rec- 
ords 2'i  cases.  Tho  liver  siihstanco  itself  was  "  never  markedly  cirrhotic; 
its  tissue  was  nearly  always  soft."  Chronic  capsulitis  of  the  s[)leen  and  a 
chronic  proliferative  peritonitis  are  almost  invarial)ly  present.  Jn  11)  of 
the  22  cases  the  kidneys  wore  granular.  Halo  White  regards  it  as  a  sequel 
of  interstitial  iu'j)hritis.  Tho  youngest  case  in  his  series  was  twenty-nine. 
The  symptoms  are  those  of  atrophic  cirrhosis — ascites,  often  recurring  and 
recpiiring  juany  tappings.  Jaundice  is  not  often  })resent.  1  have  met  with 
two  grouj)s  of  cases — the  one  in  adults  usually  with  ascites  and  regarded 
as  ordinary  cirrhosis.  1  have  never  made  a  diagnosis  in  such  a  case.  Signs 
of  interstitial  nephritis,  recurring  ascites,  and  a])sence  of  jaundice  are  re- 
garded l)y  J  (ale  White  as  im|)(n'tant  diagnostic  points.  In  tho  second 
group  of  cases  the  ])erihej)atitis,  perisplenitis,  and  proliferative  peritonitis 
are  associated  with  adherent  })ericardium  and  chronic  mediastinitis.  In  one 
siich  case  the  diagnosis  of  ca})sular  lie])atitis  was  very  clear,  as  the  liver 
could  1)0  grasped  in  the  hand  and  formed  a  rounded,  smooth  organ  resem- 
bling the  s})leen.  Tho  child  was  ta})i)ed  1^1  times  (Archives  of  I'lodiatrics, 
189G). 

Treatment  of  the  Cirrhoses. — Ordinary  cirrhosis  of  the  liver  is 
an  incural^le  disease.  Many  writers,  sj)eaking  of  the  curability  of  certain 
forms,  show  a  lack  of  a]ii)reciation  of  the  essential  conditions  upon  which 
the  symi)toms  do])end.  Ho  far  as  we  have  any  knowledge,  no  remedies  at 
our  disposal  can  alter  or  remove  the  cicatricial  connective  tissue  which  con- 
stitutes the  materia  pcrcaiis  in  ordinary  cirrhosis.  On  tho  other  hand,  we 
know  that  extreme  grades  of  contraction  of  the  liver  may  i)ersist  for  years 
without  symptoms  when  the  compensatory  circulation  exists.  The  so-callet 
cure  of  cirrhosis  moans  tho  re-estal)lishment  of  this  compensation;  and  it 
would  be  as  unreasonable  to  speak  of  healing  a  chronic  valvular  lesion  when 
with  digitalis  we  have  restored  the  circulatory  balance  as  it  is  to  speak  of 
curing  cirrhosis  of  the  liver,  when  by  tapping  and  other  measures  the  com- 
pensation has  in  some  way  been  restored. 

The  patient  should  abstain  entirely  from  alcohol,  and,  if  possible,  should 
take  a  milk  diet,  which  has  been  highly  recommended  by  Semmola.  In 
any  case,  the  diet  shoidd  be  nutritious,  but  not  too  rich.  Measures  should 
be  enii)loyed  to  reduce  tho  gastro-intestinal  catarrh,  and  the  patient  should 
lead  a  quiet,  out-of-door  life  and  kee]i  the  skin  active,  the  bowels  regular, 
and  the  urine  abundant.  In  non-syi)hilitic  cases  it  is  useless  to  give  either 
mercury  or  iodide  of  potassium.  When  a  well-marked  history  of  syphilis 
exists  these  remedies  should  be  iised,  but  neither  of  them  has  any  more 
influence  u]ion  the  dcvolo])ment  of  a  new  growth  of  connective  tissue  in 
the  liver  than  it  has  u])on  the  progressive  development  of  a  scar  tissue  in 
a  keloid  or  in  an  ordinary  developing  cicatrix.  The  ascites  should  be 
ta])])ed  early,  and  tho  o]ieration  may  be  rojieatcd  so  soon  as  tho  distention 
becomes  distressing.  The  continuous  drainage  with  a  Southey's  tidje  may 
be  eni])loyed.  It  is  much  better  to  resort  to  tapping  early  if  after  a  few 
days'  trial  the  fluid  does  not  subside  rapidly  under  the  use  of  saline  purges. 


ABSCESS  OF  tup:  liveu. 


677 


From  Imlf  nn  ounce  to  iin  (niiicc  aiid  a  half  of  siilpliato  of  ina;fnosia  may 
be  given  in  a.s  little  water  as  possible  half  an  hour  before  breakfast.  Ehite- 
iniiii,  the  coiniiound  jalap  powder,  or  the  bitartrate  of  poljish  may  also  bo 
employed.  JJigitalis  and  sqiulls  are  oi'ten  usefid.  Surjiical  treatmenl  has 
])eeu  advocated  ol'  late.  The  lluid  is  thoroughly  drained  and  tiie  surface 
oi'  the  liver  and  spleen  and  the  ])arietal  j)eritonieuni  is  then  lirmly  scrubbe(l^ 
ISO  as  to  i)romote  adhesioJis,  in  which  compensatory  vessels  could  develop. 
Of  three  cases  recently  treated  in  my  wards  in  this  way  one  has  recovered. 
Jn  the  syphilitic  cases,  or  when  syphilis  is  sus[)ected,  iodide  of  potassium  nuiy 
be  given  in  doses  oi"  from  15  to  30  droi)8  of  the  saturated  solution  three 
times  a  day,  and  mercury,  which  is  conveniently  given  with  squills  and 
digitalis  in  the  form  of  Addison's  or  Niemeyer's  pill.  A  ])atient  of  well- 
marked  syphilitic  cirrhosis  with  recurring  ascites,  in  which  tapping  was  re- 
sorted to  on  eight  or  ten  occasions,  took  this  pill  at  intervals  for  a  year  with 
the  greatest  benefit  and  subsequently  had  four  years  of  tolerably  good 
health. 


VIII.     ABSCESS    OF   THE    LIVER. 

Dtiology. — Su])])uration  within  the  liver,  either  in  the  ])arenchyma  or 
in  the  blood  or  bile  passages,  occurs  under  the  following  conditions: 

(1)  The  tropical  abscess.  In  hot  cliuuites  this  form  nuiy  develop  idio- 
])athically,  but  more  commonly  follows  dysentery.  It  fre(iuently  occurs 
among  Europeans  in  India,  ])articularly  those  who  drink  alcohol  freely  and 
are  exposed  to  great  heat.  The  relation  of  this  form  of  aljscess  to  dysen- 
tery is  still  under  discussion,  and  An;j!o-In(lian  })ractitionors  are  by  no 
means  unanimous  on  the  subject.  Certainly  cases  may  develop  without 
a  history  of  previous  dysentery,  and  there  have  been  fatal  cases  without 
any  affection  of  the  large  bowel.  In  this  country  the  large  solitary  tro])ical 
abscess  also  occurs,  oftenest  in  the  Southern  States.  In  Baltimore  it  is  not 
very  infrecpient. 

The  relation  of  this  form  of  abscess  to  the  annvha  oil  has  been  care- 
fully studied  by  Kartulis  and  exhaustively  considered  in  a  monograph  by 
Councilman  and  I^afleur.  The  descri))tions  and  illustrations  .of  these  au- 
thors are  most  convincing  as  to  the  direct  etiological  association  of  this 
organism  with  liver  abscess.  Clinically  the  ]iatient  may  have  ania'hv  coli 
in  the  stools  and  well-marked  signs  of  liver  abscess  without  nuirked  symp- 
toms of  dysentery  and  even  with  the  fipces  well  formed. 

(2)  Traumatism  is  an  occasional  cause.  The  iiijury  is  generally  in  the 
hepatic  region.  Two  instances  have  come  nnder  my  notice  of  it  in  brake- 
men  who  were  injured  while  coupling  cars.  Injury  to  the  head  is  not  in- 
frequently followed  by  liver  abscess. 

(3)  End)olic  or  ])yiX'mic  abscesses  are  the  most  nnmerons,  and  may  de- 
vclo])  in  a  general  i)y;emia  from  any  cause  or  follow  foci  of  su])puration  in 
the  territory  of  the  jiortal  vessels.  The  infective  agents  may  reach  the 
liver  throngh  the  he])atic  artery,  as  in  those  cases  in  which  the  original 
focus  of  infection  is  in  the  area  of  tlie  systemic  circulation;  though  it  may 
happen  occasionally  that  the  infective  agent,  instead  of  passing  through 


578 


DKSHASKS  ol-'  THE   DUiKSTlVE  SYSTEM. 


Hk'  liinj^'s,  rcaclics  tlic  liver  llir(»n<,'li  llic  inl'ci'ior  vciiii  c.-iva  nnd  (lie  ln'initic 
veins.  A  reiiiiiikiihle  iii>limee  of  iiiiilti|ile  iil)sc'i'ssert  ol'  arterial  origin  was 
aH'ordcd  hy  11h'  ease  ol'  aiieiirisin  of  the  hepatic;  artery  reported  hy  lloss 
and  myself.  iiilVction  tliron^^h  the  portal  vein  is  nuicli  more  common.  JL 
results  from  dy.^entery  and  other  nieei'ative  all'eetions  oi'  the  howels,  appen- 
dicitis, occasionally  after  typhoid  i'ever,  in  rectal  all'eetions,  and  in  ahscessi's 
in  the|>elvis.  In  these  cases  the  ahseesses  are  multiple  and,  as  a  rule,  within 
the  branches  of  the  poital  vein — suppurative  pyle|)hlel)itis. 

(I)  .\  not  uncommon  cause  oi'  suppuration  is  inllamination  of  the  bilo- 
passa^cs  caused  hy  jiall-stones,  moiv  rarely  l»y  parasites — suppurative  cho- 
langitis. 

Jn  Honio  instances  of  tuberculosis  of  the  liver  tlu'  alfection  is  chielly  of 
the  hile-ducts,  with  the  formation  of  inulti[)lc  tuberculous  ubsces.ses  con- 
laiiiiii;^;'  a  bile-stained  i)us. 

(o)  I''orei}i;n  bodies  and  parasites.  In  rare  instances  forei<fn  bodies,  such 
as  a  lu'cdie,  may  i)ass  from  the  stomach  or  gullet,  lodge  in  the  liver,  and 
excite  an  abscess,  or,  as  in  several  instances  which  have  been  reported,  a 
foreign  body,  such  as  a  needle  or  a  iish-bone,  has  ])erforated  a  bramdi  or 
the  ])ortal  vein  itself  and  induced  extensive  ])yleplilebitis.  Judiinococcus 
cysts  fre(|ucntly  cause  su[)puration;  the  i)eiu't]'alion  of  round  worms  into 
tlie  liver  less  commonly;  and  most  rarely  of  all  the  liver-ihike. 

Morbid  Anatomy. — (a)  Of  Ihe  SoUlanj  or  Tropical  Abscess. — This 
is  not  always  single;  there  may  bo  two  or  even  more  large  abscess  cavities, 
ranging  in  size  from  an  orange  to  a  child's  head.  The  largest-sized  ab- 
scess may  contain  from  3  to  G  litres  of  pus  and  involve  more  than  three 
fourths  of  the  entire  organ.  In  Waring's  statistics,  63  per  cent  of  the  cases 
were  single.  The  abscess  in  nearly  70  per  cent  of  the  cases  was  in  the 
right  lobe,  more  toward  the  convexity  than  the  concave  side.  In  long- 
standing cases  the  abscess-wall  may  be  firm  and  thick,  but,  as  a  rule,  the 
cavity  possesses  no  definite  limiting  membrane,  and  section  of  the  wall 
shows  an  internal  layer  grayish  in  color,  shreddy,  and  made  up  of  necrotic 
liver  substance,  pus-cells,  and  amcoba-;  a  middle  layer,  brownish  red  in 
color;  and  an  external  zone  o-  hypei'ivmic  liver  tissue.  The  jius  is  often 
reddish  brown  in  color,  closely  resembling  anchovy  sauce.  In  other  in- 
stances it  is  grayish  white,  mucoid,  and  may  be  quite  creamy.  The  odor 
is  at  times  very  ])eculiar.  In  one  instance  it  had  the  sour  smell  of  chyme, 
though  no  connection  with  the  stomach  was  found.  In  amoebic  dysen- 
tery there  nuiy  also  be  multijile  miliary  abscesses  in  the  liver,  containing 
amo'ba'. 

The  bacteriological  examination  of  the  contents  show  cither  a  sterile  pus 
or,  in  some  cases,  staphylococci,  streptococci,  or  the  colon  bacillus.  The 
termination  of  this  form  of  abscess  may  be  as  follows,  as  noted  in  Waring's 
oOO  cases:  IJemaiued  intact,  5()  per  cent;  opened  by  operation,  1(5  ])er  cent; 
perforated  the  right  pleura,  nearly  5  per  cent;  ru])tured  into  the  right  lung, 
9  i)er  cent:  ruptured  into  the  peritonanim,  5  per  cent;  ruptured  into  the 
colon,  nearly  ?>  \)vv  cent;  and  there  were,  in  addition,  instances  which  rup- 
tured into  the  hepatic  and  l)ilo-vessels  and  into  the  gall-bladder.  Flcxnor 
has  reported  two  cases  of  perforation  into  the  inferior  vena  cava.     For  a  full 


AnsrFHS  OP  T!IK    I.I  VEIL 


5Yl) 


lu'imlic 
;iu  WHS 
ly  J{(iss 
on.  It 
apin'U- 

,  within 

lie  hilo- 
ivo  cIhj- 

liffly  ol' 
■ics  cun- 

crf,  sucli 
vol",  and 
ortcd,  a 
aneh  or 

lOCOCCllS 

■ms  into 

s.— This 
cavities, 
dzed  ah- 
an  tliree 
Lhe  casrs 
s  in  the 
]i  lun>,'- 
ule,  the 
the  wall 
necrotic 
I   red   in 
is  often 
ther  in- 
'lie  odor 
■  chyme, 
dysen- 
itaining 

rile  pus 
^.  The 
iVa  ring's 
)er  cent; 
ht  Inner, 
nto  the 
icli  nip- 
Floxner 
or  a  full 


cunslderutiou  of  the  snhjert   of  anm'hic  nhscess  of  the  liver  the  reader  in 
referred  to  lialleiir's  artich'  in  AJIinitt's  Sy>tfni  ol'  Meditiiic. 

{b)  Of  Sej)lic  and  l*ij(vmic  Alm-csscH. — These  are  usnally  multiple,  thouj;h 
occasionally,  following  injury,  there  may  l)e  a  large  solitary  colh'ciion  of  pus. 

In  su[)purative  pylepldchitis  the  liver  is  nnil'ormly  enhirgcil.  The  cap- 
sule may  be  smooth  and  the  external  surface  of  the  organ  of  nurmal  ap- 
iicarance.  In  other  instances,  numerous  yellowish-white  points  ap|»ear  be- 
neath the  cai)sule.  i)\\  section  there  are  isolated  pockets  of  pus.  either 
having  a  round  outline  or  in  some  places  distinctly  dendritic,  and  from 
these  the  pns  may  be  scpieczed.  They  look  like  snndl,  solitary  abscesses, 
hut,  on  j)robing,  arc  found  to  coniniunicate  with  the  portal  vein  and  to 
represent  its  branches,  distended  and  su[)purating.  The  entire  portal  sys- 
tem within  the  liver  nuiy  be  involved;  sometimes  territories  are  cut  olf  by 
lhrond)i.  The  suppuration  nmy  exleiul  into  the  nuiin  branch  or  even  into 
the  mesenteric  and  gastric  veins.  The  ])us  nuiy  be  fetid  and  is  often  bile- 
stained;  it  may,  however,  be  thick,  tenacious,  and  laudable.  In  suppura- 
tive cholangitis  there  is  usually  obstructi(jn  by  gall-stones,  the  duels  are 
greatly  distended,  the  gall-bladder  enlarged  and  full  of  i)Us,  and  the  branches 
within  the  liver  are  extremely  distended,  so  that  on  section  there  is  an  a[)- 
pearance  not  unlike  that  described  in  pylephU^bitis. 

Su])i)uration  about  the  echinococcus  cysts  may  be  very  extensive,  forming 
(■Mornu)Us  abscesses,  the  characters  of  which  are  at  once  recognized  by  the 
remnants  of  the  cysts. 

Symptoms. — {a)  Of  the  Large  Solilarij  Ahsress. — In  the  tropics  there 
lire  instances  in  which  the  abscess  ap])ear8  to  be  latent  tuid  to  run  a  course 
without  definite  symi)tonis;  death  may  occur  suddenly  from  ru])ture. 

Fever,  pain,  enlargement  of  the  liver,  and  the  develo[)mcnt  of  a  septic 
condition  are  the  important  symptoms  of  hei)atic  abscess.  The  tempera- 
ture is  elevated  at  the  outset  and  is  of  an  intermittent  or  septic  type.  It 
is  irregular,  and  may  remain  normal  or  even  subnormal  for  a  few  days; 
then  the  patient  has  a  rigor  and  the  temperature  rises  to  103°  or  higher. 
Owing  to  this  intermittent  character  of  the  fever  the  cases  are  usually,  in 
this  latitude,  mistaken  for  malaria.  The  fever  may  rise  every  afternoon 
without  a  rigor.  Profuse  sweating  is  conunon,  particularly  when  the  ])a- 
tient  falls  asleep.  In  chronic  cases  tlicre  may  be  little  or  no  fever.  One 
(if  my  patients,  with  a  liver  abscess  which  had  perforated  the  lung,  coughed 
up  |)us  after  his  temjjerature  had  been  nornuil  for  weeks.  -  The  pain  is 
variable,  and  is  usually  referred  to  the  back  or  shoulder;  or  there  is  a  dull 
lulling  sensation  in  the  right  hypochondriuni.  When  turned  on  the  left 
side,  the  patient  often  com])lains  of  a  heavy,  dragging  sensation,  so  that 
he  usually  prefers  to  lie  on  the  right  side;  at  least,  this  has  been  the  case 
in  a  majority  of  the  instances  which  have  come  \nider  my  observation.  Pain 
on  pressure  over  the  liver  is  usually  present,  particularly  on  deep  pressure 
at  the  costal  margin  in  the  nipple  line. 

The  enlargement  of  the  liver  is  most  marked  in  the  right  lobe,  and.  as 
ihe  abscess  cavity  is  usually  situated  more  toward  the  upper  than  the  un- 
der surface,  the  increase  in  volume  is  upward  and  to  the  right,  not  down- 
ward, as  in  cancer  and  the  other  affections  producing  enlargement.     Per- 


680 


DISHASKS  OF  TIIK   DKJKSTIVE  SYSTEM. 


/ 


cussion  ill  the  inid-stcnial  iiiid  imnislcniiil  lines  iiiiiy  .sliow  n  noniinl  limit. 
At  the  ni|>ple-iine  the  eiirvc  of  liver  (liiliiess  lie^riiis  to  rise,  and  in  tlie  iiiid- 
nxillarv  it  may  reaeh  the  lil'th  rih,  while  heliiiul,  near  the  spine,  the  area 
ol'  (lidness  may  he  almost  on  a  level  with  the  an^k'  of  the  scapula.  Ol' 
course  there  are  instances  in  which  this  characteristic;  feature  is  not  present, 
as  when  the  ahscess  occu|»ii's  the  h'ft  lohe.  The  enlar;j;enu'nt  of  tlu!  liver 
may  he  so  great  as  to  cause  hulying  oi'  the  rigiit  side,  and  the  edge  muy 
project  a  hand's-hreadth  or  more  helow  the  costal  margin.  Jn  such  in- 
stances tiie  surface  is  smooth.  I'alpation  is  painful,  and  there  may  he 
fremitus  on  deep  inspiration.  In  some  instances  lluclualioii  may  he  de- 
tected. Adhesions  may  form  to  the  ahdominal  wall  and  the  ahscess  may 
point  helow  the  margin  of  the  rihs,  or  even  in  the  epigastric  region.  Jn 
many  lases  the  appearance  of  the  jmtient  is  suggestive.  The  skin  has  a 
sallow,  slightly  icteroid  tint,  the  face  is  pale,  the  complexion  muddy,  the 
conjunctiva'  are  inliltrated,  and  often  slightly  bile-tinged.  There  is  in  the 
facies  and  in  the  general  appearance  of  the  patient  a  strong  suggestion  of 
the  existence  of  abscess.  There  is  no  internal  aU'ection  associated  with  sup- 
puration which  gives,  I  think,  just  the  same  hue  as  certain  instances  of 
abscess  of  the  liver.  Marked  jaundice  is  rare.  Diarrlura  may  be  present 
and  may  give  an  important  clew  to  the  luiture  of  the  case,  jjarticularly  if 
anuehiu  are  found  in  the  stools,     t.'onstipation  nuiy  oeeur. 

Remarkable  and  characteristic  symptoms  arise  when  the  abscess  invades 
the  lung.  The  extension  may  occur  through  the  diaphragm,  without  actiuil 
ru))ture,  and  with  the  ]iroduction  of  a  ])urulent  pleurisy  and  invasion  of 
the  lung.  The  ])atients  gradually  develoj)  a  severe  cough,  usually  of  an 
aggravated  and  convulsive  character,  there  are  signs  of  involvement  at  the 
l)ase  of  the  right  lung,  defective  resonance,  feeble  tubular  breathing,  and 
increase  in  the  tactile  fremitus;  but  the  most  characteristic  feature  is  the 
])resence  of  a  reddish-brown  exi)ectoration  of  a  brick-dust  color,  resembling 
anchovy  sauce.  This,  which  was  noted  originally  by  ]}udd,  was  ])resent 
in  our  cases,  and  in  addition  Reese  and  LaHenr  found  the  aiiuvlxe  c.oli  iden- 
tical with  those  which  exist  in  the  liver  abscess  and  in  the  stools.  They 
are  ])resent  in  variable  numbers  and  display  active  anucboid  movements. 
The  brownish  tint  of  the  expectoration  is  due  to  blood-|)igment  and  blood- 
corj)uscles,  and  there  may  be  orange-red  crystals  or  haMuatoidin. 

The  abscess  may  perforate  externally,  as  mentioned  already,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  The  duration  of  this 
form  is  very  variable.  It  nuiy  run  its  course  and  j)rove  fatal  in  six  or  eight 
■weeks  or  may  persist  for  several  years. 

The  ]n'ognosis  is  serious,  as  the  mortality  is  more  than  50  per  cent. 
The  deatli-rate  has  been  lowered  of  late  years,  owing  to  the  greater  fearless- 
ness with  which  surgeons  now  attack  these  cases. 

{h)  Of  the  ri/wmic  Ahscess  and  SxtppuraUve  Pylephlehiiis. — Clinically 
these  conditions  cannot  be  separated.  Occurring  in  a  general  pyjemia,  no 
special  features  may  be  added  to  the  ca^;e.  When  here  is  supimration 
within  the  portal  vein  the  liver  is  uniforudy  enlarged  and  tender,  though 
pain  may  not  be  a  marked  feature.  There  is  an  irregular,  septic  fever,  and 
the  complexion  is  muddy,  sometimes  distinctly  icteroid.     The  features  are 


AIJSCKSS  OF  TIIK    LIVKU. 


581 


1 


indeed  lliose  of  pyivmiii,  plus  n  sli;:li(  i(  tcniid  tiii;:('.  mid  an  (>nlnrj:od  luid 
|iiiinl'iil  liver.  'I'lio  Iiitter  IVaturcs  idunc  ai»'  |»f(idiiir.  'I'lic  .sweats,  cliills, 
|l|■n^t^ati()n,  and  I'evcr  have  iiolliiiiii:  distinctive. 

DiagnoaiB.— Ahscess  of  liic  livci'  mav  l)e  eonfoundcd  witli  iiitcrniit- 
Uiit  fever,  a  eoninion  mistake  in  malarial  re<,Mnns.  Practically  an  intermil- 
Icnt  fever  which  resists  ([uinine  is  n(tt  malarial.  Laveran's  orpmisms  are 
idx)  absent  from  the  hlond.  When  the  ahscess  hnrsts  into  the  |»l(Mini  ti 
litilit-sided  empyema  is  |)r(»dnced  and  perforation  of  the  lun;;  usually  fol- 
lows. When  the  liver  ahscess  has  been  latent  and  dysenteric  symptoms  have 
not  heen  marke(l,  the  condition  may  he  considered  empyema  or  al)scess  of 
I  he  hin;,'.  In  such  cases  the  anchovy-sauce-like  ('(dor  of  the  pus  and  the 
presence  of  the  aiiKehii-  will  enable  one  to  maki'  a  definite  diaj,Miosis,  as  has 
been  done  in  cases  by  liaileur.  Perforation  externally  is  readily  r<'c<»<;ni/ed, 
and  yet  in  an  abscess  cavity  in  the  epipistric  re<,Mon  it  nniy  be  dilb.ult  to  say 
whether  it  has  jn'oeeeded  from  the  liver  or  ia  in  the  abdominal  wall.  When 
the  abscess  is  lar^^e,  and  the  adhesions  are  so  firm  that  the  liver  does  not  de- 
scend durin;^'  inspiration,  the  e.xploratoi'y  needle  does  not  make  an  up-and- 
down  movement  durinj,'  aspiration.  In  an  instance  of  this  kind  which  I 
saw  with  1  learn  nt  the  rhiladel[)hia  Hospital,  all  the  features,  local  and 
^H'lieral,  seemed  to  ])()int  to  abscess  in  the  abdominal  wall,  but  the  operation 
revealed  a  large  i)erforating  abscess  cavity  in  the  left  lobe  of  the  liver.  Tho 
diagnosis  of  suppurating  echinococeus  cyL;t  is  rarely  possible,  exeei)t  in 
Australia  and  Iceland,  where  hydatids  are  so  common. 

Perhaps  the  most  inqtortant  ad'ection  from  which  su])purati()n  within 
the  liver  is  to  be  se[)arated  is  the  intermittent  hepatic  fever  associated  with 
gall-stones.  Of  the  eases  rci)orted  a  majority  have  been  considered  due  to 
su|)pnration,  and  in  two  of  my  cases  the  liver  had  Ijeen  repeatedly  asjjirated. 
Post-mortem  examinations  have  shown  conclusively  that  the  higli  fever  and 
cliills  may  recur  at  intervals  for  years  without  su|)purati()n  in  the  ducts. 
The  distinctive  features  of  this  condition  are  ]»aroxysms  of  fever  with 
rigors  and  sweats — which  may  occur  with  great  regularity,  Imt  which  more 
often  are  separated  by  long  intervals — the  deepening  of  the  jaundice  after 
the  paroxysms,  the  entire  a])yrcxia  in  the  intervals,  and  the  maintenance 
of  the  general  nutrition.  The  time  element  also  is  important,  as  in  some 
of  these  cases  the  disease  has  lasted  for  several  years.  I''inally,  it  is  to  bo 
reiiiend)ered  that  abscess  of  the  liver,  in  temperate  clinuites  at  least,  is  in- 
variably secondary,  and  the  primary  source  must  be  carefully  sought  for, 
either  in  dysentery,  slight  idccration  of  the  rectum,  suppurating  hivmor- 
I'lioids,  ulcer  of  the  stomach,  or  in  suppurative  diseases  of  other  parts  of  the 
iiody,  i)articularly  in  the  skull  or  in  the  bones. 

The  presence  of  a  leucoeytosis  is  the  most  important  feature  in  all  forms 
of  suppuration  of  the  liver. 

Ill  suspected  cases,  whether  the  liver  is  enlarged  or  not,  ex])loratory 
aspiration  may  be  performed  without  risk.  The  needle  may  be  entered  in 
tho  anterior  axillary  line  in  the  lowest  intersjiace,  or  in  the  seventh  inter- 
s])ace  in  the  mid-axillary  line,  or  over  the  centre  of  the  area  of  dulness 
lu'hind.  The  patient  should  he  placed  under  ether,  for  it  may  be  neccs- 
.<ary  to  make  several  deep  punctures.     It  is  not  well  to  use  too  small  an 


BMJ 


DISKASKS  OF  TIIK   I »!» > KST I V K  SVS'I'KM. 


/ 


ns|iirnt(ir.  No  ill  cH'iils  rnllow  IIiIm  jtroccdiirc,  cvfii  tli(Mi;,'h  \)Uuh\  mnv 
Inik  irilo  llic  |>('rilurital  ciivily.  Iv\tt'ii.-i\r  sii|)|>iiiiiti(in  may  vwM,  uiid  yvi 
lie  iiii»c(l  ill  till'  aspiniliiiii,  particularly  wlii'ii  tlii'  hiaiiclicH  of  tlio  porliil 
vi'in  aro  distcDilcd  wit  h  |iiis. 

Treatment.— Pya'iiiii!  abscesH  and  sii|i|tiirativ('  |»ylf]ili|('l)i(i.s  are  in- 
varialily  lalal.  Trcvt'S,  liowcvcr,  reports  a  case  id'  pya-iiiic  alisccss  lulluwiiii^' 
apptiidicitiH  in  vvhirli  the  patient  recovered  after  au  exploratory  operatitjn. 
Siir;^i(al  measures  are  not  just  ilicd  in  tiieso  eases,  iiide.-s  an  ubseess  shows 
si^Mis  of  poinlinjr.  As  the  abscesses  associated  with  dysentery  are  often  singh', 
tlicy  all'ord  a  reas<»iial»l<'  hope  of  heiiclil  from  operation.  If,  however,  tin; 
piilient  is  expecloialiiig  the  pus,  if  the  general  condition  is  good  and  tho 
iiiclic  fever  iioi  marked,  it  is  heJ't  to  dtd'er  operation,  us  many  of  these  in- 
Htanees  recover  spontaneously.  The  largo  single  abscesses  are  the  most 
favornhlc  I'oi'  o|»eralioi'.  The  general  medical  treatment  of  the  ca.-es  is  tliuL 
oi'  ordinary  septiciemia. 


IX.     NEW    GROWTHS    IN    THE    LIVER. 

1'heso  may  he  cancer,  either  primnry  or  s<'condary.  sarcoma,  or  angioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frecpiency  of  in- 
ternal cancer.  It  is  rarely  primary,  nsually  secondary  to  cancer  in  other 
organs.  Jt  is  il  disease  of  late  adult  life.-  According  to  Lcichtenstern, 
over  oU  ])er  cent  of  the  cases  occur  between  the  fortieth  and  the  si.xtietli 
years.  It  occasionally  occurs  in  children.  Womcni  are  attacked  less 
I'reiiuently  than  men.  It  is  stated  by  some  authors  that  secondnry  can- 
cer is  more  common  in  women,  owing  to  the  fre(piency  of  cancer  of  the 
uterus.  Heredity  is  bel.eved  to  have  an  inlluence  in  from  1.")  to  20  jier 
cent. 

In  many  cases  trauma  is  an  atdecedent,  and  cancer  of  the  bile-passages 
is  associated  in  many  instances  with  gall-stones.  Cancer  is  stated  to  be  less 
coiiiiiioii  in  the  tropics.  Its  relative  ])r<)portion  to  otlier  dist-ases  may  be 
judged  from  the  fact  that  among  the  ilrst  3,UU0  patients  admitted  to  the 
wards  of  tlie  .lohns  Hopkins  Hospital  there  were  seven  cases  of  cancer  of 
the  liver. 

Morbid  Anatomy. — The  following  forms  of  new  growths  occur  in 
the  liver  and  have  a  clinical  importance: 

Cancer. — (1)  Priinarij  canrrr,  of  which  three  forms  may  be  recognized.* 

(<i)  The  massive  cancer,  which  causes  great  enlargement  and  on  section 
shows  a  uniform  mass  of  new  growth,  which  cccujiies  a  large  portion  of 
the  organ.  It  is  grayish  white,  usually  iu)t  softened,  and  is  abruj)tly  out- 
lini'd  from  the  contigiious  liver  substance. 

(h)  Nodular  cancer,  in  which  the  liver  is  occupied  hy  nodidar  masses, 
some  large,  some  small,  irregularly  scattered  throughout  the  orgai,.  Usu- 
ally in  one  region  there  is  a  larger,  perhaps  firmer,  older-looking  mass, which 
indicates  the  primary  seat,  and  the  numerous  nodules  are  secondary  to  it. 

*  llaaot  and  Gilbert,  ^fitudes  sur  les  Maladies  du  Foio,  Paris,  1888. 


ood  niny 
niid  }(l 

li<   put'tiit 

I  luv   iii- 
.'(lUowiii;,' 

IHTlltioll. 

■ss  shows 
.'11  siiigli', 
uvcr,  till! 
ami  till' 
tlicso  iii- 

us  iti  thuL 


NKW   (HIOWTHS   IN   TIIK   I.IVKIt. 


688 


imgioiiui. 
cy  ("l"  iii- 

in  olluT 
iluiisteni, 
D  sixtictli 
•kiMl  less 
lary  ean- 

r  of  the 
20  per 

-l)iissa<:('s 
()  1)L'  loss 
may  Ix.' 
3(1  to  tlio 
•anccr  of 

occur  ill 

[iii/A'd."' 
n  section 
)i'ti()n  of 
)tly  out- 

r  masses, 
TJsu- 
ss,  which 
iry  to  it. 


This  form  is  much  lilxc  the  sccomhiry  cancerous  iii\Mlvi  incut.  cxiTpt  lliat 
it  schhmi  readies  a  lar<;o  hi/e. 

((■)  Tlic  third  is  ,iie  rcmaikalple  and  rare  vari«'ly.  niiicn'  irilli  rirrlniHls, 
which  forms  an  anatomieal  |iieliii'e  |)erfectly  iiiiMtiie  and  at  l\\>\  \eiy  |iii/- 
zlin^'.  'J"'u'  hvi'r  is  not  much  cnhirged,  rarely  weighing  nioir  than  •.',]  or 
;i  kilojr  lines.  The  surface  is  grayish  yelhiw,  studded  over  with  iiothil.ir 
vcllowisii  masses,  rcst'iiilding  the  [trojectioii.s  in  an  ordinary  cirriiotic  li\er. 
On  section  the  c;:nceroiis  nodules  are  seen  scattered  throiighoiil  the  entire 
organ,  varying  in  diameter  from  IJ  to  J<)  or  more  millimetres  and  sur- 
lounded  with  lihrous  tissue. 

Jlistologically,  the  |)riinary  cancers  arc  eiiitheliomala — alveolar  and 
trahcciilar.  The  chaiactci  of  the  cells  varies  greatly,  in  some  varieties  they 
are  |)olynioi'|ilioiis;  in  others  small  i»olyhcdial;  in  others,  again,  giant  cells 
are  found.  In  rare  instancos,  us  in  one  descrihed  hy  (ireendeld,  tlio  cells  are 
cylindrical.  The  trabecular  form  of  ejiithelioma  is  also  known  aii  adenoma 
or  adeiio-carcinoma. 

{'i)  i^ccoiidai!/  l.'iiiiccr. — The  organ  is  usually  enormously  enlarged,  and 
may  weigh  20  pounds  or  more.  The  cancerous  r  dules  project  heneati: 
till'  capsule,  and  can  be  felt  during  life  or  even  seen  throng!)  the  thin  ab- 
dominal walls.  They  are  usually  di.sseminated  ecpially,  though  in  rare  in- 
stances they  may  be  condiied  to  one  'obe.  The  consistence  of  the  iiodiili'd 
varies;  in  some  ca.-es  they  are  linn  ai.  'jird  and  those  on  the  surface  show 
a  distinct  umbilication,  duii  to  the  shrinking  of  the  librous  tis-sue  in  the 
centre.  These  supcrllcial  cancerous  masses  are  still  sonietinies  spoken  of 
as  "  Farrc's  tubercles.''  .More  I'reciuently  the  niasses  are  on  section  grayish 
while  in  color,  or  ha'inorrhagic.  liiipture  of  blood-vessels  i.s  not  uncommou 
ill  these  cases,  in  one  specimen  there  was  an  enormous  clot  licneatli  the 
capsule  of  the  liver,  together  with  lueniorrhage  into  the  gall-bladder  and 
into  the  ])erit()nieiini.  The  secondary  cancer  shows  tbe  same  structure  as 
tlie  initial  lesion,  and  is  usually  either  an  alveolar  or  cylindrieal  carcinoma, 
hegeneration  is  common  in  these  secondary  growths;  thus  the  hyaline 
transformation  may  convert  large  areas  into  a  dense,  dry,  grayish-yellow 
mass.  Kxtensive  areas  of  fatty  degeneration  may  occur,  sclerosis  is  not 
iinconimon,  and  luemorrhages  are  frequent  Sujipuration  sometimes 
follows. 

(3)  Cancer  of  the  hilc-passar/cs  which  lias  hecn  already  considered. 

Sarcoma. — Of  jn-imary  sarcoma  of  the  liver  very  few  cases  have  been 
reported.  Secondary  sarcoma  is  more  frecpient,  and  many  e.xamides  of 
lympho-sarconia  and  myxo-sarcoma  are  on  record,  less  frequently  glio-sar- 
coiiia  or  the  smooth  or  striped  myoma. 

The  most  imjiortant  form  is  the  inelano-sarcoma,  which  develojis  in  the 
liver  secondarily  to  sarcoma  of  the  eye  or  of  the  skin.  Very  rarely  nielano- 
sarcoina  develo])S  ])riinarily  in  tlie  liver.  Of  the  reportt'd  cases  TIanot  ex- 
cludes all  but  one.  In  tliis  form  the  liver  is  greatly  enlarged,  is  cither  uni- 
formly infiltrated  with  the  cancer,  which  gives  the  eut  surface  the  ajipear- 
ance  of  dark  granite,  or  there  are  large  nodular  masses  of  a  deep  black  or 
marbled  c(dor.  There  are  nsually  extensive  metastases,  and  in  some  in- 
stances every  organ  of  the  body  is  involved.     Nodules  of  raelano-sarcoma 


584 


DISEASES  OP  TOE  DIGESTIVE  SYSTEM. 


/ 


UM\ 


of  tlio  skin  may  jfivt'  a  clew  to  the  diagnosis,    nainbiirgor  (J.  II.  II.  Bulle- 
tin,.] S!J,S)  lias  n'])orto{l  tlio  cases  wliicli  Jiave  been  in  my  wards. 

Other  Forms  of  Liver  Tumor.— One  of  the  commonest  tumors  in  the 
liver  is  the  angionui,  which  occurs  as  a  small,  reddish  body  the  size  of  a 
walnut,  ami  consists  simply  of  a  series  of  dilated  vessels.  Occasionally  in 
cliildren  angionuita  have  develo})ed  and  produced  large  tumors. 

Cysts  are  occasionally  foun(l  in  tlie  liver,  either  single,  which  are  not 
very  uncommon,  or  multiple,  when  they  usually  coexist  with  congenital 
cystic  kidneys. 

Symptoms. — It  is  often  imjjossiblc  to  differentiate  primary  and  sec- 
ondary cancer  of  the  liver  unless  tiie  jn-imary  seat  of  the  disease  is  evident, 
as  in  the  case  of  scirrhns  of  the  breast,  or  cancer  of  the  rectum,  or  of  a 
tumor  in  the  stomach,  which  can  be  felt.  As  a  rule,  cancer  of  the  liver  is 
associated  with  ])rogressive  enlargement;  but  there  arc  cases  of  primary 
nodular  cancer,  and  in  the  cancer  with  cirrhosis  the  organ  may  not  be  en- 
larged. Gastric  disturbance,  loss  of  appetite,  nausea,  and  vomiting  are  fre- 
(pient.  Progressive  loss  of  flesh  and  strength  may  be  the  first  symptoms. 
Tain  or  a  sensation  of  uneasiness  in  the  right  hypochondriac  region  may 
be  ])resent,  but  enormous  enlargement  of  the  liver  may  occur  without  the 
slightest  pain.  Jaundice,  which  is  present  in  at  least  one  half  of  the  cases, 
is  usually  of  moderate  extent,  unless  the  common  duct  is  occluded.  As- 
cites is  rare,  except  in  the  form  of  cancer  with  cirrhosis,  in  which  the  clinical 
picture  is  that  of  the  atro})hic  form.  Pressure  by  nodules  on  the  portal 
vein  or  extension  of  the  cancer  to  the  poritonamm  may  also  induce  ascites. 

Inspection  shows  the  abdomen  to  be  distended,  particularly  in  the  upper 
zone.  In  late  stages  of  the  disease,  when  emaciation  is  marked,  the  can- 
cerous nodules  can  be  plainly  seen  beneath  the  skin,  and  in  rare  instances 
even  the  umbilications.  The  superficial  veins  are  enlarged.  On  palpi^tion 
the  liver  is  felt,  a  hand's-breadth  or  more  below  the  costal  margin,  de- 
scending with  each  inspiration.  The  surface  is  usually  irregular,  and  may 
present  large  masses  or  smaller  nodular  bodies,  either  rounded  or  with  cen- 
tral dejjressions.  In  instances  of  diffuse  infiltration  the  liver  may  be  greatly 
enlarged  and  ]iresent  a  perfectly  smooth  surface.  The  growth  is  progres- 
sive, and  the  edge  of  the  liver  may  ultimately  extend  below  the  level  of  the 
navel.  Although  generally  uniform  and  ])roducing  enlargement  of  the 
whole  organ,  occasionally,  when  the  tumor  develops  from  the  left  lobe,  it 
may  form  a  solid  mass,  which  occuj^ies  the  epigastric  region.  By  percussion 
the  outline  can  uo  accurately  limited  and  the  progressive  growth  of  the 
tumor  estimated.  The  spleen  is  rarely  enlarged.  Pyrexia  is  present  in  many 
cases,  usually  a  continuous  fever,  ranging  from  100°  to  102°;  it  may  be  in- 
termittent, with  rigors.  This  may  be  associated  with  the  cancer  alone,  or, 
as  in  one  of  my  cases,  with  su])puration.  (Edema  of  the  feet,  from  aufemia, 
usually  su])ervencs.  Cancer  of  the  liver  kills  in  from  three  to  fifteen  months 
One  ])atient  lived  for  more  than  two  years. 

Diagnosis. — The  diagnosis  is  easy  when  the  liver  is  greatly  enlarged 
and  the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may 
at  first  be  mistaken  for  fatty  or  amyloid  liver,  but  the  presence  of  Jaun- 
dice, the  rapid  enlargement,  and  the  more  marked  cachexia  will  usually 


FATTY  LIVER. 


)85 


.  BuUo- 

5  in  the 
ize  of  ii 
nally  in 

are  not 
ngeuital 

and  sec- 
evident, 
or  of  a 
5  liver  is 
primary 
»t  be  en- 
are  fre- 
mi)toms. 
ion  may 
hout  the 
he  cases, 
ed.     As- 
e  clinical 
le  portal 
e  ascites. 
|he  npper 
the  can- 
instances 
lalpotion 
gin,  de- 
ll d  may 
ith  ccn- 
e  greatly 
progres- 
el  of  the 
of  the 
lobe,  it 
rcussion 
of  the 
in  many 
iiy  be  in- 
lone,  or, 
anemia, 
months 

enlarged 
)ma  •  may 
of  jaun- 
nsually 


sullice  to  ditferentiate  it.  IVrhaps  tlie  most  puzzling  conditions  occur  in 
the  rare  eases  of  enlarged  amyloid  liver  with  irregidar  gunnnata.  Tlie 
large  echinococciis  liver  may  present  a  striking  similarity  to  ean-inoma,  but 
the  })r()jecting  nodules  are  usually  softer,  the  disease  lasts  much  lunger,  and 
the  cachexia  is  not  marked. 

]lyj)ertroi)hic  cirrhosis  may  at  first  be  mistaken  for  carcinonui,  as  the 
jaundice  is  usually  deep  and  the  liver  very  large;  but  the  absence  of  a 
]uarked  cachexia  and  wasting,  and  the  painless,  smooth  character  of  the 
enlargement  are  points  against  cancer.  When  in  doubt  in  these  cases, 
aspiration  may  be  safely  performed,  and  positive  indication  may  be  gained 
from  the  materials  so  obtained.  In  large,  rapidly  growing  secondary  can- 
cers the  superficial  rounded  masses  may  ahnost  iluctiuite  and  these  soft 
tumor-like  projections  may  contain  blood.  The  form  of  cancer  with  cir- 
rhosis can  scarcely  be  separated  from  atrophic  cirrhosis  itself.  I'erhajJS 
the  wasting  is  more  extreme  and  more  rapid,  Init  the  jaundice  and  the 
ascites  are  identical.  Melano-sarcoma  causes  great  enlargement  of  the 
organ.  There  are  frequently  symi)toms  of  involvement  of  other  viscera, 
as  the  lungs,  kidneys,  or  spleen.  Secondary  tumors  may  develop  on  the 
skin.  A  very  important  symptom,  not  present  in  all  cases,  is  melanuria, 
the  passage  of  a  very  dark-colored  urine,  A\hich  may,  however,  when  first 
voided,  be  quite  normal  in  color.  The  existence  of  a  melano-sarcoma  of 
the  eye,  or  the  history  of  blindness  in  one  eye,  with  subsequent  extirpa- 
tion, may  indicate  at  once  the  true  nature  of  the  hepatic  enlargement. 
The  secondary  tumors  may  develop  some  time  after  the  extirpation  of 
the  eye,  as  in  a  case  under  tlie  care  of  J.  C.  Wilson,  at  the  Philadelphia 
nos])ital,  or,  as  in  a  case  under  Tyson  at  the  same  institution,  the  pa- 
tient may  have  a  sarcoma  of  the  choroid  which  had  never  caused  any  symp- 
toms. 

The  treatment  must  be  entirely  symptomatic — allaying  the  pain,  reliev- 
ing the  gastric  disturbance,  and  meeting  other  symptoms  as  they  arise. 


X.    FATTY    LIVER. 

Two  different  forms  of  this  condition  are  recognized — the  fatty  infil- 
tration and  fatty  degeneration. 

Fatty  infiltration  occurs,  to  a  certain  extent,  in  normal  livers,  since 
the  cells  always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  much  less  common  condition,  the 
proto])lasm  of  the  liver-cells  is  des^iroyed  and  the  fat  takes  its  place,  as  seen 
in  cases  of  malignant  jaundice  and  in  phosphorus  poisoning. 

Fatty  liver  occurs  under  the  following  conditions:  (a)  In  association 
with  general  obesity,  in  which  case  the  liver  appears  to  be  one  of  the  store- 
houses of  the  excessive  fat.  (h)  In  conditions  in  which  the  oxidation  pro- 
cesses are  interfered  with,  as  in  cachexia,  profound  anaemia,  and  in  ])hthisi3. 
The  fatty  infiltration  of  the  liver  in  heavy  drinkers  is  to  be  attributed  to 
the  excessive  demand  made  by  the  alcohol  upon  the  oxygen,  (e)  Certain 
poisons,  of  which  phosphorus  is  the  most  characteristic,  produce  an  intense 


■ 


680 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


/ 


fatty  (Ic'^a-neratioii  with  necrosis  of  tlie  livcr-cclls.     Tlie  poison  of  acute 
yclluw  atrophy,  whatever  its  nature,  acts  in  the  same  way. 

The  fatty  liver  is  uuii'oniily  increased  in  size.  Tlie  ed^^e  may  reach 
below  the  level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless;  on 
section  it  is  diy,  and  renders  the  surface  ol'  the  knife  greasy.  The  liver 
may  weigh  majiy  pounds,  and  yet  tlie  s])eciilc  gravity  is  so  low  that  the 
entire  organ  iloats  in  water. 

The  sym])toms  of  fatty  liver  are  not  definite.  Jaundice  is  never  pres- 
ent; the  sto(ds  may  be  light-colored,  but  even  in  the  most  advanced  grades 
the  bile  is  still  formed.  Signs  of  portal  obstruction  are  rare.  Ila'mor- 
rhoids  are  not  very  infrequent.  Altogether,  the  symiitoms  are  ill-defined, 
and  chiefly  those  of  the  disease  with  which  the  degeneration  is  associated. 
In  cases  of  great  obesity,  the  physical  examination  is  uncertain;  but  in 
])hthisis  and  cachectic  conditions,  the  organ  can  be  felt  to  be  greatly  en- 
larged, thoiigh  smooth  and  painless.  Fatty  livers  are  among  the  largest 
met  with  at  the  bedside. 


XI.     AMYLOID    LIVER. 

The  waxy,  lardaceous,  or  amyloid  liver  occurs  as  part  of  a  general  de- 
generation, associated  with  cachexias,  particularly  when  the  result  of  long- 
standing sup[mration. 

In  ])ractice,  it  is  found  oftencst  in  the  prolonged  suppuration  of  tuber- 
culous disease,  either  of  the  lungs  or  of  the  bones.  Next  in  order  of  fre- 
quency are  the  cases  associated  with  syphilis.  Here  there  may  be  ulcera- 
tion of  the  rectum,  with  which  it  is  often  connected,  or  chronic  disease  of 
the  bone,  or  it  may  be  present  when  tbere  are  no  suppurative  changes.  It 
is  found  occasionally  in  rickets,  in  prolonged  convalescence  from  the  infec- 
tious fevers,  and  in  the  cachexia  of  cancer. 

The  amyloid  liver  is  large,  and  may  attain  dimensions  equalled  only 
by  those  of  the  cancerous  organ.  Wilks  speaks  of  a  liver  weighing  four- 
teen pounds.  It  is  solid,  firm,  resistant,  on  section  an.Tmic,  and  has  a 
semitranslucent,  infiltrated  appearance.  Stained  with  a  dilute  solution  of 
iodine,  the  areas  infiltrated  with  the  amyloid  matter  assume  a  rich  mahog- 
any-brown color.  The  precise  nature  of  this  change  is  still  in  question. 
It  first  attacks  the  capillaries,  usually  of  the  median  zone  of  the  lobules, 
and  subsequently  the  interlobular  vessels  and  the  connective  tissue.  The 
cells  are  but  little  if  at  all  affected. 

There  are  no  characteristic  sj/mpfoms  of  this  condition.  Jaundice 
does  not  occur;  the  stools  may  be  light-colored,  but  th  '  secretion  of  bile 
persists.  The  ])hysical  examination  shows  the  organ  ^e  uniformly  en- 
larged and  painless,  the  surface  smooth,  the  edges  roimc'.en,  and  the  con- 
sistence greatly  increased.  Sometimes  the  edge,  oven  in  very  gre?t  enlarge- 
ment, is  sharp  and  hard.  The  spleen  also  may  be  involved,  but  there  are 
no  evidences  of  portal  obstruction. 

The  dingiwsis  of  the  condition  is,  as  a  rule,  easy.  Progressive  and  great 
enlargement  in  connection  with  suppuration  of  long  standing  or  with 


ANOMALIES   IN   FORM   AND   POSITION   OP   TIIK   LIVER. 


587 


)£  acute 

y  reach 
less;  on 
he  liver 
that  tlie 

er  pres- 
l1  grades 
Llajmor- 
-defined, 
sociated. 
hut  in 
)atly  en- 
B  largest 


Qeral  dc- 
of  loug- 

of  tuher- 

ir  of  fre- 

e  ulcera- 

isease  of 

ges.    It 

le  infec- 

ed  only 
ig  four- 
id  has  a 
ution  of 
mahog- 
uestion. 
lohules, 
le.     The 

raundicc 
of  hile 
mly  en- 
;he  con- 
enlarge- 
bere  are 

id  great 
or  with 


syi>hilis,  is  ahuost  always  of  this  nature.     In  rare  instances,  however,  the 
aniyloi<l  liver  is  reduced  in  size. 

In  Icul'cvmxa  the  liver  may  attain  considerahle  size  and  Ije  smooth  i.nd 
uniform,  resemhling,  on  physical  examination,  the  fatty  organ.  The  b'ood 
condition  at  once  indicates  the  true  nature  of  the  case. 


XII.     ANOMALIES    IN    FORM    AND    POSITION    OF   THE 

LIVER. 

In  transposition  of  the  viscera  the  right  lohe  of  the  organ  may  occupy 
the  left  side.  A  common  and  important  anomaly  is  the  tilting  forward  of 
the  organ,  so  that  the  long  axis  is  vertical,  not  transverse.  Instead  of  the 
v^iic  of  the  right  lohe  presenting  just  helow  the  costal  margin,  a  consider- 
alile  portion  of  the  surface  of  the  lobe  is  in  contact  with  the  abdominal 
]iarietes,  and  the  edge  may  be  felt  as  low,  perhaps,  as  the  navel.  This  an- 
teversion  is  ajjt  to  be  mistaken  for  enlargement  of  the  organ. 

The  "  lacing  "  liver  is  met  with  in  two  chief  types.  In  one,  the  anterior 
[)ortion,  chieflj  of  the  right  lobe,  is  greatly  prolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  sepa- 
rates the  thin  extension  from  the  main  portion  of  the  organ.  The  peri- 
toneal coating  of  this  groove  may  be  fdjroid,  and  in  rare  instances  the  de- 
formed portion  is  connected  with  the  organ  by  an  almost  tendinous  mem- 
brane. The  liver  may  be  compressed  laterally  and  have  a  pyramidal  shajjc, 
and  the  extreme  left  border  and  the  hinder  margin  of  the  left  lobe  may  be 
much  folded  and  incurved.  The  projecting  portion  of  the  liver,  extending 
low  in  the  right  flank,  may  be  mistaken  for  a  tumor,  or  more  frequently 
for  a  movable  right  kidney.  Its  continuity  with  the  liver  itself  may  not 
lie  evident  on  palpation  or  on  percussion,  as  coils  of  intestine  may  lie  in 
front.  It  descends,  however,  with  ins])iration,  and  usually  the  margin 
can  be  traced  continuously  with  that  of  the  left  lobe  of  the  liver.  The 
greatest  difficulty  arises  when  this  anomalous  lappet  of  the  liver  is  either 
naturally  very  thick  and  united  to  the  liver  by  a  very  thin  membrane,  or 
when  it  is  swollen  in  coiulitions  of  great  congestion  of  the  organ. 

The  other  princi])al  type  of  lacing  liver  is  quite  diiTerent  in  shape.  It 
is  thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  trans- 
verse line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  anterior 
1, order,  which  is  placed  more  transversely  than  normal.* 

Movable  Liver. — This  rare  condition  has  received  much  attention  of 
late,  and  J.  E.  Graham,  in  a  recent  paper,  has  collected  70  reported  cases 
from  the  literature.  In  a  very  considerable  number  of  these  there  has  been 
a  mistaken  diagnosis.  A  slight  grade  of  mobility  of  the  organ  is  found 
in  the  pendulous  abdomen  of  entero])tosis,  and  after  repeated  ascites. 

The  organ  is  so  connected  at  its  posterior  margin  with  the  inferior 
vena  cava  and  diaphragm  that  any  great  mobility  from  this  point  is  im- 


*  See  P.  Hertz,  Abnormitliten  in  dcr  Lage  und  Form  dcr  Bauchorgane,  Berlin,  1894. 


.  \ 
/ 


688 


DISKASKS  OF  TIIK    DinKSTIVR  SYSTKM. 


|K»ssil)li',  t'X('('|)t  on  tlic  tlicniT  of  ii  nu'S(»-lu'|)iU'  or  coii^ciiitiil  li;;;iUiu'Mlt»ib' 
uiiioii  lii'twrcM  llicso  struct tiri's.  'Tlio  li^iinu'iits,  liowcvcr,  iiiiiy  show  an 
I'xtiTUH'  ^M')i»Ii'  of  icIiiNjitioii  (tlif  suspensory  "('.•'"»  cm.,  nnd  tlit-  lriiin<;iiliir 
li,Uiinu'n(  I  I'M).,  in  one  of  Lciilic's  ciiscs);  niitl  wlicii  tlic  pMliciii  is  in  Uic 
I'li'cl  posturo  tlu'  ()r<'iiji  iniiy  drop  down  so  I'lir  lliat  its  upper  surt'ife  is 
entirely  Itelow  tlu' costid  niiii'^in.  'Tiie  condition  is  rarely  met  willi  in  men; 
r>()  of  the  eases  were  in  women. 


IX.     DISEASES   OF   THE   I'AiNCREAS. 

Tlie  iinportiince  of  disca;es  of  Hie  pancreas  has  l)een  empliasi/ed,  par- 
lit'uhirly  tiirou,uh  studies  made  in  (his  country  hy  l'\  \V.  Draper  on  iiu'inor- 
rhaiic  and  hy  Fit/,  on  .uute  pancreatitis,  wiiih'  (liose  of  Senn  have  created 
a  surgery  of  (he  jihind.  An  additional  in(eres(  has  heen  j,nven  to  (he  or<fan 
hy  the  work  of  v.  Merinji  and  Minkowski  on  pancreatic  diahcles.  The  works 
of  I'laessen  (ISI'J)  and  of  Ancele(  (ISdl!)  j^ive  (he  older  li(era(ure.  The 
modern  study  of  (he  suhjec(  dates  from  Senn's  paper  in  the  American 
Journal  of  the  Medical  Scienc(>s,  ISS,*),  and  l"'i(z's  Middleton  OoldsniKli 
Lecture  for  1S8!).  In  ri'wridn^'  (his  sec(ion  1  have  drawn  freely  on 
Kor(e's  reient  monograph. 


I.     HvtMORRHAGE. 

liotli  Spiess  (18()ti)  and  Zenker  (18M)  were  ac(|nainted  with  luxMiior- 
rliage  into  the  )ani'reas  as  a  cause  of  sudden  dea(h,  hut  (he  gri-at  medico- 
legal importance  of  the  suhjet't  was  tirst  fully  recognized  hy  F.  W.  l)ra|)cr, 
of  Boston,  whose  townsmen,  Harris,  Fitz,  Whitney,  and  others  have  con- 
(ril)ii(ed  additional  studies.  In  -1,000  autopsies  ])ra])er  met  with  1!)  eases 
of  pancreatic  haemorrhage,  in  !)  or  10  of  which  no  other  cause  of  tleath  was 
found.  When  the  bleeding  is  extensive  the  entire  tissue  of  the  gland  is 
destroyed  and  the  blood  invades  the  retro-i)eritoneal  (issue.  In  other  in- 
stances the  i)eritoneal  covering  is  broken  and  tlie  blood  (ills  the  lesser  peri- 
tonannn  (see  haMno-peritonanim).  The  luemorrbage  may  be  in  connection 
with  an  acute  iiancreatitis  or  witli  neerotic  intlanunation  of  the  gland.  In 
an  instance  in  which  there  was  a  small  growth  in  the  tail  of  the  pancreas  I 
found  haMuorrhage  into  the  gland  and  irto  the  retro-peritonanun,  forming 
a  blood  sac  wbii-h  snrronnded  the  left  kidney. 

Zenker  suggest!*  that  the  sudden  death  in  these  cases  is  due  to  shock 
through  the  solar  plexus. 

The  si/inpfoms  are  thus  briefly  summarized  by  Prince:  '*  The  patient, 
■who  has  previously  been  perfectly  well,  is  suddenly  taken  with  the  illness 
which  terminates  his  life.  .  .  .  When  the  luvmorrhagc  occurs  the  patient 
may  be  quietly  resting  or  pursuing  his  usual  occupation.  The  pain  which 
ushers  in  the  attack  is  usually  very  severe  and  located  in  the  upper  part  of 
the  abdomen.     It  steadily  increases  in  severity,  is  sharp  or  perhaps  colicky 


ACUTK  rANCllKATITIS. 


581> 


iniMiltni!-' 
sl\i»\v  nil 
ian^uliir 
s  ill  llu' 
irt'ii<'('  is 
in  incii; 


/.(•(I,  jKir- 
I  liii'iiior- 
L'  cri'iitt'd 
In*  or^TiUi 
lie  works 
V.  Tlu- 
^incriciiii 
oldsmiili 
ivt'ly   oil 


liiiMiior- 
iiu'dico- 

ivo  con- 

!)  cases 

'iitli  was 

iilaiul  is 

lior  iii- 

;sor  ]H'ri- 

iiiot'tion 

iiul.     In 

mcrcas  I 


;o  shocK 

patient, 
e  illness 
patient 
n  whiclr 
l^art  of 
colickv 


in  characler.  II  is  alinosi  I'roiii  llie  (irst  accoiniiMiiicd  hy  nausen  nnd  voiii- 
itiii;,f;  llie  lallcr  Ijccoiiics  rr('i|iiciil  and  oiisliiiatc,  hut  j^ivcs  no  relief.  Tlio 
liatieiil  soon  hcconies  anxious,  ri'slless,  and  dc|ii'essed;  lie  losses  about,  and 
niily  with  dilliciilty  can  lie  he  restrained  in  hed.  Tlu'  surfaee  i.s  cold  and 
tlie  forehead  is  covered  with  a  cold  sweat.  The  pulse  is  weak,  rapid,  and 
sooner  or  later  ini|)erceptil)le.  The  ahdonien  heconies  tender,  Ilic  ti'ndtr- 
iicss  heiiifi;  located  in  the  upper  |)art  of  the  ahdomen  or  epif,'astriuni.  Tyiii- 
paiiite.s  is  sonietiiiies  marked.  The  teiiiperatiire  in  most  cases  is  either 
normal  or  helow  normal.  The  howels  are  apt  to  he  constipated.  These 
syniploms  continue  without  relief,  those  which  are  most  strikiii;^'  heiii;^ 
the  ])ain,  voniilin<i',  anxioiisncss,  resllc.-sncss,  and  the  stat'  of  eolla[tso  into 
whieli  the  patient  soon  falls." 

It  has  heeii  su<f;^es|e(l  in  such  cases  to  open  the  ahdonieli,  expose  the 
pancreas,  and  relieve  the  tension,  since  the  fatal  result  is  often  due  to  tlu! 
pressure  and  not  to  the  loss  of  Mood. 


II.    ACUTE    PANCREATITIS. 

(n)  Acute  HflBmorrhagic  Pancreatitis, — In  this  form  the  inflammation 
is  combined  with  luvmorrhage,  and  it  is  dillicult  to  separate  clearly  the  two 
processes. 

Etiology. — Korte  has  colle(;ted  41  instances,  of  which  only  4  were  iu 
women.  A  large  majority  of  the  cased  occur  iu  adult  males.  JMei'liedran 
has  reported  one  in  a  nine  months'  old  (diild.  ^Many  of  the  j)atients  had 
been  addicted  to  alcohol;  others  had  sull'ered  occasionally  with  severe  pains 
and  vomiling. 

Morbid  Anatomy. — The  jiancreas  is  found  enlarged,  and  the  inter- 
lobular tissue  infiltrated  with  blood,  and  perhaps  with  clots.  Jn  some  in- 
stances the  contiguous  tissues  may  also  be  ha'niorrhagic,  and  the  whole  may 
form  a  large,  firm  mass,  situated  at  the  iipjier  and  back  part  of  the  ab- 
dominal cavity.  The  root  of  the  mesentery,  the  mesocolon,  and  the  omen- 
tum may  also  show  luemorrhages;  the  other  organs  may  l)e  practically  nor- 
mal. As  a  nde  there  can  be  seen  about  the  lobules  areas  of  opacpie  white 
tissue,  and  upon  the  omentum  and  mesentery  similar  opaque,  white  specks, 
which  will  ho  referred  to  subsequently  as  the  fatty  necrosis  of  J3alser.  In 
spots  the  gland-cells  may  also  be  found  necrotic,  while  there  may  be  cases 
showing  a  marked  increase  in  the  fibrous  tissue. 

Symptoms. — One  of  the  most  characteristic  features  is  the  sudden- 
ness of  the  onset,  usually  with  violent  colicky  pain  in  the  upper  part  of  the 
abdomen.  Nausea  and  vomiting  follow,  with  collapse  symptoms,  more  or 
loss  severe  according  to  the  intensity  of  the  attack.  The  ahdomen  hecomes^ 
swollen  and  tense  and  there  is  constipation.  The  temperature  at  first  may 
be  low;  suhsequenly  fever  sets  in,  sometimes  initiated  by  a  chill.  There 
may  he  early  delirium.  Collapse  symi)toms  supervene,  and  death  occurs 
usually  from  the  second  to  the  fourth  day,  or  even  earlier.  The  swelling 
and  infiltration  in  the  region  of  the  pancreas  necessarily  involve  the  co}liae 
I'lexus,  and  the  stretching  of  the  nerves  may  account  for  the  agonizing  paia 


/ 


590 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


i;ii(l  llio  Huddc'ii  colhiiisc.  Jii  a  cmsl-  wliicli  1  liavc  rcjiorted  tlic  piMiiiliinnr 
;4iiii;ilia  were  swollen,  tlio  lu'rve-cclls  indistinct,  and  tlicru  was  an  intersti- 
tial infiltration  of  round  cells.  'J'lie  Pacinian  corpuscles  in  the  neiglihor- 
liood  of  'lie  pancreas  were  enornu)Usly  swollen  and  cedenuitous. 

Deep  pi'cssure  on  the  up[)er  |)art  of  the  alidonien  may  give  evidence  ol' 
cii(  iiui.-crihcd  ri'sistance. 

Diagnosis. — Intestinal  ohstnictiou  or  acute  jierforatinj^  jjeritonitis 
is  usually  suspected.  Now  that  the  condition  has  Ijeconic  better  known 
the  diagnosis  intra  rirnm  has  been  made  (hy  Fitz  and  hy  Thayer).  "  Acnite 
]iancreatitis  is  to  he  sus]iecte(l  when  a  j)i'eviously  healtiiy  person  or  a  sui'- 
I'erer  I'roni  occasional  attacks  of  indigestion  is  suddenly  seized  with  a  violent 
pain  in  the  epigastrium  rollowed  by  vomiting  and  collapse,  and  in  the  conr.se 
of  twenty-four  liours  by  a  circumscribed  epigastric  swelling,  tympanitic 
or  resistant,  with  slight  elevation  of  temperature.  Circumscribed  tender- 
ness in  the  ccnirse  of  the  jnuicreas  and  tender  si)ots  througho\it  the  abdomen 
are  valuable  diagnostic  signs"  (Fitz).  An  interesting  case  admitted  to  the 
Johns  Hopkins  Hospital  illustrates  a  common  mistake.  The  ycmng  man 
liad  had  symptoms  of  obstruction  of  the  bowels  for  three  or  four  (hiys.  Tlu' 
abdomen  was  distended,  tender,  and  very  ])ainful.  1  saw  him  on  admi.ssion, 
agreed  in  the  diagnosis  of  ])roi)able  obstruction,  and  ordered  him  to  bo 
transferred  at  once  to  the  operating-room,  llalsted  found  uo  evidence  of 
obstruction,  but  in  the  region  of  the  jjancreas  and  at  the  root  of  the  mesen- 
tery there  was  a  dense,  thick,  indurated  mass,  and  there  were  areas  of  fat- 
necrosis  in  both  mesentery  and  omentum.  Oddly  enougli  this  patient  re- 
turned four  years  afterward  A\ith  another  attack,  but  he  refused  to  Ijo 
operated  u])on  and  was  taken  away  by  his  friends. 

(h)  Acute  Suppurative  Pancreatitis— Pancreatic  Abscess.— Fitz,  in  his 
monograph  in  ISSD,  re[)orted  22  cases.  To  this  list  Korte  has  added  2i. 
Of  the  cases,  32  were  in  males. 

The  clidlofj;/  in  a  nuijority  of  cases  is  doidjtful.  Dyspeptic  di-sturhances 
and  trauma  have  preceded  the  onset  in  some  instances.  In  24  eases  there 
■was  a  single  abscess;  in  14  there  were  numerous  small  abscesses.  In  other 
instances  there  was  a  dill'use  ])urulent  iiililtration.  Some  of  the  sequels 
are  jjeri-pancreatic  abscess,  ]ierf oration  into  the  stomach,  the  duodenum,  or 
the  ])eritonanim,  and  thrombosis  of  the  portal  vein. 

The  si/wptonis  of  su]ipurative  pancreatitis  are  not  always  well  defined. 
In  one  case  in  my  wards  'J'hayer  made  a  correct  diagnosis.  The  patient, 
aged  thirty-four,  had  had  occasional  attacks  of  severe  ])ain  and  vomiting. 
This  was  followed  by  fever  and  delirium.  A  deep-seated  mass  was  felt  in 
the  median  line  just  above  the  umbilicus.  P'inney  operated  and  found 
disseminated  fat-necrosis  and  a  dee])-seated  abscess  with  necrotic  ])ancr('- 
atic  tissue.  The  patient  recovered.  The  course  of  tlie  suppurative  form 
is  much  more  chronic.  Icterus,  fatty  diarrlura,  and  sugar  in  the  urine 
have  been  met  Avith  in  some  cases.  The  presence  of  a  tumor  mass  in  the 
epigastrium  is  of  the  greatc'^t  moment. 

(c)  Gangrenous  Pancreatitis. — CV)nipleto  necrosis  of  tlie  gland,  or  ]iarl 
of  it,  may  follow  eitlier  lia^morrhage,  acute  inflammation,  or  sujipurative 
infiltration,  and  in  exceptional  cases  may  occur  after  injury  or  the  perfora- 


'iiiilnnjir 
iiitcrsii- 
(.'iglihor- 

dt'iico  of 

M'itoniti? 
L'  known 
"  Acute 
)!•  a  >;u I'- 
ll violent 
ic  course 
nipauitie 
1   teiuler- 
iilxlonien 
jd  to  tlie 
LUig  man 
,ys.     Tin,. 
;1  mission, 
im  to  bo 
idcnce  of 
le  mesen- 
is  of  I'al- 
itient  re- 
ed to  l)e 


in 
dded 


Ins 


nrhauces 
ses  there 
In  other 
sequels 
'uum,  or 

defined. 

])atient, 
omitinjr. 
s  felt  in 
d   found 

l)ancre- 
ivc  form 
he  urine 
f;s  in  the 

or  pari 
»]iurative 
pcrfora- 


ACUTE   PAN( 'UHATITIS. 


591 


tion  of  nn  uloor  of  the  stoniaili.  In  l'"ii/,'s  niono^raitli  l'*  cases  are  re[iorlei|. 
Klirte  has  increased  lliis  lunnber  to  4U.  Syni|ilonis  of  Ineniorrlni^ric  |i.in- 
(i'eatitis  nniy  precede  or  he  associated  wim  it.  Death  usually  f(dlo\\s  in 
from  ten  to  twenty  days,  with  symptoms  of  collapse. 

Analoinically  the  pancreas  may  pre>ent  a  dry  necroti<'  appi'aram-e,  hnt  aa 
a  rnle  the  or^an  is  coincrteil  into  a  dark  slaty-colored  mass  lyinj;  nearly 
fice  in  the  omental  cavity  or  attac  hed  iiy  a  fi'w  shreds,  in  otlu'r  instani-cs 
ilie  totally  or  partially  sc(jnestratetl  ori;an  nniy  lie  in  a  larf^^e  alj.<iess  cavity, 
fdrminy  a  pal|ialde  tumor  in  the  t'i)iyastric  region.  In  two  cases,  reported 
liy  Cliiari,  the  ncci'otic  pancreas  was  discharj^'ed  per  n'ctuni,  with  recovery. 

Relation  of  Fat  necrosis  to  Pancreatic  Disease. — In  connection  with  all 
forms  of  pancreatic  disease  small  yelhjwish  aieas,  to  which  Ualser  llrst  di- 
rected attention,  may  he  found  in  the  interlolmlar  paiu'reatic  tissue,  in  the 
mesentery,  in  the  omentum,  and  in  the  ahdominal  fatty  tissue  generally.  In 
.-li,i;ht  grades  they  may  he  present  without  other  chanyes,  and  they  ha\f  hccn 
M'cn  in  the  living  without  any  disease  of  the  gland  heing  discovered.  They 
are  most  frecpiently  in  the  Inemorrhagie  and  necrotic  fm'ins  of  [)ancreatitis, 
less  common  in  the  supi»urative.  In  the  pancreas  the  lobules  are  seen  to  he 
sc|)arated  by  a  dead-white  necrotic  tissue,  which  gives  a  remarkable  appear- 
ance to  the  section.  In  the  abdonunal  fat  the  areas  are  usually  not  larger 
than  a  jiin's  head;  they  at  once  attract  attention,  and  may  be  mistaken,  on 
su|)eriicial  examination,  for  miliary  tubercles  or  neo])lasms.  Tiiey  may  be 
Lirger;  instances  have  been  reported  in  whitdi  they  were  the  size  of  a  hen's 
v^j:'^.  On  section  they  have  a  soft,  tallowy  consistence.  Langerhans  has 
^liown  that  this  substance  is  a  cond)ination  of  lime  with  certain  fatty  acids. 
They  may  be  crusted  with  lime,  and  in  a  man,  aged  eighty,  who  died  of 
I'.iight's  disease,  I  found  the  lobules  of  the  pancreas  entirely  isolated  by 
areas  of  fatty  necrosis  with  extensive  deposition  of  lime  salts.  There  is  no 
necessary  eti(dogical  relation  between  disease  of  the  ]>ancreas  and  dissemi- 
nated fatty  necroses  of  the  abdomen  at  the  time  the  latter  are  disc()vi're(l. 
(  a^es  have  1)een  found  accidentally  in  la|)arotomy  for  ovarian  tumor  and  in 
instances  in  which  the  ])ancreas  has  been  normal.  They  may  be  ])resent  in 
thin  ])ersons  or  in  association  with  gall-stones.  The  harlrriitiii  coli  com- 
iniiur  was  present  in  two  instances,  with  diphtheritic  colitis,  examined  by 
Welch,  though  in  nu)st  cases  the  areas  of  necrosis  are  sterile,  l.angerhans 
produced  fat-necrosis  by  injecting  extract  of  pancreas  into  the  ]>ei'i-renal 
fiitty  tissue  of  a  dog;  and  Jlildebrand  and  Williams  have  shown  experi- 
mentally that  tlie  fat-necroses  are  caused  l)y  certain  constituents  of  the  ])an- 
creatic  juice,  but  not  by  tryjjsin.  Flexuer  has  denumstrated  by  chemical 
tests  the  existence^  of  the  fat-splitting  ferment  in  ])eritoneal  fat-necroses  in 
ivceiit  human  and  experimental  eases.  The  I'ernu'ut  (stea])sin)  disa])pears 
.M'ler  five  or  six  days  in  experimoital  necroses,  ami  cannot  be  demonstrated 
ill  the  lime-inerusted  human  ones.  II.  V.  Williams  has  ])i-odneed  similar 
li'>ions  in  the  sul)Cutaneous  fat  by  inserting  bits  of  sterile  pancreas  beneath 
ilu'  skin.  In  their  ex])erinu'ntal  studies  jlildebrand,  Williams,  and  Flexner, 
while  they  were  able  to  produce  fat-necroses  by  tying  the  veins  of  and  somc- 
limes  lacerating  the  pancreas,  never  actually  succeeded  in  reproducing  the 
I'ieture  of  h.Tmorrhagic  and  necrotic  pancreatitis.     This  has  recently  been 

a? 


692 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


jU'CoiiiplisluMl  hy  1 1  lava  and  Fk'xnor  l)y  injcctini^  aiiificial  gastric  juice  and 
(liluto  tiolutions  of  liydrocliloric  acid  into  tiic  duct  of  Wirsung.  The  very 
acutely  developing  cases  in  dogs  may  result  fatally  within  twenty-four 
hours.  'J'hc  fat-necroses  in  these  cases  are  caused  not  by  the  acids  but  by 
the  fat-splitting  ferment  (Mexner). 

It  is  well  for  surgeons  to  remend)er  that  in  two  cases  at  least  the  most 
serious  symj)t()ni8  of  acute  })ancreatic  disease  have  been  found  in  association 
with  only  widesi)read  fat-necrosis  of  the  gland.  In  a  case  reported  l>y 
Stockton  and  Williams  a  man,  on  Ids  return  jounu-y  from  Europe,  was 
seized  with  vomiting  and  pain,  without  fever,  l)ut  with  a  very  small  pulse. 
The  i)atient  died  soon  after  his  arrival  in  America.  The  post  mortem 
sliowed  a  pancreas  18  cm.  long,  at  first  sight  normal,  but  showing  on  section 
most  extensive  fatty  infiltration  with  fat-necrosis. 


III.     CHRONIC    PANCREATITIS. 

DicckholT  recognizes  two  forms:  (1)  The  most  common,  a  chronic  inflam- 
mation which  extends  from  the  ducts,  and  is  met  with  in  association  with 
chronic  catarrhal  processes  in  the  stomach  and  duodenum  and  in  the  bik- 
passagcs;  ('^)  a  chronic  pancreatitis  of  hematogenous  origin,  resulting  from 
toxic  materials  in  the  blood,  particularly  from  alcohol  and  lues.  The  organ 
may  be  reduced  in  size  and  very  hard,  as  in  the  atrophic  sclerosis  seen  not 
infrequently  in  diabetes.  Occasionally  it  is  larger  than  normal,  and  may 
form  a  tumor  readily  palpable  in  the  upper  part  of  the  abdomen.  In  con- 
nection with  the  diabetic  form  there  may  be  pigmentary  changes  in  associa- 
tion with  a  similar  condition  in  the  liver.  The  sclerosis  may  follow  pan- 
creatic calculi,  and  occasionally  interstitial  lipomatosis  causes  great  wasting 
of  the  tissue  of  the  gland. 

The  interest  in  atrophy  of  the  pancreas  relates  ^irst  to  the  association 
with  it  of  diabetes,  which  has  been  already  considered;  and  secondly  to  the 
possibility  of  a  chronic  interstitial  pancreatitis,  particularly  at  the  head  of 
the  organ,  blocking  the  terminal  part  of  the  common  bile-duct.  Itiedel 
refers  to  severe  cases  in  which  he  found  during  operation  for  gall-stones 
the  head  of  the  pancreas  enlarged  and  hard  as  stone,  so  that  he  dreaded  the 
possibility  of  new  growth;  but  two  of  his  patients  recovered  and  were  well: 
for  years,  and  in  the  third  the  post  mortem  showed  that  the  condition  was 
one  of  chronic  pancreatitis.  In  one  of  Korte's  cases  a  small  nodule  of  tlu; 
gland  involved  in  a  chronic  pancreatitis  had  pressed  directly  upon  the 
ductus  communis  choledochus  and  caused  the  Jaundice. 


IV.     PANCREATIC   CYSTS. 


Of  121  cases  operated  upon  by  surgeons  60  were  in  males  and  56  in 
females;  in  5  the  sex  was  not  given  (Korte).  Sixty-six  of  the  cases  oc- 
curred in  the  fourth  decade.  T.  C.  Railton's  ease  (which  is  not  in  Korte's 
series),  an  infant  aged  six  months,  and  Shattuck's  case  in  a  child  of  thir- 


i 


PANCREATIC  CYSTS. 


693 


nice  and 
I'ho  very 
'uly-foiir 
s  but  l)y 

the  most 
;s()('iati()n 
ortt'd  by 
•dpo,  Wiis 
all  pulsL". 
,  mortem 
in  section 


ic  inflam- 
tion  with 
the  bile- 
ting  from 
Che  organ 
i  seen  not 
and  may 
In  con- 
n  associa- 
ow  pan- 
wasting 

sociation 
ly  to  the 
head  of 
Riedel 
all-stonos 
aded  the 
were  woU 
ition  was 
lie  of  tlu; 
upon  the 


nd  5G  in 
cases  oc- 
1  Korte's 
I  of  thir- 


teen and  n  lialf  months,  an-  the  youngest  in  the  literature.     According  to 
the  origin  Kiirte  recognizes  three  varieties. 

(I)  Traumatic  Cases.— In  this  list  of  ;i:}  cases  :U)  were  in  men  and  only 
;{  in  women.  JUows  on  the  abdomen  or  constantly  repeated  [ircssure  are  the 
most  comnu)n  forms  of  trauma.  One  case  followed  severe  massage.  Usu- 
ally with  the  onset  there  are  inilamnuitory  symptoms,  \nnn,  and  vomiting, 
soiiu'timcs  suggestive  of  peritonitis.  The  contents  of  the  cyst  are  usually 
l)loody,  though  in  ll{  of  the  traumatic  cases  it  was  clear  or  yellowish. 

(•i)  Cysts  following  Inflammatory  Conditions.— In  51  cases  the  trouble 
liegan  gradually  after  attacks  of  dyspepsia  with  colic,  simulating  somewhat 
that  of  gall-stones.  Occasionally  the  attack  set  in  with  very  severe  symp- 
toms, suggestive  of  obstruction  of  the  bowel.  In  this  group  the  t\imor  a})- 
])cared  in  ID  cases  soon  after  the  onset  of  the  pain;  in  others  it  was  delayed 
for  a  period  of  from  a  few  weeks  to  two  or  three  years.  ^IcPhedran  has  re- 
ported a  renuirkable  instance  in  which  the  tumor  develo})ed  in  the  epigas- 
trium with  signs  of  severe  inflammation.  It  was  ojiened  and  drained  and 
believed  to  be  a  hydrops  of  the  lesser  peritoneal  cavity.  Three  months 
later  a  second  cyst  developed,  which  appeared  to  spring  directly  from  the 
pancreas. 

(3)  Cysts  without  any  Inflammatory  or  Traumatic  Etiology.— Of  33 
cases  in  this  group  20  were  in  women.  A  remarkable  feature  is  the  pro- 
longed period  of  their  existence — in  one  case  for  forty-seven  years,  in  one 
for  between  sixteen  and  twenty  years,  in  others  for  sixteen,  nine,  and  eight 
years,  in  the  majority  for  from  two  to  four  years. 

Anatomically  Kiirte  recognizes  (1)  retention  cyt^ts  due  to  plugging  of 
the  main  duct;  (2)  proliferation  cysts  of  the  pancreatic  tissue — the  cysto- 
adenoma;  (3)  retention  cysts  arising  from  the  alveoli  of  the  gland  and  of  the 
smaller  ducts,  which  become  cut  off  and  dilate  in  consequence  of  chronic 
interstitial  pancreatitis;  (4)  pseudo-cysts  following  inflammatory  or  trau- 
matic affections  of  the  pancreas,  nsually  the  result  of  injury,  causing 
hamiorrhage  and  hydrops  of  the  lesser  peritonieum. 

Situation. — In  its  growth  the  cyst  may  (1)  develop  in  the  lesser  peri- 
tonaium,  push  the  stomach  upward,  and  reach  the  abdominal  wall  between 
the  stomach  and  the  transverse  colon;  (2)  more  rarely  the  cyst  appears 
al)ove  the  lesser  curvature  and  pushes  the  stomach  downward;  in  both  of 
these  cases  the  situation  of  the  tumor  is  high  in  the  abdomen,  but  in  (3) 
it  may  develop  between  the  leaves  of  the  transverse  meso-colon  and  lie 
below  both  the  colon  and  the  stomach.  The  relation  of  these  tw^o  organs 
to  the  tumor  is  variable,  but  in  the  majority  of  cases  the  stomach  lies 
above  and  the  transverse  colon  below  the  cyst.  Occasionally,  too,  as  in  T. 
C.  Railton's  case,  the  cyst  may  develop  from  the  tail  of  the  pancreas  and 
])roject  far  over  in  the  left  hypochondrium  in  the  position  of  the  spleen 
or  of  a  renal  tumor. 

General  Symptoms. — Apart  from  the  features  of  onset  already  re- 
ferred to,  the  patient  may  comjilain  of  no  tronble  whatever,  particularly  in 
tlie  very  chronic  cases,  unless  the  cyst  reaches  a  very  large  size.  Painful 
onlicky  attacks,  with  nausea  and  vomiting  and  progressive  enlargement  of 
the  abdomen,  have  frequently  been  noted.     Fatty  diarrhoea  from  disturb- 


59-t 


DISKASKS  OP  THE   DIOKSTIVK  SVSTKM. 


/ 


iincf  of  tlic  fiiiu'tinii  of  the  piiiicrt'iis  is  rare.  Su^mt  in  the  urine  liii.s  liceii 
jireseiit  ill  a  niiiiiiier  ul'  eases.  Iiiereased  sei-relioii  <il'  the  saliva,  llie  s()-ealh'(| 
panereatie  salivation,  is  also  rare.  I'ressnre  ul'  tlie  cyst  may  Honielinu  > 
canst'  janndice,  and  in  rare  instances  dyspntea.  N'ery  nnirkecl  Iosh  of  lU'sh 
has  Itei'n  present  in  a  niiniher  of  cases.  A  ri'niarl\ahU'  featnre  often  noticed 
has  l)een  the  transitoi'y  tiisappcarance  of  the  cyst.  In  one  of  llalsted's  cases 
the  <;irlh  of  tiie  ah(h)jnen  decreased  from  4.'J  to  'M  inches  in  ten  days  with 
jtrofnsc  diarrhcea.     Sometimes  the  disappearance  lias  followed  Idows. 

Diagnosis. — The  cyst  occupies  the  upper  iihdonien,  usually  forming,' 
a  seniiciiciilar  liiil<:iiit,'  in  the  median  line,  rarely  to  eitlici'  side.  In  Id 
cases  Kilrte  states  that  the  chief  projection  was  helow  the  navel.  In  one  case 
opi'rated  upon  hy  llalste(l  the  tumor  occupied  the  i;i'eatcr  pari  of  the  ahdo- 
iiieii.  The  cyst  in  immohile,  respiration  liaviii;.,'  litth-  or  no  iiilliieiice  on 
it.  As  already  nicnt  ioiied.  the  stoiiiacli,  as  a  rule,  lies  a  hove  it  and  the  colon 
helow. 

In  n  majority  of  the  cases  tlie  lliiid  is  of  a  reddish  or  dark-hrown  color, 
and  contains  l)lood  or  hlood  coloring;  matter,  cell  detritus,  fat  granules, 
and  sometimes  cholesterin.  The  consistence  of  the  fluid  is  usually  mucoid, 
rarely  thin.  The  ri'action  is  alkaline,  the  specilic  gravity  from  I.OIO  to 
l.O'^^o.    Jn  "22  cases  Kilrte  states  that  the  Jliiid  was  not  hu'inorrhagic. 

The  existence  of  ferments  is  important.  Jn  ."if  cases  they  wore  present 
in  the  fluid  or  in  the  material  from  the  fistula.  Jn  20  cases  only  one  ferment 
was  ]n'esent,  in  20  cases  two,  and  in  If  cases  all  three  of  the  pancreatic  fer- 
ments were  found.  As  diastatie  and  fat  emulsifying  ferments  occur  widely 
in  various  exudates  the  most  important  and  only  jiositive  signs  in  the  diag- 
nosis of  the  pancreatic  secretion  is  the  digestion  of  fibrin  and  albumin. 

Jicsnlls. — T\()i'te  states  of  101  cases  in  which  the  cyst  was  opened  and 
drained  4  deaths  followed  the  oi)eratiou  directly;  1  resulted  from  infec- 
tion of  the  fistula.  In  14  cases  the  cyst  was  extirpated;  of  these  1;^  re- 
covered. 


V.     TUMORS    OF   THE    PANCREAS. 


Of  new  growths  in  the  organ  carcinoma  is  the  most  frequent.    Sarcoma, 
adenoma,  and  lymphoma  are  rare. 

Frcqucncjj. — At  the  General  Hospital  in  Vienna  in  l(S,06n  autopsies 
there  were  22  cases  of  cancer  of  the  pancreas  (l)iach).  In  11,472  jiost- 
mortems  at  ]\rilan,  Segre  found  132  tumors  of  the  ])ancrcas,  127  of  which 
Mere  carcinomata,  2  sarcomata,  2  cysts,  and  1  sy])hiloma.  In  6,000  autop- 
sies at  Guy's  Hospital  there  were  only  20  cases  of  primary  malignant  dis- 
ease of  the  organ  (Hale  AVliite).  In  the  first  1,000  autopsies  at  the  Johns 
Hopkins  Hospital  there  were  5  cases  of  adeno-carcinor.ia,  and  1  doubt- 
ful case  in  which  the  exact  origin  could  not  l)e  stated.  There  Avere  5  cases 
of  secondary  malignant  disease  of  th.)  pancreas.  The  liead  of  the  gland 
is  most  commonly  involved,  hut  the  disease  may  he  limited  to  the  hody  or 
to  the  tail.    The  majority  of  the  patients  are  in  tlie  middle  period  of  life. 

Symptoms. — The  diagnosis  is  not  often  possible.  The  following  are 
the  most  important  and  suggestive  features:    {a)  Epigastric  pains,  often 


U18  l»0('ll 

«i()-c:all('(l 

IlU'lilllr-. 

of  lloli 

noticed 

d's  cases 

ays  willi 

kVS. 

forming' 

III    Hi 

OiK'  CllSO 

111'  al)(lo- 

iclicc   oil 

he  colon 

I'ANCUEATIC  CALlULl. 


595 


,vn  color, 
>,M'aniilcs, 

mucoid, 

l.olO  to 
iic. 

('  present 
>  IVrnnMit 
eatic  I'er- 
Lir  widely 
tlio  diag- 

niin. 

ned  and 
m  infec- 
1^  ro- 


larcoma, 

utopsics 
r2  i)08t- 
1"  which 
0  auto])- 
aiit  dis- 
c  Jolms 
L  doiiht- 
e  5  cases 
le  Poland 
hodv  or 
f  life, 
wing  nre 
IS,  often 


occurring  in  paroxysms.  (A)  .Fnundicc,  due  to  [iressnic  (d'  the  tumor  in 
ilie  head  of  the  pancreaH  on  the  hile-diict.  'I'he  jaundice  in  intense  and 
{ici'nianent,  and  associate<l  with  dilatation  of  the  gall-Madder,  which  may 
iciicli  a  very  large  si/.e.  (r)  The  pre.»cni'u  of  a  tumor  in  the  epiga>trium. 
ThJH  JH  very  variahle.  in  1.17  oaseri  Dii  Costa  found  llie  tumor  pri'sent 
ill  only  I.'i.  l*al|)alion  under  ana'stlu'sia  with  the  stomaidi  em[)ty  would 
|iioliaMy  give  a  very  much  larger  percentage.  As  the  tumor  rests  directly 
upon  the  aorta  there  Is  nsually  a  marked  degree  oi  pulsation,  sometimes 
uith  a  hriiit.  There  may  he  pressure  on  the  portal  vein,  causing  throm- 
hosis  and  its  usnal  secpieLs.  (d)  Symptoms  due  to  loss  of  function  of  the 
|iancrea8  are  less  important.  i''atty  diarrluea  is  not  very  often  i)resent.  Jn 
( iiiiscciueiU'e  of  the  ahsence  of  hile  the  stools  are  usually  very  clay-colored 
and  greasy,  niahetcs  al^-o  is  not  common,  (r)  A  very  rapid  wasting  and 
(iU'he.xia.  Of  other  symptoms  muisea  and  vomiting  are  common.  In  some 
instances  the  pylorus  is  compressed  and  there  is  great  tlilutation  of  the 
."lomaidi.     In  a  few  cases  there  has  hecn  profnsi'  salivation. 

The  i»oints  (tf  greatest  ini|)ortance  in  tlu!  diagnosis  are  the  inli'nse  and 
permanent  jaundice,  with  dilitatioJi  of  the  gall-hladder,  rajtid  emaciation, 
and  the  presence  of  a  tumor  in  the  epigastric  region.  Of  less  importance 
are  features  pointing  to  disturbance  of  the  function  of  the  gland. 

Of  other  new  growths  sarc()ma  and  lymphoma  have  hei'U  occasionally 
found,  ^liliary  tuhercle  is  not  very  uiicomiiion  in  the  gland.  Sy|)hilid 
may  occur  as  rather  a  chronic  interstitial  inllammation,  or  in  the  form  of 
gummous  tumors. 

The  outlook  in  tumors  of  the  i)ancrens  is,  as  a  rule,  hoiteless.  How- 
ever, of  lU  cases  operated  upon  of  late  years,  G  recovered  (Korte). 


VI.     PANCREATIC    CALCULI. 

Pancreatic  lithiasis  is  comparatively  rare.  In  ls,s;5  (Jeorge  W.  John- 
ston collected  35  cases  in  the  literature.  In  1,000  auto])sies  at  the  Johns 
Hopkins  iros])ital  there  were  2  cases. 

The  stones  are  usually  numerous,  either  round  in  shape  or  rough, 
s|iinous  and  coral-like.  The  color  is  ojiaipie  white.  They  are  composed 
cliiedy  of  earhonate  of  lime.  The  eifects  of  the  stones  are:  (1)  A  chronic 
interstitial  inllammation  of  the  gland  substance  with  dilatation  of  the  duct; 
sometimes  there  is  cystic  dilatation  of  the  gland;  (2)  acute  inflammation 
with  suppuration;  (;>)  the  irritation  of  the  stojies,  as  in  the  gall-bladder, 
may  lead  to  carcinoma. 

Symptoms. — Pe])])er  in  1SS2  made  a  diagnosis  of  calculus  of  the  pan- 
creas, of  which,  however,  there  was  no  confirmation  either  hy  the  passage 
of  tl:e  stone  or  hy  auto])sy.  ^linnich  has  reported  a  case  in  which,  after  an 
attack  of  colic,  calculi  comjiosed  of  calcic  caroonato  and  phos])hato  were 
passed  in  the  stools.  Lichtheim,  in  a  case  with  severe  colic,  diahetes,  and 
fatty  diarrhopa,  made  the  diagnosis  of  pancreatic  calculi,  which  was  after- 
ward confirmed  hy  autopsy. 


500 


IHSKASKS  OK  TUK   DKiKSTIVK  SYSTKM. 


X.    DISEASES   OF  THE   PERITONAEUM. 


I.    ACUTE    GENERAL    PERITONITIS. 


/ 


Definition. — Acute  inllainniatioii  uT  (lie  pcritonu'iim. 

Etiolog^y. — Tlio  ('(mdition  may  he  jirimary  or  K-coiulary. 

(rt)  Primary,  Idiopathic  Peritonitis. — CouHidcring  liow  fmiucntly  tho 
])]c>iira  and  iicrictiKiiiiiii  arc  primarily  inllaiiu-d  llu;  rarity  of  idiopathic  in- 
ilammatioii  cd'  (lie  pcriloiwi'iim  is  somcwiiat  rcmarkahlc.  Jt  may  follow 
cold  or  exposure  and  is  then  known  as  rlu'umatic  peritonitis.  No  instanec 
of  the  kind  has  come  umler  my  notice.  In  iiright's  disease,  gout,  and 
arterio-Hclerosis  acute  peritonitis  nuiy  dcveloj)  aa  a  terminal  event.  Of  102 
cases  of  peritonitis  which  came  to  autopsy  at  the  Johns  Hopkins  ]I(wpital, 
12  were  of  this  form.  In  theae  there  was  some  pre-existing  chronic  disease 
([•'lexner). 

(b)  Secondary  peritonitis  is  due  to  extension  of  inllamnuition  from,  or 
])crforation  of  one  of  the  organs  covered  l)y  the  peritouieum.  Peritonitia 
from  extension  may  follow  inllamniation  of  the  stomach  or  intestines,  ex- 
tensive ulceration  in  these  ])arts,  cancer,  acute  suppurative  inllanimations 
of  tlie  Bpleen,  liver,  i)ancreas,  retroperitoneal  tisisues,  and  the  pelvic  vis- 
cera. 

Perforative  ])eritonitis  is  the  most  common,  following  external  wounds, 
perforation  of  rdccr  of  the  stomach  or  ])owcls,  perforation  of  the  gall- 
bladder, ahscess  of  the  liver,  sjjlcen,  or  kidneys.  Two  im])ortant  causes  are 
appendicitis  and  sui)|)urating  inllamniation  about  the  Fallojuan  tubes  and 
ovaries.  There  are  instances  in  which  peritonitis  has  followed  rupture  of 
an  ai)])arcntly  normal  Graafian  follicle. 

Of  the  al)ove  lOti  cases,  50  originated  in  an  extension  from  some  dis- 
eased abdominal  viscns.  The  remaining  3-4  followed  surgical  operations 
upon  the  peritonanmi  or  the  contained  organs. 

The  ])eritonitis  of  septicaemia  and  ])y.Tmia  is  almost  invariably  the  re- 
sult of  a  local  ])roccss.  An  exceedingly  acute  form  of  jjcritonitis  may  be 
caused  by  the  development  of  tul)ercles  on  the  membrane. 

Morbid  Anatomy. — In  recent  cases,  on  opening  the  abdomen  the 
intestinal  coils  are  distended  and  glued  together  by  lymph,  and  the  peri- 
tonanim  presents  a  patchy,  sometimes  a  uniform  injection.  The  exuda- 
tion may  be:  (o)  Fibrinous,  with  little  or  no  fluid,  except  a  few  pockets 
of  clear  serum  between  the  coils.  (/;)  Sero-fibrinous.  The  coils  are  cov- 
ered with  lymph,  and  there  is  in  addition  a  large  amount  of  a  yellowish, 
«!ero-fd)rinous  fluid.  In  instances  in  which  the  stomach  or  intestine  is 
perforated  this  may  be  mixed  with  food  or  fa-ccs.  (c)  Purulent,  in  which 
the  exudate  is  cither  thin  and  greenish  yellow  in  color,  or  opaque  white 
and  creamy,  (r/)  Putrid.  Occasionally  in  puerperal  and  perforative  peri- 
tonitis, particularly  when  the  latter  has  been  caused  by  cancer,  the  exudate 
is  thin,  grayisli  green  in  color,  and  has  a  gangrenous  odor,  (e)  Hemor- 
rhagic. This  is  sometimes  found  as  an  admixture  in  cases  of  acute  peri- 
tonitis following  wounds,  and  occurs  in  the  cancerous  and  tuberculous 


ACUTE  OKNRRATi  rRUIToNITIS. 


607 


itMitly  tlio 
patliic  in- 
iiiy  follow 

0  iii8tani'o 
j,'()iit,  1111(1 
;.    01"  10  v' 

ll('sj)ital, 
lie  cUseaso 

1  I'roin,  or 
IVritonitis 
stines,  ex- 
iinmations 
pelvic  vis- 

il  wounrls, 
the  gall- 

caiisc's  aru 
tubes  and 
uptiiro  of 

some  dis- 
jporations 

y  the  re- 
s  may  be 

DTncn  the 

tlie  pcri- 

le  exuda- 

V  pockets 

are  cov- 
,'ellowish, 
estine  is 
in  which 
lie  white 
ive  pcri- 
!  exudate 

Hfemor- 
ute  pcri- 
)erculous 


forms.  (/')  A  rare  ronu  in(  urn  in  which  the  injection  i«  present,  l)ut  almost 
all  -mwH  of  exudation  are  .anting;.  C'Ioho  inHpcriiun  mny  be  neci-sHary  to 
ditcct  a  »li;,'ht  duiliu;,'  of  the  Heroun  burfaccH,  'i'lie  bactfriolo^'ical  exanii- 
iiatioM  reveals  lar;i:e  MUiubers  of  bacteria. 

Tlie  MMioinil  of  tlie  elVusiou  varies  from  lialf  a  litre  to  •.'()  or  'M  litres. 
'i'lh  re  are  jtrobaitly  essential  diirerenccH  betwei'U  Ibe  various  kind.s  of  peri- 
idiiilis. 

Bacteriology  of  Acute  Peritonitis. — Much  work  has  been  (bme  lately 
upon  llie  subject,  i'lexuer  ba.s  analyzed  10:.'  ca.ses  of  peritonilis,  in  wliieli 
baeteriolojfical  studies  were  made,  which  came  to  autopsy  in  the  iJohn.s 
Hopkins  'iospital.  He  makes  threi'  classes.  The  liriit  class  embraces  the 
piimary  or  idiopalliie  form,  of  which  \'i  cases  were  found.  These  were 
with  one  exception  mono-inb'ctions.  The  prevailinj,'  micro-or<fanism  was 
(be  streptococcus  pyo^^enes  (live  times), the  remaining  ones  being  Ibe  sta[)by- 
lococcus  aureus,  ndcroeoccus  laneeolatus,  bacillus  proteu.s,  pyocyaneu.s,  and 
coli  communis.  The  second  class  followed  operations  upon  the  peritonu'uni, 
excepting  operations  upon  the  intestine.  Tlie  niaj(»rity  of  these  cases  were 
examples  of  wound  infection.  They  were  'Mi  in  number.  In  v*.')  of  these 
mono-infections,  in  8  mixed  infections  existed.  The  prevailing  miero- 
nrganism  was  the  staphylococcus  aureus,  which  was  i)rcsent  alone  in  12 
.ind  coml)incd  in  2  cases.  The  streptococcus  occurred  5  times  uncom- 
bined  and  4  tinu-s  combined.  The  bacillus  coli  was  found  5  times  in  all, 
being  unassociatcd  in  3  cases.  Other  organisms  found  w  mv  tin;  micro- 
coccus laneeolatus,  staphylococcus  albus,  bacillus  pyocyaneus,  and  icrogenes 
( iipsulatus.  The  remaining  bii  cases,  forming  the  third  class,  were  instances 
of  intestinal  infection.  These  com|)rise(i  23  mon(»-  and  33  |)olyinfections. 
The  i)rcd()minating  micro-organism  was  the  bacillus  coli  communis  which 
occurred  in  43  cases,  8  times  alone  and  35  in  association.  The  strepto- 
coccus was  present  in  37  cases,  being  alone  in  7.  The  staphylococci,  pneu- 
mococcus,  bacillus  ))roteus,  jiyocyaneus,  tyi)hosus,  and  aerogenes  capsulatus 
occurred  in  a  smaller  number  of  instances. 

Among  the  micro-organisms  thus  far  found  rarely  in  i)eritonitis,  may 
be  mentioned  the  gonococcus,  the  anthrax  bacillus,  the  i)roteus  bacillus, 
;ind  the  typhoid  bacillus.  As  illustrating  the  importance  of  the  gonoeoc- 
<us,  I  may  state  that  as  I  write  there  are  two  young  girls  both  of  mIioiu 
were  admitted  to  my  wards  with  diffuse  jieritonitis  arising  from  fresh 
gonorrho'al  salpingitis.  JJoth  Mere  ojicrated  u])on  by  Cushing  success- 
fully. Welch  has  found  the  bacillus  coli  communis  in  peritonitis  due  to 
ulceration  of  the  intestines  without  perforation. 

Symptoms. — In  the  ])crforative  and  septic  cases  the  onset  is  nuirkcd 
by  chilly  feelings  or  an  actual  rigor  with  intense  ))ain  in  the  abdomen.  In 
typhoid  fever,  when  the  sensorium  is  benumbed,  the  onset  may  not  be 
noticed.  The  i)ain  is  general,  and  is  usually  intense  and  aggravated  by 
movements  and  pressure.  A  position  is  taken  which  relieves  the  tension 
of  the  abdominal  muscles,  so  that  the  yiaticnt  lies  on  the  back  with  the 
tliighs  drawn  up  and  the  shoulders  elevated.  The  greatest  pain  is  usually 
lielow  the  umbilicus,  but  in  peritonitis  from  perforation  of  the  stomach 
pain  may  be  referred  to  the  back,  the  chest,  or  the  shoulder.    The  respira- 


508 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


/ 


lion  in  aiipcrficial — co.stal  in  type — as  it  is  paiui'ul  to  use  the  cliaplira<jjm. 
For  the  same  reason  the  action  of  cou<,Hiing  is  restrained,  and  even  tlie 
initvcincnts  necessary  for  talking  are  hniitid.  In  this  early  stage  the  sensi- 
tiveness may  be  great  and  the  abdominal  muscles  are  often  rigidly  con- 
tracted. If  the  ])atient  is  at  jierfect  rest  the  pain  may  be  very  slight,  and 
there  are  instances  in  which  it  is  not  at  all  marked,  and  may,  indeed,  be 
absent. 

The  abdomen  gradnally  l)Ccomes  distended  and  tense  and  is  tympanitic 
on  jxMi'nssion.  The  i)ulse  is  rapid,  small,  and  hard,  and  ol'ten  has  a  peculiar 
wiry  quality.  It  ranges  from  llU  to  I'A).  The  temperature  may  rise  rapid- 
ly after  the  chill  and  reach  1U4°  or  105°,  but  the  subsequent  elevation  is 
moderate.  In  some  very  severe  eases  tliere  nuiy  be  no  fever  throughout. 
The  tongue  at  first  is  white  and  moist,  but  subsequently  becomes  dry  and 
often  red  and  fissured.  A'omiting  is  an  early  and  prominent  feature  and 
causes  great  pain.  The  contents  of  the  stomach  are  lirst  ejected,  then  a 
yellowish  and  bile-stained  fluid,  and  finally  a  greenish  and,  in  rare  in- 
stances, a  brownish-black  licpiid  with  slight  ftecal  odor.  The  bowels  may 
be  loose  at  the  onset  and  then  constipation  may  follow.  Fretpient  micturi- 
tion may  be  present,  less  often  retention.  The  urine  is  usually  scanty  and 
high-colored,  and  contains  a  large  quantity  of  indican. 

The  appearance  of  the  patient  when  these  symptoms  liav^  fully  devel- 
oped is  very  characteristic.  The  face  is  pinched,  the  eyes  are  sunken,  and 
the  ex])ression  is  very  anxious.  The  constant  vomiting  of  fluids  causes  a 
wasted  appearance,  and  the  hands  sometimes  present  the  washer-woman's 
skin.  Except  in  cholera,  wo  see  the  Hippocratic  facies  more  frequently 
in  this  than  in  any  other  disease — "a  sharp  nose,  hollow  ^i/es,  collapsed 
iemples:  the  cars  cold,  contracted,  and  their  lahes  turned  nut;  the  sl'in  about 
the  forehead  being  rouj/h,  distended,  and  parched;  the  color  of  the  whole  face 
being  brown,  blacl',  livid,  or  lead-colored."  There  are  one  or  two  additional 
points  about  the  abdomen.  The  tj'mpany  is  usually  excessive,  owing  to  the 
great  relaxation  of  the  walls  of  the  intestines  by  inflammation  and  exuda- 
tion. The  splenic  dulness  may  l)o  obliterated,  the  dia])hragm  pushed  up, 
and  the  apex  beat  of  the  heart  dislocated  to  the  fourth  interspace.  The 
liver  dulness  may  be  greatly  reduced,  or  may,  in  the  mammary  line,  be 
obliterated.  It  has  been  claimed  that  this  is  a  distinctive  feature  of  per- 
forative ]ieritonitis,  but  on  several  occasions  I  have  been  able  to  demon- 
strate that  the  liver  dulness  in  the  middle  and  mammary  line  was  obliter- 
ated by  tympanites  alone.  In  the  axillary  line,  on  the  other  hand,  the 
liver  dulness,  though  diminished,  may  jiersist.  Pneumo-peritona}uni  fol- 
lowing ])erforation  more  certainly  obliterates  the  hepatic  dulness.  In  such 
cases  the  fluid  efTused  produces  a  dulness  in  the  lateral  region;  but  with 
gas  in  the  ])eritomeum.  if  the  patient  is  turned  on  the  left  side,  a  clear 
note  is  heard  beneath  the  seventh  and  eighth  ribs.  Acute  peritonitis  may 
present  a  flat,  rigid  abdomen  throughout  its  course. 

KfTusion  of  fluid — ascites — is  usually  ]n"esent  except  in  some  acute 
ra])idly  fatal  cases.  The  flanks  are  dull  on  percussion.  The  di  'ness  may 
be  movable,  thougii  this  de]iends  altogether  upon  the  degree  of  adhesions. 
There  may  be  considerable  elTusion  without  either  movable  dulness  or 


ACUTE  GENERAL  PERITONITIS. 


599 


fluctuation.    A  friction-rub  may  be  present,  as  first  ;  )inteJ  out  by  Briglit, 
but  it  is  not  nearly  so  couiuion  in  acute  as  in  chronic  peritonitis. 

Course. — The  acute  diltuse  peritonitis  usually  terminates  in  death. 
The  most  intense  forms  may  kill  withiu  thirty-six  to  iorty-eiyht  hours; 
iiiDre  commonly  death  results  in  four  or  five  days,  or  the  attack  may  be 
]>rol()nged  to  eiglit  or  ten  days.  The  pulse  becomes  irregular,  the  heart- 
sounds  weak,  the  breathing  shallow;  there  are  lividity  with  ])allor,  a  cold 
skin  witli  high  rectal  temperature — a  group  of  symptoms  indicating  [)r()- 
found  failure  of  the  vital  functions  for  which  Gee  has  revived  the  old  term 
lipulhymia.  Occasionally  death  occurs  with  great  suddenness,  owing,  })os- 
sibly,  to  paralysis  of  the  heart. 

Diagnosis. — In  typical  cases  the  severe  pain  at  onset,  the  distention 
of  the  abdomen,  the  tenderness,  the  fever,  the  gradual  develoiuncnt  of 
elfusion,  collai)se  symptoms,  and  the  vomiting  give  a  characteristic  picture. 
Careful  inquiries  should  at  once  be  nuide  concerning  the  i)revious  condi- 
tion, from  which  a  clew  can  often  be  had  as  to  the  starting-point  of  the 
trouble.  In  young  adults  a  considerable  i)roportion  of  all  cases  depends 
upon  i)erforating  api)endicitis,  ana  there  nuiy  be  an  account  of  previous 
attacks  of  pain  in  the  iliac  region,  or  of  consti])ation  alternating  with  diai'- 
rhcea.  In  women  the  most  frequent  causes  are  supijurative  processes  in 
the  pelvic  viscera,  associated  witi:  sal])ingitis,  abscesses  in  the  broad  liga- 
ments, or  acute  puerperal  infection,  i'erforation  of  gastric  ulcer  is  a  more 
common  factor  in  women  than  in  men.  It  is  not  always  easy  to  determine 
the  cause.  ^Many  cases  come  under  observation  for  the  first  time  witii  the 
abdomen  distended  and  tender,  and  it  is  impossible  to  make  a  satisfactory 
examination.  In  such  instances  the  i)elvic  organs  should  be  examined 
with  the  greatest  care.  In  tyi)lioid  fever,  if  the  patient  is  conscious,  the 
sudden  onset  of  i)ain,  the  development  of  great  meteorism,  and  the  aggra- 
vation of  the  general  symptoms  indicate  clearly  what  has  haiipened.  A\'heu 
the  ])atient  is  in  deep  coma,  on  the  othc.  hand,  the  perforation  may  be 
overlooked.  The  following  conditions  arc  most  apt  to  be  mistaken  for 
acute  peritonitis: 

(a)  Acute  Entero-colilis. — Here  tlie  ])ain  and  distention  and  the  sen- 
sitiveness on  pressure  may  be  marked.  Tlie  ])ain  is  more  colicky  in  cliar- 
acter,  the  diarrhea  is  more  frequent,  and  the  collapse  is  more  extreme. 

(h)  The  So-caUed  ni/sterical  Pcriloiiilis. — This  has  deceived  the  very 
elect,  as  almost  every  feature  of  genuine  peritonitis,  even  the  colla])se,  may 
be  simulated.  The  onset  may  be  sudden,  with  severe  ]iain  in  the  abdomen, 
tenderness,  vomiting,  diarrluea,  dil!iculty  in  micturition,  and  tlie  charac- 
teristic decubitus.  Even  the  temperature  may  be  elevated.  There  may  he 
recurrence  of  the  attack.  A  case  has  been  reported  by  Bristowe  in  which 
four  attacks  occurred  within  a  year,  and  it  was  not  until  special  hysterical 
symptoms  developed  that  the  true  natTire  of  the  troulile  was  susiiectcd. 

(r)  Ohsh-uclinn  of  flic  hoircl,  as  already  iuentioned,  may  simulate  peri- 
tonitis, both  having  pain,  vomiting,  tym]ianites,  and  constipation  in  com- 
mon. It  may  for  a  cou])le  of  days  really  be  impossible  to  make  a  diagnosis 
in  the  absence  of  a  satisfactory  history. 

((7)    Eupt'ure  of  an  obdominaJ  aneurism   or  emdnlisin   of  tlie  superior 


600 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


mesenteric  arlenj  may  caiise  symi)toins  which  simulate  peritonitis.  In  tlie 
latter,  sudden  onset  with  severe  pain,  the  collapse  symptoms,  I'rei^uent 
vomiting,  and  great  distention  of  tlie  abdomen  may  be  present. 

(e)  I  have  already  referred  to  the  fact  that  acute  hemorrhagic  pan- 
creatitis may  be  mistaken  for  peritonitis.  Lastly,  a  ruptured  tubal  prog- 
nancy  may  resemble  acute  peritonitis. 


.  \ 
/ 


t. 


11.    PERITONITIS    IN    INFANTS. 

Peritonitis  may  occur  in  the  ftctus  as  a  consequence  of  syphilis,  and 
may  lead  to  constriction  of  the  bowel  by  fibrous  adhesions. 

In  the  new-born  a  septic  peritonitis  may  extend  from  an  inflamed  cord. 
Distention  of  the  abdomen,  slight  swelling  and  redness  about  the  cord,  and 
not  infrequently  jaundice  are  present.  It  is  an  uncommon  event,  and 
existed  in  only  4  of  51  infants  dying  with  inflammation  of  the  cord  and 
septicaemia  (Eunge). 

During  childhood  peritonitis  develops  from  causes  similar  to  those  af- 
fecting the  adult.  Perforative  appendicitis  is  common.  Peritonitis  fol- 
lowing blows  or  kicks  on  the  abdomen  occurs  more  frequently  at  this 
})eriod.  In  boys  injury  while  playing  foot-ball  may  be  followed  by  diffuse 
peritonitis.  A  rare  cause  in  children  is  extension  through  the  diaphragm 
from  an  empyema.  There  are  on  record  instances  of  peritonitis  occurring 
in  several  children  at  the  same  school,  and  it  has  been  attributed  to  sewer- 
gas  poisoning.  It  was  in  investigating  an  epidemic  of  this  kind  at  the 
"Wandsworth  school,  in  London,  that  Anstie  received  the  post-mortem 
wound  of  which  he  died. 


PI.    LOCALIZED    PERITONITIS. 

1.  Subphrenic  Peritonitis. — The  general  peritonaeum  covering  the  right 
and  left  lobes  of  the  liver  may  be  involved  in  an  extension  from  the  pleura 
of  suppurative,  tuberculous,  or  cancerous  processes.  In  various  affections 
of  the  liver — cancer,  abscess,  hydatid  disease,  and  in  affections  of  the 
gall-bladder — the  inflammation  may  be  localized  to  the  peritonaeum  cover- 
ing the  upper  surface  of  the  organ.  These  forms  of  localized  subphrenic 
peritonitis  in  the  greater  sac  are  not  so  important  in  reality  as  those  which 
occur  in  the  lesser  peritonaeum.  The  anatomical  relations  of  this  struc- 
ture are  as  follows:  It  lies  behind  and  below  the  stomach,  the  gastro- 
liepatic  omentum,  and  the  anterior  layer  of  the  great  omentum.  Its 
lower  limit  forms  the  upper  layer  of  the  transverse  meso-colon.  On  either 
side  it  reaches  from  the  hepatic  to  the  splenic  flexure  of  the  colon,  and 
from  the  foramen  of  Winslow  to  the  hilus  of  the  spleen.  Behind  it  cov- 
ers and  is  tightly  adherent  to  the  front  of  the  pancreas.  Its  upper  limit 
is  formed  by  the  transverse  fissure  of  tlie  liver,  and  by  that  portion  of  the 
dia])hragm  which  is  covered  by  the  lower  layer  of  the  right  lateral  liga- 
ment of  the  liver;  the  lobus  Spigelii  lies  bare  in  the  cavity.    The  foramen 


LOCALIZED  PERITONITIS. 


601 


of  Winslow,  through  which  the  lesser  communicates  with  the  greater  peri- 
toiuTum,  is  readily  closed  hy  inflammation. 

lullammatory  processes,  exudates,  and  haemorrhages  may  he  confined 
entirely  to  the  lesser  peritonanim.  The  exudate  of  tuberculous  peritonitis 
may  be  confined  to  it.  Perforations  of  certain  parts  of  the  stomach,  of 
the  duodenum,  and  of  the  colon  may  excite  inllammation  in  it  alone;  and 
in  various  all'ections  of  the  i)ancreas,  particularly  trauma  and  luemorrhage, 
the  eil'usion  into  the  sac  has  often  been  confounded  with  cyst  of  this  organ. 
"  Pathological  distention  of  the  lesser  peritonieum  gives  rise  to  a  tumor 
in  the  left  hypochondriac,  epigastric,  and  umbilical  regions  of  a  somewhat 
characteristic  shape,  but  which  appears  to  vary  from  time  to  time  in  form 
and  size,  according  to  the  conditions  of  the  overlying  stomach;  for  when 
the  viscus  is  full  of  liquid  contents  it  increases  the  area  of  the  tumor's 
(lulness,  while  it  makes  its  outlines  less  definable  hy  palpation,  and  if  the 
stomach  is  distended  with  gas  the  dull  area  becomes  resonant  and  apparent- 
ly the  tumor  may  disappear  altogether.  The  colon  always  lies  below  the 
tumor  and  never  in  front  of  or  above  it,  as  is  the  case  in  kidney  enlarge- 
juent "  (Jordan  Lloyd). 

Sj)ecial  mention  must  he  made  of  the  remarkable  form  of  subi)lirenic 
abscess  containing  air,  which  may  simulate  closely  pneumothorax,  and 
hence  was  called  by  Leyden  Pyo-pneumothorax  snhphrenicus.  The  affection 
has  been  thoroughly  studied  of  late  years  by  Scheurlen,  Mason,  j\Ieltzer, 
and  Lee  Dickinson.  In  142  out  of  170  recorded  cases  the  cause  was  known. 
In  a  few  instances,  as  in  one  reported  by  Meltzer,  tlie  subphrenic  abscess 
seemed  to  have  followed  pneumonia.  Pyothorax  is  an  occasional  cause. 
By  far  the  most  frequent  condition  is  gastric  ulcer,  which  occurred  in  80 
of  the  cases.  Duodenal  ulcer  was  the  cause  in  6  per  cent.  In  about  10 
]>er  cent  of  the  cases  the  appendix  was  the  starting-point  of  the  abscess. 
Cancer  of  the  stomach  is  an  occasional  cause.  Other  rare  causes  are  trauma, 
which  was  present  in  one  of  my  cases,  perforation  of  an  hepatic  or  a  renal 
abscess,  lesions  of  the  si)leen,  abscess,  and  cysts  of  the  pancreas. 

In  a  majority  of  all  the  cases  in  which  the  stomach  or  duodenum  is  per- 
forated— sometimes,  indeed,  in  the  cases  following  trauma,  as  in  Case  3 
■of  my  series — the  abscess  contains  air. 

The  symptoms  of  subphrenic  abscess  vary  very  considerably,  depending 
a  good  deal  upon  the  primary  cause.  The  onset,  as  a  rule,  is  abrupt,  par- 
ticularly when  due  to  perforation  of  a  gastric  ulcer.  There  are  severe 
pain,  vomiting,  often  of  bilious  or  of  bloody  material;  respiration  is  em- 
l)arrassed,  owing  to  the  involvement  of  the  diaphragm;  then  the  constitu- 
tional symptoms  develop  associated  with  suppuration,  chills,  irregular 
fever,  and  emaciation.  Subsequently  perforation  may  take  place  into  the 
]iloura  or  into  the  lung,  with  severe  cough  and  abundant  purulent  ex- 
pectoration. 

The  conditions  are  so  obscure  that  the  diagnosis  of  subphrenic  abscess 
is  not  often  made.  The  perihepatic  abscess  beneath  the  arch  of  the  dia- 
]>hragm,  whether  to  the  right  or  left  of  the  suspensory  ligament,  when  it 
does  not  contain  air,  is  almost  invariably  mistaken  for  empyema.  "When  a 
pus  collection  of  any  size  is  in  the  lesser  peritonaeum,  the  tumor  is  formed 


602 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


/ 


wliich  liiis  the  clianictLTs  alix'tidy  lufnlioiiud  in  u  (luutaliuii  from  Mr.  Jor- 
dan Lliiyd. 

The  most  remarkable  features  aic  those  whieli  are  superadded  wlieii 
the  aljseesd  cavity  contains  air.  Here,  on  tiie  riglit  side,  wlieu  tlie  abscess 
is  in  the  greater  peritonivum,  above  tlie  rijfjit  lobe  of  the  liver,  the  dia- 
phragm may  be  pushed  up  to  the  level  of  the  second  or  third  rib,  and  the 
physical  signs  on  j)ercussion  and  ausiultation  are  those  of  pneuiiKithoiax. 
particularly  the  tympanitic  resonance  and  the  movable  dulncss.  The  liver 
is  usually  greatly  de[)ressed  and  there  is  l)ulging  on  the  right  side.  Still 
more  obscure  are  the  cases  of  air-containing  abscesses  due  to  perforatidu 
of  the  stomach  or  duodenum,  in  which  tlie  gas  is  contained  in  the  lesser 
pcritonannn.  Here  the  diai)hragm  is  i)Uslu'd  up  and  there  are  signs  nf 
])neumothorax  on  the  left  side.  In  a  large  majority  of  all  tlie  cases 
which  follow  perforation  of  a  gastric  idcer  the  elfusion  lies  between  the 
diaphragm  a])ove,  and  the  s]tleen,  stonuich,  and  the  left  lobe  of  the  liver 
below. 

The  ])rognosis  in  subphrenic  abscess  is  not  very  ho]ieful.  Of  the  cases 
on  record  al)out  ^0  ])er  cent  only  have  recovered.  Of  the  live  cases  which 
have  come  undt'r  my  observation,  three  recovered  after  o})eration. 

2.  Appendicular. — 'J'he  most  frequent  cause  in  the  male  of  localized 
peritonitis  is  inflammation  of  the  appendix  vermifornus.  The  situation 
varies  with  the  ])osition  of  this  extremely  variable  organ.  The  adhesion, 
perforation,  and  intraperitoneal  abscess  cavity  may  be  within  the  pelvis, 
or  to  the  left  of  the  median  line  in  the  iliac  region,  in  the  lower  right 
quadrant  of  the  umbilical  region — a  not  uncommon  situation — or,  of  course, 
most  frequently  in  the  right  iliac  fossa.  In  the  most  common  situation 
the  localized  abscess  lies  upon  the  i)Soas  muscle,  bounded  by  the  ca?cum 
on  the  right  and  the  terminal  portion  of  the  ileum  and  its  mesentery  in 
front  and  to  the  left,  lu  many  of  tliese  cases  the  limitation  is  perfect, 
and  ])ost-mortcm  records  show  that  complete  healing  may  take  place  with 
the  obliteration  of  the  ai)|)endix  in  a  mass  of  firm  scar  tissue. 

3.  Pelvic  Peritonitis. — The  most  fre([uent  cause  is  inflammation  about 
the  uterus  and  l-'allo])ian  tul)es.  Puerperal  septicaMnia.  goiujrrha'a,  and 
tuberculosis  are  the  usual  causes.  The  tubes  are  the  starting-point  in  a 
majority  of  the  cases.  The  findjrin?  become  adherent  and  closely  matted 
to  the  ovary,  and  there  is  gradually  produced  a  condition  of  thickening  of 
the  parts,  in  which  the  individual  organs  are  scarcely  recognizable.  Tlu 
tubes  are  dilated  and  filled  with  cheesy  matter  or  pus,  and  there  may  lie 
small  abscess  cavities  in  tlie  broad  ligaments.  Eupture  of  one  of  these  may 
cause  general  peritonitis,  or  the  membrane  may  be  involved  by  extension, 
as  in  tuberculosis  of  these  juirts. 


IV.    CHRONIC    PERITONITIS. 


The  following  varieties  may  be  recognized:  (a)  Local  adhesive  perito- 
nitis, a  very  common  condition,  which  occurs  particularly  about  the  s])leen. 
forming  adhesions  between  the  capsule  and  the  diaphragm,  about  the  liver, 


CriRONIC  PERITONITIS. 


C03 


loss  frequently  about  the  iutcstinos  and  nu'sentcry.  Points  of  tliickcnin^' 
ov  pufkuriii^-  on  tlu'  [)ei'it(iiia'uni  occur  sonictinics  with  union  of  the  coils 
or  with  ill)n)U.s  Ijanils.  In  a  majority  of  such  cases  the  eoiulition  is  met 
accidentally  post  mortem.  Two  sets  of  sym[)toms  may,  however,  ho  caused 
liv  tiiese  adlu'sions.  Wlicii  a  tiorous  hand  is  attached  in  such  a  way  as 
to  form  a  loop  or  snare,  a  coil  of  intestine  may  i)ass  throu;^h  it.  Thus, 
111'  tile  'i*J')  cases  of  intestinal  ohstruction  analyzed  hy  Fitz,  li3  were  due  to 
this  cause.  Tlie  second  group  is  less  si'rious  and  coni[)ris(,'S  cases  with  i)er- 
sisteiit  ahdduiinal  pain  of  a  colicky  character,  sometimes  rendering  life  mis- 
(  lahle.  instances  of  this  kind  have  heen  successfully  operated  upon  hy 
I  loinaiis  and  II.  .\.  Kt'lly. 

(//)  Diffuse  Adhesive  Peritonitis. — This  is  a  conse((uenee  of  an  acute  in- 
llanunation,  cither  sim[)le  or  tulierculous.  Tiie  })eritonieum  is  ohliterated. 
Oil  cutting  through  the  ahdoniinal  wall,  the  coils  of  intestines  are  uni- 
loniily  matted  together  and  can  neither  he  separated  from  each  other  nor 
can  the  visceral  and  ])arietal  layi'i's  he  distinguished.  There  may  he  thick- 
ening of  the  layers,  and  the  liver  and  spleen  are  usually  involved  in  the 
adhesions. 

(r)  Proliferative  Peritonitis. — A])art  from  cancer  and  tuherclc,  which 
])rodiice  typi  -al  lesions  of  chronic  peritonitis,  the  most  characteristic  form 
is  that  which  may  be  described  under  tliis  heading.  The  essential  ana- 
tomical feature  is  great  thickening  of  the  peritoneal  layers,  usually  without 
much  adhesion.  The  cases  are  sometimes  seen  with  sclerosis  of  the  stom- 
ach. In  one  instance  I  found  it  in  connection  Avith  a  sclerotic  condition 
of  the  CRH-uin  and  the  first  ])art  of  the  colon.  In  the  inspection  of  a  case 
of  this  kind  there  is  usually  moderate  elfusion,  more  rarely  extensive  ascites. 
The  i^eritona'um  is  opaque-white  in  color,  and  everywher».  thickened,  often 
ill  patches.  The  omentum  is  usually  rolled  and  forms  a  Uiickened  mass 
transversely  placed  between  the  stomach  and  the  colon.  Tlie  pei'itoiueum 
over  the  stomach,  intestines,  and  mesentery  is  sometimes  greatly  thickened. 
The  liver  and  sjileen  may  simply  be  adherent,  or  there  is  a  condition  of 
chronic  jierihepatitis  or  perisplenitis,  so  that  a  layer  of  firm,  almost  gristly 
connective  tissue  of  from  one  fourth  to  half  an  inch  in  thickness  encircles 
these  organs.  Usually  the  volume  of  the  liver  is  in  consequence  greatly 
reduced.  The  gastro-lie])atic  omentum  may  be  constricted  by  this  new 
growth  and  the  caliljre  of  the  portal  vein  ranch  narrowed.  A  serous  effu- 
sion may  be  jiresent.  On  account  of  the  adhesions  which  form,  the  peri- 
tonanim  may  be  divided  into  three  or  four  diU'erent  sacs,  as  is  more  fully 
described  under  the  tuberculous  jieritonitis.  In  these  cases  the  intestines 
are  usually  free,  though  the  mesentery  is  greatly  shortened.  There  are  in- 
stances of  chronic  peritonitis  in  which  the  mesentery  is  so  shortened  by 
this  proliferative  change  that  the  intestines  form  a  ball  not  larger  than  a 
cocoa-nut  situated  in  the  middle  lino,  and  after  the  removal  of  the  exuda- 
tion can  be  felt  as  a  solid  tumor.  The  intestinal  wall  is  greatly  thickened 
and  the  mucous  membrane  of  the  ileum  is  thrown  into  folds  like  the  valvuUe 
conniventes.  This  proliferative  peritonitis  is  fonnd  frequently  in  the  sub- 
jects of  chronic  alcoholism.  In  cases  of  long-continued  ascites  the  serous 
surfaces  generally  become  thickened  and  present  an  opaque,  dead-white 


604 


DISEASES  OP  THE  DIOESTIVE  SYSTEM. 


/ 


color.  This  condition  is  observed  especially  in  hepatic  cirrhosis,  but  attends 
tumors,  chronic  passive  congestions,  etc. 

In  all  forms  of  chronic  j)eritonitis  a  friction  may  be  felt  usually  in  tho 
up])C'r  zone  of  the  abdonun. 

In  some  instances  of  chronic  i)eritonitis  the  membrane  presents  numer- 
ous nodular  thickenings,  which  may  be  mistaken  for  tubercles.  They  may 
be  scattered  in  numl)ers  on  the  membranes,  and  it  may  be  extremely  dilli- 
cult,  without  the  most  careful  microscopical  examination,  to  determine  their 
nature.  J.  F.  Payne  has  described  a  case  of  this  sort  associated  with  dis- 
seminating growths  throughout  the  liver  which  were  not  cancerous.  It  has 
been  suggested  that  some  of  the  cases  of  tuberculous  peritonitis  cured  by 
operation  have  been  of  this  nature,  but  histological  examination  would,  a^* 
a  rule,  readily  determine  between  the  conditions.  Miura,  in  Japan,  has 
reported  a  case  in  which  these  nodules  contained  the  ova  of  a  parasite.  One 
case  has  been  reported  in  which  the  exciting  cause  was  regarded  as  choles- 
terin  plates,  which  were  contained  within  the  granulomatous  nodules. 

{(l)  Chronic  HaBmorrhagio  Peritonitis. — Blood-stained  effusions  in  the 
peritonaeum  occur  particularly  in  cancerous  and  tuberculous  disease.  There 
is  a  form  of  chronic  inflammation  analogous  to  the  h.^morrhagic  pachymen- 
ingitis of  the  brain.  It  was  described  first  by  Virchow,  and  is  localized 
most  commonly  in  the  pelvis.  Layers  of  new  connective  tissue  form  on 
the  surface  of  the  peritonaeum  with  large  wide  vessels  from  which  haemor- 
rhage occurs.  This  is  repeated  from  time  to  time  with  the  formation  of 
regular  layers  of  haemorrhagic  effusion.  It  is  rarely  diffuse,  more  com- 
monly circumscribed. 


V.    NEW   GROWTHS    IN    THE    PERITON>EUM. 


(a)  Tuberculous  Peritonitis. — This  has  already  been  considered. 

(h)  Cancer  of  the  Peritonseum. — Although,  as  a  rule,  secondary  to  disease 
of  the  stomach,  liver,  or  pelvic  organs,  cases  of  primary  cancer  have  been 
described.  It  is  probable  that  the  so-called  primary  cancers  of  the  serous 
membranes  are  endotheliomata  and  not  carcinomata.  Secondary  malig- 
nant peritonitis  occurs  in  connection  with  all  forms  of  cancer.  It  is  usually 
characterized  by  a  numbe .  of  round  tumors  scattered  over  the  entire  peri- 
tonaeum, sometimes  small  and  miliary,  at  other  times  large  and  nodular., 
with  puckered  centres.  The  disease  most  commonly  starts  from  the  stom- 
ach or  the  ovaries.  The  omentum  is  indurated,  and,  as  in  tuberculous 
peritonitis,  forms  a  mass  which  lieo  transversely  across  the  upper  portion 
of  the  abdomen.  Primary  malignant  disease  of  the  peritonaeum  is  extremely 
rare.  Colloid  is  said  to  have  occurred,  forming  enormous  masses,  which  in 
one  case  weighed  over  100  pounds.  Cancer  of  this  membrane  spreads, 
either  by  the  detachment  )f  small  particles  which  are  carried  in  the  lymph 
currents  and  by  the  movements  to  distant  parts,  or  by  contact  of  opposing 
surfaces.  It  occurs  more  frequently  in  women  than  in  men,  and  more  com- 
monly at  the  later  period  of  life. 

The  diagnosis  of  cancer  of  the  peritoneeum  is  easy  with  a  history  of  a 


ASCITES. 


C05 


local  malignant  disease;  as  when  it  occurs  with  ovarian  tumor  or  with 
cancer  of  the  pylorus.  In  cases  in  which  tliere  is  no  evidence  of  a  primary 
lesion  the  diagnosis  may  be  doubtful.  Tlie  clinical  picture  is  usually  that 
of  chronic  ascites  with  progressive  enuiciation.  There  may  be  no  fever. 
If  there  is  much  elfusion  notliing  definite  can  be  felt  on  examination.  After 
tapping,  irregular  nodules  or  the  curled  omentum  may  be  felt  lying  trans- 
versely across  the  upper  portion  of  tlie  abdomen.  Unfortunately,  this  tumor 
upon  which  so  much  stress  is  laid  occurs  as  frequently  in  tuberculous  peri- 
tonitis and  may  be  present  in  a  typical  manner  in  the  chronic  i)rolil'erative 
form,  so  that  in  itself  it  has  no  8})ecial  diagnostic  value.  Multiple  nodules, 
if  large,  indicate  cancer,  particularly  in  persons  aljove  middle  lil'e.  Nodu- 
lar tuberculous  peritonitis  is  most  fre(iucnt  in  cliildren.  Tiie  presence 
about  the  navel  of  secondary  nodules  and  indurated  masses  is  more  com- 
mon in  cancer.  Inflammation,  suppuration,  and  the  discharge  of  pus  from 
tlie  navel  rarely  occurs  except  in  tuberculous  disease.  Considerable  en- 
largement of  the  inguinal  glands  may  be  present  in  cancer.  The  nature 
of  the  fluid  in  cancer  and  in  tubercle  may  be  much  alike.  It  may  be  luvmor- 
rhagic  in  both;  more  often  in  the  latter.  The  histological  examiiuxtion  in 
cancer  may  show  large  multinuclear  cells  or  groups  of  cells — the  sprouting 
cell-groups  of  Foulis — which  are  extremely  suggestive.  The  colloid  cancer 
may  produce  a  totally  different  picture;  instead  of  ascitic  fluid,  the  abdo- 
men is  occupied  by  the  semi-solid  gelatinous  substance,  and  is  Arm,  not 
fluctuating. 

And,  lastly,  there  are  instances  of  echinococci  in  the  peritonanim  which 
may  simulate  cancer  very  closely.  I  have  reported  a  case  of  this  kind,  in 
which  the  enlarged  liver  and  the  innumerable  nodular  masses*  in  the  peri- 
tona3um  naturally  led  to  this  diagnosis. 


)posing 


ry  of  a 


VI.    ASCITES  (ITydro-peritonceum). 

Definition. — The  accumulation  of  serous  fluid  in  the  peritoneal  cavity. 

Etiology. — (1)  Local  Causes. — (a)  Chronic  inflammation  of  tlie  peri- 
tonaMim,  either  sim])le,  cancerous,  or  tuberculous,  (h)  Portal  obstruction  in 
the  terminal  branches  within  the  liver,  as  in  cirrhosis  and  chronic  passive 
congestion,  or  by  compression  of  the  vein  in  the  gastro-hepatic  omentum, 
either  by  proliferative  peritonitis,  by  new  growths,  or  by  aneurism,  (c) 
Tumors  of  the  abdomen.  The  solid  growths  of  the  ovaries  may  cause  con- 
siderable ascites,  which  may  completely  mask  the  true  condition.  The  en- 
larged spleen  in  leukasmia,  less  commonly  in  malaria,  may  be  associated, 
with  recurring  ascites. 

(2)  General  Causes. — The  ascites  is  part  of  a  general  dropsy,  the  result 
of  mechanical  effects,  as  in  heart-disease,  chronic  emidiysema,  and  sclerosis 
of  the  lung.  In  cardiac  lesions  the  effusion  is  sometimes  confined  to  the 
])eriton[eum,  in  which  case  it  is  due  to  secondary  changes  in  the  liver,  or  it 
has  been  suggested  to  be  connected  with  a  failure  of  the  suction  action  of 
this  organ,  by  which  the  peritoneum  is  kept  dry.  Ascites  occurs  also  in. 
the  dropsy  of  Bright's  disease,  and  in  hydra^mic  states  of  the  blood. 


606 


DISKASr-N  OF  TflE   DIGESTIVE  SYSTEM. 


/ 


Symptoms. — A  .miidunl  iniirnriii  (■iiliir;^fiiiL'iil  nl'  the  alxlimii'ii  is  tlio 
chuiaclL'iifetic  !«3iii]ttuiii  ol"  usciles.  Tlio  pliysical  tiiy;iis  jiru  usually  distinctive. 
(it)  I iisiiccdoii. — Acc'()i'(liii_!,f  111  lilt'  iiiiiouut  dl'  lliiid  lilt'  alitldiiu'ii  is  prd- 
liilti'i'aiit  and  llaUcMcd  at  the  sides,  \\illi  lai'^ic  cll'iisioiis,  iIk-  skin  is  Iciiso 
and  may  pivst'id  tlic  liniii'  albicanUs.  l''i'i'(|Ut'ntly  llic  navel  ilsell'  and  the 
pai'ls  ahdut  it  are  \t'ry  pidnnnent.  In  many  cases  the  superlieial  veins  are 
enlai'^i't'd  and  a  plexus  Joinin;^  I  lie  mamillary  vessels  can  he  seen.  Sometinu's 
it  can  lie  dclermineil  hy  pressmv  (Hi  lliise  veins  that  the  current  is  I'roin 
iielow  upward.  Jn  smiie  instances,  as  in  throiiiho^is  (ir  ohlilei'alion  of  the 
pdilai  vein,  these  superlieial  alidnminal  vessels  may  he  extensively  varicose. 
.MmiiiI  the  navel  in  eases  of  cirrhosis  there  is  occasioiially  a  lar;if  hiiiieh  of 
distended  veins,  the  so-called  caput   .Medusa*. 

(Ii)  J'lilpdiiaii. —  l-"liictiiatioJi  is  ohtained  hy  placinjj;  the  llnj^'ers  of  oin* 
hand  upon  one  side  of  the  ahdonien  and  hy  giving  a  sharp  tap  on  the  op- 
posite side  with  the  other  hand,  when  a  wave  is  felt  to  strike  as  a  definite 
shock  against  the  ap[ilit'd  lingers,  l-^veii  comparatively  small  ([uantities  of 
lluid  may  give  this  iluctuation  shock.  When  the  ahdominal  walls  are 
thick  or  very  fat,  an  assistant  may  place  the  edge  of  the  hand  oj'  a  piece 
of  cardhoard  in  the  front  of  the  ahdoinen.  A  diU'erent  ^irocedure  is 
adopted  in  [laljiating  for  the  solid  organs  iji  case  of  ascites.  Instead  of  plac- 
ing tlu'  liiiiid  Hat  ii|M)n  the  ahdonien,  as  in  the  ordinary  method,  the  pads 
of  the  lingers  only  ai'e  jilaced  lightly  upon  the  skin,  and  then  hy  a  sudden 
de|iression  of  the  lingers  the  lluid  is  disjilaced  and  the  solid  organ  or  tuiimr 
may  he  felt.  V>y  this  method  of  "  dipping  "  or  displacement,  as  it  is  called, 
the  liver  jiiay  he  felt  helow  the  costal  mai'gin,  or  the  spleen,  or  sometimes 
solid  tumors  of  the  omentum  or  i.ntestine. 

(r)  I'l'iTHssioii. — Jn  the  dorsal  jxisition  with  a  moderate  quantity  of 
lluid  in  the  jieritona'um  the  Hanks  are  dull,  while  the  umhilical  and  epi- 
gastric regions,  into  which  the  intestines  lloat,  are  tympanitic.  This  area 
of  cleai'  resonance  may  have  an  oval  outline.  Having  ohtained  the  lateral 
limit  of  the  dulness  on  one  side,  if  the  iiatient  turns  on  the  opposite  side, 
the  lluid  gravitates  to  the  dependeiit  ])art  and  the  uppermost  Hunk  is 
now  tympanitic.  In  moderate  eU'usions  this  movahle  dulness  changes  great- 
ly in  the  dilfereiit  jiostures,  JSmall  amounts  of  lluid,  jirohahly  under  a 
litre,  would  scarcely  give  movahle  dulness,  as  the  pelvis  ajid  the  renal  re- 
gions hold  a  considcrahle  quantity.  Jn  such  cases  it  is  best  to  ])lace  tlie 
])atient  in  the  knee-elhow  jiosition,  when  a  dull  note  will  be  detei'inined  at 
the  most  de])en(h'nt  inu'tion.  By  careful  attention  to  these  details  mis- 
takes are  usually  avoided. 

The  following  are  among  the  conditions  which  may  be  mistaken  for 
dropsy:  Orariaii  tumor,  in  which  the  sac  develops,  as  a  rule,  unilaterally, 
though  when  large  it  is  centrally  ])laced.  The  dulness  is  anterior  and  the 
resonance  is  in  the  flanks,  into  which  the  intestines  are  puslied  by  the  cyst. 
Examination  per  vayinani  may  give  important  indications.  In  those  rare 
instances  in  which  gas  develo])s  in  the  cyst  the  diagnosis  may  be  very  dilTi- 
cult.  Succussion  has  been  obtained  in  such  cases.  A  dislciuled  hkuhler 
may  reach  above  the  umbilicus.  In  such  instances  some  urine  dribbles 
away,  and  suspicion  of  ascites  or  a  cyst  is  occasionally  entertained.     I  once 


ASCITES. 


60" 


indor  a 
'luil  ri'- 
iici'  the 
I  i  110(1  at 
mis- 

kcii  fdi' 
iterally. 
ind  the 
ic  cyst. 
■)se  raro 
•y  diffi- 
1)1  adder 
Iribbk'S 
I  once 


saw  n  troclmr  thrust  into  a  distended  liladdtr.  wliich  was  snuposod  to  bo 
an  ovarian  cyst,  anil  it  iri  stated  tiiat  .lohn  Ihinler  tapiied  a  l)lad(ler,  sup- 
|Hisin,L,f  it  t(i  be  ascites.  Siicli  a  niistal\e  siiould  be  avoided  by  careful 
catiieterization  prior  to  any  operative  i)roci'(lures.  And  lastly,  there  are 
lar<re  pancreatic  or  hydatid  cysts  in  the  abdomen  winch  nuiy  simulate  ascites. 

Xatiirc  of  llir  Ascilic  Fluid. —  I'snally  this  is  a  cloar  scrum,  light  yel- 
low in  the  ascites  of  ana-mia  and  Urii^ht's  diseasi',  often  darker  in  c(dor  in 
( irrhosis  of  the  liver,  'i'lio  spocitic  gravity  is  low,  seldom  more  than  I.OIO 
or  1.015,  whereas  in  the  tlind  of  ovarian  cysts  the  spocilic  gravity  is  high, 
l,t>'i(»  or  over.  It  is  allmminous  and  souu'times  coagulates  spontaneously, 
hock  has  called  attention  to  the  importaiu'c  of  the  study  of  the  cells  iu 
llie  I'xudate.  In  cancer  very  characteristic  forms,  with  unclear  figures,  luay 
lie  found.  llaMuorrliagic  ell'usion  usually  occurs  in  cancer  and  tubercu- 
losis, and  occasionally  in  cirrhosis.  1  have  already  referred  to  the  in- 
:-tanccs  of  luemorrhagic  elfusion  in  connection  with  ruptured  tubal  preg- 
uaney.  A  chylous,  milky  exudate  is  occasionally  found.  Iluscy  has  col- 
lected .'i;5  cases  from  the  literature,  'riiero  arc,  as  (^)uincko  has  pointed  out, 
two  distinct  varieties,  a  fatty  and  a  chylous,  whieh  may  bo  distinguislu'd 
liy  the  nucroscopc,  as  in  the  former  there  are  distinct  fat-globules.  Those 
cases  have  been  sometimes  connected  with  ix-ritonoal  or  mesenteric  cancer. 
In  the  true  chylous  ascites  the  tluid  is  turbid  and  milky.  In  some  of  the 
cases,  as  in  A\'liitla's,  a  perforation  of  the  thoracic  duct  has  been  found. 
The  condition  does  not  necessarily  follow  obliteration  of  the  thoracic  duct. 
Mild  grades  of  chylous  ascites,  which  are  occasionally  found  clinically,  may 
lie  due  to  the  fact  that  the  ])atient  upon  a  milk  <liet  has  a  pei'manent 
lipaunia,  such  as  is  present  in  young  aninnils  and  in  diabetics,  in  whom  the 
liquor  sanguinis  is  always  fatty.  Under  such  circumstances  an  exudate 
may  contain  enough  of  the  molecular  base  of  the  chyle  to  produce  turbid- 
ity of  the  fluid.  Some  of  the  cases  have  boon  associated  with  lilariasis. 
In  a  recent  case  in  my  clinic  X.  ^IcL.  Harris  isolated  the  bacillus  diph- 
theria' from  the  chylous  fluid. 

Treatment  of  the  Previous  Conditions. — {</)  Acute  Peri- 
tonitis.— licst  is  enjoined  upon  the  patient  by  the  severe  pain  which  fol- 
lows the  slightest  movement,  and  he  should  be  propped  in  the  ])osition 
which  gives  him  greatest  relief.  For  the  pain  mori)hia  should  be  injected 
liypodcrmically 'in  full  doses.  In  an  adult  it  is  l)etter  to  give  a  third  or 
half  a  grain  at  once,  and  subsequently  at  intervals  r(>peat  it  in  smaller 
(loses,  Avhen  necessary.  The  action  of  the  drug  should  lie  carefully 
watched  ....d  the  ])aticnt  should  iu)t  be  allowed  to  ]»ass  into  such  a  degree 
of  unconsci(Uisncss  that  he  cannot  be  aroused.  The  respiration  and  the 
condition  of  the  ])upils  also  give  valuable  information.  The  amount  of 
o])ium  which  has  l)cen  given  in  certain  instances  is  romarka1)le,  and  indi- 
cates a  tolerance  of  the  drug.  The  (bises  given  Ity  the  late  Alonzo  ("lark, 
of  Xew  York,  may  be  truly  ternu'd  heroic.  Austin  Flint  notes  that  a  pa- 
tient under  the  care  of  this  ])hysiciau  took  "in  the  first  twenty-four  hours, 
cf  opium  and  the  sulphate  of  mor]diia.  a  (piantity  e(|uivalent  to  10(i  grains 
of  niMum;  in  the  second  twenty-four  hours  she  took  472  grains;  on  the 
third  day,  23G  grains;  on  the  fourth  day,  120  grains;  on  the  fifth  day, 
38 


PF"'^ 


608 


DISEASES  OF  TIIR   DKIKSTIVF']  SYSTEM. 


/ 


C4  grains;  on  the  sixth  (hiy,  2'i  graiiiH;  on  the  seventh  day,  IS  grains;  nfl(  r 
which  the  treatment  was  snspended."  ]t  is  unnecessary  to  use  these  enor- 
mous doses,  as,  even  when  the  pain  is  most  intense,  from  a  third  to  a  half 
grain  of  iii(ir|»hiii  every  few  hours  will  usually  keep  the  patient  thoroughly 
under  the  intluence  of  the  dru;i.  Jn  a  robust,  strong  patient,  seen  at  the 
outset,  twenty  leeches  ai)plied  over  the  ahdomen  will  give  great  relief. 

JiOCid  applications — either  hot  turj)entini!  stupes  or  cloths  wrung  out 
of  ice-water — may  he  laid  u|)on  the  alidonici\  The  patients  sonietimeii 
declare  tiiat  they  are  greatly  relieved  by  the  latter. 

Tiie  (pu'stion  of  the  use  of  purgatives  in  ^)eritoniti8  has  of  late  been 
warndy  discussed.  Lawson  Tait  and  other  gymecologists  have  used  the 
saline  ])urges  with  the  greatest  benedt  in  post-oi)eration  peritonitis.  Theo- 
retically it  appears  corri'ct  to  give  salines  in  coiu'cntraled  form,  which 
cause  a  rapid  and  profuse  exosniosis  of  serum  from  the  intestiiud  vessels, 
relieving  the  congestion  and  re<Uicing  the  (edema,  which  is  one  important 
factor  in  causing  the  meteorism.  It  is  also  urged  that  the  increased  peri- 
stalsis ])revents  the  formation  of  adhesions.  ]n  reading  the  reports  of  these 
successful  cases,  one  is  not  always  convinced,  however,  that  i)eritonias 
actually  existed.  Still,  in  cases  of  acute  peritonitis  due  to  extension  or 
following  o])eration  or  in  septic  conditions  the  judgment  of  nuany  careful 
men  is  decidedly  in  favor  of  the  use  of  salines.  1  cannot  speak  from  per- 
sonal experience  on  this  question.  The  majority  of  cases  of  jieritonitis 
which  come  under  the  care  of  the  physician  follow  lesions  of  the  abdominal 
viscera  or  are  due  to  perforation  of  ulcer  of  the  stomach,  the  ileum,  or  the 
appendix.  In  such  cases,  particularly  in  the  large  group  of  appendix  cases, 
to  give  saline  purgatives  is,  to  say  the  least,  most  injudicious  treatment. 
The  safety  of  the  i)atient  lies  in  the  restriction  of  the  peristalsis  and  the 
localization  of  the  inflammation,  for  which  purpose  opium  alone  is  of 
service.  In  these  instances  rectal  injections  should  he  employed  to  relieve 
the  large  bowel.  No  symptom  in  acute  peritonitis  is  more  serious  than 
the  tympanites,  and  none  is  more  ditficult  to  meet.  The  use  of  the  long 
tube  and  injections  containing  turpentine  may  be  tried.  Drugs  by  the 
mouth  cannot  be  retained. 

For  the  vomiting,  ice  and  small  quantities  of  soda  water  may  be  em- 
ployed. The  patient  should  be  fed  on  milk,  but  if  the  vomiting  is  dis- 
tressing it  is  best  not  to  attempt  to  give  food  by  the  mouth,  but  to  use 
small  nutrient  enemata.  In  all  cases  of  peritonitis  it  is  best  to  have  a  sur- 
geon in  consultation  early  in  the  disease,  as  the  question  of  operation  may 
come  up  at  any  moment.  I  have  already  mentioned  the  conditions  under 
which  laparotomy  is  indicated  in  perforative  appendicitis.  The  acute 
purulent  cases,  particularly  those  in  which  the  streptococci  occur,  usually 
die;  but  the  results  of  operative  interference  even  in  this  form  are  steadily 
improving.  In  the  acute  forms  of  tuberculous  peritonitis  operative  meas- 
ures ap])ear  to  be  more  hopeful,  but  they  are  not  always  successful. 

(b)  Chronic  Peritonitis. — For  the  cases  of  chronic  proliferative  peri- 
tonitis very  little  can  be  done.  The  treatment  is  practically  that  of  ascites. 
In  all  these  forms,  when  the  distention  becomes  extreme,  tapping  is  indi- 
cated.    The  treatment  of  tuberculous  peritonitis  has  fallen  largely  into 


ASCITKS. 


6oa 


Tlic..- 
wllirli 


the  luindH  (»f  tlio  Mur^'i'oiiH,  and  the  rcsiills  in  many  rases  nro  very  good. 
Acconliu};  to  the  statistics  ol"  Mannui^M',*  ot'  71  eases,  '^S  svrvived  the  opera- 
tion for  more  tlian  a  year.  Of  v'(!  additiomil  eases  wliieh  ;  havc^  eoll('cted,f 
1  I  were  dead  at  the  time  of  the  report.  Wiliiin  two  years  and  three  months 
tliere  were  (5  operations  performed  at  the  Johns  Hopkins  Hospital  in  tuber- 
cidons  i)eritonitis,  with  4  recoveries. 

{(')  Ascites. — 'I'lie  treatment  (h'peiids  somewhat  on  the  nature  (d'  the 
ease.  In  cirrhosis  early  and  repcatc(l  tapping'  may  give;  time  for  ti>e  estah- 
Ushment  of  the  colhiteral  circidation,  and  temporary  cures  have  foUowed 
this  preceduto.  Permanent  drainage  witli  Sonthey's  tube,  incision,  and 
washing  out  the  peritona'iim  have  a'so  been  practised.  In  the  ascites 
of  cardiac  and  riMial  disease  the  cathartics  are  most  satisfactory,  particiihirly 
the  l)itartrate  of  potash,  given  ah)ne  or  witli  jahip,  and  the  hirge  (h)ses  of 
salts  given  an  hour  before  l)reakfast  with  as  little  water  as  possible.  These 
sometimes  cause  rapid  disap[)earanco  of  the  etfusion,  but  they  are  not  so 
successful  in  ascites  as  in  ])leurisy  with  elTusion.  The  stronger  cathartics 
may  sometimes  he  necessary.  The  ascites  forming  i)art  of  the  general 
anasarca  of  Bright's  disease  will  receive  consideration  under  another  sec- 
tion. 


re  pen- 

ascites. 

lis  indi- 

lly  into 


*  Paris  Tlicsis,  1889. 

t  On  Tuberculous  Peritonitis,  Jolins  Hopkins  Hospital  Reports,  1800. 


be  cm- 
is  dis- 
to  use 
le  a  sur- 
lon  may 
nnder 
acute 
usually 
Isteadily 
le  nieas- 


1 ' 


SI-XTIOX   VI. 
DISEASES  OF  THE    liESlMilATORY   SYSTEM. 


/ 


m 


I.    DISEASES  OF  THE  NOSE. 
I.    ACUTE    CORYZA. 

AciTr:  cnliirrliiil  iiilliiiimmlinii  of  Ihc  iiiipcr  iiir-pnissiifro!',  popularly 
known  as  a  "  catarrli  "  or  a  "  cold,"  is  usually  an  independent  uU'eclion, 
1/ut   may  iircccdt'  the  (levelopnicnt  of  another  disease. 

Etiology. — It  i>revailH  most  extensively  in  the  ehanji'eahle  weather  nf 
the  spring;  and  early  winter,  and  ni:iy  occur  in  epideinic  form,  many  cases 
{levelo|)in<,'  in  a  eomnmnity  within  a  IV'w  weeks.  These  outbreaks  are 
very  like.  tliou<:h  less  intense  than  the  epidemic;  influenza,  cases  of  which 
may  lie^^in  with  symptoms  of  ordinary  cory/.a.  'I'lie  disease  i)rol)al)ly  de- 
)ien(ls  upon  a  mic  ro-di'pmism.  lrritatin«i;  fumes,  such  ns  those  of  iodine  or 
ummonia,  also  may  cause  an  acute  catarrh  of  the  no.se. 

Symptoms. — The  patient  IVels  indisposed,  ]ierha|ts  chilly,  has  sli;j;lit 
luadache,  and  suec/.es  friMpU'ntly.  In  severe  cases  there  are  pains  in  the 
hack  and  limiis.  There  is  usually  sli<;ht  fevi'r,  the  temperature  risinj,'  to 
]0l°.  The  pulse  is  (pnik,  the  skin  is  dry,  and  thei'e  are  all  the  feature's  of 
a  feverish  attack.  .\t  lirst  the  mucous  memhrane  of  the  nose  is  swollen, 
■'•stulfed  up,""  and  the  |)aticnt  has  to  hreathe  tlirou<:h  the  mouth.  A  thin, 
clear,  irritatin<r  secretion  Hows,  and  nuikes  the  viljxv:^  of  the  nostrils  sore. 
The  mucous  niemliraiie  of  the  tear-ducts  is  swollen,  so  that  the  eyes  w<'e|t 
and  the  conjunctiv:e  are  injected.  '^Jlio  .sense  of  snu'll  ami,  in  part,  tlu' 
sense  of  taste  is  lo<t.  ^\'itll  the  nasal  catai'rli  there  is  slijiht  soreness  ot' 
the  throat  and  stilfness  of  the  neck;  the  ])harynx  looks  red  and  swollen, 
and  sometinu's  the  act  of  swallowinj?  is  ])ainiul.  The  larynx  also  may  I'l' 
involved,  and  the  voice  becomes  husky  or  is  even  lost,  if  the  inllamnm- 
tiou  extends  to  the  Juistaehian  luhes  there  may  he  impairment  of  tln' 
lK'arin^^  Tn  more  severe  cases  there  are  bronchial  irritation  and  couliIi. 
Occasionally  Ciiere  is  an  outbi'cak  of  labial  or  nasal  hei'pes.  Tsually  within 
thirty-six  lioui's  the  nasal  secretion  becomes  turbid  and  more  jtrofuse,  lln' 
swelling  (d'  the  mucosa  subsides,  the  |)atieni  gradually  becomes  able  In 
breathe  throuLih  the  nostrils,  and  within  four  oi'  five  days  the  symptoms 
tlisai)]»pear,  with  the  exeei)tioii  of  the  increased  discharge  from  the  iw^.c 
610 


C'lIItoNIC    XASAJi   CATAIIUII. 


<;ii 


niid  ii|t|)('r  |tliarvii\.  'riicic  nic  niicly  any  I'ail  circits  I'miii  a  siiuplf  coryzii. 
W'Ik'Ii  till'  attacks  are  I'nMpU'iitly  rfpi-atod  tlic  disL'a.su  may  Im'coiik'  fliroiiic. 

'I"lu'  iliiiiiiiiiKis  is  always  <'asy,  ImiI  cant  ion  iiiii>t  Im'  rxt'iTisfil  lot  iln- 
initial  catanli  ol'  iiicaslcH  or  ttcvcri!  iiilliti'ii/.u  should  hn  luislaki'ii  for  tlii! 
hiinpit'  cory/a. 

Treatment.  —  Many  cases  are  so  mild  that  the  i»ati«'iits  are  ahic  to  he 
idioiit  and  to  allcnd  to  their  work,  il'  there  are  fever  and  const  itntional 
ilistnrliance,  tlic  palient  should  he  kept  in  hcd  and  should  take  a  simple 
IcMT  mixture,  and  at  ni^dd  a  drink  (d'  hot  lemonade  and  a  full  'osc  n\' 
hover's  powder.  .Many  persons  nml  jxreat  henelil  from  the  'I'm.  ;  ii  hath, 
for  the  distressing'  sense  of  ti;.;htness  and  pain  over  the  friuilal  siiuisi-s, 
cocaine  is  very  useful  and  sometimes  ^dvcs  immediate  relief.  The  l-per- 
c(id  solution  may  he  injected  into  the  no>triIs,  or  cotton-wool  soaked  in 
it  may  ho  inserted  into  them.  Later,  the  snuif  rccoinmended  hy  I'errier 
is  advanla«;eous,  composed,  as  it  is,  of  morphia  (jrr.  ij),  hismuth  (."►  i\ ), 
acacia  powder  (."ij).  'i'his  may  oecasiomdiy  he  hlown  or  snulfed  into  thu 
nostrils.  'I"he  lluid  extract  of  hamameli.s,  "  suulVcil  "  from  the  hand  every 
two  or  three  houis,  is  inueli  helter. 


II.  CHRONIC  NASAL  CATARRH. 

(Rhinitis;  Jihinitis  hypcrlropkica ;  lihiniliti  atroiihirn). 

In  siwpk  chronic  calnrrh  there  is  increased  irritahility  of  the  mueoiis 
inemhrane,  particularly  of  the  erectile  tissue  on  the  septum  and  turhinated 
l)ones.  'J'here  is  a  tendency  to  frecpient  stopp.i^'e  of  one  or  hoth  iu)stril.s 
and  the  |)atient  very  easily  catches  cold.  The  secretion  is  at  ilrst  clear 
;ind  afterward  thick  and  tenacious.  The  sense  of  smoll  is  not  specially 
(listufhed  at  this  sta<fe.  With  the  mirror  the  mucinis  membrane  looks 
(■on^'cslcd  and  swollen  and  the  veins  may  he  distended. 

In  lii/pniroijliic  ritliiilis,  which  is  usually  a  sequel  of  the  lormer  con- 
dition, the  nasal  passages  arc  ohstrueted,  chiefly  hy  enlar^fcment  of  the 
lower  turhinated  bodies  and  swelling;  of  the  nineous  mend)rane  of  the  sep- 
lum.  \'ery  often  theri;  is  hypertrophy  of  the  adenoid  tissue  in  the  vault 
of  the  ])liarynx  and  of  the  mucous  membrane  about  the  orifices  of  the 
I'lustachian  tubes.  The  two  conditions  freciueiitly  <.ro  toj,M'ther  as  expressed 
ill  the  desi<i;nation,  chronic  naso-pharyn<real  catarrh.  The  sym[)toms  of 
this  hyperlroi)hic  rhinitis  may  be  local  or  <feneral. 

The  most  important  local  symptoni  is  the  obstruction  of  the  ])assa<re  of 
air  throu<ih  the  nostrils,  so  that  the  patieids  become  mouth-breaiiu'r>. 
Durinji;  the  day  thi.s  may  not  be  very  distressinjr,  but  at  ni,u;bt  the  mouth 
and  throat  ^et  extremely  dry  and  the  sleep  is  disturbed,  'i'he  voice  be- 
comes nasal  in  ((  lality  and  in  advanced  cases,  when  the  Eustachian  tubes 
are  obstructed,  there  may  be  deafness.  It  should  ever  1)0  born(>  in  nund  !)y 
ihe  practitioner  tiuit  a  very  laru'e  ])ro])ortion  of  all  cases  of  deafness  orijii- 
uate  in  chronic  naso-])haryn<real  catarrh.  The  jjfeneral  sym])tonis  have 
been  considered  more  fully  under  chronic  pharyngeal  catarrh  and  moutli- 
hrcathing. 


C12 


DISKASKS  OF  THE  RESPIRATORY  SYSTKM. 


/ 


Atroiiliic  rliinitis,  wliicli  is  also  known  nndcr  the  nunios  coryza  fetida 
and  ozii'na,  may  be  a  sequence  ol'  the  liypertrophic  I'orin.  Uza^na  is  only  a 
symptom,  and  is  met  with  in  many  ulcerative  conditions  of  the  nostrils, 
])articularly  as  a  result  of  syi)hilis,  foreign  bodies,  caries  and  necrosis  of 
the  bones,  and  glanders.  Fortunately,  the  atrophic  form  by  no  means 
necessarily  follows  the  hy{)ertroj>hic  stage.  The  cases  are  much  more  fre- 
quent in  women  than  in  men,  and  usually  occur  early  in  life.  The  mucous 
membrane  is  thin  and  covered  with  grayish  crusts  which,  when  removed, 
show  a  slightly  excoriated  surface,  but  true  ulcers  are  rarely  seen.  The 
erectile  tissue  is  completely  atrophied  by  a  process  of  slow  connective-tissue 
growth,  or,  as  J.  N.  Mackenzie  calls  it,  a  cirrhosis.  The  mucous  mem- 
Ijrane  of  the  pharynx  is  usually  dry  and  glazed. 

The  symptoms  are  most  distinctive,  owing  to  the  horrible  odor  which 
comes  from  the  nose,  and  of  which,  fortunately,  the  patient  is  himself 
unconscious,  because  the  sense  of  smell  is  lost.  The  secretion,  which  is 
])uriform,  dries  and  forms  large  crusts,  which  are  dislodged  by  picking  or 
which  gradually  fall  off.  The  cause  of  the  offensive  odor  his  been  much 
discussed — whether  it  is  due  to  a  sjjecial  organism  or  to  specially  favorable 
conditions  for  the  growth  and  development  of  the  germs  of  putrefaction. 
Probably  the  latter  view  is  correct. 

The  treatment  of  hypertrophic  rhinitis  consists  in  the  thorough  cleans- 
ing of  the  nasal  passages,  the  removal  of  the  pharyngeal  growths,  and  the 
reduction  of  the  hy])ertrophied  nasal  mucosa.  It  is  best  to  use  a  simple 
douche,  in  order  to  keep  the  membrane  absolutely  clean.  The  Birming- 
ham nasal  douche  is  the  most  simple  and  satisfactory,  and  may  be  filled 
with  alkaline  and  antiseptic  or  deodorizing  solutions.  One  of  the  most 
satisfactory  is  the  bicarbonate  of  soda  (1^  drachm),  listerine  (6  drachms), 
and  water  (1  ounce).  Operative  procedures  are  necessary  in  a  majority 
of  the  cases,  and  the  practitioner  shoidd  early  call  to  his  assistance  the 
specialist.  It  is  sad  to  think  of  the  misery  which  has  been  entailed  upon 
thousands  of  peoi)le  owing  to  neglect  of  naso-pharyngeal  catarrh  by  parents 
and  physicians. 

The  treatment  of  atrophic  rhinitis  comes  more  properly  under  the 
s]iecial  monographs. 


III.    AUTUMNAL    CATARRH  {Hmj  Fever). 

An  affection  of  the  upper  air-passages,  often  associated  with  asthmatic 
attacks,  due  to  the  action  of  certain  stimuli  upon  a  hypersensitive  mucous 
membrane. 

This  affection  was  first  doseribed  in  1819  by  Bostock,  who  called  it 
catarrlnts  (vsfivv.<i.  !^^orrill  Wyman,  of  Cambridge,  Mass.,  wrote  a  mono- 
graph on  the  subject,  and  described  two  forms,  the  "  June  cold,"  or  "  rose 
cold,"  Avhich  comes  on  in  the  spring,  and  the  autumnal  form  which,  in 
this  country,  docs  not  develop  until  August  and  September,  and  never 
persists  after  a  severe  frost.  Blakely  studied  its  connection  with  the  uol- 
len  of  various  grasses  and  flowers.      The  late  George  M.  Beard  made  uic.iy 


!a  fetida 

,3  only  a 

nostrils, 

crosis  of 

0  means 
more  fre- 

1  mucous 
I'emoved, 
n.  The 
ve-tissue 
us  mom- 

ar  Avliich 
1  himself 
which  is 
icking  or 
en  much 
favorable 
•efaction. 

h  cleans- 
,  and  the 

a  simple 
Birming- 

be  filled 
the  most 

rachms), 

majority 
ance  the 

ed  ii])on 
parents 

idcr  the 


;thmatic 
mucous 

?allcd  it 
ii  mono- 
■»r  "  rose 
lich,  in 
d  never 
the  nol- 
le iiic.y 


AUTUMNAL  CATARRH. 


013 


I 


<  arcful  observations  on  i'^"^  disease.  Tntil  recently  this  form  of  catarrh 
was  believed  to  result  cav  .usively  from  the  action  of  certain  irritants  on 
ihc  mucous  membrane  of  the  nose,  particularly  the  pollen  of  i)lants, 
which,  as  the  experiments  of  Blakeley  showed,  ])lay  an  important  rule  in 
the  disease.  Other  emanations  also  may  induce  an  attack,  as  in  the  case 
of  the  late  Austin  Flint,  who  was  liable  to  coryza,  or  even  asthma,  if  he 
A(}\)t  on  a  certain  sort  of  feather  pillow.  This,  however,  is  only  one  factor 
in  the  disease.  A  second,  most  important  one,  was  discovered  in  the  con- 
dition of  the  nasal  mucous  membrane  in  these  cases.  Voltolini,  of  Breslau, 
ill  1871,  observed  the  cure  of  a  case  of  asthma  by  the  removal  of  a  nasal 
polypus.  Since  that  date  the  observations  of  Hack,  in  Germany,  and  par- 
ticularly of  Daly,  of  Pittsburg,  Koe,  of  Kochester,  John  X.  ilackenzie,  of 
lialtimore,  and  Harrison  Allen,  of  riiiladelphia,  have  demonstrated  the 
association  of  asthmatic  attacks  with  nasal  disease.  Dalv  discovered  that 
in  a  large  proportion  of  the  cases  of  hay  asthma  there  was  local  disease  of 
the  mucous  mendirane  of  the  nose,  the  cure  of  which  rendered  the  pa- 
tient insuscei)tible  to  cond''  ons  previously  exciting  the  attacks.  This  has 
been  abundantly  confirmed.  Still  identical  lesions  exist  in  many  ])eople 
who  never  suffer  With  the  disease,  so  that  there  must  be  a  third  factor,  a 
neurotic  constitution.  In  the  etiology  of  hay  fever,  then,  these  three  ele- 
ments prevail — a  nervous  constitution,  an  irritable  nasal  mucosa,  and  the 
?tim\tlus. 

The  disease  affects  certain  families,  particularly,  it  is  said,  those  with  a 
neurotic  taint.  The  peculiarity  may  occur  through  several  generations. 
It  is  certainly  more  common  in  the  United  States  than  in  Europe,  and 
much  more  common  in  the  United  States  than  in  Canada.  The  United 
States  Hay  Fever  Association  now  numbers  thousands  of  members. 

Dwellers  in  cities  are  more  subject  than  residents  in  the  country.  The 
structural  ])eculiarities  of  the  nasal  mucous  membrane  are  those  of  hyper- 
1ro])hic  rhinitis.  Harrison  Allen  states  that  the  inferior  turbinated  bones 
lie  well  above  the  floor  of  the  nostrils,  which  renders  the  mucous  mem- 
brane more  liable  to  irritation  from  inhaled  substances.  Deflection  of  the 
tieptum,  hypertrophy  of  the  soft  parts,  and  excessive  hyperesthesia,  so  that 
tlie  mere  touch  with  a  probe  may  be  sufficient  to  induce  an  attack,  are 
common  conditions. 

Symptoms. — These  are,  in  a  majority  of  the  cases,  very  like  those  of 
ordinary  coryza.  There  may,  however,  be  much  more  i  adache  and  dis- 
tress, and  some  patients  become  very  ]ow-s])irited.  Cough  is  a  common 
symptom  and  may  bo  very  distressing.  Paroxysms  of  asthma  may  develop, 
so  like  as  to  be  indistinguishable  from  the  ordinary  bronchial  form.  The 
two  conditions  may  indeed  alternate,  the  patient  having  at  one  time  an 
attack  of  common  hay  fever  and  at  another,  under  similar  circumstances, 
nn  attack  of  bronchial  asthma.  Of  the  immediate  exciting  causes  of  the 
attack,  unquestionably  in  a  majority  of  the  cases  coming  on  in  the  autumn 
there  is  an  association  with  the  presence  of  pollen  in  the  atmosphere,  but 
this  is  only  one  of  a  host  of  exciting  causes.  In  certain  persons  the  parox- 
ysms may  develop  at  any  season  from  sudden  changes  in  the  temperature. 
An  attack  may  even  come  on  through  association  of  ideas.      The  well- 


GU 


DISEASES  OF   THE   RESPIRATORY  SYSTEM. 


.  \ 


liJf. 


known  experiment  of  J,  X.  ]\[ackenzie,  of  inducing  an  attack  in  a  sus- 
eei)tible  jjert^on  by  oltering  her  an  artificial  rose  to  smell,  strikingly  illus- 
trates tile  neurotic  element  in  the  disease. 

Treatment. — This  may  be  comprised  under  three  heads:  First,  since 
the  disease  a])[)ears  in  numy  instances  to  be  a  form  of  chronic  neurosis, 
remedies  wliicJi  improve  the  stability  of  the  nervous  system  may  he  cm- 
ployed — sucli  as  arsenic,  i)]iosphorus,  and  strychnia.  Second,  climatic. 
J)\vellers  in  tlie  cities  of  tlie  Atlantic  seaboard  and  of  tlie  Central  States 
enjoy  com])lete  immunity  in  tlie  Adiroudacks  and  Wliite  Mountains.  As 
a  rule  the  disease  is  aggravated  by  residence  in  agricultural  districts.  Tlie 
dry  mountain  air  is  uiupicstionably  the  best;  there  are  cases,  however,  which 
do  well  at  the  seaside.  Third,  the  thorough  local  treatment  of  the  nose, 
particularly  the  destruction  of  the  vessels  and  sinuses  over  the  sensitive 
areas. 

IV.    EPISTAXIS. 

Etiology. — Bleeding  from  the  nose  may  result  from  local  or  consti- 
tutional conditions.  Among  local  causes  nuiy  be  mentioned  traumatism, 
small  ulcers,  i)icking  or  scratching  the  nose,  new  growths,  and  the  presence 
of  foreign  bodies.  In  chronic  nasal  catarrh  hleeding  is  not  infrequent. 
The  blood  may  come  from  one  or  both  nostrils.  The  How  nu;y  be  profuse 
after  an  injury. 

Among  general  conditions  with  which  nosc-blceding  is  associated,  the 
following  are  the  most  important:  It  occurs  with  great  frequency  in  grow- 
ing children,  particularly  about  the  age  of  puberty;  more  frequently  in 
the  delicate  than  in  the  strong  and  vigorous.  I  have  soon  two  cases  of 
chronic  recurring  ejnstaxis  in  adults  associated  with  remarkahle  telangiec- 
tases of  the  skin  and  visible  mucous  membranes. 

Epistaxis  is  a  very  common  event  in  persons  of  so-called  plethoric 
habit.  It  is  stated  sometimes  to  jjrecede,  or  to  indicate  a  liability  to,  apo- 
plexy, hut  this  is  very  doul)tful. 

In  venous  engorgement,  due  to  heart  or  pulmonary  disease,  epistaxis  is 
not  common  and  there  may  he  a  most  extreme  grade  of  cyanosis  without 
its  occurrence.  In  balloon  and  mountain  ascensions,  in  the  very  rarefied 
atmo8])here,  hannorrhage  from  the  nose  is  a  common  event.  In  ha^mo- 
Ijhilia  tiic  nose  rank?  first  of  the  mucous  membranes  from  which  bleeding 
arises.  It  occurs  in  all  forms  of  clironic  anamiias.  It  precedes  the  onset 
of  certain  fevers,  more  particularly  ty])hoid,  with  which  it  seems  associated 
in  a  special  manner.  Vicarious  epistaxis  has  been  described  in  cases  of 
su])]ircssion  of  the  menses.  liastly,  it  is  said  to  l)e  brought  on  by  certain 
psychical  im])ressions,  but  the  observations  on  tliis  point  arc  not  trust- 
worthy. The  hlood  in  epistaxis  results  from  capillary  oozing  or  diai)edosis. 
The  mucous  meml)rane  is  deeply  congested  and  there  may  be  small  ecchy- 
moscs.  The  bleeding  area  is  usually  in  the  respiratory  ])ortion  of  one  nos- 
tril and  u])on  the  cartilaginous  se|)tum. 

Symptoms. — Slight  luvmorrbage  is  not  associated  with  any  special 
features.     When  the  Idccding  is  protracted  the  patients  have  the  more 


ACUTE  CATARRHAL   LARYNGlTIli. 


G15 


serious  mniiifc'stutions  of  loss  of  IjIooH.  In  the  slow  tlrippi.ig  which  tukea 
])liU'0  ill  Hoiiie  in.staiu'os  of  ha'ino])iiiliii,  there  may  l)e  formed  a  remarkable 
lilood  tumor  projecting'  from  one  nostril  and  extending  even  below  the 
mouth. 

Death  from  ordinary  cpistaxis  is  very  rare.  The  more  blood  is  lost, 
the  fireater  is  tlie  tendency  to  clotlin<^-  with  spontaneous  cessation  of  tiuj 
l)leediiig. 

The  (liafjiwsis  is  usually  easy.  One  point  oidy  need  l)e  mentioned; 
namely,  that  bleeding  from  the  posterior  nares  occasionally  occurs  during 
sleep  and  the  blood  trickles  into  tlie  j)harynx  and  may  be  swallowed.  1 1; 
vomited,  it  may  be  confounded  with  luematemesis;  or,  if  coughed  \\\),  with 
luemo])tysis. 

Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself. 
Various  simple  measures  may  be  emi)loyed,  such  as  holding  the  armsj 
aI)ove  t'iO  head,  the  a})|)lication  of  ice  to  the  nose,  or  the  injection  of  cold 
or  hot  n-ater  into  the  nostrils.  Astringents,  such  as  zinc,  alum,  or  tannin, 
may  be  used;  and  the  old-fashioned  and  sometimes  successful  remedy,  a 
cobweb,  may  be  introduced  into  the  nostrils.  If  the  bleeding  comes  from 
an  ulcerated  surface,  an  attem])t  should  Ije  made  to  apply  chromic  acid  or 
to  cauterize.  If  the  bleeding  is  at  all  severe  and  obstinate,  the  posterior 
nares  shoidd  be  plugged.  Ergot  may  be  given  internally  or  hypodermically. 
The  inhalation  of  carbonic-acid  gas  may  be  tried  or  a  solution  of  gelatine 
injected  into  the  nostril. 


II.  DISEASES   OF   THE   LARYXX. 


ithout 
rarefied 

liaMuo- 
Leeding 
onset 
iociated 
lascs  of 
certain 

trust- 
)edesis. 

ecchy- 
nc  nos- 

speoial 
more 


I.  ACUTE  CATARRHAL  LARYNGITIS. 

This  may  come  on  as  an  independent  affection  or  in  association  with 
general  catarrh  of  the  upper  respiratory  passages. 

Etiology. — Many  cases  are  due  to  catching  cold  or  to  overuse  of  the 
voice;  others  develop  in  consequence  of  the  inhalation  of  irritating  gases. 
It  may  occur  in  the  general  catarrh  associated  • 'ith  influenza  and  measles. 
Very  severe  laryngitis  is  excited  by  traumatism,  either  injuries  from  with- 
out or  the  lodgment  of  foreign  bodies.  It  may  be  caused  by  the  action  of 
verv  hot  liquids  or  corrosive  poisons. 

Symptoms. — There  is  a  sense  of  tickling  referred  to  the  larynx;  the 
cold  air  irritates  and,  owing  to  the  increased  sensibility  of  the  mucous  mem- 
brane, the  act  of  inspiration  may  be  painful.  There  is  a  dry  cough,  and 
the  voice  is  altered.  At  first  it  is  simply  husky,  but  soon  phonation  be- 
comes painful,  and  finally  the  voice  may  be  comidetely  lost.  In  adults  the 
rcsi)irations  are  not  increased  in  frequency,  but  in  children  dyspnoea  is  not 
uncommon  and  may  occur  in  spasmodic  attacks.  If  much  a^lema  accom- 
])anies  the  inflammatory  swelling,  there  may  be  urgent  dyspnoea. 

The  laryngoscope  sliows  a  swollen  and  tumefied  mucous  membrane  of 
the  larynx,  particularly  the  ary-epiglottidean  folds.     The  vocal  cords  have 


(516 


DISEASES  OP  THE  HKSPIRATOUY  SYSTEM. 


/ 


lost  llioir  siiKiotli  iuul  sliiniiig  iippoaruiict'  aiul  are  rcddt'iiocl  and  swollen. 
'J'lic'ir  mobility  also  is  greatly  inipairod,  owing  to  the  inliltration  of  the 
adjoining  ninct)us  nienihrane  and  of  the  nuiscles.  A  slight  mucoid  exuda- 
tion covers  the  jjarts.  The  constitutional  symptoms  are  not  severe.  There 
is  rarely  much  fever,  and  in  many  cases  the  patient  is  not  seriously  ill.  Occa- 
sionally cases  come  on  with  greater  intensity,  the  cough  is  very  distressing, 
deglutition  is  i)ainful,  and  there  may  be  urgent  dyspnoea 

Diagnosis. — There  is  rarely  any  difficulty  in  dete  ining  the  nature 
of  a  ease  if  a  satisfactory  laryngoscoi)ic  examination  can  be  made.  The 
severer  forms  may  simulate  a'dema  of  the  glottis.  When  the  loss  of  voice 
is  marked,  the  case  may  be  mistaken  for  one  of  nervous  aphonia,  but  the 
laryngoscope  would  decide  the  question  at  once.  Much  more  difficult  is 
the  diagnosis  of  acute  laryngitis  in  children,  particularly  in  the  very  young, 
in  whom  it  is  so  lu.rd  to  make  a  proper  examination.  From  ordinary  laryn- 
gismus it  is  to  be  distinguished  by  the  presence  of  fever,  the  mode  of  onset, 
and  i)articularly  the  coryza  and  the  previous  symptoms  of  hoarseness  or  loss 
of  voice.  Membianous  laryngitis  may  at  first  be  quite  impossible  to  diff'er- 
entiate,  but  in  a  majority  of  cases  of  this  affection  there  are  patches  on  the 
l)harynx  and  early  swelling  of  the  cervical  glands.  The  symptoms,  too,  are 
much  more  severe 

Treatment. — ]?est  of  the  larynx  should  be  enjoined,  so  far  as  phona- 
tion  is  concerned.  In  cases  of  any  severity  the  patient  should  be  kept 
in  bed.  The  room  should  be  at  an  even  temperature  and  the  air  saturated 
with  moisture.  Early  in  the  disease,  if  there  is  much  fever,  aconite  and 
citrate  of  potash  may  be  given,  and  for  the  irritating  painful  cough  a  full 
dose  of  Dover's  powder  at  night.  An  ice-bag  externally  ofte^i  gives  great 
relief. 


II.    CHRONIC    LARYNGITIS. 


Etiology. — The  cases  usually  follow  repeated  acute  attacks.  The  most 
common  causes  are  overuse  of  the  voice,  particularly  in  persons  whose  occu- 
pation necessitates  shouting  in  the  open  air.  The  constant  inhalation  of 
irritating  substances,  as  tobacco-smoke,  may  also  cause  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  severe 
cases  may  be  almost  lost.  There  is  usually  very  little  pain;  only  the  un- 
pleasant sense  of  tickling  in  the  larynx,  which  causes  a  frequent  desire  to 
cough.  "With  the  laryngoscope  the  mucous  membrane  looks  swollen,  but 
much  less  red  than  in  the  acute  condition.  In  association  with  the  granu- 
lar pharyngitis,  the  mucous  glands  of  the  epiglottis  and  of  the  ventricles 
may  be  involved. 

Treatment. — The  nostrils  should  be  carefully  examined,  since  in  some 
instances  chronic  laryngitis  is  associated  Avitli  and  even  dependent  upon 
obstruction  to  the  free  passage  of  air  through  the  nose.  Local  application 
must  be  made  directly  to  the  larynx,  either  with  a  brush  or  by  means  of  a 
spray.  Among  the  remedies  most  recommended  are  the  solutions  of  nitrate 
of  silver,  chlorate  of  potash,  perchloride  of  zinc,  and  tannic  acid.  Insuffla- 
tions of  bismuth  are  sometimes  useful. 


SPASMODIC  LARYNGITIS. 


617 


Among  directions  to  be  given  are  the  avoidiuce  of  heated  rooms  and 
hnid  ypt'aking,  and  abstiiu'iice  from  tobacco  and  alcohol.  Tlie  tlu'oat  should 
not  be  too  much  mulllod,  and  morning  and  evening  the  neck  should  bo 
sponged  witli  cold  water. 


III.    CEDEMATOUS    LARYNGITIS. 

Etiology. — CEdema  of  the  glottis,  or,  more  correctly,  of  the  structures 
Avhich  form  the  glottis,  is  a  very  serions  affection  which  is  met  with  (n)  As 
41  rare  sequence  of  ordinary  acute  laryngitis,  (h)  In  chronic  diseases  of  the 
larynx,  as  syi)hilis  or  tubercle,  (c)  In  severe  inflammatory  diseases  like 
diphtheria,  in  erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis.  ((/) 
Occasionally  in  the  acute  infectious  diseases — scarlet  fever,  typhus,  or 
typhoid.  In  Bright's  disease,  either  acute  or  chronic,  there  may  be  a  rap- 
idly developing  a'dema.     (e)  In  angio-neurotic  codema. 

Symptoms. — There  is  dyspnoea,  increasing  in  intensity,  so  that  with- 
in an  hour  or  two  the  condition  becomes  very  serious.  There  is  sometimes 
marked  stridor  in  respiration.  The  voice  becomes  husky  and  disappears. 
The  laryngoscope  shows  enormous  swelling  of  the  epiglottis,  which  can 
■sometimes  be  felt  with  the  finger  or  even  seen  when  the  tongue  is  strongly 
depressed  with  a  spatula.  The  ary-epiglottidean  folds  are  the  scat  of  the 
chief  swelling  and  may  almost  meet  in  the  middle  line.  Occasionally  the 
oedema  is  below  the  true  cords. 

The  diagnosis  is  rarely  difficult,  inasmuch  as  even  without  the  laryn- 
goscope the  swollen  epiglottis  can  be  seen  or  felt  with  the  finger.  The 
disease  is  very  fatal. 

Treatment. — An  ice-bag  should  be  placed  on  the  larynx,  and  the  pa- 
■fient  given  ice  to  suck.  If  the  symptoms  are  urgent,  the  throat  should  be 
sprayed  with  a  strong  solution  of  cocaine,  and  the  swollen  epiglottis  scari- 
fied. If  relief  does  not  follow,  tracheotomy  should  immediately  be  per- 
formed. The  high  rate  of  mortality  is  due  to  the  fac  t  that  this  operation 
is  as  a  rule  too  long  delayed. 


IV.    SPASMODIC    LARYNGITIS  {Laryngismus  stridulus). 

Spasm  of  the  glottis  is  met  with  in  many  affections  of  the  larynx,  but 
there  is  a  special  disease  in  children  which  has  received  the  above-mentioned 
and  other  names. 

Etiology. — A  purely  nervous  affection,  without  any  inflammatory  con- 
dition of  the  larynx,  it  occurs  in  children  between  the  ages  of  six  months 
and  three  years,  and  is  most  commonly  scon  in  connection  with  rickets. 
As  Escherich  has  shown,  the  disease  has  close  relations  with  tetany  and 
may  display  many  of  the  accessory  phenomena  of  this  disease.  Often  the 
attack  comes  on  when  the  child  has  been  crossed  or  scolded.  Mothers 
sometimes  call  the  attacks  "  passion  fits "  or  attacks  of  "  holding  the 
breath."    It  was  supposed  at  one  time  that  they  were  associated  with  en- 


0J8 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


/ 


M 


liii'^'iiiont  of  tlic  tliyimis,  and  the  condition  therefore  received  the  name 
of  lln/iuic  adhma. 

Tlie  actual  state  of  the  larynx  dnrinjj  a  paroxysm  is  a  P]ia.«m  of  the 
adductors,  hut  the  precise  nature  of  the  iniluences  causin«f  it  is  nol  yet 
known,  whether  centric  or  I'cllcx  from  periplu'ral  irritation.  'I'ho  disease 
is  not  so  common  in  Anicricii  as  in   Mnjiland. 

Symptoms, — The  attacks  may  come  on  either  in  the  ni<fht  or  in  the 
day;  often  just  as  the  I'hild  awakes.  There  is  no  cou«ih,  no  hoarseness, 
but  the  resjjiration  is  arrested  and  tlie  child  stru<;<fles  for  breath,  the  face 
gets  congested,  and  then,  with  a  sudden  relaxation  of  tlie  spasm,  the  air 
is  drawn  into  the  lungs  with  a  high-pitched  crowing  sound,  which  has 
given  to  the  alfection  the  name  of  "  child-crowing."  Convulsions  may 
occur  during  an  attack  or  there  nuiy  be  carpo-pedal  spasms.  Death  may, 
but  rarely  does,  occur  during  the  attack.  \\\.{\\  the  cyanosis  the  spasm  re- 
laxes and  respiration  begins.  The  attacks  may  recur  with  great  frequency 
throughout  the  day. 

Treatment. — The  gums  should  be  carefully  examined  and,  if  swol- 
len and  hot,  freely  lanced.  The  bowels  should  be  carefully  regulated,  and 
as  these  children  arc  nsually  delicate  or  rickety,  nourishing  diet  and  cod- 
liver  oil  should  be  given.  By  far  the  most  satisfactory  method  of  treat- 
ment is  the  cold  sponging.  In  severe  cases,  two  or  three  times  a  day  the 
child  should  be  placed  in  a  warm  bath  and  the  l)ack  and  clicst  thoroughly 
sponged  for  a  minute  or  two  with  cokl  water.  .Since  learning  this  practice 
from  l?inger,  at  the  University  Hospital,  I  have  seen  many  cases  in  which 
it  proved  successful.  It  may  be  employed  when  the  child  is  in  a  paroxysm, 
though  if  the  attack  is  severe  and  the  lividity  is  great  it  is  much  better  to 
dash  cold  water  into  the  face.  Sometimes  the  introduction  of  the  finger 
far  hack  into  the  throat  will  relieve  the  spasm. 

Spasmodic  croup,  believed  to  be  a  functional  spasm  of  the  muscles  of 
the  larynx,  is  an  affection  seen  most  commonly  between  the  ages  of  two  and 
five  years.  According  to  Trousseau's  description,  the  child  goes  to  bed  well, 
and  about  midnight  or  in  the  early  morning  hours  awakes  with  oppress(.'d 
breathing,  harsh,  croujjy  cough,  and  perhaps  some  huskiness  of  voice.  The 
oppression  and  distress  for  a  time  are  very  serious,  the  face  is  congested,  and 
there  are  signs  of  approaching  cyanosis.  The  attack  passes  oif  abruptly, 
the  child  falls  asleep  and  awakes  the  next  morning  feeling  perfectly  well. 
These  attacks  may  be  repeated  for  several  nights  in  succession,  and  usually 
cause  great  alarm  to  the  parents.  Whether  this  is  entjrely  a  functional 
spasm  is,  I  think,  doubtful.  There  are  instances  in  which  the  child  is 
somewhat  hoarse  throughout  the  day,  and  has  slight  catarrhal  symptoms 
and  a  brazen,  croupy  cough.  There  is  ])robably  slight  catarrhal  laryngitis 
with  it.  Those  cases  are  not  infrequently  mistaken  for  true  croup,  and 
parents  are  sometimes  unnecessarily  disturbed  by  the  serious  view  which 
the  physician  takes  of  the  case.  Too  often  the  poor  child,  deluged  with 
drugs,  is  longer  in  recovering  from  the  treatment  than  he  would  be  from 
the  disease.  To  allay  the  s])asm  a  whilf  of  chloroform  may  be  administered, 
which  will  in  a  few  moments  give  relief,  or  the  child  may  be  placed  in  a 
hot  bath.     A  prompt  emetic,  such  as  zinc  or  wine  of  ipecac,  wall  usually 


TUBERCULOUS  LARYNGITIS. 


G19 


relieve  the  H[)nsni,  mid  is  spcciully  iiidicntcd  if  the  cliild  has  overloaded  the 
stoninch  thi'dii^li  the  day. 


V.    TUBERCULOUS    LARYNGITIS. 

Etiology.' — Tiihci'clcs  iiiay  develop  itriiiiiirily  in  the  InryiiLreal  inticosa, 
hut  ill  the  yreiit  iiiiijority  of  cases  tlie  iill'eclioii  is  secondary  to  pulmonary 
tuhereulosis,  in  which  it  is  met  with  in  a  vai'ialjle  |)rop()rtion  of  from  18 
to  30  iier  cent,  l^arynjiitis  may  occur  very  early  in  pulmonary  tubercu- 
losis. There  may  he  well-marked  invoivenu'nt  of  the  larynx  with  si^iis  of 
very  limited  trouble  at  one  apex.  These  are  cases  w  liich,  in  my  experience, 
run  a  very  unfavoralile  course. 

Morbid  Anatomy. — The  mucosa  is  at  first  swollen  and  presents  scat- 
tered tubercles,  which  seem  to  begin  in  the  neighborhood  of  the  blood-ves- 
sels. \>y  their  fusion  small  tuberculous  masses  arise,  which  cnseato  and 
iinally  ulcerate,  leaving  shallow  irregular  losses  of  substance.  The  ulcers 
are  usually  covered  with  a  grayish  exudation,  and  there  is  a  general  thick- 
ening of  the  mucosa  about  thein,  which  is  jjarticularly  marked  upon  tlio 
arytenoids.  The  ulcers  may  erode  the  true  cords  and  finally  destroy  them, 
and  i)assing  dee|)ly  may  cause  perichondritis  with  necrosis  and  occasionally 
exfoliation  of  the  cartilages.  The  disease  may  extend  laterally  and  involve 
the  pharynx,  and  downward  over  the  mucous  membrane,  covering  the  cri- 
coid cartilage  toward  the  u'sopliagus.  Above,  it  may  reach  the  posterior 
wall  of  the  ])liarynx,  and  in  rare  cases  extend  to  the  fauces  and  tonsils. 
'J'lie  epiglottis  may  be  entirely  destroyed.  There  are  rare  instances  in 
which  cicatricial  changes  go  on  to  such  a  degree  that  stenosis  of  the  larynx 
is  induced. 

Symptoms. — The  first  indication  is  slight  huskincss  of  the  voice, 
which  finally  deepens  to  hoarseness,  and  in  advanced  stages  there  may  ho 
complete  loss  of  voice.  There  is  something  very  suggestive  in  the  early 
hoarseness  of  tuherculous  laryngitis.  ]\Iy  attention  has  frequently  heen 
directed  to  the  lungs  simply  hy  the  quality  of  the  voice. 

The  cough  is  in  ])ai't  due  to  involvement  of  the  larynx.  Early  in  the 
disease  it  is  not  very  troublesome,  hut  when  the  ulceration  is  extensive  it 
becomes  husky  and  ineffectual.  Of  the  symptoms  of  laryngeal  tuberculo- 
sis, none  is  moi'c  aggravating  than  the  dysphagia,  which  is  met  with  par- 
ticularly when  the  e[)iglottis  is  involved,  and  when  the  ulceration  has  ex- 
tended to  the  pharynx.  There  is  no  mt)re  distressing  or  iiaiiiful  compli- 
cation in  phthisis.  In  instances  in  which  the  epiglottis  is  in  great  part 
destroyed,  with  each  attem[)t  to  take  food  there  are  distressing  paroxysms 
of  cough,  and  even  of  sulfocation. 

AVitli  the  laryngoscope  there  is  seen  early  in  the  disease  a  pallor  of  the 
mucous  niemhrane,  which  also  looks  thickened  and  infiltrated,  ])articularly 
that  covering  the  arytenoid  cartilages.  The  tuherculous  ulcers  are  very 
characteristic.  They  are  hroad  and  shallow,  with  gray  hases  and  ill-defincd 
outlines.  The  vocal  cords  are  infiltrated  and  thickened,  and  ulceration  is 
verv  common. 


<;2(> 


DISEASES  OF  THE    ItKSmiATOUY  SYSTEM. 


/ 


The  (liaf^jnosis  of  tiilu'rc-ulous  laryngitis  is  nuvly  diHiciilt,  iis  it  is  usually 
associated  with  wt'll-markod  puhnonary  disease.  In  case  of  (k)ubt  some  of 
the  secretion  from  the  base  of  an  ulcer  shoukl  be  renujved  and  examined  for 
l)acilli. 

Treatment. — Piiysicians  i)ay  scarcely  suilicicnt  attention  to  the  laryn- 
geal complications  of  consumption.  The  ulcers  should  be  s[»rayed  and  kcpl 
thoroughly  cleansed.  Solutions  of  tannic  acid,  nitrate  of  silver,  or  sulphide 
of  zinc  may  be  employed.  The  insulHation,  two  or  three  times  a  day,  of  ii 
])()W(ler  of  iodoform,  with  nu)r[)hia,  after  tiioroughly  cleansing  the  ulcers 
with  a  s])ray,  relieves  the  pain  in  a  majority  of  tiie  cases.  Cocaine  (1-per- 
cent solution)  applied  with  the  atomizer  will  often  enable  the  patient  to 
swallow  his  food  comfortably.  There  are,  however,  distressing  cases  of  ex- 
tensive laryngeal  and  phaiTUgcal  ulceration  In  which  even  cocaine  loses  its 
good  eU'ects.  When  the  epiglottis  is  lost  the  dilliculty  in  swallowing  be- 
comes very  great.  Wolfenden  states  that  this  may  be  obviated  if  the  pa- 
tient hangs  his  head  over  the  side  of  the  bed  and  sucks  milk  through  a  rub- 
ber tubing  from  a  mug  placed  on  the  floor. 


^l 

ill 

V 

(1 


^ 


VI.    SYPHILITIC    LARYNGITIS. 

Sypliilis  attacks  the  larynx  Avith  great  frequency.  It  may  result  from 
the  inherited  disease  or  be  a  secondary  or  tertiary  manifestation  of  the  ac- 
quired form. 

Symptoms. — In  secondary  sy])hilis  there  is  occasionally  erythema  of 
the  larynx,  which  may  go  on  to  definite  catarrh,  but  has  nothing  charac- 
teristic. The  process  nuiy  proceed  to  the  formation  of  superficial  whitish 
ulcers,  usually  symmetrically  placed  on  the  cords  or  ventricular  bands. 
Mucous  patches  and  condylomata  are  rarely  seen.  The  symptoms  are  prac- 
tically those  of  slight  loss  of  voice  with  laryngeal  irritation,  as  in  the  simple 
catarrhal  form. 

The  tertiary  laryngeal  lesions  are  numerous  and  very  serious.  True 
gummata,  varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  develop 
in  the  submucous  tissue,  most  commonly  at  the  base  of  the  epiglottis.  They 
go  through  the  changes  characteristic  of  these  structures  and  may  either 
break  down,  producing  extensive  and  deep  ulceration,  or — and  this  is  more 
characteristic  of  syphilitic  laryngitis — in  their  healing  form  a  fibrous  tissue 
which  shrinks  and  produces  stenosis.  The  ulceration  is  apt  to  extend 
deeply  and  involve  the  cartilage,  inducing  necrosis  and  exfoliation,  and 
even  haMuorrhage  from  erosion  of  the  arteries.  (Edema  may  suddenly  prove 
fatal.  The  cicatrices  which  follow  the  sclerosis  of  the  gummata  or  the 
healing  of  the  ulcers  produce  great  deformity.  The  epiglottis,  for  instance, 
may  be  tied  down  to  the  pharyngeal  wall  or  to  the  epiglottic  folds,  or  even 
to  the  tongue;  and  eventually  a  stenosis  results,  which  may  necessitate 
tracheotomy. 

The  laryngeal  symptoms  of  inherited  syphilis  have  the  usual  course  of 
these  lesions  and  appear  either  early,  within  the  first  five  or  six  months,  or 
after  puberty;  most  commonly  in  the  former  period.     Of  76  cases,  J.  jST, 


ACUTE   nUONCIIITIS. 


0-Jl 


NraflcciiXH!  foiiP'l  that  03  ocfurn.'il  within  llic  lirst  yciir.  Tlic  i^iiimiintuuA 
iiiliili'iilion  ifiids  t(»  nlct'i'atjoii,  most  cumir.diily  (if  tlit-  ('|iii,'l()ttis  and  in  tiic 
ventricles,  and  the  [jtoccss  may  extend  deeply  and  iiiv()lv(!  the  (•artila;^e. 
(Jicntrieial  contraetion  may  also  oceiir. 

The  Uia<fii()sis  of  syi)lulis  oi  tlie  larynx  is  rarely  dillieult,  since  it  oceur* 
most  commonly  in  connection  with  other  symptoms  of  the  disease. 

Treatment. — The  administration  ol'  constitutional  remedies  is  the 
most  im[)ortant.  and  under  nu'renry  and  iodide  ol'  potassium  the  loral  symp- 
toms may  rapidly  he  relieved.  'I'he  tertiary  laryngeal  manifestations  are 
always  serious  and  ditlicult  to  treat.  The  deep  ulceration  is  specially  hard 
to  condjat,  and  the  cicatrization  may  necessitate  tracheotomy,  or  the  gradual 
dilatation,  us  practised  hy  Schroetter. 


III.   DISEASES   OF  THE   BRONCHI. 


I.   ACUTE    BRONCHITIS. 

Acute  catarrlial  inflammation  of  the  l)ronehial  mucous  mcm1)rane  is  a 
very  common  disease,  rarely  serious  in  healthy  adults,  hut  very  fatal  in  the 
old  and  in  the  young,  owing  to  associated  pulmoiuiry  complications.  It  is 
hilateral  and  all'ects  either  the  larger  and  medium  sized  tuhes  or  the  smaller 
bronchi,  in  which  case  it  is  known  as  capillary  bronchitis. 

We  shall  speak  only  of  the  former,  as  the  latter  is  part  and  parcel  of 
broncho-pneumonia. 

[Etiology. — Acute  bronchitis  is  a  common  sequel  of  catching  cold,, 
and  is  often  nothing  more  than  the  extension  downward  of  an  ordinary 
coryza.  It  occurs  most  frequently  in  the  changeable  weather  of  early  spring 
and  late  autumn.  Its  association  with  cold  is  well  indicated  by  the  popu- 
lar expression  "  cold  on  the  chest."  It  may  prevail  as  an  epidemic  apart 
from  influenza,  of  which  it  is  an  important  feature. 

Acute  bronchitis  is  associated  with  many  other  affections,  notably 
measles.  It  is  by  no  means  rare  at  the  onset  of  typhoid  fever  and  malaria. 
It  is  present  also  in  asthma  and  whooping-cough.  The  subjects  of  spinal 
curvature  are  specially  liable  to  the  disease.  The  bronchitis  of  Bright's 
disease,  gout,  and  heart-disease  is  usually  a  chronic  form.  It  attacks  per- 
sons of  all  ages,  but  most  freqxiently  the  young  and  the  old.  There  are  in- 
dividuals who  have  a  special  disposition  to  bronchial  catarrh,  and  the 
slightest  exposure  is  apt  to  bring  on  an  attack.  Persons  who  live  an  out- 
of-door  life  are  usually  less  subject  to  the  disease  than  those  who  follow 
sedentary  occupations. 

The  affection  is  probably  microl)ic,  though  we  have  as  yet  no  definite 
evidence  upon  this  point. 

Morbid  Anatomy. — The  mucous  membrane  of  the  trachea  and 
bronclii  is  reddened,  congested,  and  covered  with  mucus  and  muco-pus, 
which  niav  be  seen  oozing  from  the  smaller  bronchi,  some  of  which  are 
dilated.    The  finer  changes  in  the  mucosa  consist  in  desquamation  of  the 


022 


DISEASES  OF  TFIK  TIESIMUATOIIV  SYSTEM. 


/ 


ciliated  ('|)itlu'liiiiii,  HWi'lliii^'  and  (L'dt'iua  of  tiic  siiliniucdsa,  and  iiililtnitiim 
(if  till'  ti.<siH'  with  Iciicofytt'tJ.    'i'lic  miu.'ouri  ^flands  are  imu'li  hwcdii'ii. 

Symptoms. — 'I'lie  syinptom.s  of  an  ordinarv  "cold"  acconipaii}'  the 
oii.-ct  of  an  acute  hroiicliitis.  TIic  coryza  extends  to  tlie  tnhes,  and  may 
jdso  all'ect  tile  larynx,  jiroducin^'  hoai'seness,  which  in  many  cases  is  marki'd. 
A  chill  is  rare,  hut  there  is  invariahly  a  sensi'  of  oppression,  with  heavi- 
ness and  lan<,Mior  and  pains  in  the  hones  and  hack.  In  mild  cases  there  is 
scarcely  any  fever,  hut  in  severer  forms  the  ranf,'e  is  from  1(M°  to  lO.T. 
The  hronchial  symptoms  set  in  with  a  fcclinjf  of  tij,ditness  and  rawness 
heneath  the  sternum  and  a  sensation  <d'  oppression  in  the  chest.  The 
cou^di  is  ron^h  at  (ii'st,  and  often  of  a  rin;,dn^f  character.  It  conies  on  in 
paroxysms  which  rack  and  distress  the  patient  extremely.  During'  the 
severe  spells  the  pain  may  he  very  intense  heneath  the  sternum  and  aloii;,^ 
the  attachments  of  the  diaplira«zin.  At  first  the  c(m^h  is  dry  and  the  ex- 
pectoration scanty  and  viscid,  hut  in  a  few  days  the  secretion  Ijccomes 
muco-purnlent  and  ahundant,  and  linally  purulent.  With  the  loosening- 
(d'  the  coiijih  p'eat  relief  is  cxpei'icnccd.  Tlit;  sputum  is  made  up  lai'j,''ely 
of  pus-cells,  with  a  variahle  nundjcr  of  the  large  round  alvi'olar  cells,  many 
of  wliich  contain  carljon  grains,  while  others  have  undergone  the  myelin 
degeneration. 

I'hijsical  iSii/iis. — The  respiratory  movoments  arc  not  greatly  increased 
in  freiiuency  unless  the  fever  is  high.  There  are  instances,  however,  in 
which  the  hreatiiing  is  rapid  and  when  the  smalh-r  tuhes  are  involved 
there  is  dysjmcea.  On  i)al|)ation  the  bronchial  fremitus  may  often  he  felt. 
On  auscultation  in  the  early  stage,  ])iping  sihilant  rales  are  everywheic  to 
he  heard.  They  are  very  changeable,  and  appear  aiul  disap))car  with  cough- 
ing. With  the  relaxation  of  the  hroiu'hial  membranes  and  the  greater 
abundance  of  the  secretion,  the  rales  change  and  become  mucous  and  bub- 
bling in  quality.  The  bases  of  the  lungs  should  be  carefully  examined 
each  day,  ])articulaily  in  children  and  the  aged. 

The  course  of  the  disease  de])ends  on  the  conditions  under  which  it 
develo])s.  In  healthy  adults,  by  the  end  of  a  week  the  fever  subsides  and 
the  cough  loosens.  In  another  week  or  ten  days  convalescence  is  fully 
established.  In  young  children  the  chief  risk  is  in  the  extension  of  the 
]»rocess  downwai'd.  In  measles  and  whooping-cough,  the  ordinary  bron- 
chial catarrh  is  very  ajit  to  descend  to  the  liner  tubes,  which  becouu'  dilated 
and  ])luggcd  with  muco-pus,  inducing  areas  of  colla[)se,  and  fimiUy  lironcho- 
])ncuraonia.  This  extension  is  indicated  by  changes  in  the  i)hyc:cal  signs. 
Usually  at  the  base  the  rales  are  subcrepitant  and  numorons  and  there 
may  be  areas  of  defective  resonance  and  of  feeble  or  distant  tuliular  breath- 
ing. In  tl'c  aged  and  debilitated  tliere  arc  similar  dangers  if  the  ])rocess 
extends  fron;  the  larger  to  the  smaller  tuljcs.  In  old  age  the  bronchial 
mucosa  is  less  capable  of  ex]K'lling  the  mucus,  which  is  more  apt  to  sag  to 
the  deiiendcnt  parts  and  induce  dilatation  of  the  tubes  with  extension  of 
the  inflammation  to  the  contiguous  air-cells. 

The  (Unrjnnsift  of  acute  bronchitis  is  rarely  diiricult.  Although  the 
mode  of  onset  may  be  brus(pie  and  ])erhaps  simnlate  pneumonia,  yet  the 
absence  of  dulness  and  blowing  breathing,  and  the  general  character  of 


f'ni{(»\Tr   nRONTITTTIM. 


023 


filtration 
I'll. 

Itimy  tilt' 
iiiiil  iiiiiy 

luarkcil. 
til  licavi- 
}  tluTc  is 

to  Kl.'V. 

lilWllCSS 
*t.  'Phc 
ics  on  ill 
irin^j  tilt' 
ml  iiloiii;- 

I  lilt'  f\- 
becDint'S 

loosening' 
|»  lar;;fl3 
Us,  many 
t'  iiiyt'liii 

iiu-rt-'ast'd 

wc'vor,  in 

involvt'il 

II  be  felt. 

wlllTl'   to 

h  C'()n<;ii- 
^n'cattT 
11(1  Inili- 
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licli  it, 
k'S  and 
is  fully 

of  thr 

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tlilatctl 

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d   tiifiv 

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oncliiiil 

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yet  tlio 
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rv 


ilic  bronchial  inllainMiation,  n-ndiT  tlic  tlia;;i)(>His  Hini|)l(<.  About  once  a 
year  1  Heo  a  cant'  (»!'  ty|ilioiil  IVvcr,  in  wliicb  the  dia«,fn()sirt  at  lirat  hua  bt't'n 
iicuti.'  Ijronchitis.  Tiic  ('oni|>lication  of  bronclio-|»ncnint»nia  i.s  intlicatcd  by 
llic  jfrcattT  severity  of  the  syiii[ttoins,  part  iciilarly  the  dyspiKea,  the  chanj^'ed 
color,  and  the  i»liysical  sij^ns. 

Treatment.  Ill  mild  chhos,  household  nieasnres  sulliee.  The  ht)t 
foot-bath,  or  the  warm  bath,  a  drink  of  hot  lemonade,  and  a  mustard  plaster 
nil  the  chest  will  often  give  relief.  For  the  di'y,  racking  cough,  the  sym|i- 
inin  most  complained  of  by  the  jiatient,  Dover's  powder  is  the  best  remedy. 
1 1  is  u  popular  belief  that  (piinim.',  in  full  doses,  will  check  an  oncoming 
cold  on  the  chest,  but  this  is  doubtful.  It  is  u  common  custom  when  per- 
xiiis  feel  the  apprttacli  of  u  cold  to  take;  a  'J'urkish  bath,  and  though  the 
lightness  and  op|)ressi()n  nuiy  be  relieved  by  it,  tlu're  is  in  a  majority  of  the 
( uses  great  risk.  Some  of  the  severest  cases  of  bronchitis  which  I  have 
cell  have  ftillowed  this  initial  Turkish  bath.  Xo  doubt,  if  the  person 
tould  go  to  bed  directly  from  the  bath,  its  action  woulil  be  beneficinl,  Init 
(here  is  great  risk  of  catching  adtlitional  "cold"  in  going  home  from  the 
bath.  J{elief  is  obtained  from  tlu;  unpleasant  sen.se  of  rawness  by  kee|)- 
ing  tiio  air  of  the  room  saturated  with  moisture,  and  in  this  dry  stage 
I  he  old-fashioned  mixture  of  the  wines  of  antimony  and  ipecacuanha  with 
Htpior  ammonii  acetatis  and  nitrous  ether  is  useful.  If  the  pul.se  is  very 
rapid,  tincture  of  aconite  may  be  given,  ])art icularly  in  the  cast;  of  chil- 
dren. Ft)r  the  cough,  when  dry  and  irritating,  oi)ium  should  be  freely 
used  in  the  form  of  Dover's  ])owder.  Of  course,  in  the  very  young  and 
the  ageil  care  must  be  exercised  in  the  use  of  opiuni,  particularly  if  the 
M'cretious  are  free;  but  for  the  distressing,  irritative  cough,  which  keeps 
the  ])atient  awake,  no  remedy  can  take  its  place.  As  t.'e  cough  loosens 
iiiid  the  expectoration  is  more  abundant,  the  patient  becomes  more  com- 
fortable. In  this  stage  it  is  custonniry  to  i)ly  liim  with  expectorants  of 
various  sorts.  Though  useful  occasionally,  they  should  not  be  given  as  a 
matter  of  routine.  A  mixture  of  stpiills,  ammonia,  ami  senega  is  a  favorite 
one  with  many  iiractitioners  at  this  stage. 

Tn  the  acute  l)ronchitis  of  children,  if  the  amount  of  secretion  is  hirgo 
mid  dillicult  to  expectorate,  or  if  there  is  dyspntca  and  the  color  begins 
lo  get  dusky,  an  emetic  (a  tablespoonful  of  ipecac  wine)  should  be  given 
at  once  and  repeated  if  necessary. 


II.    CHRONIC    BRONCHITIS. 

Etiology. — This  alTection  may  follow  repeated  attacks  of  acute  bron- 
chitis, but  it  is  most  commonly  met  with  in  chronic  lung  affections,  hcart- 
•liseaso,  aneurism  of  the  aorta,  gout,  and  renal  disease.  Tt  is  frequent  in 
the  aged;  the  young  rarely  are  ad'ected.  riimale  and  .season  have  an  im- 
portant influence.  It  is  the  winter  cough  of  the  old  man,  which  recurs 
with  regularitv  as  the  weather  gets  cold  and  changeable. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  great  variety 
of  changes,  depending  somewhat  upon  the  disease  with  which  chronic 
39 


024 


DISKASRS  OK  TIIK   UKSPIHATollY  SYSTKM. 


/ 


if:; 


Itroiu'liilis  is  Ms«*ociat<'<l.  In  Hnmc  ciihch  llw  iniifoiN  inciiiltrnno  Is  vory 
tliii),  so  tliiit  tilt'  l(iii;>itii)litiiil  litinds  of  t'Inslic  lissii*'  stiiiiil  out  |)i'oiiiin<>ntly. 
Tlic  tiilx's  nil'  tliliitcil.  I  lie  iiiiisciilai'  iiiul  glaiidiilar  tissues  arc  atroitliii'd,, 
and  the  ('|iitlu'linni  is  in  j^M'cal  part  sli(>(l. 

In  (itlicr  instances  the  niiicosii  is  thickened,  ^M'annlii;'.  and  inliltrMtcd. 
Tlicrc  may  In'  nlcei'ati<»n,  particMlarly  ol'  llw  mucous  I'ollicjes.  Uronchial 
dihitali«»ns  are  not  uncommon  and  emphysenm  is  u  constant  acconi|iani- 
ment. 

Symptoms.  In  the  form  met  with  in  old  men,  associated  with  eni- 
physenia,  ^out,  or  licart-disease,  the  chicr  syni|itoms  are  as  ftdlows:  Sliorf- 
ness  of  hreath,  wliicli  may  not  he  noticeable  e\ce|it  on  exertion.  'I'lie 
luitients  "  pull"  and  lilow  "  on  jioin^'  up  hill  or  up  a  lli^dit  ol"  stairs.  This  is 
<luo  not  8o  much  to  the  chronic  hronehitiH  itself  as  to  associated  emphysema 
or  even  to  cardiac  weakness.  They  complain  of  no  pain.  The  cou;ih  is 
variahle,  cluin;:in;:  with  the  weather  and  with  the  season.  During'  the 
summer  ihcy  mav  remain  free,  hut  each  succeeding-  winter  the  cou;;h  conu's 
on  with  severity  and  persists.  There  may  he  only  a  spell  in  the  uiornin;:'. 
or  the  chief  distress  is  at  ni^ht.  The  sputum  in  chronic  hronihitis  is  very 
varialile.  In  cases  (d'  the  so-called  dry  catarrh  there  is  no  expeetoratinn. 
I'sually,  however,  it  is  abundant,  muco-[iurulcnt,  or  tlislinctly  purulent  in 
charactci'.  Tlu-re  are  instances  in  which  the  patient  cou^dis  up  for  years 
a  thin  lluid  sputum.  There  is  rarely  fever,  'i'he  <i('neral  heallli  may  be 
<:ood  and  the  disease  nuiy  present  no  seri(»us  features  apart  from  the  lia- 
bility to  induce  emphyni'ma  and  bronchiectasy.  In  many  cases  it  is  an 
incurable  all'ection.  I'atients  improve  and  the  coujih  (Iisap[)ears  in  the 
summer  time  only  to  return  during  the  winter  months. 

Physical  Signs. — The  chest  is  usually  distended,  the  movements  are 
limited,  and  the  coiuiition  is  often  that  which  we  see  in  emphyseuui.  The 
percussion  note  is  clear  or  hyperresonant.  On  auscultation,  e.xpiruli(tn  is 
prolonged  and  wheezy  and  rhonchi  of  various  sorts  are  heard — some  high- 
])itched  and  piping,  others  deep-toned  and  snoring.  Crepitation  is  coni- 
nion  at  the  bases. 

Clinical  Varieties. — The  description  just  given  is  of  the  ordinary 
chronic  bronchitis  which  occurs  in  connection  with  enii>hysema  aiul  heai't- 
disease  and  in  many  elderly  men.  There  are  certain  forms  which  nu'rit 
s])ecial  description:  (a)  On  several  occasions  I  have  met  with  a  form  of 
rhninic  hroiirhilis.  particularly  in  women,  which  comes  on  between  the  ages 
of  twenty  and  thirty  and  may  continue  indelinitcly  without  serious  impair- 
ment of  the  health. 

(h)  BrnnchorrJuiii. — Kxcessivo  hronchial  secretion  is  met  with  nndei' 
several  conditions.  It  mnst  not  he  mistaken  for  the  ])rofuse  expectoration 
of  hronchiecta.'^y.  The  secretion  may  be  very  liipiid  and  watery — hminhor- 
rhd'o  spnisn,  and  in  extraordimiry  amount.  ]\lore  commoidy,  it  is  purulent 
though  thin,  and  with  greenish  or  yellow-green  ma.sses.  It  may  he  thick 
and  uniform.  This  ])r()Xu!*c  hronchial  secretion  is  usually  a  manifestation 
of  chronic  bronchitis  and  may  lead  to  dilatation  of  the  tul)es  aiul  ullinuitely 
to  fetid  hronchitis.  Tn  the  young  the  condition  may  persist  for  years  with- 
out impairiuent  of  health  and  without  apparently  damaging  the  lungs. 


rilROXK'   IIKONCIIITIS. 


035 


at  ion  is 
hi-h- 
18  c'oni- 

)i(liiiary 
licai't- 
1  merit 
'orin  of 
he  ajri'S 
iinpair- 

iiiider 
ttiratinii 
nnich")'- 
)iirulent. 
)e  tliick 
estatitm 
limately 
rs  with- 


(()  J'lilrlil  Jh'onrJiills.  I'eti<l  I'Xpt'ctoriitioii  is  mcl  with  in  ronnoctioii 
will)  l)rMiieliiectasis,  piiigreiie,  altHccHH,  or  witli  (Iccotiiiiosilioii  of  HeerctioiiH 
^^illlill  |)litliisieal  cavities  ami  in  an  (Mnpyema  wliidi  has  peil'oraletl  the 
Inn;:.  There  are  instaincs  in  which,  apart  Irnni  any  oj'  these  slates,  tins 
expectoration  has  a  I'etid  character.  'I'he  spnta  are  iilinnilani,  usually 
thin,  ;,'rayi.-li-white  in  color,  and  they  separate  into  an  npper  llnid  layer 
capped  with  frothy  ninciis  and  a  thick  sedinieid  in  which  may  someiimeei 
lie  i'oimd  dirty  yellow  niassi-s  tlu'  si/e  of  peas  or  heans— the  so-called  Dit- 
trich's  pln^fs.  The  all'ecti(Mi  is  very  rare  apart  from  the  ahove-nientioned 
conditions.  In  severt'  cases  it  Icails  to  chan^^es  in  the  hronchial  wall)^, 
])nenmonia.  and  often  to  ahseess  or  ;,'an;:refn'.  Metastatic  brain  ahsee.ss  ha.n 
followed  putrid  hronchifis  in  a  certain  niimher  of  cases. 

((/)  />/•//  Ciihirrli. — 'I'he  cdlnrrhv  src  of  liaeniu'c,  a  not  nnconunon  form, 
is  characterized  hy  paroxysms  of  con^fhin;;  of  ;,'reat  intensity,  with  little  or 
no  expectoration.  It  is  usually  met  with  in  elderly  persons  with  emphy- 
sema, and  is  one  of  the  most  ohslinate  of  all  varieties  of  hronchitis. 

in  i"ln;^dand  the  damp  cold  of  the  nnwarmed  houses  is  responsible  in 
^ireat  part  for  the  prevalence  of  chroiue  bronchitis  am<»n;f  the  aged  and 
weak.  An  e(piable,  warm  temperature  is  of  the  first  importance  to  all 
persons  jiroiie  to  the  disease. 

Treatment. — r>y  far  the  most  satisfadory  method  of  treating  the 
I'ccurring  winter  bronchitis  is  change  of  climate.  Removal  to  a  soulheru 
latitnde  may  ])rovont  the  onset.  Southern  France,  southern  California, 
and  Florida  furnish  winter  climates  in  which  the  subjects  of  chronic  bron- 
chitis live  with  the  greatest  comfort.  All  cases  of  [)rol()nged  bronchial 
irritation  are  benefited  by  change  of  air. 

The  first  encb-avor  in  treating  a  case  of  chronic  bronchitis  is  to  ascer- 
tain, if  [tossibli',  whether  there  i\n\  constitutional  or  local  all'ections  with 
which  it  is  associated.  In  many  instances  the  urine  is  found  to  be  highly 
acid,  ])erliaps  slightly  albuminous,  anil  the  arteries  an;  stilf.  in  the  form 
associated  with  this  condition,  sometimes  called  gouty  bronchitis,  the  at- 
tacks seem  related  to  the  defective  renal  elimination,  and  to  this  condition 
the  treatment  should  be  first  directed.  In  other  instances  there  are  heart- 
disease  and  em])liysema.  In  the  form  occurring  in  old  nu'ii  much  may  bo 
(lone  in  the  way  of  prophylaxis.  Septuagenarians  sh(.,.id  read  Oliver  Wen- 
dell Holmes's*  "  De  Senectute"  with  referenci!  to  the  care  of  the  health. 
There  is  no  doubt  that  with  ])rudence  even  in  our  changeable  winter 
weather  much  may  be  done  to  ]jrevent  the  onset  of  chronic  bronchitis. 
Woollen  undt'rgarments  should  be  used  ami  es])ecial  care  shoidd  be  taken 
in  the  spring  months  not  to  change  them  I'or  lighter  ones  before  the  warju 
weather  is  established. 

Cure  is  seldom  effected  by  medicinal  remedies.  There  are  instances 
in  which  iodide  of  ])otassium  acts  with  remarkable  benefit,  and  it  should 
always  be  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure  origin. 
lM)r  the  morning  cough,  bicarbonate  of  sodium  (gr.  xv),  chloride  of  sodium 
(gr.  v),  spirits  of  chloroform  (niv)  in  anise  water  and  tal'en  with  an  equal 

*  Over  the  Tea-cui)s,  Boston,  1890. 


G2G 


DISEASES  OP  THE  RESI'IRATOUY  SYSTEM. 


/ 


uiiiuuiit  of  wiiiin  Wiiti'T  will  be;  Joiiiul  iiscrul  (FuwJcr).  When  llicro  is  imicli 
Hcnse  I'  lixlitiH'^^*  mid  iiilncss  of  the  chest,  the  |)orlable  Turki.sli  hath  may 
l)e  tiled.  W  hell  I  lie  secretion  is  excessive  muriate  of  ammonia  and  senega 
iire  iiseruL  Stiniuialing  expectoraids  are  eontraindieated.  Wiieu  the  Jieart 
is  feebk',  tiie  eoiiihiiiation  of  digitalis  and  strveliiiia  is  very  henetieial.  Tur- 
])entine,  tlie  ohl-lasiiioned  remedy  so  warmly  I'eeonunended  by  tlie  Dnbhii 
physicians,  has  in  many  «iuarters  fallen  undeservedly  into  disuse.  Prepara- 
tions of  tar,  creasote,  and  terebene  are  sometimes  useful.  Of  other  balsanuu 
remedies,  sandal-wood,  the  compound  tincture  of  benzoin,  copaiba,  balsam 
of  Peru  or  tolu  may  be  used,  inhalations  of  eucalyi)tus  and  of  the  spray 
of  ipecacuanha  wine  are  often  very  useful.  If  fetor  he  present,  carbolic 
acid  in  the  form  oT  spray  (lU  to  20  per  cent  solution)  will  lessen  the  odor, 
or  thymol  (1  to  l.OOO).  For  urgent  dyspna'a  with  cyanosis,  bleeding  from 
the  arm  tjives  most  relief. 


III.    BRONCHIECTASIS. 


Etiology. — Dilatation  of  the  bronchi  occurs  under  the  following  con- 
ditions: (1)  As  a  congenital  defect  or  anomaly.  Such  cases  are  extremely 
rare,  commonly  unilateral.  Cirawitz  has  described  the  condition  as  hron- 
chU'clasis  iinlrcrsalis.  "Welch  has  met  an  instance  in  a  young  girl.  (2)  In 
connection  with  inflammation  of  the  jjronchi,  particularly  when  this  leads 
to  weakness  of  the  walls  Avith  the  accumulation  of  secretion.  I  have  seen 
an  instance  after  inlluenza.  Under  this  category  comes  the  dilatation  met 
with  in  chroiHC  bronchitis  and  emidiysema,  the  dilated  bronchi  in  chronic 
]»hthisis,  in  the  catarrhal  i)neunionias  of  children,  and  particularly  the  dila- 
ution  which  results  from  the  presence  of  foreign  bodies  in  the  air-tubes 
or  from  ])ressure,  as  of  an  aneurism  on  one  bronchus.  (3)  In  extreme 
contraction  of  the  lung  tissue,  whether  due  to  interstitial  pneumonia  or  to 
compression  by  jileural  adhesions,  bronchial  dilatation  is  a  common  though 
not  a  constant  a('comi)animent. 

Unquestionably  the  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, probaldy  the  essential,  factor  in  inducing  bronchiectasy,  since  the  wall 
is  then  not  able  to  resist  the  pressure  of  air  in  severe  spells  of  coughing 
and  in  straining.  In  some  instances  the  mere  wxMght  of  the  accumulated 
secretion  may  ])e  siifhcient  to  distend  the  terminal  tubules,  as  is  seen  in 
comiu'cssion  of  a  bronchus  by  aneurism. 

Morbid  Anatomy. — Two  chief  forms  are  recognized — the  cyliii- 
dricnl  and  the  saccular — which  may  exist  together  in  the  same  ^nng.  The 
condition  may  be  general  or  partial.  Universal  bronchiectasis  is  always 
unilateral.  It  occurs  in  rare  congenital  cases  and  is  occasionally  seen  as  a 
sequence  of  interstitial  pneumonia.  The  entire  bronchial  tree  is  repre- 
sented by  a  series  of  sacculi  opening  one  into  the  other.  The  wa.is  are 
smooth  and  possibly  without  ulceration  or  erosion  except  in  the  dejiendent 
parts.  The  lining  membrane  of  the  sacculi  is  usually  smooth  and  glisten- 
ing. The  dilatations  may  form  large  cysts  immediately  beneatli  the  ])l(Mira. 
Intervening  between  the  sacculi  is  a  dense  cirrhotic  lung  tissue.      The 


BRONCHIECTASIS. 


G27 


ci/h'n- 

'T\\e 

always 

'11  as  a 

rcpre- 

.is  arc 

'iideiit 

listen- 

iil(Mira. 

The 


})artial  dilatations — the  saccular  and  cylindrical — arc  common  in  chronic 
|)lithisis,  particidarly  at  llic  apex,  in  chronic  [)lcurisy  at  the  ha.sc,  and  in 
cMipliyscma.  Here  the  dilatation  is  more  commonly  cylindrical,  some- 
times I'usil'orm.  Tiie  hroiichial  mucous  mcmhrano  is  much  involved  and 
sometimes  there  is  a  narro\vin<'-  of  the  lumen.  Occasionally  one  meets 
with  a  sin«,de  saccular  bronchiectasy  in  connection  with  chronic  hronchilitj 
or  emphysema.  Some  of  these  look  like  sini[)le  cysts,  with  smooth  walls, 
without  iluid  contents.  A  form  of  acute  bronchiectasis  in  children  has 
been  described  by  Sharkey,  Carr,  and  others.  A  good  accoujit  of  it  is  given 
in  Fowler  and  Ciodlee's  work  on  the  lungs. 

Histologically  the  bronchi  which  are  the  seat  of  dilatation  show  im- 
|)ortant  changes.  In  the  large,  smooth  dilatations  the  cylindrical  is  re- 
placed by  a  pavement  epithelium.  The  muscular  layer  is  stretched,  atro- 
})hicd,  and  the  fibres  se})arated;  the  elastic  tissue  is  also  much  stretched 
and  separated.  In  the  large  saccular  bronchiectases  and  in  some  of  the 
cylindrical  forms,  due  to  retained  secretions,  the  lining  membrane  is  ulcer- 
ated. The  contents  of  some  of  the  larger  bronchiectatic  cavit ','s  are  hor- 
ribly fetid. 

Symptoms. — In  the  limited  dilatations  of  j)lithisis,  emphysema,  and 
chronic  bronchitis,  the  syni])toms  are  in  great  part  those  of  the  original 
disease,  and  the  condition  often  is  not  susi)ected  during  life. 

In  extensive  saccular  bronchiectasy  the  characters  of  the  cough  and 
expectoration  are  distinctive.  The  patient  -will  pass  the  greater  part  of 
the  day  without  any  cough  and  then  in  a  severe  paroxysm  will  bring  up- 
a  large  quantity  of  si)utuni.  Sometimes  change  of  the  position  will  bring, 
on  a  violent  attack,  probably  due  to  the  fact  that  some  of  the  secretion 
flows  from  the  dilatation  to  a  normal  tube.  The  daily  spell  of  coughing 
is  usually  in  the  morning.  The  expectoration  is  in  many  instances  very 
characteristic.  It  is  grayish  or  grayish  lirown  in  color,  fluid,  purulent, 
with  a  peculiar  acid,  sometimes  fetid,  odor.  Placed  in  a  conical  glass,  it 
separates  into  a  thick  granular  layer  below  and  a  thin  mucoid  intervening 
layer  above,  which  is  capped  by  a  brownish  froth.  Microscopically  it 
consists  of  pus-corpuscles,  often  large  crystals  of  fatty  acids,  which  are 
sometimes  in  enormous  numbers  over  the  field  and  arranged  in  bunches. 
Ihvmatoidin  crystals  are  sometimes  present.  Elastic  fibres  are  seldom 
found  except  when  there  is  ulceration  of  the  bronchial  walls.  Tubercle 
liacilli  are  not  present.  In  some  cases  the  expectoration  is  very  fetid 
and  has  all  the  characters  of  that  described  under  fetid  bronchitis.  Num- 
mular ox])ectoration,  such  as  comes  from  ])hthisical  cavities,  is  not  com- 
mon. Ilamiorrhage  occurred  in  14  out  of  35  cases  analyzed  by  Fowler. 
Abscess  of  the  brain  has  in  a  few  instances  followed  the  bronchiectasis. 
T^heumatoid  affections  may  develop,  and  it  is  one  of  the  conditions  with 
which  the  pulmonary  osteo-arthro]iatliy  is  commonly  associated. 

The  diag  >s  is  not  possible  in  a  large  number  of  the  cases.  In  the 
extensive  sac  .d  forms,  unilateral  and  associated  with  interstitial  pneu- 

monia or  chrunic  pleurisy,  the  diagnosis  is  easy.  There  is  contraction  of 
the  side,  wnich  in  some  instances  is  not  at  all  extreme.  The  cavernous 
signs  may  be  chiefly  at  the  base  and  may  vary  according  to  the  condi- 


/ 


028 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


/ 


tiiiii  of  tlio  cavity,  wlictlu'r  full  or  empty.  'IMicro  niny  bo  the  most  ex- 
quisite amphoric  phenomemi  and  loud  resonant  rales.  'Die  condition 
])ersist.s  for  years  and  is  not  inconsistent  with  a  tolerably  active  life.  The 
patients  frc(picntly  show  si<(ns  of  marked  eml)arrassnient  of  the  ])ul- 
monary  circulation.  There  is  cyanosis  on  exertion,  the  finger-tii)s  are 
clubbed,  and  the  nails  incurved.  A  condition  very  difficult  to  distin- 
guish from  bronchiecta.sy  is  a  limited  pleural  cavity  communicating  with  a 
bronchus. 

Treatment. — Aledical  treatment  is  not  satisfactory,  since  it  is  impos- 
sible to  heal  the  cavity.  I  have  practised  the  injection  of  antiseptic  fluids 
in  some  instances  with  Ijcnefit.  Intratracheal  injections  have  been  very 
Avarndy  reconnnended  of  late.  With  a  suitable  syringe  a  drachm  may  be 
injected  twice  a  day  of  the  following  solution:  Menthol  10  parts,  guaia- 
col  2  i)arts,  olive  oil  88  i)arts.  The  creasote  vapor  bath  may  be  given  in  a 
small  room.  The  patient's  eyes  must  be  protected  with  well-fitting  goggles, 
and  the  nostrils  stulTed  with  cotton-Mool.  Commercial  creasote  is  poured 
into  a  metal  saucer  on  a  tripod  and  the  saucer  heated  by  a  spirit  lamp.  At 
first  the  vapor  is  very  irritating  and  disagreeable,  but  the  patient  gets  used 
to  it.  The  hath  should  be  taken  at  first  every  other  day  for  fifteen  min- 
utes, then  gradually  increased  to  an  liour  daily.  The  treatment  should 
he  continued  for  three  months.  Fowler  states  that  he  has  known  the 
fetor  to  disappear.  In  suitable  cases  drainage  of  the  cavities  may  be  at- 
tempted, particularly  if  the  patient  is  in  fairly  good  condition.  For  the 
fetid  secretion  turpentine  may  be  given,  or  terebene,  and  inhalations  used 
of  carbolic  acid  or  thymol. 


IV.    BRONCHIAL   ASTH     A. 


Asthma  is  a  term  which  has  been  applied  to  various  conditions  associ- 
ated with  dyspneea — hence  the  names  cardiac  and  renal  asthma — but  its 
"use  should  be  limited  to  the  alfection  known  as  bronchial  or  spasmodic 
asthma. 

Etiology. — All  writers  agree  that  there  is  in  a  majority  of  cases  of 
bronchial  asthma  a  strong  neurotic  element.  Many  regard  it  as  a  neu- 
rosis in  which,  according  to  one  view,  spasm  of  the  bronchial  muscles,  ac- 
cording to  the  other  turgescence  of  the  mucosa,  resulis  from  disturbed  in- 
nervation, pneumogastric  or  vaso-motor.  Of  the  numerous  theories  the 
following  are  the  most  importanl- 

(1)  That  it  is  due  to  spasm  o','.  the  bronchial  muscles,  a  theory  which 
has  perha])s  the  largest  number  of  adherents.  The  original  experiments 
of  C.  J.  B.  Williams,  upon  which  it  is  largely  based,  have  not,  however, 
been  confirmed  of  late  years. 

(2)  That  the  attack  is  due  to  swelling  of  the  bronchial  miicous  mem- 
brane— fluctionary  hy])erannia  (Traidjc),  vaso-motor  turgescence  (Weber), 
diffuse  hypera^mic  swelling  (Clark). 

(3)  That  in  many  cases  it  is  a  special  form  of  inflammation  of  the 
smaller  bronchioles — hronchioUtis  exudaliva    (Curschmann).      Other  theo- 


The 


of  the 
theo- 


BRONCIIIAL  ASTHMA. 


6120 


rics  Avliicli  may  bo  inenlioiu'il  ai'o  tliat  the  attack  dcpoiids  on  spasm  oi'  tho 
<lia^)liragm  or  on  reflex  spasm  oi'  all  the  inspiratory  muscles. 

As  already  mentioned,  the  so-called  hay  fever  is  an  atl'ection  which  has 
many  resemblances  to  bronciiial  asthma,  with  which  the  .ittacks  may  alter- 
nate, in  the  suddenness  of  onset  and  in  many  of  their  features  these  dis- 
eases have  the  same  origin  and  dilfer  only  in  site,  as  suggested  by  Sir 
Andrew  Clark  and  now  generally  acknowledged  by  specialists.  ^Making 
due  allowance  for  anatomical  dilferences,  if  the  structural  changes  oeeur- 
ling  in  the  nasal  mucous  mendjrane  during  an  attack  of  hay  fever  were  to 
occur  also  in  various  i)arts  of  the  bronchial  mucosa,  their  presence  there 
would  alford  a  complete  and  adequate  ex])lanation  of  the  fads  observed 
during  a  i)aroxysni  of  bronchial  asthma  (Clark).  "With  this  statement  I 
fully  agree,  but  the  observations  of  Curschmann  have  directed  attention 
to  a  feature  in  asthma  which  has  been  neglected;  namely,  that  in  a  nui- 
jority  of  the  cases  it  is  associated  with  an  exudation,  such  as  might  be 
supposed  to  come  from  a  turgescent  mucosa  and  which  is  of  a  very  cluirac- 
leristic  and  pecnliar  character.  The  liypenumia  and  swelling  of  the  mu- 
cosa and  the  extremely  viscid,  tenacious  mucns  explain  well  the  hindrance 
to  inspiration  and  expiration  and  also  the  qnality  of  the  rules.  An  a'denia 
of  the  angio-neurotic  type  has  been  described  in  the  hands  and  arms  in 
asthma  (J.  S.  Billings,  Jr.). 

Some  general  facts  with  reference  to  etiology  may  bo  mentioned.  The 
aU'ection  sometimes  rnns  in  families,  ])articularly  those  with  irritable  and 
nnstable  nervous  systems.  The  attack  may  bo  associated  with  neuralgia 
or,  as  Salter  mentions,  even  alternate  with  epilepsy.  !Men  are  more  fre- 
quently affected  than  women.  The  disease  often  begins  in  childhood  and 
sometimes  lasts  luitil  old  age.  It  may  follow  an  attack  of  whooping-cough. 
■One  of  its  most  striking  peculiarities  is  the  bizarre  and  extraordinary  variety 
of  circumstances  which  at  times  induce  a  paroxysm.  Among  these  local 
conditions  climate  or  atmosphere  are  most  important.  A  person  may  be 
free  in  the  city  and  invariably  suffer  from  an  attack  when  he  goes  into  the 
country,  or  into  one  sjjecial  part  of  the  country.  Such  cases  are  by  no 
moans  uncommon.  Breathing  the  air  of  a  particular  room  or  a  dusty  at- 
nu)sphere  nuiy  bring  on  an  attack.  Odors,  particularly  of  flowers  and  of 
hay,  or  emanations  from  animals,  as  the  horse,  dog,  or  cat,  may  at  once  cause 
an  outbreak.  Fright  or  violent  emotion  of  any  sort  inay  bring  on  a  ]uirox- 
ysm.  Uterine  and  ovarian  troubles  were  formerly  thought  to  induce  at- 
tacks and  may  do  so  in  rare  instances.  Diet,  too,  has  an  important  inilu- 
c'lu/o,  and  in  persons  snbject  to  the  disease  severe  paroxysms  may  be  induced 
by  overloading  the  stomach,  or  by  taking  certain  articles  of  food.  Chronic 
cases,  in  which  the  attacks  recur  year  after  year,  gradually  become  asso- 
ciated with  emphysema,  and  e\ery  fresh  "cold  "  induces  a  paroxysm.  And 
lastly,  many  cases  of  bronchial  astlima  are  associated  with  affections  of  the 
nose,  particularly  with  hypertrophic  rhinitis  and  nasal  pol}'i)i.  According 
to  some  s])ecialists  of  large  experience,  all  cases  of  bronchial  aslhuui  have 
some  alfection  of  the  njiper  air-jjassages,  but  I  am  convinced  from  jiersonal 
observation  that  this  is  erroneous.  Still  physicians  must  acknowled"o  the 
ileljt  which  we  owe  to  Yoltolini,  Hack,  Daly,  Boe,  and  others  who  have 


/<Ov_ 


G3U 


DISEASES  OF  THE  IIESPIRATOIIY   SYSTEM. 


/ 


hliowu  lliu  dusu  connc'ftioii  which  exists  between  aU'ectiuiis  of  the  imso- 
phiU'^iix  and  niaiiy  cases  of  bioiicliial  asthma. 

Ui'iclly  stated  then,  bronchial  astliiua  is  a  neurotic  aU'ection,  cliaractcr- 
ized  ljy  iiy|ieneniia  and  tnrj;('scence  of  tlie  mucosa  of  the  smaller  bronciiial 
tubes  and  a  pemdiar  exudate  of  mucin.  The  attacks  may  l)e  due  to  direct 
irritation  of  the  bronchial  mucosa  or  may  be  induced  rellexly,  l)y  irritation 
of  the  nasal  mucosa,  and  intlirectly,  too,  by  rellex  inlluences,  from  stonuich, 
intt'stincs,  or  <;-cnital  organs. 

Symptoms. — Premonitory  sensations  precede  some  attacks,  sucli  as 
chilly  feelings,  a  sense  of  tightness  in  the  chest,  llatulenee,  the  passage  of  a 
large  (juantity  of  urine,  or  great  depression  of  spirits.  Nocturnal  attacks 
are  common.  After  a  few  hours'  slcc[),  the  i)aticnt  is  aroused  with  a  dis- 
tressing sen.se  of  want  of  breath  ami  a  feeling  of  great  oj)pression  in  the 
chest.  Soon  the  resi)iratory  eH'orts  beoomo  violent,  all  the  accessory  mus- 
cles arc  brought  into  play,  and  in  a  few  minutes  the  patient  is  in  a  paroxysm 
of  the  most  intense  d3spna'a.  The  face  is  ])ale,  the  cxjjression  anxious, 
speech  is  imi)ossible,  and  in  spite  of  the  most  strenuous  inspiratory  elforts 
very  little  air  enters  the  lungs.  Exjuration  is  prolonged  and  also  wheezy. 
The  nundjcr  of  resi)irations,  however,  is  not  much  increased.  The  asth- 
matic lit  may  last  from  a  few  minutes  to  several  hours.  When  severe,  the 
signs  of  defective  aeration  soon  appear,  the  face  becomes  bedewed  with 
sweat,  the  pulse  is  snudl  and  (puck,  the  extrenuties  get  cold,  and  just  as 
the  patient  seems  to  be  at  his  worst,  the  breathing  begins  to  get  easier,  and 
often  with  a  paroxysm  of  coughing  relief  is  obtained  and  he  sinks  ex- 
hausted to  sleep.  The  relief  may  be  but  temjiorary  and  a  second  attack 
may  soon  come  on.  In  a  majority  of  the  cases  even  in  the  intervals  be- 
tween the  asthmatic  fits  the  respiration  is  somewhat  embarrassed.  The 
cough  is  at  first  very  tight  and  dry  and  the  expectoration  is  expelled  with 
the  greatest  difficulty. 

The  ])hysical  signs  during  an  attack  arc  very  characteristic.  On  in- 
spection the  thorax  looks  enlarged,  barrel-.slia])ed,  and  is  fixed,  the  amount 
of  ex])ansion  being  altogether  disproportionate  to  the  intensity  of  the  in- 
spiratory movements.  The  diaphragm  is  lowered  and  moves  but  slightly. 
Ins])iration  is  short  and  quick,  expiration  prolonged.  Percussion  may  not 
reveal  any  special  dilfei'cnce,  but  there  is  sometimes  marked  hyperrcso- 
nance,  particularly  in  cases  which  have  had  repeated  attacks. 

On  auscultation,  with  ins])iration  and  exi)iration,  there  are  innumer- 
able sibilant  and  sonorous  rales  of  all  varieties,  piping  and  high-pitched, 
low-pitched  and  grave.    Later  in  the  attack  there  are  moist  rales. 

The  spiilinn  in  bronchial  asthma  is  quite  distinctive,  unlike  that  which 
occurs  in  any  other  affection.  Early  in  the  attack  it  is  brought  up  with 
great  difliculty  and  is  in  the  form  of  rounded  gelatinous  masses,  the  so- 
called  "  perlcs  "  of  Laennec.  Though  ball-like,  they  can  be  unfolded  and 
really  represent  moulds  in  mucus  of  the  smaller  tubes.  The  entire  expec- 
toration may  be  made  up  of  these  somewhat  translucent-looking  pellets, 
floating  in  a  small  quantity  of  thin  mucus.  Some  of  them  are  opaque. 
Often  with  a  naked  eye  a  twisted  spiral  character  can  be  seen,  particularly 
if  the  sputum  is  spread  on  a  glass  with  a  black  background.     Microscopic- 


BRONCIITAL   ASTHMA. 


631 


all}',  mail}'  of  thoso  pellets  have  a  spiral  strueliire,  whieli  renders  tlieiii 
aiiiun^f  the  most  ivjiiarkalile  bodies  met  uitli  in  sputum.  It  is  not  a  liltio 
eurious  that  tlioy  should  have  been  practieally  overlooked  until  deseribed  a 
lew  years  ago  by  Curschmann.  Under  the  mieroscoi)e  the  spirals  are  of 
two  I'orins.  h\  one  there  is  simply  a  twisted,  spirally  arran^^cd  mucin,  in 
which  are  entan<;led  leiieocytes,  the  majority  ol'  which  are  eosinophiles. 
'J'he  twist  may  be  loose  or  tight.  The  second  form  is  much  more  peculiar. 
In  the  centre  of  a  tightly  eoiled  skein  of  mucin  lil)rils  with  a  few  scattered 
cells  is  a  lilameut  of  extraordiiiary  clearness  and  translucency,  probably 
composed  of  transformed  mucin.  As  Curschmann  suggests,  these  spirals 
are  doubtless  formed  in  the  liner  bronchioles  and  constitute  the  product 
of  an  acute  bronchiolitis.  It  is  dillicult  to  explain  their  s})iral  nature.  I 
do  not  know  of  any  observations  upon  the  course  of  the  currents  produced 
by  the  ciliated,  epithelium  in  the  hronchi,  hut  it  is  quite  possible  that  their 
action  may  he  rotatory,  in  which  case,  particularly  when  combined  with 
sjjasm  of  the  bronchial  muscles,  it  is  i)ossible  to  conceive  that  the  mucus 
formed  in  the  tube  might  be  compelled  to  assume  a  spiral  form.  Within 
two  or  three  days  the  sputum  changes  entirely  in  character;  it  becomes 
muco-])urulent  and  Curschmann's  spirals  arc  no  longer  to  be  found.  Thoy 
occur  in  all  instances  of  true  bronchial  asthma  in  the  early  period  of  the 
attack.  I  have  never  seen  the  true  spirals  either  in  bronchitis  or  pneu- 
monia. There  are,  in  addition,  in  many  cases,  the  pointed,  octahedral  crys- 
tals described  by  Leyden  and  sometimes  called  asthma  crystals.  They  are 
identical  with  the  crystals  found  in  the  semen  and  in  the  blood  in  leu- 
kaemia. At  one  time  they  were  supj)osed,  by  their  irritating  character,  to 
induce  the  paroxysms.  Eosinophiles  in  the  blood  arc  enormously  increased 
in  asthma — to  25  or  35  per  cent  of  the  leucocytes,  or  even  to  53.6  per  cent 
in  one  case  (J.  S.  Billings,  Jr.). 

The  course  of  the  disease  is  very  variable.  In  severe"  attacks  the  par- 
oxysms recur  for  three  or  four  nights  or  even  more,  and  in  the  intervals 
and  during  the  day  there  may  be  wheezing  and  cough.  Early  in  the  disease 
the  patient  may  be  free  in  the  morning,  without  cough  or  much  distress, 
and  the  attacks  may  appear  at  first  to  be  of  a  i)urely  nervous  character.  In 
the  long-standing  cases  emphysema  almost  invariably  develops,  and  while 
the  pure  asthmatic  fits  diminish  in  frequency  the  chronic  bronchitis  and. 
shortness  of  breath  become  aggravated. 

We  have  no  knowledge  of  the  morbid  anatomy  of  true  asthma.  Death 
during  the  attack  is  unknown.  In  long-standing  cases  the  lesions  are  those 
of  chronic  bronchitis  and  emphysema. 

Treatment. — The  asthmatic  attack  usually  demands  inmiediate  and 
jirompt  treatment,  and  remedies  should  be  administered  which  experience 
has  shown  are  capable  of  relieving  the  condition  of  the  bronchial  mucosa. 
A  few  whiffs  of  chloroform  will  jiroduce  prompt  though  temporary  relaxa- 
tion. In  a  child  with  very  severe  attacks,  resisting  all  the  usual  remedies, 
the  treatment  by  chloroform  gave  immediate  and  finally  permanent  relief, 
llypoderniie  injections  of  pilocarpin  (gr.  -J)  will  sometimes  relax  the  mu- 
cosa in  the  ])rofuse  sweating.  Perles  of  nitrite  of  amyl  may  be  broken 
ou  the  handkerchief  or  from  two  to  five  drops  of  the  solution  may  be  placed 


f.n2 


DISHASES   OF   THK    IIKSIMUATOIIY    SYSTFOM. 


/ 


u|Miii  c()tt<in-\v(i(il  iiiid  inhaled.  Slronji  stimulants  jiivon  hot  or  a  Jose  of 
spirits  of  tlilorofnrni  in  hot  whisky  will  s(jnu'tinu's  induce  relaxation.  More 
licrniaiicnt  relief  is  given  by  the  liypoderniic  fnjeetiou  of  morphia  or  of 
morphia  and  eoeaino  combined.  In  obstinate  and  repeatedly  recurring 
attacks  this  has  proved  a  very  satisfactory  j»lan.  The  sedative  antispas- 
modics, such  as  l)i'llad()nna,  henbane,  stranu)niuni.  and  lobelia,  nuiy  be 
given  in  solution  or  used  in  the  form  of  cigarettes.  A'early  all  the  popular 
reniedii'S  eilher  in  this  form  or  in  ])astilles  contain  some  ])lant  of  the  order 
sohuuircd',  with  nitrate  or  chlorate  of  jxitasb.  Jvxcellent  cigaretti's  are  now 
manufactured  and  astlnnatics  try  various  sorts,  since  one  form  benefits  one 
l)atient,  aiuilhcr  form  another  i)atient.  Nitre  paper  made  with  a  strong 
solution  of  nitrate  of  jjotash  is  very  serviceable.  Filling  the  room  with  the 
fumes  of  this  i)a|)er  jjrior  to  retiring  will  sometimes  ward  olf  a  nocliirnul 
attack.  1  have  known  several  jjatients  to  whom  tobacco  smoke  inhaled  was 
■quite  as  potent  as  the  prepared  cigarettes. 

The  use  of  comjjressed  air  in  the  i)neunuitic  cabinet  is  very  beneficial; 
oxygen  inhalations  may  also  be  tried.  Jn  i)reventing  tbe  recurrence  of 
the  attacks  there  is  no  remeily  so  useful  as  iodide  of  potassium,  which  some- 
times acts  like  a  si)ecilic.  From  10  to  5iO  grains  three  times  a  day  is  usu- 
ally sufficient. 

Particular  attention  should  be  paid  to  the  diet  of  asthnuitic  patients. 
A  rule  which  exi)erience  generally  comi)els  them  to  nuike  is  to  take  the 
heavy  meals  in  the  earlv  part  of  the  day  and  not  retire  to  bed  before  gas- 
trie  digestion  is  completed.  As  the  attacks  are  often  induced  by  flatu- 
lency, the  carbohydrates  should  1)e  restricted.  Coffee  is  a  more  suitable 
drink  than  tea.  Jn  resjjcct  to  climate  it  is  very  difficult  to  lay  down  rules 
for  asthmatics.  The  i)atients  are  often  much  better  in  the  city  than  in 
the  country.  The  high  and  dry  altitudes  are  certainly  more  beneficial  than 
the  sea-shore;  but  in  i)rotracted  cases,  with  emphysema  as  a  secondary  com- 
plication, the  rarefied  air  of  high  altitudes  is  not  advantageous.  In  young 
persons  I  have  known  a  residence  for  six  months  in  Florida  or  southern 
■California  to  be  followed  by  2)rolonged  freedom  from  attacks. 


V.    FIBRINOUS    BRONCHITIS. 


An  acute  or  chronic  affection,  characterized  by  the  formation  in  certain 
of  the  bronchial  tubes  of  fibrinous  casts,  which  are  expelled  in  paroxysms  of 
dys])na\i  and  cough. 

In  several  diseases  fibrinous  moulds  of  the  bronchi  are  formed,  as  in 
diphtheria  and  croup  (with  extension  into  the  trachea  and  bronchi),  in 
])neumonia,  and  occasionally  in  phthisis — conditions  which,  however,  have 
nothing  to  do  with  true  fibrinous  bronchitis.  These  casts  are  not  to  be 
confounded  with  the  blood-casts  which  occur  occasionally  in  hemoptysis. 

Etiology. — Xothing  is  known  of  its  causation.  It  occurs  more  frc- 
(picntly  in  males.  It  is  met  with  at  all  periods  of  life,  but  is  more  common 
between  the  ages  of  twenty  and  forty.  It  has  been  known  to  attack  several 
members  of  the  same  family.     Instances  have  been  described  occurring 


FIBUIXOUS   HUOXl'IHTIS. 


033 


to^'i'tlicr  US  if  diH'  to  some  ciKli-mic  iiifhu'iut.'  (Picliini).  Tlii'  cnsts  aro  rare, 
particularly  in  hospital  practiri".  The  attacks  occur  most  commouly  in 
the  spriiij,'  months.  An  association  with  tuberculosis  luis  been  J'reiiuently 
notc(l.  Modi'l,  in  an  article  Irom  IJiiumler's  clinic,  states  that  tuberculo- 
sia  was  j)resent  in  ten  of  twenty-one  post  niortems.  Jt  luis  been  met  with 
also  in  connection  with  skin-diseases,  such  as  pemphi^^nis,  inipeti;,fo,  and 
herpes.  'JMie  attacks  api)eare(l  to  be  related  in  some  cases  to  the  menstrual 
period.  Several  instances  have  been  described  with  lieart-diseaso,  but  it 
seems  probable  that  in  all  these  conditions  the  connection  was  not  causal. 

Symptoms.— Acute  cases  are  rare.  'JMiey  may  set  in  with  hi<rh  fever, 
riji'oi's,  severe  paroxysms  of  cou^di,  and  perha[is  with  ha'm(»|»tysis.  'i'he 
clinical  i)icture  resend)les  that  of  acute  bronchitis,  and  oidy  the  e.\[)ulsion 
of  the  membranous  casts  gives  the  characteristic  features  to  the  case.  It  is 
much  more  serious  than  the  chronic  form  and  fatal  leiiuination  is  not  un- 
common. >«'.  S.  J)avis  has  re])orted  two  fatal  cases,  in  some  of  the  acute 
cases  there  has  been  aJl'ection  of  the  tonsils,  ajul  it  is  possible  that  the  dis- 
<'ase  may  have  been  truly  dii)htheritic  in  character  and  due  to  extension  of 
the  membrane  into  the  trachea  and  bronchi.  The  casts  in  these  cases  are 
not  only  more  extensive,  but  they  also  do  not  i)resent  the  laminated  struc- 
•ture  characteristic  of  true  ])]astie  bronchitis. 

A  patient  may  have  a  single  attack  without  any  recurrence,  but  in  the 
chronic  form  the  attacks  come  on  at  varying  intervals  ami  the  disease  may 
last  for  ten  or  even  twenty  years.  Instances  are  on  record  in  vhich  the 
paroxysms  have  occurred  at  definite  intervals  for  many  months.  The  at- 
tacks nuiy  recur  weekly  or  a  [)eriod  of  a  year  or  more  nuiy  intervene.  The 
onset  is  marked  by  bronchitic  symi)toms,  not  necessarily  with  fever.  The 
cough  becomes  distressing  and  paroxysmal  in  character;  the  sputa  nuiy  be 
I)l()od-stained  and  the  })atient  brings  up  rounded,  ball-like  nuisses,  which, 
when  disentangled,  are  found  to  be  moulds  of  bronchi;  the  lueniorrhago 
may  be  jjrofuse.  In  one  of  the  two  cases  which  I  have  seen  it  invariably 
accompanied  the  attack,  and  the  whitish  dendritic  casts  of  the  tubes  were 
always  entangled  in  the  blood  and  clots.  Urgent  dyspncea  and  cyanosis 
may  be  present  in  severe  attacks.  The  phi/stical  signs  are  those  of  a  severe 
lironchitis.  It  nuiy  occasionally  be  ])ossible  to  determine  the  weakened  or 
suj)pressed  breath  sounds  in  the  affected  territory  and  there  may  be  delicient 
expansion  or  even  retraction  of  the  chest  wall  in  a  corresponding  area,  but 
this  is  in  reality  very  dilTicult,  and  twice  prior  to  the  expulsion  of  the  casts 
I  failed  to  determine  by  physical  examination  the  affected  region. 

x\s  mentioned,  the  casts  are  usually  rolled  up  and  mixed  with  mucus  or 
blood.  "When  unravelled  in  water  they  present  a  complete  mould  of  a 
secondary  or  tertiary  bronchus  with  its  ramifications.  The  size  of  the  cast 
may  vary  with  different  attacks,  liut.  as  has  often  been  noticed,  the  form 
and  size  may  be  identical  at  each  attack  as  if  ])recisely  the  same  bronchial 
area  was  involved  each  time.  The  casts  arc  hollow,  laminated,  the  size  of 
the  lumen  varying  with  the  number  and  thickness  of  the  lamina?.  Some- 
times they  are  almost  solid.  Transverse  sections  show  a  beautiful  concen- 
tric arrangement.  The  casts  have  been  determined  by  fi randy  to  be  com- 
liosed  of  mucus  and  not  of  fibrin.    He  regards  the  process  as  analogous  to 


I 


G3i 


IHSMASKS   OK  TIIK   UIISIM  UATORY   SVSTKM. 


/ 


llic  iiuicotis  (.'ulitis.  'J1ic  iiiiiciii  !i|)|»('iirs  in  jilaces  to  rotiiiii  its  lil)rillary 
struc'turt';  in  utlicis,  iis  in  diplitlicritic  nu'in'oninc,  it  has  undi.'r;^'ono  the 
hyaline  transfonnalinM.  liCiu-ocylcs  are  iniln-ddcMl  in  the  meshes.  In  the 
centre,  parlieulariy  in  the  sniallei'  easts,  it  is  not  uneoniinon  tu  see  alveohir 
epitheliuin  willi  niinu'i'oiis  earhon  jmrtieles.  Leyden's  crystals  arc  some- 
times found  and  occasionally  Curschmann's  spirals. 

The  patholo^fy  of  the  disease  is  obscure.  The  membrane  is  identical 
with  that  to  which  the  term  croupous  is  applied,  arul  the  obscurity  relates 
uot  so  much  to  the  jiiechanism  of  the  j)roduction,  which  is  })rol)ably  the 
same  as  in  other  mucous  surfaces,  as  to  the  curious  limitation  of  the  all'ee- 
tlon  to  certain  broncliial  territories  and  the  remarkable  recurrence  at  statetl 
or  irregular  intervals  throu^^iiout  a  ])eriod  of  many  years. 

In  the  acute  cases  the  Irculincnt  should  be  that  of  ordinary  acute  bron- 
chitis. We  know  of  nothinji;  which  can  prevent  the  recurrence  of  the  at- 
tacks in  the  chronic  form.  In  the  uncomplicated  cases  there  is  rarely  any 
danger  during  the  paroxysm,  even  though  the  symptoms  may  be  most  dis- 
tressing and  the  dyspmea  and  cough  very  severe,  lidialations  of  ether, 
steam,  or  atomized  lime-water  aid  in  the  separation  of  the  membranes. 
Pilocarpine  might  be  useful,  as  in  some  instances  it  increases  the  bronchial 
secretion.  The  employment  of  emetics  may  be  necessary,  and  in  some 
cases  they  are  .effective  in  promoting  the  removal  of  the  casts. 


lY.   DISEASES   OF  THE  LUNGS. 


I.    CIRCULATORY    DISTURBANCES    IN    THE    LUNGS. 

Congestion. — There  are  two  forms  of  congestion  of  the  lungs — active  and 
passive. 

(1)  Active  Cungesiiun  of  the  Lungs. — Much  doubt  and  confusion  still 
exist  on  this  subject.  French  writers,  following  Woillez,  regard  it  as  an 
independent  prinmry  alTection  {maladie  de  Woillez),  and  in  their  diction- 
aries and  text-books  allot  much  space  to  it.  English  and  American  au- 
thors more  correctly  regard  it  as  a  symptomatic  affection.  Active  fluxion 
to  the  lungs  occurs  with  increased  action  of  the  heart,  and  when  very  hot 
air  or  irritating  substances  are  inhaled.  In  diseases  which  interfere  locally 
with  the  circulation  the  capillaries  in  the  adjacent  imafrected  portions  may 
he  greatly  distended.  The  importance,  however,  of  this  collateral  fluxion, 
as  it  is  called,  is  probably  exaggerated.  In  a  whole  series  of  pulmonary  afl'ec- 
tions  there  is  this  associated  congestion — in  pneumonia,  bronchitis,  pleu- 
risy, and  tuberculosis. 

The  symptoms  of  active  congestion  of  the  lungs  are  by  no  means  defi- 
nite. The  descri]ition  given  by  AYoillez  and  by  other  French  writers  is  of 
an  afTection  which  is  difficult  to  recognize  from  anomalous  or  larval  forms 
of  pneumonia.  Tlie  chief  symptoms  described  are  initial  chill,  pain  in  the 
side,  dyspna'a,  moderate  cough,  and  temperature  from  101°  to  103°,  The 
physical  signs  are  defective  resonance,  feeble  breathing,  sometimes  bronchial 


ClUCL'liA'roltY    DISTUUHANCKS   IN   Till':   lil'NOS. 


onr) 


in  clmnutcr,  iiikI  liiu'  nilfs.  A  innjority  of  cliiiic'iil  physicians  would  uii- 
(ioiilik'dly  C'liiss  such  cases  under  inllaniuiation  of  the  hin;^'.  In  many  i'|(i- 
(hniics  tiie  al)nornial  and  larval  I'ornis  are  s|teeially  prevalent.  This  is  no 
dtiul/t  the  condition  to  which  I'orchei-,  u(  ('hai'le>toii,  called  attention  a  short 
time  ajLfo  as  a  "  hitherto  undescrihed  allVction  of  the  1uiij,'h/' 

The  occurrence  ol'  an  intense  and  rapidly  I'atal  couf^cstion  of  the  lung, 
followiM<,'  cxtreuic  heat  or  cold  or  sonictiines  violent  exertion,  is  recognized 
hy  stiuie  authors.  Jicnl'orth,  the  oarsman,  is  said  to  have  died  I'rom  this 
cause  (luring  the  race  at  Halifax.  Leuf  has  de.scrihod  cases  in  wliich,  in 
association  with  drunkenness,  exposure,  and  cold,  death  occurred  suddenly, 
or  within  twenty-four  hours,  the  only  lesion  found  hcing  an  extreme,  almost 
hu'morrhagic,  congestion  of  the  lungs.  It  is  hy  no  means  certain  that  in 
these  cases  death  really  occurs  from  pulmonary  congesti(m  in  the  ahsenee 
of  s[)ccille  statements  with  reference  to  the  coroiuuy  arteries.  Several 
times  in  sudden  death  from  disease  of  these  vessels  I  have  seen  great  en- 
gorgement of  the  lungs  though  not  the  extreme  grade  mentioned  hy  Leuf. 
1  have  no  personal  knowledge  of  cases  such  as  he  descrihes. 

{'i)  Pussirc  Comjcslion. — Two  forms  of  this  may  be  recognized,  the  me- 
chanical and  the  hyj)ostatic. 

{({)  ^lechanical  congestion  occurs  whenever  there  is  an  ohstacle  to  the 
return  of  the  hlood  to  the  heart.     It  is  a  common  t  in  nniiiy  ail'ections 

of  the  left  heart.  'IMie  lungs  are  voluminous,  I'usset  hrown  in  color,  cut- 
ting and  tearing  with  great  resistance.  On  section  they  show  at  first  a 
hrownish-red  tinge,  and  then  the  cut  surface,  exposed  to  the  air,  becomes 
rapidly  of  a  vivid  red  color  from  oxidation  of  the  abundant  hirmoglobin. 
This  is  the  condition  known  as  brown  indiiral'uni  of  the  lung.  Jlistologic- 
idly  it  is  characterized  by  (a)  great  distention  of  the  alveolar  capillaries; 
(/3)  increase  in  the  connective-tissue  elements  of  the  lung:  (y)  the  i)res- 
ence  in  the  alveolar  walls  of  many  cells  containing  altered  l)lood-pignu!nt; 
(8)  in  the  alveoli  numerous  ejiithelial  cells  containing  blood-pigment  in  all 
stages  of  altei'ation,  which  are  also  found  in  great  inunbers  in  the  s]tutum. 

It  occasionally  happens  that  this  mechanical  hyperieniia  of  the  lung 
results  from  pressure  by  tumors.  So  long  as  compensation  is  maintained 
the  mechanical  congestion  of  the  lung  in  heart-disease  does  not  produce  any 
sym|)t()ms,  but  with  enfeebled  heart  action  the  engorgement  becomes  marked 
and  there  are  dyspna>a,  cough,  and  expectoration,  with  the  characteristic 
alveolar  cells. 

{b)  Hypostatic  congestion.  In  fevers  and  adynamic  states  generally,  it 
is  wry  common  to  find  the  bases  of  the  lungs  deeply  congested,  a  condition 
iiuluccd  partly  by  the  eU'ect  of  gravity,  the  natient  lying  recumbent  in  one 
posture  for  a  long  time,  but  chiefly  by  weakened  heart  action.  That  it  is 
not  a)i  efTect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy  person 
may  remain  in  bed  an  indefinite  time  without  its  occurrence.  The  term 
iiypostatic  congestion  is  ai)plied  to  it.  The  posterior  ])arts  of  the  lung  are 
(lark  in  color  and  engorged  with  blood  and  serum;  in  some  instances  to 
>iuh  a  degree  that  the  alveoli  no  longer  contain  air  and  portions  of  the  lung 
sink  in  water.  The  term  splenization  and  hypostatic  i)neumonia  have  been 
;;iv(>n  to  these  advanced  grades.     It  is  a  common  all'ection  in  protracted 


GW 


DISKA.SKS  OK  Till-;   llKSIMKAToUY   HVSTKM. 


/ 


cjiHi's  (if  ty|»li(ii(l  fi'vcr  iiml  in  loni;  (Ichiliinliii;,'  illnesses.  Tn  iiseiles,  in(!tcnr- 
isni,  and  alxltmiinal  tumors  the  bases  oL'  iIk;  liin;^'s  may  l)e  eompres.^cd  and 
congested.  In  this  eonneclion  nin>t  he  mentioned  tlie  I'onn  of  |»Msyive  con- 
gt'Htion  met  with  in  injury  to,  and  or^'anie  disease  of,  the  hrain.  In  eeie- 
l)ral  a|)o|)le.\\  the  bases  of  the  lunj,'s  are  det'ply  en^orj^ed,  nol  (juitu  airless, 
hut  heavy,  and  on  section  drip  with  hlood  and  serum.  I  have  twice  seen 
this  condition  in  an  extreme  ;;ra(h'  throughout  the  lun^s  in  death  from  inoi'- 
pliia  poisoninji'.  In  some  instances  the  lung  tissue  has  a  hiackish,  ^'elati- 
iiourt,  inliltratc(l  appearance,  almost  like  dilTuse  pulmonary  apoplexy.  Occa- 
sionally this  conjicstion  is  most  marked  in,  and  even  conlined  to,  the 
hemiple^iie  side.  In  prolonj,f"d  coma  the  hypostatic  congestion  may  l)c 
associated  with  pati'iies  of  consolulation,  due  to  the  aspiration  of  portioiLs 
of  food  into  the  air-passa<^es. 

The  symptoms  of  hypostatic  con<,'estion  arc  not  at  all  characteristic, 
and  the  condition  has  to  he  sou^dit  for  hy  careful  examination  of  the  bases 
of  the  hm^is,  when  slight  dulness,  t'eehle,  sometimes  blowinj;,  breathing  and 
liipiid  rales  can  be  detected. 

The  Ircdlinnil  of  congestion  of  the  lungs  is  usually  that  of  the  condi- 
tion with  which  it  is  associated.  In  the  inti'iise  pulmonary  cngorg^'oient, 
which  may  possibly  occur  primarily,  and  which  is  met  with  in  hcai't-disease 
and  emphysema,  free  bleeding  should  be  practised.  From  'iO  to  oO  ounces 
of  blood  should  be  taken  from  the  arm,  and  if  the  blood  docs  not  flow 
freely  and  the  condition  of  the  patient  is  desperate,  aspiration  of  the  right 
auricle  may  be  jierformed. 

(Edema. —  In  all  foi'ms  of  intense  congestion  of  the  lungs  there  is  a 
transudation  of  serum  from  the  engorged  ca])illaries  chiefly  into  the  aii'- 
cclls,  but  also  into  the  alveolar  walls.  Not  only  is  it  very  fre([uent  in  con- 
gestion, but  also  with  inllammation,  with  new  growths,  infarcts,  and  tuber- 
cles. When  limite(l  to  the  neigliborhood  of  an  all'ected  \n\vi,  the  name 
collateral  (edema  is  sometimes  applied  to  it.  (ieneral  u'dema  occurs  nnder 
conditions  very  similar  to  those  met  with  in  congestion.  It  is  very  often. 
no  doubt,  a  terminal  event,  occurring  with  the  death  agony.  It  is  seen  in 
typical  form  in  the  cachexias,  in  death  from  ana'mia,  also  in  chronic  IJright's 
disease,  disease  of  the  heart,  and  cerebral  aU'ections. 

The  (edematous  lung  is  Jieavy,  looks  watery,  ])its  on  piessure,  and  from 
the  cut  surface  a  large  (juantity  of  clear  and,  in  cases  of  congestion,  bloody 
serum  Hows  freely;  the  tissue  may  even  have  a  gelatinous,  infiltrated  ap- 
pearance. The  condition  is  nnich  more  common  at  the  bases,  but  it  may 
exist  throughout  the  entire  lung.  The  pathology  of  i)ulmonary  (edema  is 
not  always  clear.  Two  factors  usually  ])revail  in  extreme  cases — increased 
tension  within  the  ])uhnomiry  system  and  a  diluted  hlood  plasma.  The 
increased  t(>nsion  alone  is  not  ca])able  of  ])rodncing  it.  "^rbe  experinu'uts 
of  Welch  seem  to  indicate  that  the  essential  facior  lies  in  a  disproportion- 
ate weakness  of  the  left  ventricle,  so  that  the  blood  accumulates  in  the 
lung  ca])illaries  until  transudation  occurs,  a  view  which  satisfactorily  ex- 
plains certain  cases,  ]iarticularly  the  terminal  a'demas. 

The  si/nipfoms  of  o'dema  of  the  lungs  are  often  only  an  aggravation  of 
those  already  existing,  and  are  due  to  the  primary  disease,  whether  car- 


('Il{(  ThATOHY   DISTrUHANTKS   IN  TIIK   lil'NOS. 


o;{7 


(line,  rt'iiiil,  III'  ;,M'iu'riil.  'I'licrc  iiic  iisimlly  incrciisiiijj:  (lys|iii(i'ji  mid  coiij,'!), 
1111(1  on  ('xiiiiiiiiation  thiTo  iiiiiy  '»'  (U'tVctivc  n'soinuict'  and  lai>,'t'  li»|iiid  nilcn 
at  lliu  hasi's.  'I'lu'rc  arc  cases  in  which  the  (t'dcnui  conies  on  with  ^ncat 
hiid(h'iiii('ss,  and  in  chronic  I5ri;fhl's  disease  it  may  prove  rii|)idly  fatal. 

Ill  tlic  casi'S  of  so-caHcd  inllaniniatory  (ccU'nia  fever  is  always  |iri'seiit, 
and  there  are  often  si^'iis,  more  or  less  marked,  of  pnenmoniii. 

The  tirdhiiciil  of  o'deina  of  tlie  Inn;:  is  practically  tlial  (d'  the  condi- 
tions with  which  it  is  associated.  In  the  acute  cases  active  catharsis,  iind, 
if  there  is  cyanosis,  free  venesection  should  la;  resorted  to. 

Pulmonary  Hromorrhage. — This  occurs  in  two  forms — hmnrhn-iml- 
iiniiKirif  lunnonlKK/r,  sometimes  called  hronchorrha^na,  in  which  the  Idooil 
is  poured  out  into  the  hronchi  and  is  expectorated,  and  pnlinuniinj  a/in- 
jilc.ri/  or  pneiiniori'hai^ia,  in  which  the  luemorrlia^fc  tau.s  place  into  the 
air-cells  and  the  luii^^  tissue. 

1.  Jironclio-inihiioiKir!/  Ihotion-Jutije ;  Ifd'nioplysis. — Sjiittin;,'  of  Mood, 
to  which  the  tcini  luenioptysis  should  Ix!  restricted,  results  from  a  variety 
of  conditions,  anion^f  which  the  following'  ari'  the  most  important:  (a)  In 
youn^f  healthy  persons  luenioptysis  may  occur  without  warning,  and  after 
continuing  for  a  I'l'w  days  disappear  and  leave  no  ill  traces.  There  may 
lie  at  the  time  of  the  attack  no  physical  signs  indicating  pulmonary  disease. 
In  such  cases  good  lu'altli  may  he  preserved  I'or  years  and  no  further 
trouhle  occur.  These  cases  are  not  very  uncommon.  In  Ware's  inipor- 
taiit  contrihution  to  this  subject,*  of  iJSd  cases  of  lia'nio|)tysis  noted  in 
private  iiractiee  d^  recovered  and  pulmonary  disease  did  not  sul)st'((ueiitly 
develop  in  tlieni.  I  know  three  professional  men  who  had  luenioptysis  as 
students,  and  who  now,  at  jtcriods  of  from  (ifteeii  to  eighteen  years  suhse- 
(piently,  reinain  in  ])erfect  health,  (h)  Iliemoptysis  in  jiulnionary  tuhercu- 
losis,  which  is  considered  in  pages  IJO'i-IJdI.  {<•)  In  connection  with  cer- 
tain diseases  of  the  lung,  as  pneumonia  (in  the  initial  stage)  and  cancer, 
occasionally  in  gangrene,  a1)scess,  and  bronchiectasis,  luvmoptysis  occurs. 
(d)  Ihemoptysis  is  met  witi  in  many  heart  alTectioiis,  ])arlicul;irly  miti'al 
lesions.  It  may  be  ])rofuse  and  recur  at  intervals  I'or  years,  (r)  In  ulcera- 
tive aH'cetions  of  the  larynx,  trachea,  or  bronchi.  Sometimes  the  liaunor- 
rliage  is  jirofuse  and  rapidly  fatal,  as  when  an  ulcer  erodes  a  large  branch 
of  the  ])ulnionary  artery,  an  accident  Avliich  I  luive  known  to  happen  in 
a  case  of  chronic  bronchitis  with  em])liysenia.  (/")  Aneurism  is  nn  occa- 
sional cause  of  liaMiioptysis.  It  may  be  sudden  and  rapidly  fatal  when  the 
sac  bursts  into  the  air-i)assagcs.  Slight  bleeding  may  continue  for  weeks  or 
even  longer,  due  to  pressure  on  the  mucous  membrane  or  erosion  of  the  lung; 
or  in  some  cases  the  sac  "  wce])s  "  through  the  exposed  laniiiiie  of  fibrin. 
(//)  Vicarious  hiumorrliage,  which  occurs  in  rare  instances  in  cases  of  inter- 
rupted menstruation.  The  instances  are  well  authenticated.  Flint  men- 
tions a  case  which  he  had  had  under  ol)serYation  for  four  years,  and  II i|)- 
pocrates  refers  to  it  in  the  a])horism,  "  TTa'Uioptysis  in  a  woman  is  removed 
by  an  erujition  of  the  menses."  Periodical  lia'mo])tysis  has  also  been  met 
with  after  the  removal  of  bolli  ovaries.     Even  fatal  luemorrhage  has  oc- 


Oii  IIa>moptysis  a&  a  Symptom,  by  John  Ware,  Jf.  D. 


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Photographic 

Sdences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


PIBPMgitpHllHPHI 


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638 


DISEASES   OF   TOE   RESPIRATORY  SYSTEM. 


/ 


currcd  from  the  ]iin,u-  (liirin<;  rucnstruation  Avhen  no  k'.sion  was  found  to 
aeouut  I'or  it.  (//)  'JMiore  is  a  form  of  recurring  lucnioptysis  in  artlirilic 
subjects  to  wliicli  Sir  Andrew  Clark  lias  calleil  special  attention  and  wliicli 
also  is  described  I)}'  French  writers.  The  eases  (jccur  iu  persons  over  lifty 
years  of  age  who  usually  i)resent  signs  of  the  arthritic  diathesis.  It  rarely 
leads  to  fatal  issue  and  subsides  without  iiulueing  pulmonary  changes.  (/) 
llnMHoptysis  recurs  sometimes  in  malignant  fevers  and  in  ])urpura  lurmor- 
rhagica.  Lastly,  there  is  eiulemie  ha-moptysis,  due  to  the  J)isliiiiiuiii  ircslcr- 
VKtiiiii  in  the  bi'onchial  tubes,  an  all'eetion  whieli  is  coniined  to  parts  (d' 
China  and  Japan. 

Symptoms. — Ilaunoptysis  sets  in  as  a  rule  suddoidy.  Often  with- 
out warning  the  patient  experiences  a  warm,  saltish  taste  as  the  mouth 
fills  with  blood.  Coughing  is  usually  induced.  There  may  be  only  an 
ounce  or  so  brought  up  before  the  luemorrhage  stops,  or  the  bleeding  ni  y 
continiie  for  days,  the  patient  bringing  up  small  quantities.  In  other  in- 
stances, particularly  when  a  large  vessel  is  eroded  or  an  aneurism  bursts, 
the  amount  is  large,  and  the  ])atient  after  a  few  attcmi)ts  at  coughing  shows 
t-igns  of  sull'ocation  and  death  is  produced  by  inundation  of  the  bronchial 
system.  Fatal  hipmorrhage  may  even  occur  into  a  large  cavity  in  a  patient 
debilitated  by  phthisis  without  the  production  of  luvmoptysis.  I  dissected 
a  case  of  this  kind  at  the  riiiladelphia  Hospital.  The  blood  from  the  lungs 
generally  has  characters  which  render  it  readily  distinguishable  from  the 
blood  which  is  vomited.  It  is  alkaline  in  reaction,  frothy,  and  mixed  with 
mucus,  and  when  coagidation  occm-s  air-bubbles  are  jtresent  in  the  clot, 
rdood-moulds  of  the  smaller  bronchi  are  sometimes  seen.  Patients  can 
usually  tell  whether  the  blood  has  been  brought  uj)  by  coughing  or  by 
vomiting,  and  in  a  majority  of  cases  the  history  gives  important  indica- 
tions. In  paroxysmal  haemoptysis  connected  with  menstrual  disturbances 
the  practitioner  should  see  that  the  blood  is  actually  coughed  up,  since  de- 
cej)tion  may  be  practised.  The  s])urious  haemoptysis  of  hysteria  is  consid- 
ered with  that  disease.  Xaturally,  the  patient  is  at  first  alarmed  at  the 
occurrence  of  bleeding,  but,  unless  very  profuse,  as  when  due  to  rupture 
of  an  aortic  aneurism  in  a  pulmonary  cavitj^  the  danger  is  rarely  immedi- 
ate. The  attacks,  however,  are  apt  to  recur  for  a  few  days  and  the  sputa 
may  remain  blood-tinged  for  a  longer  period.  In  the  great  majority  of 
cases  the  luvmorrhage  ceases  spontaneously.  It  should  be  remembered 
that  some  of  the  blood  may  be  swallowed  and  produce  vomiting,  and, 
after  a  day  or  two,  the  stools  may  be  dark  in  color.  It  is  not  well  during 
an  attack  of  lurmoptysis  to  examine  the  chest.  It  was  formerly  thought 
that  haemorrhage  exercised  a  prejudicial  effect  and  excited  inllammation 
of  the  lungs,  but  this  is  not  often  the  case. 

("2)  Puhmmary  Apoplexi/;  Ilmnorrhagic  Infarct. — In  this  condition 
the  blood  is  effused  into  the  air-cells  and  interstitial  tissue.  It  is  rarely 
indeed  diffuse,  the  parenchyma  1)eing  broken,  as  is  the  brain  tissue  in 
cerebral  apoplexy.  Sometimes,  in  disease  of  the  brain,  in  septic  condi- 
tions, and  in  the  malignant  forms  of  fevers,  the  lung  tissue  is  uniformly 
infdtrated  with  blood  and  has,  on  section,  a  black,  gelatinous  a])i)earance. 

As  a  rule,  the  luumorrhage  is  limited  and  results  from  the  blocking  of 


uund  to 
irthritic 
d  which 
vol-  iil'ty 
It  rurcly 
gos.     (0 

liEDmoi- 
n  li'csler- 

piirts  ot 

en  with- 
lO  mouth 
only  an 
ling  111  y 
other  in- 
ni  bursts, 
ing  shows 
Ijronc'hiiil 
a  patient 
dissected 
the  lungs 
from  the 
lixed  with 
the  clot, 
ticnts  can 
ing  or  by 
nt  indica- 
iturbances 
,  since  de- 
is  consid- 
icd  at  the 
;o  rupture 
y  immedi- 
thc  sputa 
lajority  of 
raembercd 
ting,  and, 
ell  during 
y  thought 
ammation 

condition 
t  is  rarely 

tissue  in 

)tic  condi- 

uniformly 

(jicarance. 

docking  of 


CIRCULATORY  DISTURBANCES  IN  THE   LUNGS. 


G39 


a  Ijranch  of  the  pulmonary  artery  either  by  a  tlir()ml)us  or  an  embolus, 
'{"he  condition  is  most  eomiiiou  in  chroiiie  lieart-dir-ease.  Although  the* 
pulmonary  arteries  are  termijial  ones,  bloeking  is  not  always  followed  by 
inl'aretion;  ]»artly  because  the  wide  cai)illaries  tiiriii>h  sutlicient  anasto- 
mosis, and  partly  because  the  bronchial  vessels  may  keep  up  the  circula- 
lion.  The  infarctions  are  chielly  at  the  jteriphi'ry  of  the  lung,  usually 
wedge-shaped,  with  the  base  of  the  wedge  toward  the  surface.  When  re- 
cent, they  arc  dark  in  color,  hard  and  iirm,  and  look  on  section  like  an 
ordinary  blood-clot,  (iradual  changes  go  on,  and  the  coloi-  becomes  a 
I'cddish  '.irown.  The  jjleura  over  an  infarct  is  usually  inllamed.  A  mi- 
croscopic ;;1  section  shows  the  air-cells  to  be  distended  with  red  blood-cor- 
puscles, wiiich  may  also  be  in  the  alveolar  walls.  The  infarcts  are  usually 
multiple  and  vary  in  size  from  a  walnut  to  an  orange.  Aery  large  ones 
may  involve  the  greater  ]tart  of  a  lobe.  in  the  artery  jtassing  to  the 
alTected  territory  a  thrombus  or  an  endjolus  is  found.  The  globular 
throndd,  formed  in  the  right  auricular  appendix,  play  an  important  part 
ill  the  production  of  ha-inorrhagie  infarction.  In  many  cases  the  source 
(d'  the  embolus  cannot  be  discovered,  and  the  infarct  may  have  resulted 
fi'om  throndjosis  in  the  pulmonary  artery,  but,  as  before  mentioned,  it  is 
not  infrequent  to  find  total  obslriu'tion  of  a  large  branch  of  a  puhnonary 
artery  without  lucmorrhage  into  the  corres])onding  lung  area.  The  fur- 
ther history  of  an  infarction  is  variable.  It  is  })ossible  tliat  in  some  in- 
stances tlie  circulation  is  re-established  and  the  blood  removed.  Alore 
commonly,  if  the  patient  lives,  the  usual  changes  go  on  in  the  extravasated 
Mood  and  ultimately  a  pigmented,  puckered,  fibroid  patch  results.  Slough- 
ing may  occur  with  the  formation  of  a  cavity.  Occasionally  gangrene 
ri'sults.  In  a  case  at  the  University  Hospital,  Philadelphia,  a  gangrenous 
iirfarct  ruptured  and  ])roduced  fatal  pneumothorax. 

The  )<i/)iij)liii)i,'<  of  jndmonary  ajioplexy  are  by  no  means  deHnite.  The 
condition  may  be  susi)ected  in  chronic  heart-disease  when  ha'nioptysis 
occurs,  particularly  in  mitral  stenosis,  but  the  l)leeding  may  be  due  to  the 
extreme  engorgement.  AVbcn  the  infarcts  are  very  large,  and  particularly 
ill  the  lower  lobe,  in  which  they  most  commonly  occur,  there  may  Ijo  signs 
(if  consolidation  with  blowing  breathing. 

Treatment  of  Pulmonary  Haemorrhage. — In  the  treatment 
of  luemoptysis  it  is  important  to  renuMiiber  the  condition  of  the  pulmo- 
nary circulation  and  the  nature  of  the  lesions  associated  with  the  Inemor- 
I'liage. 

The  ])ressure  within  the  ])ulmonary  aiiery  is  considerahly  less  than  that 

in  the  aortic  system,     ^\'e  have  as  yet  very  imperfect  knowledge  of  the 

eirciimstances  which  inlluence  the  lesst'r  circulation  in  man.     IJesearches, 

particularly  those  of  Uradbtrd,  indicate  that  the  system  is  under  vaso- 

iiiot(n"  control,  but  our  knowledge  of  the  mutual  relations  of  pressure  in 

I  lie  aorta  and  in  the  jiulinonary  artery,  under  varying  conditions,  is  still 

\ery  imperfect.     Ivxperiments  with  drugs  seem  to  show  that  there  may  be 

.III    influence  on   systemic  blood-pres>ure   witluuit   any  on    th(>   pulmonary, 

;iiid  the  ])ressnre  in  the  one  may  rise  while  it  falls  in  the  other,  or  it  may 

rise  and  fall  in  both  too'ether.     Tn  Andrew's  llarveian  Oration  these  rcla- 
40 


G40 


DISEASES  OF  THE  ilESPIRATORY  SYSTEM. 


tioiis  arc  llinroii^lily  dcvscribcd,  and  a  statement  is  made,  Ijased  on  Brad- 
Tord's  experiments,  as  to  the  action  on  the  pulmonary  blo(Kl-])ressure  of 
many  ol'  the  dru<is  eiiqdoyed  in  ha'inoptysis.  Thu8  ergot,  the  remedy 
l)erha[)s  most  commonly  used,  causes  a  distinct  rise  in  the  puiniouary 
blood-pressure,  while  aconite  jjroduces  a  definite  fall. 

The  anatomical  condition  in  luL'mo])tysis  is  either  hyi)erLemia  of  the 
bronchial  mucosa  (or  of  the  lung  tissue)  or  a  perforated  artery.  In  the 
latter  case  the  patient  often  passes  rajiidly  beyond  treatment,  though  there 
are  instances  of  the  most  profuse  lucmorrhagc,  which  must  have  come  fi'om 
a  perforated  artery  or  a  ru])ture(l  aneurism,  in  which  recovery  has  occurred. 
Practically,  for  treatment,  we  should  separate  these  cases,  as  the  remedies 
which  would  be  a])plicable  in  a  case  of  congested  and  bleeding  mucosa 
would  be  as  much  out  of  i)lace  in  a  case  of  ha'nu)rrhage  from  ruptured 
aneurism  as  in  a  cut  radial  artery.  When  the  blood  is  brought  up  in  large- 
quantities,  it  is  a]nu)st  certain  either  that  an  aneurism  has  ru[)tured  or  a 
vessel  has  been  eroded.  In  the  instances  in  which  the  sputa  are  blood- 
tinged  or  when  the  blood  is  in  smaller  quantities,  bleeding  comes  by 
dia])edesis  from  hypera'uiic  vessels,  in  such  cases  the  luemorrhage  may  be 
beneiicial  in  relieving  the  congested  blood-vessels. 

The  indications  are  to  reduce  the  freciuency  of  the  heart-heats  and  to 
lower  the  blood-jjressure.  Uy  far  the  most  important  measure  is  absolute 
quiet  of  Ijody,  such  as  can  only  l)e  secured  by  rest  in  bed  and  seclusion. 
In  the  nuijority  of  cases  of  nuld  luvm()])tysis  this  is  sutlicient.  Even 
when  the  })atient  insists  upon  going  aljout,  the  bleeding  may  stop  sjjon- 
taneously.  The  diet  should  be  light  and  unstimnlating.  Alcohol  should 
not  be  used.  The  ])atient  ma}^  if  he  wishes,  have  ice  to  suck.  Small 
doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  bleeding 
is  i)rotracted  styi)tic  and  astringent  medicines  are  not  indicated.  For 
cough,  which  is  always  ]n'esent  and  disturbing,  opium  should  be  freely 
given,  and  is  of  all  medicines  most  servicealile  in  hanno))tysis.  Digitalis 
should  not  be  used,  as  it  raises  the  blood-jjressure  in  the  pulmonary  artery. 
Aconite,  as  it  lowers  the  ])ressure,  may  be  used  when  there  is  much  vascu- 
lar excitement.  hh-got,  tannic  acid,  and  lead,  which  are  so  much  em- 
ployed, have  little  or  no  influence  in  hanno])tysis;  ergot  ])rol)ab]y  does  harm. 
One  of  the  most  satisfactory  means  of  lowering  the  blood-])ressure  is  purga- 
tion, and  when  the  bleeding  is  i)rotracted  salts  may  be  freely  given.  In. 
])rofuse  luvmojjtysis,  such  as  comes  from  erosion  of  an  artery  or  the  rup- 
ture of  an  aneurism,  a  fatal  result  is  common,  and  yet  ])ost-mortem  evi- 
d(Mice  shows  that  thrombosis  may  occur  with  healing  in  a  ru]iture  of  con- 
siderable size.  The  fainting  induced  by  the  loss  of  blood  is  probably  the 
most  elhcient  means  of  promoting  throndjosis,  and  it  was  on  this  jn-inciple 
that  foi'meily  patients  were  bled  from  the  arm,  or  from  both  arms,  as  in 
the  case  of  Laurence  Sterne.  Ligatures,  or  Esmarch's  bandages,  placed 
around  the  legs  may  serve  temporarily  to  check  the  bleeding.  The  ice- 
bag  on  the  sternum  is  of  doubtful  utility.  In  a  protracted  case  Cayley  in- 
duced pneumothorax,  but  without  eil'ect. 

Briefly,  then,  we  may  say  that  cases  of  ha?morrhagG  from  ru])turc  of 
aneurism  or  erosion  of  a  blood-vessel  usually  prove  fatal.     The  fainting 


Yov 

frci'ly 
digitalis 

artery. 

vascii- 
icli  cm- 
s  harm. 

piirjia- 
en.  lu 
le  nip- 
om  evi- 
of  con- 
il)ly  tlie 
•riiK'ii)lc 
IS,  as  in 

placLM  I 

ho  ic-e- 

yloy  iii- 

)ture  of 


BRONCIl  0-PNEUMONI  A. 


641 


induced  l)y  tlio  loss  of  l)h)od  is  bcnofifial,  and,  if  llio  patient  can  be  kept 
alive  for  twenty-four  hours,  a  thrombus  of  sullicient  strength  to  prevent 
further  bleeding  may  form.  Tiie  chief  danger  is  the  inundation  of  the 
bionehial  system  with  the  blood,  so  that  while  the  luemorrhage  is  profuse 
the  cough  should  l)e  encouraged.  Opium  should  not  then  be  used,  aiui 
stimulants  should  be  given  with  caution. 

In  the  other  grouj),  in  which  the  haunorrhage  comes  from  a  congested 
area  and  is  limited,  the  patient  gets  well  if  kept  absolutely  quiet,  ami 
fatal  luemorrhage  probably  never  occurs  from  this  source.  West,  reduc- 
tion of  the  blood-pressure  by  minimum  diet,  i)urging,  if  necessary,  and  the 
administration  of  opium  to  allay  the  cough  are  tin;  main  indications. 

II.     BRONCHO-PNEUMONIA    (Capillary   Bronchitis). 

This  is  essentially  an  inflannnation  of  the  terminal  bronchus  and  the 
air-vesicles  which  nud\e  up  a  })ulnu)nary  lobule,  whence  the  term  broncho- 
l)neumonia.  It  is  also  known  as  lobular,  in  contradistinction  to  lobar  j)neu- 
monia.  The  term  catarrhal  is  less  applicable.  The  process  begins  usually 
with  an  inilammation  of  the  cai)illary  l)ronchi,  which  is  a  condition  rarely,, 
if  ever,  found  without  involvement  of  the  lobular  structures,  so  that  it  is 
now  custonuiry  to  consider  the  all'cctions  together.  All  forms  of  broncho- 
pneumonia depend  upon  invasion  of  the  lung  with  microbes,  and  it  would 
luive  been  more  consistent  to  place  them  with  lobar  pneumonia  anunig  the 
infectious  disoi'ders,  but  it  is  well  perhaps  to  defer  this  until  the  bacteri- 
ology of  the  dillVrent  varieties  has  been  more  fully  worked  out. 

Etiology. ^Broncho-pneunujuia  occurs  either  as  a  primary  or  as  a  sec- 
ondary aU'ection.  The  relative  frequency  in  443  ca.ses  is  thus  given  by 
Holt:  Primarv,  without  previous  bronchitis,  154;  secondaiy  (^0  to  bron- 
chitis of  larger  tubes,  41;  to  measles,  8!);  to  whooping-cough,  (iG;  to  dij)!!- 
tlieria,  4T;  to  scarlet  fever,  ?;  to  influenza,  0;  to  varicella,  2;  to  erysi])e]as, 
"i:  and  to  acute  ileo-colitis,  1!).  The  ])roportion  of  jjrimary  to  secondary 
forms  as  shown  in  this  list  is  ])robably  too  low. 

Primary  acute  broncho-pneumonia,  like  the  lobar  form,  attacks  children 
in  good  health,  usually  under  two  years.  The  etiological  factors  are  very 
luuch  those  of  ordinary  jjueumonia,  and  probably  the  pneuniococcus  is  more 
often  associated  with  it. 

Secondary  broncho-pneumonia  occurs  in  two  great  groujjs:  l.  As  a  se- 
(pience  of  the  infectious  fevers — measles,  dijditheria,  whooping-cough,  scar- 
let fever,  and,  less  frequently,  small-pox,  erysipelas,  and  typhoid  fever.  In 
children  it  forms  the  most  serious  com])lication  of  these  diseases,  and  in 
reality  causes  more  deaths  tlian  are  due  directly  to  the  fevers.  In  large 
cities  it  ranks  next  in  fatality  to  infantile  diarrluea.  Following,  as  it  does,, 
the  contagioiis  diseases  which  ])rinci])r>lly  affect  children,  we  find  that  a 
large  majority  of  cases  occur  during  early  life.  According  to  ^lorrill's  IJos- 
tnii  statistics,  it  is  most  fatal  during  the  first  two  years  of  life.  The  nundjer 
of  cases  in  a  community  increases  or  decreases  with  the  prevalence  of 
measles,  scarlet  fever,  and  diphtheria.     It  is  most  prevalent  in  the  winter 


<;i2 


DISKASKS  OF  THE   RKSI'IIIATORY   SVSTKM. 


/ 


and  spring  mnntlis.  In  the  fi'l)rik'  nnVclioiis  df  ndiilts  bronclio-piu'iinionia 
is  not  vriT  cdinMion.  Tlius  in  ly|>li()i(l  I'l'vcr  il  is  not  so  t'rf(|Ut'iit  as  lul)ar 
])iu'iinioniii.  lli(i!i;^li  isolated  areas  ot"  consolidation  at  the  hases  are  l)y  no 
means  rare  in  |irol  raeti'il  eases  of  tliis  disease.  In  old  people  it  is  an  ex- 
tremely common  aH'cction,  followin":  dehilitatini:  eanses  of  any  sort,  and 
snpervenin;;'  in  llie  eoui'si'  (d'  elii'onie  jiri^'ht's  disease  and  various  acute  and 
ciiroiue  maladies. 

2.  \n  the  sceond  division  of  this  alfection  are  endjraced  the  cases  of 
so-called  aspiration  or  dcLiiutition  pneuiiioiua.  Whenever  the  sensitiveness 
of  the  larynx  is  henumhed,  as  in  the  coma  of  apo[>le\y  or  ura'mia,  nunuto 
])articles  of  food  or  drink  are  allowed  to  pass  the  rliiia,  and,  reaching  tinally 
the  smaller  lulics.  excite  an  intenst'  inllammation  similar  to  the  vagus  ])neu- 
monia  which  follows  the  section  of  the  pnt'uniogastrics  in  the  dog.  Cases 
ai'c  veiT  common  after  operations  alxjut  the  mouth  and  nose,  aftei  tracheot- 
omy, and  in  lancer  of  the  lai'ynx  and  (esophagus.  The  as[)irated  i)articles 
in  some  instances  induce  such  an  intense  hroncho-pnt'umonia  that  suppura- 
tion or  even  gangrene  supervenes.  The  ether  pneumonia,  already  described 
(p.  lvM»),  is  often  lobular  in  type. 

An  as])iration  broncho-])neunionia  may  follow  Inrnioptysis  (which  lias 
l)een  a.ready  considered),  the  aspiration  of  material  from  a  l)ronchiec- 
tatie  cavity,  and  occasionally  the  material  from  an  empyema  which  has 
ruptured  into  the  lung. 

A  common  and  fatal  form  of  broncho-i)neum()nia  is  that  excited  by  the 
tul)ercle  bacillus,  which  has  already  been  considered. 

Among  general  predisposing  causes  may  be  mentioned  age.  As  just 
noted,  it  is  prone  to  attack  infants,  and  a  majority  of  cases  of  pneumonia 
in  children  under  [\\v  years  of  age  are  of  this  foi'ui.  Of  370  cases  in  chil- 
dicn  under  live  years  cd'  age.  To  ycv  cent  were  broncho-pneumonia  (Holt).  At 
the  opposite  extreme  of  life  it  is  also  common,  in  association  with  various  de- 
l)ilitating  circumstances  and  with  the  chronic  diseases  incident  to  the  old. 
In  cliildrt'ii.  rickets  and  diarrluea  are  marked  i)redisj)osing  causes,  and  bron- 


clio-pneumoiii 


Il   is  oiu'  of  the  most    fre([uent   post-mortem-room  lesions  ii 


infants'  homes  aui 


loum 


lling  asylums.     The  disease  prevails  nu)st  exten- 


sivelv  among  the  poorei'  classes. 

Morbid  Anatomy. — On  the  pleural  surfaces,  particularly  toward  the 
base,  ai'e  seen  depressed  bluish  oi'  hlue-brown  areas  of  colIa[)se,  between 
which  the  lung  tissue  is  of  a  lightei'  cohu'.  Ih're  and  there  are  ])rojecting 
])ortions  over  which  the  plei'i'a  may  be  slightly  turbid  or  granular.  The 
lung  is  fuller  and  firmer  than  normal,  and,  though  in  great  ])art  cre|)itaut. 


ther 


e  can   he 


111  place; 


throujdiout  the  substance  solid,  nodular  bodie? 


he  dai'k  depi'essed  areas  may  he 


isolated  or  a  large  section  of  one  lobe  mav 


be  in  the  condition  of  collaiise  or  atelectasis.     CJradual  inilation  bv  a  1 


)|OW- 


pipe  inserti'd   in  tlie   hroiichus  wi 
lapsed  ai'( 


ill  distend  a  jireat  maioritv  of  the 


se  col 


usu 


as.  On  section,  the  general  sui'face  lias  a  dark  reddish  color  and 
ally  drips  blood.  Pi'ojeciing  above  the  level  of  the  section  are  lighter 
I'cd  or  reddish-gray  ai'eas  representing  the  ])atches  of  broncho-pneumonia. 
These  may  l)e  isolated  and  scjiarated  from  each  other  by  tracts  of  unin- 
flamed  tissue  or  they  may  be  in  groups;  or  the  greater  jiart  of  a  lobe  may 


BUONfllO- PNEl'>M()XIA. 


643 


•umoiua 
[IS  lul)ar 
J  by  no 
i  an  c\- 

ii't,  1111(1 
■iiU;  iiiid 

rases  of 
itivi'iK'SS 
,  miiuito 
g  linally 
lis  ])iieii- 
.  Cases 
,  raelieot- 
partieles 
su|ti)iira- 
k'sci'ibed 

liic'li  lias 
roiieliiee- 
liieh  has 

d  1)y  tlie 

As  just 

leumonia 

5  ill  cliii- 

olt).     At 

rious  (le- 

the  ol.l. 

lid  Iji'on- 

sioiis  in 

st  exteii- 

ward  the 
between 
rojeetiiii,' 
ar".     The 
repitaiii. 
r  bodies, 
lube  may 
V  a  blow- 
liese  et)l- 
L'olor  and 
e  li,uhter 
emiidiiia. 
of  un ill- 
lobe  iiiav 


lie  invcdveil.  Study  of  a  fav(iral)le  neetion  of  an  isolati'd  |»aleli  shows:  (»/) 
A  diluted  eentral  bronchiole  full  of  teiiaeioiis  purulent  niiieus.  A  fortu- 
iiaie  section  parallel  to  the  loiii^-  axis  in.  y  show  a  raeetnose  aiTanueiiieiit — ■ 
I  lie  alvt'olar  passages  full  of  iniieo-[)iis.  (h)  Surfcniiuling  the  broni-hus  for 
iroiii  ;)  to  5  mm.  or  even  more,  an  area  of  grayisli-red  consolidation,  usii- 
allv  elevatetl  above  the  surface  and  llrni  to  the  toiuli.  rtilike  tbi'  con- 
>olidalion  of  lobar  pneiiiiioiiia,  it  may  })reseiit  a  [n'ld'ectly  smooth  surface, 
I  hough  in  some  instances  it  is  distinctly  granular.  In  a  late  stage  of  th'.' 
disease  small  grayish-while  points  may  be  seen,  which  on  |»ressiii'e  may  bo 
sipieezed  out  as  purulent  tlroplets.  A  section  in  tlie  a.\is  of  the  lobule  may 
present  a  somewhat  grajje-like  arrangement,  the  stalks  and  stems  repre- 
senting the  bronchioles  and  alveolar  passages  lilU'd  with  a  yellowish  or 
grayish-whit 0  i)us,  while  surrounding  them  is  a  ri'ddish-brown  hepatized 
tissue,  (r)  In  the  immediate  ni'ighboi'hood  of  this  peribronchial  inllam- 
iiiat!<in  the  tissue  is  dark  in  color,  smooth,  aii'lcss,  at  a  somewhat  lower 
level  than  the  he})atized  portion,  and  dilfers  distinctly  in  color  and  ap- 
pearance from  the  (.)ther  portions  o(  the  lung.  This  is  the  condition  to 
which  the  term  ftpJcuizdtion  has  been  given.  It  really  re[tresents  a  tissue 
in  the  early  stage  of  inllammatioii,  and  it  perhaps  would  be  as  well  to  give 
up  the  use  of  this  term  and  also  that  of  carni/iriilicn,  which  is  only  a  more 
advanced  stage.  The  condition  of  collapse  probably  always  precedes  this, 
and  it  is  dillicult  in  some  instances  to  tell  the  diU'erence,  as  one  shades  into 
the  other.  In  fact,  colla[)se,  s[)lenization.  and  carnilication  are  but  i)relim- 
iiiary  steps  in  broncho-juieumonia. 

While,  in  many  cases,  the  areas  of  bi'oncho-pneiimonia  present  a  red- 
dish-brown color  and  are  indistinctly  granular,  in  others,  i)articularly  in 
adults,  the  nodules  may  resemble  more  closely  gray  heiiatization  and  the 
air-cells  arc  tilled  with  a  grayish,  mueo-purulent  material.  ^Linute  luem- 
orrhages  are  sometimes  seen  in  the  neighborhood  of  the  inllained  areas  or 
on  the  pleural  surfaces.  Em[)hysema  is  commonly  seen  at  the  anterior 
borders  and  u|)per  ])ortions  of  the  lung  or  in  lobules  adjacent  to  the  in- 
llamed  ones.  Jn  many  cases  following  diphtheria  and  measles  the  process 
is  so  extensive  that  the  greater  jiart  of  a  lobe  is  in  vol  veil,  and  it  looks  like 
a  case  of  lobar  hepatization.  It  has  not,  however,  the  uniformity  of  this 
alfection,  and  collapsed  dark  strands  may  be  seen  between  extensive  areas 
of  hepatized  tissue. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  bronchitis  ami 
bronchiolitis  are  most  marked,  and  in  which  there  may  be  no  definite  con- 
solidation, and  yet  on  microscopical  examination  many  of  the  alveolar  pas- 
sages and  adjacent  air-cells  ajijjcar  lilled  with  inllammatory  jjroducts.  (2) 
The  disseminated  broncho-])neiinionia,  in  which  there  are  scattered  ari'as 
of  iieribroncbial  hcpatiz;:tion  with  jiatches  of  coIlai)se,  while  a  considerable 
liro]iortioii  of  the  lob*^  is  still  crejiitant.  This  is  by  far  the  most  common 
e(Uulition.  (3)  The  pseudo-lobar  form,  in  which  the  greater  portion  of  the 
lobe  is  cojisolidated,  but  not  uniformly,  for  intervening  strands  of  dark 
congested  lung  tissue  separate  the  groups  of  liei)atized  loliules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  iilled  with  a  plug 
of  exudation,  consisting  of  leucocytes  and  swollen  epithelium.     Section  iii 


r.44 


DISKASKS  OF  THE  RKSl'Ill  ATOIIY  SYSTKM. 


/ 


the  lon^  axis  niuy  show  irregular  dilatations  of  the  tube.  The  bronchial 
wall  is  swollen  and  inliltraied  with  cells.  Under  a  low  power  it  is  readily 
seen  that  the  air-ctdls  next  the  hronclnis  are  nidst  densely  filled,  while 
toward  the  periphery  of  the  locus  the  alveolar  exudation  becomes  less.  The 
contents  of  the  air-cells  are  nuule  up  of  leucocytes  and  swollen  endothelial 
cells  in  varyin^^  pioportions.  ifcd  corpuscles  are  not  often  j)reseiit  and  a 
lihrin  network  is  rarely  seen,  thou;^h  il  may  be  present  in  st)me  alveoli,  la 
the  swollen  walls  are  seen  distended  ca|»illaries  aid  numerous  leucocytes. 
As  Delatield  has  j)ointed  out,  the  interstitial  inllauunation  of  the  bronchi 
and  alveolar  walls  is  the  si)eciul  feature  of  bronclio-i)neumouia. 

The  histological  chauges  in  the  as[)iration  or  deglutition  broncho-pneu- 
monia diirer  frcnn  the  t)rdimiry  jjost-febrile  form  in  a  more  intense  inllltra- 
tion  of  the  air-cells  with  leucocytes,  jjrodueing  suppuraticui  and  foci  of 
softening;  even  gangrene  nuiy  be  present. 

liacteriolog!/  of  Bruiichu-pncumunia. — The  organisms  most  commonly 
found  in  broncho-i)neumonia  are  the  niicrucoccus  lanccuhdus,  the  slreptu- 
tiicrus  pi/()(jcites  (either  alone  or  with  the  ])neuinococcus),  the  stiipln/liiroccus 
(dirciis  cl  alhus,  and  Friedliimler's  Ixirilliis  piiciiinoiiia'.  TJie  Klebs- 
LoefUer  bacillus  is  not  infrequently  found  in  the  secondary  lesions  of 
diphtheria.  Except  the  pneumoeoccus  these  microbes  are  rarely  found  in 
l)ure  cultures.  In  the  lobular  type  the  strej)tococcus  is  the  most  constant 
organism,  in  the  ])seudo-lol)ar  the  pneumoeoccus.  ^lixed  infections  are  al- 
most the  rule  in  broncho-pneumonia. 

M.  Wollstein,  in  3  7  primary  cases,  found  the  micrococcus  lanceolatiis 
alone  in  !),  with  the  stre])tococcus  in  7.  Of  l-i  secondary  cases  the  micro- 
coccus hiNccoldtus  was  fouiul  alone  in  2  and  with  other  organisms  in  t).  The 
])rinuiry  form  is  the  result  of  infection  Avith  tlie  pneumoeoccus,  the  sec- 
ondary most  often  with  the  streptococcus. 

Terminations  of  Broncho-pneumonia. — (1)  In  resolution,  which  when  it 
once  begins  goes  on  more  rapidly  than  in  tibrinous  ])neumonia.  ])roncho- 
])neumonia  of  the  ajjices,  in  a  child,  persisting  for  three  or  more  weeks, 
])articularly  if  it  follows  measles  or  diphtheria,  is  often  tuberculous.  In 
these  instances,  when  resolution  is  supposed  to  be  delayed,  caseation  has  in 
reality  taken  ])lace.  (2)  In  suppuration,  which  is  rarely  seen  ai)art  from 
the  aspii'ation  ami  deglutition  fornis,  in  which  it  is  extremely  common.  (3) 
In  (jaiH/rciw,  whii'h  occurs  under  the  same  conditions.  (f)  In  fibroid 
changes — chronic  broncho-pneumonia — a  rare  termination  in  the  simple,  a 
connnon  secpience  of  the  tuberculous,  disease.  Formerly  it  was  thought 
that  one  of  the  most  connnon  changes  in  broncho-pneumonia,  i)articularly 
in  children,  was  caseation;  but  this  is  really  a  tuberculous  process,  the 
natural  termination  of  an  originally  specific  broncho-])neumonia.  It  is  of 
course  (piite  ])ossibl.^  that  a  broncho-pneumonia,  simple  in  its  origin,  may 
subsequently  be  the  seat  of  infection  by  the  bacillus  tuberculosis. 

Symptoms. — The  primary  form  sets  in  abruptly  with  a  chill  or  a  con- 
vulsion. The  child  has  not  had  a  previous  illness,  but  there  may  have  been 
slight  exposure.  The  temperature  rises  rapidly  and  is  more  constant;  the 
]»hysical  signs  are  more  local  and  there  is  not  the  widespread  diffuse  catarrh 
of  the  smaller  tubes.     Many  cases  are  mistaken  for  lobar  pneumonia.     In 


lUlONCITO-rNEUMONIA. 


045 


Ijroneliial 
is  ri'iidily 
.'(1,  wliilo 
,'ss.  Tlie 
ulotliclial 
lit  iind  ii 

L'oli.  ill 
llCOCVtl'S. 

;  broiiclii 

•hu-pnc'U- 
i  inliltni- 

I  I'ofi  of 

oiuinonly 
i  alri'pto- 
\ijhict)ccus 
i  Kk"l)s- 
?sions  of 
i<nind  in 
constant 
IS  are  al- 

nccohilus 

It'  mirro- 

!).    Tlie 

Uic  sec- 

M'lien  it 
W'oiU'lio- 
weeks, 
JUS.     In 

II  has  in 
irt  from 
on.     (;]) 

fihruid 
iiiplo,  a 
tliou<iht 
icularly 
CSS,  the 
It  is  of 
in,  may 

r  a  con- 
vc  been 
nt;  the 
catarrh 
Ilia.     In 


withers  the  i)ulmonary  feadiri's  are  in  the  hackground  or  are  overlooked  in 
ihe  intensity  of  the  general  or  cerebral  symptoms.  The  teiiiiiiiation  is  often 
liy  crisis,  ami  the  recovery  is  prompt.  'J'he  mortality  of  tiiis  form  is  slight. 
S.  West  has  recently  (Urilish  Medical  .loiinial,  IS'.IS,  i)  called  attention  to 
the  iini)ortance  of  recognizing  these  [trimary  cases  and  to  their  rescnihlance 
in  cliincal  features  with  acute  lobar  pnenmonia.  The  scrdndarij  form  begins 
usually  as  a  bronchitis  of  the  smaller  tubes.  ^luch  confusion  has  arisen 
fi'om  the  descrijjtion  of  capillary  l)ronchitis  as  a  separate  all'ection,  whereas 
it  is  only  a  i)art,  though  a  ])rimary  and  important  one,  of  broncho-pneu- 
iiionia.  At  the  outset  it  may  be  said  that  if  in  convalescence  from  measles 
or  in  whooping-cough  a  child  has  an  accession  of  fever  with  cough,  rapid 
pulse,  and  rapid  breathing,  and  if,  on  auscultation,  tine  rales  are  heard  at 
the  bases,  or  widely  spread  throughout  the  lungs,  even  though  neither  con- 
solidation nor  blowing  breathing  can  be  detected,  the  diagnosis  of  broncho- 
])neumonia  nuiy  safely  l)e  made.  I  have  never  seen  in  a  fatal  case  after 
diphtheria  or  meat:les  a  ca})illary  bronchitis  as  the  sole  lesion.  The  onset 
is  rarely  sudden,  or  with  a  distinct  chill;  but  after  a  day  or  so  of  indispo- 
sition the  child  gets  feverish  and  begins  to  cough  and  to  get  short  of  breath, 
'i'lie  fever  is  extremely  variable;  a  range  of  from  i()"^°  to  l(il°  is  coininon. 
The  skin  is  very  dry  and  pungent.  The  cough  is  hard,  distressing,  and 
may  be  painful.  Dyspncca  gradually  becomes  a  prominent  feature.  Ex- 
piration may  be  jerky  and  grunting.  'V\\(i  respirations  may  rise  as  high 
as  GO  or  even  80  })er  minute.  Within  the  first  forty-eight  hours  the  })cr- 
cussion  resonance  is  not  impaired;  the  note,  indeed,  nuiy  be  very  full  at  the 
anterior  borders  of  the  lungs.  On  auscultation,  many  rales  are  heard, 
<liiefly  the  fine  subcrepitant  variety,  with  sibilant  rhonchi.  There  may 
really  be  no  signs  indicating  that  the  ])arenchyma  of  the  lung  is  involved, 
and  yet  even  at  this  early  stage,  within  forty-eight  hours  of  the  onset  of  the 
pulmonary  symptoms,  I  Have  repeatedly,  after  diplitheria.  found  scattered 
nodules  of  lobular  he))atization.  Xorthrup,  in  a  case  in  which  death  oc- 
<-urred  within  the  first  twenty-four  hours,  in  addition  to  the  extensive  in- 
volvenu'iit  of  the  smaller  bronchi,  found  the  intralobular  tissue  also  in- 
volved in  ])laccs.  The  dyspnroa  is  constant  and  progressive  and  soon  signs 
of  deficient  aeration  of  the  blood  are  noted.  The  face  becomes  a  little  suf- 
fused and  the  finger-tips  bluisl  .  The  child  has  an  anxious  expression  and 
gradually  enters  \\\)o\\  the  met  distressing  stage  of  asphyxia.  At  first  the 
urgency  of  the  symptoms  is  nuirked,  but  soon  the  benuihljing  induenco  of 
the  carbon  dioxide  on  tiie  nerve-centres  is  seen  and  the  child  no  longer  makes 
strenuous  efforts  to  breathe.  The  cough  subsides  and,  with  a  gradual  in- 
crease in  lividity  and  a  drowsy  restlessness,  the  right  ventricle  becomes  more 
and  more  distended,  the  bronchial  rales  become  more  liquid  as  the  tubes 
fill  M'ith  mucus,  and  death  occurs  from  heart  paralysis.  These  are  symp- 
toms of  a  severe  case  of  broncho-pneumonia,  or  what  the  older  writers  called 
s uffoca tire  ca la rrh . 

The  phj/slral  signs  may  at  first  be  those  of  ca])illavy  bronchitis,  as  in- 
dicated by  the  absence  of  dulncss,  the  presence  of  fine  subcrepitant  and 
whistling  rales.  In  many  cases  death  takes  ])lace  before  any  definite  i)neu- 
monic  signs  are  detected.     When  these  exist  they  are  much  more  frequent 


040 


DISKASKS  OF  TUi:  ItKSl'IUATOIiV  SVSTKM. 


nt  ilic  l)as('3,  wlii'ii'  tlicri'  may  be  niras  of  iiiipaiivd  resonance'  or  even  of 
|Misiiiv('  (liihu'iris.  Wlii'M  niiiiitTous  lui-i  involvo  tliu  ^M'falor  j)art  of  u  lulie 
the  hrt'Mlliin;;  may  liccumi'  tubular,  but  in  tlie  scatlcri'd  |iati'hos  ol'  ordi- 
nary lii'oiK  lin-[iii(  iiiiKiuia,  I'dllowinj^-  Ihf  I'l'vois,  tlie  brrathiuj,'  is  more  com- 
mtinly  hai^li  than  blowing'.  In  '^nwv  tases  thero  is  rt'lrucliou  of  the  base 
of  the  stciimm  and  ol'  the  lower  eostal  (  nrtila^cs  durin^f  insj)irati(jn,  point- 
in^''  III  dt'lit'ii'iit  luiiu'  e\j)ansion. 

Diagnosis. — W'itli  lohar  imcuiiionia  it  may  readily  l)o  confounded  if 
I  he  areas  of  consolidation  an-  \;\v<^v  and  merged  together.  It  is  to  be  re- 
mendit'red.  as  .Holt's  iigures  ui'll  show,  that  l)ronclio-|)neunu)nia  occurs 
chielly  in  children  undi'r  one  year,  whereas  kihar  pneumonia  is  more  common 
after  the  third  year.  Xo  writer  luis  so  ck'arly  brought  out  the  tiilference 
between  pneumonia  at  these  periods  as  CJerhard,'"  of  i'hiladelphia,  wdiose 
])apers  on  this  sul)ject,  though  published  nearly  sixty  years  ago,  have  the 
freshness  and  accuracy  which  characterize  all  the  writings  of  that  eminent 
physician.  IJetween  lobar  ])neumonia  antl  the  seeomlary  form  of  broncho- 
juieumonia  the  diagnosis  is  easy.  The  mode  of  onset  is  essentially  dill'erent 
in  the  two  infections,  the  one  develoi)ing  insidiously  in  the  course  or  at  the 
conclusion  d'  another  disease,  the  other  setting  in  abru[)tly  in  a  child  in 
good  health.  Jn  lobar  pneumonia  tlie  disease  is  almost  always  unilateral, 
in  broncho-pneumonia  bilateral.  The  chief  trouble  arises  in  cases  of  pri- 
mary broncho-pneumonia,  Avhicli  by  aggregation  of  the  foci  involves  the 
greater  part  of  one  lobe.  Here  the  dilliculty  is  very  great,  and  the  physical 
signs  nuiy  be  ])ractically  identical,  but  in  broncho-pneunujiua  it  is  much 
more  likely  that  a  lesion,  however  slight,  w  ill  be  found  on  the  other  side. 

A  still  more  ditlicult  question  to  decide  is  whether  an  existing  broncho- 
pneumonia is  simi)le  or  tuberculous.  In  many  instances  the  decision  can- 
not be  nuide,  as  the  circumstances  under  which  the  disease  occurs,  the 
mode  of  onset,  and  the  physical  signs  ni'iy  be  identical.  It  has  often  been 
my  exi)crience  that  a  case  has  been  sent  down  fi'om  the  chiklren's  ward  to 
the  dead-house  with  the  dis'.gnosis  of  post-febrile  broncho-pneumonia  in 
Avhich  there  was  no  suspicion  of  the  existence  of  tuberculosis;  but  on  sec- 
tion there  were  found  tuberculous  bronchial  glands  and  scattered  areas  of 
brouclio-i)ncumonia,  some  of  which  were  distinctly  caseous,  while  others 
showed  signs  of  softening.  I  have  already  spoken  fully  of  this  in  the  sec- 
tion on  tuberculosis,  but  it  is  well  to  emphasize  the  fact  that  there  arc 
numy  cases  of  broneho-i)neumonia  in  children  which  time  alone  enables 
us  to  distinguish  from  tuberculosis.  The  existence  of  extensive  disease 
at  the  a[)ices  or  central  regions  is  a  suggestive  indication,  and  signs  of  soft- 
ening may  be  detected.  In  the  vomited  matter,  which  is  brought  up  after 
severe  s])ells  of  coughing,  sputum  may  be  picked  out  and  elastic  tissue  and 
bacilli  detected. 

It  is  a  superfluous  refinement  to  make  a  diagnosis  between  capillary 
bronchitis  and  catarrhal  pneumonia,  for  the  two  conditions  are  part  and 
parcel  of  the  same  disease.  In  sim]de  bronchitis  involving  the  larger  tubes 
urgent  dyspnoea  and  pulmonary  distress  are  rarely  present  and  the  rales 


*  Amorican  Journal  of  the  Medical  Sciences,  vols,  xiv  and  xv. 


BUOXCnO-PNRUMoXIA. 


CA'i 


•  oven  (jf 
ut'  u  luljo 

of  oi'di- 
itiro  coiii- 

tliL-  I)a.>L' 
III,  |)oinl- 

iiuuU'd  ir 
tu  bo  rc- 
lu  ocr Ill's 
coimiioii 
liirorencL' 

iu,    wllU.SL' 

have  tliL' 
(.'iiiiiioiit 
bronchu- 
diirtTcnl 
ov  at  tlu' 
fluid  iu 
nilalural, 
'S  oi'  pri- 
dIvus  the 
physical 
is  luucli 
side, 
jronclio- 
iou  cau- 
urs,  the 
eu  been 
ward  to 
louirt  in 
on  sec- 
areas  of 
e  others 
tlie  sec- 
lere  are 
enables 
disease 
of  soft- 
Lip  after 
sue  and 

apillarv 
art  and 
!r  tubes 
18  rales 


are  coarser  and  more  sibilant,  it  iiui>t  iml  he  ror;,'ol(cn  lliat,  as  in  Inbar 
piieiiiuoiiia,  ecrclnal  svniptonis  may  mask  I  lie  true  iiiiturc  nl  ilic  (H^'ase. 
and  may  even  lead  tu  the  dia^fiiosis  (d'  ineniiif^itis.  J  I'crall  luure  than  one 
instance  in  which  it  could  not  be  salisl'aclnrily  dctcrmini'd  wlutlicr  the 
iid'ant  had  lidjcrciilous  nieiiin^iitis  or  u  cerebral  complication  of  an  acute 
]iulmonary  atrecllon. 

Prognosis.  —  Iu  the  primary  form  the  outlook  is  <:o()d.  In  (liiMrm 
enfeebled  by  constitutional  disease  and  prolonged  fevers  broncho-piieumoniu 
is  terribly  fatal,  but  in  cases  coming  on  in  I'oniicction  with 'w  lioo|»ing- 
cougli  or  after  measles  recovery  may  take  phu'c  in  tl'.e  most  desperate  i-ascs. 
It  is  iu  this  disease  that  the  li-uth  of  the  oM  maxim  is  shown — "  Xevi'r 
despair  of  a  sick  child."'  The  death-rate  in  children  under  live  has  been 
variously  estimated  at  from  ',iO  to  ')0  per  cent.  After  diphtheria  and 
measles  thin,  wiry  chiUlrcn  seem  to  stand  broiu'ho-piu'umonia  much  better 
than  fat,  llabby  ones.  Iu  adults  the  usj)irution  or  deglutition  pneumonia 
is  a  very  fatal  disease. 

Prophylaxis.— Much  can  be  done  to  reduce  the  pr(d)a])ility  of  attack 
i\\\vv  febrile  alfections.  Thus,  in  the  convalescence  from  measles  and 
whooping-cough,  it  is  very  inn)orlaiit  that  the  child  should  not  be  exjiosed 
lo  cold,  particularly  at  night,  when  the  tem])erature  of  the  room  naturally 
falls,  la  a  nocturnal  visit  to  the  nursery — sometimes,  too,  1  am  sorry  to 
say,  to  n  children's  hospilal — how  often  one  sees  chihlivn  almost  naked, 
having  kicked  aside  the  bedclothes  and  having  the  night-clothes  up  about 
the  arms!  The  use  of  light  llannel  "combinations''  obviates  this  noctur- 
nal chill,  which  is,  I  am  sure,  an  important  factor  in  the  colds  and  pulmo- 
nary aU'ections  of  young  children,  both  in  i)rivate  houses  and  in  institu- 
tions. The  catarrhal  troubles  of  the  nose  and  throat  should  be  carefully 
attended  to,  and  during  fevers  the  mouth  should  be  washed  two  or  three 
times  a  day  with  an  antiseptic  solution. 

Treatment. — The  freipiency  and  the  seriousness  of  broncho-pneu- 
monia render  it  a  disease  which  taxes  tt)  the  utmost  the  resources  of  the 
practitioner.  There  is  no  acute  pulmonary  aU'ection  over  which  he  at  times 
so  greatly  despairs.  On  the  other  hand,  there  it  not  one  in  which  he  will 
be  more  gratified  in  saving  cases  which  have  seemed  past  all  succor.  The 
general  arrangements  should  receive  special  attention.  The  room  should 
Ije  ke])t  at  an  even  temperature — about  (35°  to  G8° — and  the  air  should  be 
kept  moist  with  vapor. 

At  the  outset  the  bowels  should  be  o))ened  by  a  mild  uurge,  either 
castor  oil  or  small  doses  of  calomel,  one  twelfth  to  one  s.  of  a  grain 
hourly  until  a  movement  is  obtained,  and  care  should  be  takjii  throiighmit 
the  attack  to  secure  a  daily  movement.  The  common  saline  fever  mixture 
of  citrate  of  potash,  li(|uor  ammonii  acetatis,  and  aromatic  spirits  of  am- 
numia  may  be  given  every  two  or  three  houi's.  If  tlu'  disease  comes  on 
alu'uptly  with  high  fever,  minim  or  minim  and  a  luilf  doses  of  the  tincture 
of  aconite  may  be  given  -with  it.  The  pain,  tlu'  distressing  sym]itoms,  and 
the  incessant  cough  often  demand  o|)ium,  which  must  of  course  be  use<l 
with  care  and  judgment  in  the  case  of  young  children,  l)ut  which  is  cer- 
tainly not   contra-indicated  and  may  be  usefully  given   in  the  form  of 


648 


DISKASKS  OP  THE   llKSIMKAToRV  SVSTKM. 


/ 


Dover's  powder.  Illislcr.s  nrc  now  rnrely  if  ever  ciniiloycd,  and  even  tin; 
jacket  poiillice  liiis  jfrne  out  of  fashion,  l-'or  (lie  latter,  liowever,  I  con- 
fess to  ii  si  roll;,'  |»i'ejii(liee,  luiil  wlien  li;^litly  made  and  fi'rcnienlly  eiuinged 
it  nndonlttedly  j^ives  jiicat  relief.  .Much  more  commonly  we  jiow  bcc, 
hodi  ill  private  and  in  hospital  practice,  the  jacket  of  cotton-hattinjf. 
Ice-ptiiilt  ices  to  the  chest  I  have  seen  nsed  jippiirciitly  with  ^M'cat  henc- 
lit,  and  they  are  warmly  reeomniended  hy  many  (icrman  physicians  as 
Avoll  «H  l)y  Cfoodharl  and  otlu-rs  in  l"]ii;,dand.  The  diet  shonld  consist 
of  milk,  hroths,  and  (■<;;,'  alliunicii.  Milk  often  curds  and  is  disaj^roeable. 
Mji^r-white  is  piirticiilarly  siiitahle  and  very  acceptable  when  ^iveii  in  cold 
■water  with  a  little  siij.;iir.  It  forms,  indeed,  an  excellent  mcfliiim  for  the  ad- 
nunistration  of  the  slimnhints.  if  the  pnlse  shows  si^ns  of  l'iiilin<;',  it  is  best 
to  bej^in  early  with  hnuidy.  As  in  all  febrile  iiU'eciions  of  children,  cold 
water  should  be  constantly  at  the  bedside,  and  the  child  should  be  encour- 
aged to  drink  freely.  With  these  niciisiires,  in  mnny  cases  the  disease  pro- 
;,q'esses  to  ii  fiivorable  termination,  but  too  often  other  and  more  serious 
symptoms  arise.  ('ou«,di  becomes  more  distressin<r,  dyspntea  increases,  the 
■ominous  rattling,''  of  the  mucus  can  be  heard  in  the  tid)es,  the  child's  color 
is  not  so  good,  and  there  is  greater  restlessness.  I'nder  these  circum- 
stances stimulant  expectorants — ammonia,  S(piills,  and  senegi. — should  be 
given.  Together  they  inaki;  a  very  ilisagreeable  dose  for  a  young  child, 
particularly  with  the  carbonate  of  ammonia.  The  aromatic  s[)irits  of  am- 
monia is  somewhat  better.  11'  the  carbonate  is  employed,  it  must  be  given 
in  small  doses,  not  more  than  a  grain  to  an  infant  of  eighteen  months.  If 
the  child  has  increasing  dilliculty  in  getting  u|)  the  mucus,  an  emetic 
shonld  be  given — either  the  wine  of  ipecac  or,  if  necessary,  tartar  enu'tic. 
There  is  no  necessity,  however,  to  keep  the  child  constantly  nauseated. 
Kncnigh  should  be  given  to  cause  j)rompt  emesis,  and  the  benelit  results  in 
the  ex|)nlsion  of  mucus  from  the  larger  tubes.  In  this  stage,  too,  strych- 
nine is  undoubtedly  helpful  in  stimulating  the  depressed  respiratory  cen- 
tre. AVith  commencing  cyanosi'^?,  iiilialations  of  oxygen  may  be  employed, 
sometimes  with  great  benefit. 

AVith  ra|)id  failure  of  the  heart,  loud  mucous  rattles  in  the  throat,  and 
increasing  lividity,  every  measure  should  be  used  to  arouse  the  child  and 
excite  coughing.  Alternate  douches  of  hot  and  cold  water,  electricity, 
which  I  have  seen  ap])lied  with  good  lesults  at  AViederhofer's  clinic  in 
A'ienna,  and  hypodermic  injections  of  ether  may  l)e  tried.  For  the  reduc- 
tion of  tem])erature.  jiarticularly  if  cerebral  symptoms  are  prominent,  there 
is  nothing  so  satisfactoi'y  as  the  wet  ])ack  or  the  cold  bath.  In  the  case 
of  children,  when  the  latter  is  used  it  should  be  graduated,  beginning  with 
a  tem])erature  mIhcIi  is  ])leasantly  warm  and  gradually  reducing  it  to  75° 
or  80°.  Kv(>n  when  the  temperature  is  not  high,  the  cerebral  symptoms 
are  greatly  relieved  by  the  bath  or  the  pack. 


niUONir   IXTKItSTITIAIi   PXEl'MOMA. 


«VI9 


t'Vfii  tin; 
r,  1  con- 

(•liaM;;;t'(l 
iKtw  woe, 
l-hilttillj,'. 
I'jit  ht'iic- 
"ic'iaiis  lis 
(1  consist 
iffrcoahlo. 
II  ill  cold 
)r  tlie  lul- 

it  id  boat 
liTii.  cold 
0  c'liL'oiir- 
^t'uso  pro- 
re  soriourf 
ciisos,  tlu' 
ill's  color 
.'  ci  renin - 
diould  1)0 
ng  child, 
tri  of  ani- 

1)0  given 
)ntlis.    If 
ciiiclic 
onu'tic. 

ni  son ted, 

osults  in 
strycli- 
)ry  coii- 
1  ployed, 

)nt,  and 
lild  and 
otricity, 
linic  in 
0  roduc- 
,  there 
the  case 
ng  with 
t  to  75" 
y'niptoms 


111.    CHRONIC    INTERSTITIAL    PNEUMONIA 

(Cin/iDnis  of  thv  Liinij — Fihniid  l'ltthini»). 

This  consists  in  tlx-  gradual  snhstitution  to  a  greater  or  less  extent  of 
connective  tissue  tor  iho  iiornial  lung.  It  is  a  liliroid  change  which  may 
have  its  starting-point  in  tlie  tissue  ahoiit  the  broiiclii  and  blood-vssols, 
the  interlobular  septa,  tlu'  alveolar  walls,  or  in  the  |)l('iira.  So  diverse  are 
the  diil'creiit  forms  and  so  varied  the  conditions  under  which  this  change 
occurs  that  a  pro|ii'r  classincation  is  extremely  dilllcult.  We  may  recog- 
nize, however,  two  cliicl'  forms — the  htrdi,  which  involves  only  a  limited 
area  of  the  lung  siil)ftancc,  and  the  dilfiisr,  invading  cither  both  lungs  or 
an  entire  organ. 

Etiology. — Loral  fibroid  change  in  the  lungs  is  common.  It  is  a 
constant  accomp.inimont  of  tuber' 'o  ai.l  in  every  case  of  j)hthisis  tlu; 
chronic  interstitial  changes  |)lay  a  very  important  rule.  In  tumors,  ab- 
scess, gummala,  hydatids,  and  emphysema  it  also  occurs.  Fibroid  pro- 
cesses are  frc(piently  mot  with  at  tlu!  apici'S  of  the  lung  and  may  hi'  duo 
cither  to  a  limited  healed  tuberculosis,  to  iibroid  induration  in  consi'- 
(pience  of  i)igment,  or,  in  a  few  instances,  may  result  from  tl  keiiing  of 
the  pleura.     They  have  been  described  at  page  .'{;{|. 

Dilfusc  iiilcn<lilial  piicitnniiiid  is  met  with  under  the  following  cir- 
cumstances: 1.  As  a  seqnenc!  of  acute  fibrinous  pneumonia.  Although 
extremely  rare,  this  is  recognized  ,'s  a  i)o.<sil)le  termination.  From  un- 
known causes  resolution  fails  to  take  i)laco.  A  gradual  process  of  organ- 
ization goes  on  in  the  fibrinous  ]ilugs  within  the  air-colls  and  the  alveolar 
Mulls  become  greatly  tliickciu'd  by  a  new  growth,  first  of  nuclear  and 
subsequently  of  fibrillati'd  lonncctivc  tissue.  ^lacrosco])ically  there  is  ])ro- 
duced  a  smooth,  grayish,  homogeneons  tissue  which  has  the  i)eculiar  trans- 
liiconcy  of  all  new-formed  connective  tissue.  This  has  been  ca]le(1  gray  in- 
duration. A  majority  of  the  cases  terminate  within  a  few  months,  and  in- 
stances which  have  been  followed  from  the  outset  arc  very  rare. 

2.  Chronic  Bronrho-Pueuntonid. — Tiie  rclatKjn  of  bronclio-|)neumonia 
to  cirrhosis  of  the  lung  has  been  s])Ocially  studied  by  Charcot,  who  states 
I  hat  it  may  follow  the  acute  or  subacute  form  of  this  disease,  juirticularly  in 
children.  The  librosis  extends  from  tlie  bronchi,  which  are  usually  found 
dilated.  IJronchiocta: "  itself  may  be  followed  by  fdjrosis  of  the  lung. 
The  alveolar  walls  are  thickened  and  the  lobules  converted  into  firm  gray- 
ish masses,  in  which  there  is  no  trace  of  normal  lung  tissue.  This  ])rocoss 
may  go  on  and  involve  an  entire  lobe  or  oven  the  whole  lung.  ]Many  of 
these  cases  are  tuberculous  from  the  outset. 

3.  ricurof/eiiniix  Tiilcrslilldl  I'lii'iniioii'ui. — Charcot  ap]dios  this  t'''rm 
to  that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the  ]deura. 
Doubt  has  been  ex])ressed  by  some  writers  whether  this  really  occurs. 
While  Wilson  Fox  is  ])robably  correct  in  ([ucstioning  whether  an  entire 
lung  can  become  cirrhosed  by  the  gradual  invasion  from  the  pleura,  there 
can  be  no  doubt  that  there  are  instances  of  primitive  dry  pleurisy,  which. 


05.) 


DISEASES  OF  THE  KKSPlllATOKY  SYSTEM. 


ns  Sir  Andrew  Clark  liiis  jiointcd  out,  j^nidiiiilly  ('()iiipr('s>i('s  tlio  lung  and 
at  the  same  time  leads  to  interstitial  eirrliosis.  This  may  ])e  due  in  part 
to  the  til)r()id  change  whiih  t'ollows  i)i'oh)n;;'ed  compression.  In  some 
cases  there  seems  to  he  a  distinct  conneetiou  hetween  the  greath'  thick- 
ened i)lcnra  and  tlie  ileiiso  strands  of  lihrous  tissue  passing  from  it  into 
the  lung  suhritani-e.  Instance,;  occur  in  which  one  lohe  or  the  greater 
part  of  it  jiresents,  on  section,  a  mottled  a])[)earance,  owing  to  the  in- 
creased thickness  of  the  interlohar  septa — a  condition  which  nuiy  exist 
without  a  trace  of  involvi'int'iit  of  the  ])leura.  In  many  other  cases, 
however,  the  extension  seems  to  he  so  definitely  associateil  with  pleurisy 
that  there  is  no  douht  as  to  the  causal  connection  Ijctween  the  two 
])rocesses.  In  these  instances  the  lung  is  removed  with  great  ditliciilly, 
owing  to  the  tliickness  and  close  adhesion  of  the  pleura  to  the  chest 
wall. 

•1.  Chronic  inlcrnlilUil  pneumonia,  due  to  inhalation  of  dust,  which  is 
considered  in  a  sejjaraie  sectioii. 

5.  Sijphilis  of  the  lung  jjresents  the  features  of  a  chronic  lihrosis  of  the 
organ  (sec  p.  ^-17). 

().  Iiulurative  changes  in  the  lung  may  follow  the  compression  hy 
aneui'ism  or  new  growth  (H*  the  irritation  of  a  foreign  body  in  a  hronehns. 

Morbid  Anatomy. — There  are  two  chief  forms,  the  massive  or  lobar 
and  the  insular  or  hroncho-pnenmonic  form.  In  the  massive  type  the  dis- 
ease is  unilateral;  tin;  chest  of  the  affected  side  is  sunken,  deformed,  and  the 
shoulder  much  depressed.  On  o])ening  the  thorax  the  heart  is  seen  drawn 
far  over  to  the  alfected  side.  The  unalfected  lung  is  emphysematous  and 
covers  the  greater  portion  of  the  mediastinum.  It  is  scarcely  credible  in 
how  small  a  space,  close  to  the  spine,  the  cirrhosed  lung  nuvy  lie.  The 
adhesions  between  the  pleural  membranes  may  be  extremely  dense  and 
thick,  jiarticularly  in  the  pleurogenons  cases;  but  when  the  disease  has 
originated  in  the  lung  there  may  be  little  thickening  of  the  pleura.  The 
organ  is  airless,  firm,  and  hard.  It  strongly  resists  cutting,  and  on  section 
shows  a  grayish  fibroid  tissue  of  variable  amount,  through  which  pass  the 
blood-vessels  and  bronchi.  The  latter  may  be  either  slightly  or  enor- 
mously diiated.  There  are  instances  in  which  the  entire  lung  is  converted 
into  a  series  of  bronchiccfatic  cavities  and  the  cirrhosis  is  ap])arent  only 
in  certain  areas  or  at  the  root.  The  tuberculous  cases  can  usually  be  dif- 
ferentiated by  the  ])resence  of  an  apical  cavity,  not  bronchiectatic,  and 
often  large;  and  the  other  lung  almost  invariably  shows  tidjerculous 
lesions.  I'uhnonary  aneurisms  are  not  infrequent  in  the  cavities.  The 
other  lung  is  always  greatly  enlarged  and  emphysenuitous.  The  heart  is 
hypertrophied,  particidarly  the  right  ventricle,  and  there  may  be  marked 
atheromatous  cluinges  in  the  pulmonary  artery.  An  amyloid  condition 
of  the  viscera  is  found  in  some  cases. 

In  the  br()ncho-])neumonic  forjn  the  areas  are  smaller,  often  centrally 
placed,  and  most  fre(|Uontly  in  the  lower  lobes.  They  are  deeply  pigmented, 
show  dilated  bronchi,  and  when  multiple  are  separated  by  emphysematous 
liuig  tissue. 

A  rclicidar  form  of  fibrosis  of  the  lung  has  been  described  by  Percy 


CIIKUNIC   INTERSTITIAL    PNEUMONIA. 


051 


iin<:^  and 

in  part 

III    some 

_v   thick- 

1  il  into 

I  greater 

tlie  iu- 

lay  L'xist 

L'l"    casoH, 

plourisy 

the   two 

lilliculty, 

ho   cliL'st 

M'liich  is 

:is  oi'  the 

ssion   l)y 

nclms. 

or  lobar 

the  dis- 

,  and  tlie 

'u  drawn 

tons  anil 

dible  in 


Till 


;a 


lie. 

nse  and 

ase  lias 

The 

section 

oass  tlio 

lor  enor- 

)n  verted 

nt  only 

be  dil"- 
tie,  and 

rculous 
s.  Tlie 
heart  is 

marked 
Diidition 

•ontvally 
iiientetl, 
ematous 

y  Percy 


Kidd  and  W.  McColliini,  in  wliich  tlu'  lun^^s  ai'c  inlcrsceted  by  grayish 
liliroid  strands  loUowing  tlic  lint's  of  the  intcrlobnhir  septa. 

Symptoms  and  Course. — The  disease  is  essentially  chronie,  ex- 
tending over  a  perio(|  of  many  years,  and  when  onei'  the  condition  is  I'stab- 
li>hed  the  lu'ahh  may  bi'  fairly  good.  In  a  well-marked  ease  the  patient 
(•(implains  (udy  of  his  ehronie  cough,  perhaps  a  slight  shortness  of  breath. 
In  other  ri'spects  he  is  ((uite  well,  and  is  usually  aide  to  do  light  work. 
The  cases  are  commonly  regarded  as  phthisical,  though  there  may  be 
seareely  a  sym[)tom  oi'  that  allVction  except  the  cough.  There  are  in- 
stani'cs,  liowcver,  oi'  iibroid  |dithisis  which  cannot  ln'  distinguished  troiu 
cirrhosis  of  the  lung  exce[)t  by  the  preseive  oL'  tubercle  bacilli  in  the 
I'Xpectoration.  As  the  bronchi  are  usually  dihiteil,  the  symptoms  and 
physical  signs  may  be  those  ol  bronchiectasis.  The  cough  is  paroxysmal 
and  the  expectoration  is  geiu'i'ally  cojjious  and  of  a  muco-purulent  or  sero- 
|iurulcnt  nature.  it  is  sometimes  I'etid.  Ihemorrhage  is  by  no  means 
infrecpicnt,  and  occurred  in  more  than  one  half  of  the  cases  analyzed  by 
IJastian.  Walking  on  the  level  and  in  the  ordinary  all'airs  of  life  the  })atient 
may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exer- 
tion there  may  be  dyspnoea. 

Physical  Signs. — Iitspccliait. — The  airected  side  is  immobile,  retracted, 
and  shrunken,  and  contrasts  in  a  striking  way  with  the  voluminous  sound 
side.  The  intercostal  spaces  are  obliterated  and  the  ribs  may  even  over- 
hip.  The  shoulder  is  drawn  down  and  from  behind  it  is  seen  that  the 
spine  is  bowed.  The  heart  is  greatly  dis[)laced,  being  drawn  over  by  the 
slirinkage  of  the  lung  to  the  aifected  side.  When  the  left  lung  is  aU'ected 
there  may  be  a  large  area  of  visible  impulse  in  the  second,  third,  and 
fourth  inters])aces.  Mensuration  shows  a  great  diminution  in  the  alfected 
side,  and  with  the  saddle-tape  the  expansion  may  be  seen  to  be  negative. 
The  i)Ciruf<si(jii  note  varies  with  the  condition  of  the  bronchi.  It  may  be 
absolutely  Hat,  particnhiily  at  the  base  or  at  the  apex.  Jn  the  axilla 
there  mav  be  a  flat  (vnipany  or  even  an  ainuhorie  note  over  a  large  sac- 
cuhited  bronchus.  On  the  c])posite  side  the  ])ercussion  note  is  usually 
liypeiresoiuint.  On  aitscullalion  the  breath-sounds  have  either  a  cavern- 
niis  (!!■  amphoric  (piality  at  the  apex,  and  at  the  base  are  feeble,  with 
inucous,  bubbling  rales.  The  voice-sounds  are  usually  exaggeraled.  Car- 
diae  inui'miirs  are  not  uncommon,  particularly  late  in  the  disease,  when 
the  I'jglit  heart  fails.  These  are,  of  c()urse,  the  physical  signs  of  the  dis- 
c'n>e  when  it  is  well  established.  '^IMiey  naturally  vary  considerably,  ac- 
cording to  the  stage  of  the  ])rocess.  The  dii^easc  is  csseidially  chronie, 
.'Hid  may  persist  for  ilfteen  or  twi'nty  years.  Dt'ath  occurs  sometimes  from 
lia'inorrhage,  more  commonly  from  gradual  failure  of  the  right  heart  with 
dropsy,  and  occasicuially  fi'oiii  amyloid  degenei'aiion  of  the  organs. 

The  (li<t(iii(isi)i  is  never  dilliciilt.  It  may  be  imi)ossible  to  say.  without 
a  clear  history,  whether  the  origin  i>  |)leiiritic  or  ])ncumoiiic.  Between 
cjises  of  this  kind  and  Iibroid  phthisis  it  is  not  always  easy  to  discriminate, 
iis  the  conditions  may  be  almost  identical.  When  tnlxTculosis  is  present, 
li'iwever,  even  in  long-standing  cases,  bacilli  ai'c  usually  present  in  the 
sputa,  and  there  mav  be  si<>ns  of  disease  in  tljc  other  lung. 


652 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


Treatment.  —  It  is  onl}  ("or  an  intt'rcurrL'iit  afrcjlioii  or  for  an  aggra- 
vation ol"  the  euiiyli  that  the  j)atit'nt  seeks  roliof.  Nothing'  can  bo  done 
i'or  the  conditioji  itself.  AVhen  jjossible  the  patient  should  live  in  a  mild 
climate,  and  should  avoid  exposui'e  to  cold  and  damp.  A  distressing 
feature  in  some  cases  is  the  i)iitrefaction  of  the  contents  of  the  dilated 
tubes,  for  which  the  same  measures  may  be  used  as  iu  fetid  bronchitis. 


IV.    PNEUMONOKONIOSIS. 

Under  this  term,  introduced  by  iienker,  are  endjraced  those  forms  of 
fibrosis  of  the  lung  due  to  the  inhalation  of  dusts  in  various  occupations. 
They  have  received  various  names,  according  to  the  nature  of  the  inhaled 
l)articles — aiilhrarosis,  or  coal-miner's  disease;  siderusia,  due  to  the  iidiala- 
tion  of  metallic  dusts,  jjarticularly  iron;  chaUcunis,  due  to  the  inhalation 
of  mineral  dusts,  producing  the  so-called  stone-cutter's  phthisis,  or  the 
"grinder's  rot"  of  the  Sheilicld  workers. 

The  dust  ]iarti('les  iniialed  into  the  lungs  are  dealt  with  extensively  by 
the  ciliati'd  epithelium  and  by  the  })hagocytes,  which  exist  normally  in  the 
respiratory  oi-gans.  The  ordinary  mucous  corimscles  take  in  a  large  num- 
ber of  the  i)articles,  which  fall  u})on  the  trachea  and  main  bronchi.  The 
cilia  sweep  the  mucus  out  to  a  point  from  M'liich  it  can  be  expelled  by 
coughing.  It  is  doubtful  if  the  ])articles  ever  reach  the  air-cells,  Init  the 
swollen  alveolar  cells  (in  which  they  are  in  numbers)  ]>robably  pick  them 
up  on  the  way.  The  mucous  and  the  alveolar  cells  are  die  normal  respira- 
tory scavengers.  In  dwellers  in  the  country,  in  which  the  air  is  pure, 
they  are  able  to  prevent  the  access  of  dust  particles  to  the  lung  tissue, 
so  that  even  in  adults  these  organs  present  a  rosy  tint,  very  dilferent  from 
the  dark,  carbonized  ai)])earance  of  the  lungs  of  dwellers  in  cities.  When 
the  impurities  in  the  air  are  very  abundant,  a  certain  proportion  of  the 
dust  ])articles  escapes  these  cells  and  penetrates  the  mucosa,  reaching  the 
lymph  spaces,  where  they  are  attacked  at  once  by  the  cells  of  the  connec- 
tive-tissue stroma,  which  are  capable  of  ingesting  and  retaining  a  large  quan- 
tity. In  coal-miners,  coal-heavers,  and  others  whose  occupations  neces- 
sitate the  constant  breathing  of  a  very  dusty  atmos])here  even  these  forces 
are  insufficient.  !Many  of  the  particles  enter  the  lymph  stream  and,  as 
Arnold  has  shown  in  his  beautiful  researches,  are  carried  (1)  to  the  lymph 
nodules  surrounding  the  bronchi  and  blood-vessels;  (2)  to  the  interlobular 
eepta  1)eneath  the  ])leura,  where  they  lodge  in  and  between  the  tissue  ele- 
ments; and  (;'))  along  the  larger  lymiih  channels  to  the  substernal,  bronchial 
and  tracheal  glands,  in  which  the  stroma  cells  of  the  follicular  cords  dis- 
pose of  them  ])ermanently  and  ])';event  them  from  entering  the  general 
circulation.  Occasionally  in  anthracosis  the  carbon  grains  do  reach  the 
general  circulation,  and  the  coal  dv^t  is  found  in  the  liver  and  spleen.  As 
Weigert  has  shown,  this  occurs  when  the  densely  ])igmented  bronchial 
glands  closely  adhere  to  the  ])ulmonary  veins,  through  the  waiis  of  which 
the  carbon  ])articles  pass  to  the  general  circulation.  The  lung  tissue  has 
a  remarkable  tolerance  for  these  particles,  probably  because  a  large  propor- 


n  uggra- 
Ijc  done 
II  u  inihl 
.stret-sing 
i  dilated 
litis. 


PNEUMONOKONIOSIS. 


GSa 


forms  of 
iil)atioiis. 
!  iiil'ak'd 
e  inliala- 
ilialatiun 
i,  or  the 

sively  l^y 

ly  in  tho 

'ge  niiin- 

lii.     Tho 

Ji'llcd  by 

,  but  the 

ick  tlicm 

I  resi)ira- 

is  pure, 

g  tissue, 

nt  from 

Wlien 

of  the 

the 

conncc- 

e  (|uaii- 

ueces- 

forces 

and,  as 

lymph 

rlobular 

sue  elc- 

oncliial 

rds  dis- 

goneral 

ach  the 

fen.    As 

ronchial 

f  which 

isue  has 

propor- 


iing 


^e 


tion  of  thorn  is  warehoused,  so  to  speak,  in  protoj)lasmic  cells.  By  con- 
.-tant  exposure  a  limit  is  readied,  and  there  is  brought  about  a  very  deflnilo 
pathological  condition,  an  interstitial  sclerosis.  In  coal-miners  this  may 
occur  in  patches,  even  before  the  lung  tissue  is  uniformly  inliltrated  with 
iho  dust.  In  others  it  api)ears  only  after  the  entire  organs  have  become 
so  laden  that  they  are  dai'k  in  color,  and  an  ink-like  juice  Hows  from  the 
cut  surface.  The  lungs  of  a  miner  mny  be  black  tbrougliout  ami  yet  show 
no  local  lesions  and  bo  everywhere  crei)itant. 

As  already  mentioned,  the  jiarticles  are  deposited  in  large  numbers  in 
the  follicular  cords  of  the  tracheal  and  bronchial  glands  and  of  the  peri- 
bronchial and  ])cri-arterial  lymj)!!  nodules,  and  in  these  they  iinally  excite 
])rolifcration  of  the  connective-tissue  elements.  It  is  by  no  means  un- 
common to  find  in  persons  whose  lungs  are  only  moderately  carbonized 
llie  bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  libroid 
( lianges  usually  begin  in  the  peri-bronchial  lymph  tissue,  and  in  the  early 
stage  of  the  process  the  sclerosis  may  bo  largely  conlined  to  these  regions. 
A  Xova  Scotian  miner,  aged  thirty-six,  died  under  my  care,  at  the  Mont- 
real General  Hospital,  of  black  small-pox,  after  an  illness  of  a  few  days. 
1)1  his  lungs  (externally  coal-black)  there  were  round  and  linear  patches 
nmging  in  size  fro'  i  pea  to  a  hazel-nut,  of  an  intensely  black  color,  air- 
less and  firm,  and  surrounded  by  a  crepitant  tissue,  slate-gray  in  color. 
In  the  centre  of  each  of  these  areas  was  a  small  bronchus.  Many  of  tlioni! 
were  situated  Just  beneath  the  ])leura,  and  formed  typical  oxami)les  of 
limited  fibroid  broneho-jjneumonia.  In  addition  there  is  usually  thicken- 
ing of  the  alveolar  walls,  i)articidarly  in  certain  areas.  By  the  gradual 
coalescence  of  these  fibroid  patches  large  })ortions  of  the  lung  may  lie- 
converted  into  llrm  grayish-black,  in  the  case  of  the  coal-minor — steel- 
gray,  in  the  case  of  the  stone-worker — areas  of  cirrhosis.  In  the  case  of  a 
Cornish  miner,  aged  sixty-three,  who  died  under  my  care,  one  of  these 
libroid  areas  measured  18  by  G  cm.  and  4.5  cm.  in  depth. 

A  second  important  factor  in  these  cases  is  chronic  bronchitis,  which 
is  present  in  a  large  projiortion  and  really  causes  the  chief  symptoms.  A 
tliird  is  the  occurrence  of  emiihysema,  which  is  almost  invariably  associ- 
aled  with  long-standing  cases  of  pnoumonokoniosis.  With  the  changes  so- 
far  described,  unless  the  cirrhotic  area  is  unusually  extensive,  the  case  may 
piesent  the  features  of  chronic  bronchitis  with  emphysema,  out  finally 
iinother  element  comes  into  play.  In  the  fibroid  areas  softening  occurs, 
])robably  a  process  of  necrosis  similar  to  that  by  which  softening  is  pro- 
duced in  fibro-myomata  of  the  uterus.  At  first  these  are  small  and  con- 
tain a  dark  liquid.  Charcot  calls  them  iikcrcs  dii  poiimon.  They  rarely 
attain  a  large  size  unless  a  communication  is  formed  with  the  bronchus,. 
in  which  case  they  may  become  converted  into  suppurating  cavities.  The 
([uestion  has  been  much  discussed  of  late  as  to  what  ])art  the  tubercle  bacil- 
lus plays  in  these  cases  of  ])neumonokoniosis  Mitli  cavity  formation.  In 
sdine  instances  there  is  certainly  a  tuberculous  process  ingrafted,  but 
tliat  large  excavations  may  occur,  or  in  other  instances  hronchiectasis 
wit  bout  the  ])resence  of  bacilli,  I  have  convinced  myself  by  the  examina- 
tion of  several  characteristic  specimens. 


';ii 


u 


/ 


054 


DISEASES  OP  THE  KESPlUATUllY  SYSTEM. 


TIic  sidcrosis  iinliict'd  by  tlu'  oxide  ol'  iroji  causes  an  interstitial  pneu- 
monia siiiiilai"  to  aiilhraeosis.  Workers  in  brass  and  in  bronze  are  liable 
to  a  like  aU'ection. 

Cliulicosis,  due  to  the  deposit  of  particles  of  silex  and  alumina,  is 
found  in  the  makers  of  null-stones,  ])articularly  the  Frencli  null-stones, 
and  also  in  knife  and  axe  grinders  and  stone-cutters.  Anatomicall}',  this 
form  is  characterized  by  the  ])ro(-luction  of  nodules  of  various  sizes,  which 
ai'e  cut  with  tbe  greatest  dilliculty  and  sometimes  j)rese)it  a  curious  gray- 
ish, even  glittering,  crystalloid  appearance. 

Workers  in  llax  and  in  cotton,  and  grain-shovellers  are  also  subject  to 
those  chronic  interstitial  changes  in  the  lungs.  In  all  these  occupations, 
as  shown  l)y  (Jreenhow,  to  whoso  careful  studies  we  owe  so  much  of  our 
knowledge  of  these  diseases,  the  condition  of  the  lung  nuiy  ultimately  be 
almost  identical. 

The  tii/mploins  do  not  come  on  luitil  the  patient  has  worked  for  a  vari- 
able number  of  years  in  the  dusty  atmosphere.  As  a  rule  there  are  cough 
and  failing  health  for  a  ])rolonged  period  of  time  before  complete  disa- 
bility. The  coincident  emphysema  is  responsible  in  great  part  for  the 
shortness  of  breath  and  wheezy  condition  of  tliese  ])atients.  The  expec- 
toration is  usually  niuco-purulent,  often  profuse;  in  a  case  of  anthra- 
cosis,  very  dark  in  color — the  so-called  "  black  spit  "  ;  in  a  case  of  chalicosis 
tliere  may  be  seen  under  the  microscope  the  bright  angular  particles  ol' 
silica. 

Even  when  there  are  physical  signs  of  cavity,  tubercle  bacillus  are  not 
necessarily,  and  indeed  in  my  experience  they  are  not  usually  present.  It 
is  remarkable  for  how  long  a  time  a  coal-miner  may  continue  to  bring  up 
sputum  laden  with  coal  particles  even  when  there  are  only  signs  of  a 
clironic  bronchitis.  .M.my  of  the  particles  are  contained  in  the  cells  of  the 
alveolar  ei)ilheliui;  .  In  these  instances  it  appears  that  an  attempt  is  made 
by  the  leucocytes  to    id  the  lungs  of  some  of  the  carbon  grains. 

The  (Jiacjnosis  of  me  condition  is  rarely  difficult;  the  expectoration  is 
usually  characteristic.  It  must  always  be  borne  in  mind  that  chronic 
bronchitis  and  em])hysenia  form  essential  parts  of  the  process  and  that  in 
late  stages  there  may  be  tuberculous  infe  '"'^n. 

The  Ircdhiicnt  of  the  condition  is  practically  that  of  chronic  bronchitis 
and  emphysema. 


V.    EMPHYSEMA. 


Definition. — The  condition  in  which  the  infundibular  passages  and 
the  alveoli  are  dilated  and  the  alveolar  walls  atroi)hied. 

A  practical  division  nuiy  be  made  into  compensatory,  hypertro])hic. 
and  atro]ihic  forms,  the  acute  vesicular  eni])hysema,  and  the  interstitial 
forms.  The  last  two  do  not  in  reality  come  under  the  above  definition,  but 
for  convenience  they  may  be  considered  here. 


;ial  pnou- 
are  liable 

iiniina,  is 
ill-stones, 
.-ally,  this 
:os,  which 
10  us  gray- 

subJL'ct  to 
[jui)ations, 
c'li  of  our 
mately  bu 

lor  a  vari- 

arc  cough 
)k'lo  disa- 
•t  for  the 
'ho  expec- 
)f  anthra- 
chalicosis 
articles  of 

us  are  not 

•oscnt.  It 
bring  up 
igns  of  a 
dUs  of  the 
)t  is  made 

oration  i:^ 
:  chronic 
d  that  in 

bronchitis 


sagos  and 


ortroi)liif. 
iiterstitial 
ition,  but 


EMPHYSEMA. 


I.     COMPEXSATOIIY     EmPIIYSKMA. 


056 


"Whenever  a  region  of  the  lung  does  not  e\[)aMd  fully  in  ins[)inition, 
t'ither  anotber  jjortioii  of  the  lung  must  expand  or  the  chest  wall  sink  in 
(irder  to  occupy  the  space.  The  former  almost  invarialily  occurs.  We 
liiive  already  mentioned  that  in  broiicbo-pneumonia,  there  is.  a  vicarious 
(lisli'Mtion  of  the  air-vesicles  in  the  adjacent  healthy  lobules,  and  the  same 
liiippens  in  the  neighborhood  of  tubi'rculous  areas  and  cicatrices,  in  gen- 
eral jdeural  adhesions  there  is  often  comi)eMsatory  emphysenui,  particu- 
I  ii'ly  at  the  anterior  margins  of  the  lung.  'J'he  nu)st  advanced  exami»le  of 
this  form  is  seen  in  cirrhosis,  when  the  unalTected  lung  increases  greatly 
ill  size,  owing  to  distention  of  the  air-vesicles.  A  similar  though  less 
marked  condition  is  seen  'in  extensive  })leurisy  with  elfusion  and  in  pneu- 
mothorax. 

At  first,  this  distention  of  the  air-vi'sicles  is  a  simple  physiological 
process  and  the  alveolar  walls  are  stretched  but  ]iot  atrophied.  Ulti- 
mately, however,  in  many  cases  they  waste  and  the  contiguous  air-cells 
fuse,  producing  true  emphysema. 

IT.  IlYi'EHTKoriiic  Emphysema. 

The  large-lunged  emphysema  of  Jenner,  also  known  as  substantive  or 
idiopathic  emphysema,  is  a  well-uiiirked  clinical  affection,  characterized  by 
enlargement  of  the  lungs,  due  to  distention  of  the  air-cells  and  atrophy  of 
their  walls,  and  clinically  by  imperfect  aeration  of  the  blood  and  more  or 
less  marked  dyspneea. 

Etiology. — Emi)hysema  is  the  result  of  persistently  high  intra- 
alveolar  tension  acting  upon  a  congenitally  weak  lung  tissue.  If  the 
mechanical  views  as  to  its  origin,  which  have  ])revailed  so  long,  were  true, 
the  disease  would  certainly  be  much  more  connnon;  since  violent  res^jira- 
tory  efforts,  believed  to  be  the  essential  factor,  are  ])erformed  by  a  majority 
(if  the  working  classes.  Strongly  in  favor  of  the  view,  that  the  nutritive 
change  in  the  air-cells  is  the  i)rimary  factor,  is  the  markedly  hereditary 
(haracter  of  the  disease  and  the  fref|uency  with  whicli  it  starts  early  in 
hfe.  These  are  two  ])oints  upon  which  scarcely  suilicient  stress  has  been 
laid.  To  James  Jackson,  Jr.,  of  ISoston,  mc  owe  the  first  observations 
on  the  hereditary  character  of  em])hysema.  Working  under  Louis'  direc- 
tions, he  found  that  in  IS  out  of  2S  cases  one  or  both  i)areuts  were  af- 
fected. 

I  have  been  impressed  by  the  freciuency  of  its  origin  in  childhood.  It 
may  follow  recurring  asthmatic  attacks  due  to  adenoid  vegetations.  It 
may  develo]i,  too,  in  several  memljers  of  the  same  family.  We  are  still 
ignorant  as  to  the  nature  of  this  congenital  p)ulmonary  weakness,  ("ohn- 
lieim  thinks  it  probal)ly  due  to  a  defect  in  the  development  of  the  elastic- 
tissue  fibres — a  statement  which  is  borne  out  by  p]ppinger's  observations. 

Heightened  pressure  within  the  air-cells  may  be  due  to  forcible  in- 
spiration or  expiration.  ^Much  discussion  has  taken  place  as  to  the  ])art 
plaved  by  these  two  acts  in  the  production  of  the  disease.  The  inspiratory 
41 


650 


DISKASES  OP  TIIK  RESPIRATORY  SYSTEM. 


/ 


theory  was  advanced  by  Lnoniu'c  and  subsequently  modified  by  Guirdnor, 
wlio  lield  that  in  chronic  l)ronchitis  areas  of  colhijKSo  were  induced,  and  com- 
pensatory distention  took  phice  in  the  adjacent  h)hulcs.  This  un(iues- 
tional^ly  does  occur  i.i  the  vicarious  or  compensatory  emphysema,  hut 
it  pr()l)ably  is  not  a  factor  of  mucli  moment  in  the  form  now  unth'r  ciui- 
sideratioii.  f'he  cx[)iratory  theory,  whi(h  was  sui))>orted  by  ^U'ikU'IssoIiii 
and  Jenner,  accounts  for  the  condition  \\->  a  much  more  satisfactory  way. 
In  all  straining  elTorts  and  violent  attacks  of  coughin;^-,  liie  glottis  is  closed 
and  the  chest  walls  are  strongly  compressed  by  muscular  elTorts,  so  that 
the  strain  is  thrown  upon  those  i)arts  of  the  lung  least  protected,  as  tlie 
apices  and  the  anterior  margins,  in  which  we  always  lind  the  emphy- 
sema most  advanced.  The  sternum  and  costal  cartilages  gradually  yield 
to  the  heightened  intrathoracic  pressure  and  are.  in  advanced  cases,  pushed 
forward,  giving  the  characteristic  rotundity  to  the  thorax.  The  cartilages 
gradually  become  calcilied.  One  theory  of  the  disease  is  that  there  is  a 
gradual  enlargenient  of  the  thorax  and  the  lungs  increase  in  volume  to 
fill  uj)  the  space. 

Of  other  etiological  factors  occupation  is  the  most  important.  The 
disease  is  met  with  in  players  on  wind  instruments,  in  glass-blowers,  and 
in  occu})ation8  necessitating  heavy  lifting  or  straining.  Whooping-cough 
and  bronchitis  play  an  important  rule,  not  so  much  in  the  changes  which 
they  induce  in  the  bronchi  as  in  consequence  of  the  prolonged  attacks  of 
coughing. 

Morbid  Anatomy. — Tlie  thorax  is  capacious,  usually  barrel-shai)ed, 
and  the  cartilages  are  calcified.  On  removal  of  the  sternum,  the  anterior 
mediastinum  is  found  completely  occupied  by  the  edges  of  the  lungs,  and 
the  pericardial  sac  nuiy  not  be  visible.  The  organs  are  very  large  and 
have  lost  their  elasticity,  so  that  they  do  not  collapse  either  in  the  thorax 
or  when  phv  A  on  the  table.  The  pleura  is  pale  and  there  is  often  an 
absence  of  ])igment,  sometimes  in  })atches,  termed  by  Virchow  albinism  of 
the  lung.  To  the  touch  they  have  a  peculiar,  downy,  feathery  feel,  and 
pit  readily  on  pressure.  This  is  one  of  the  most  marked  features.  Be- 
neath the  pleura  greatly  enlarged  air-vesicles  may  be  readily  seen.  They 
vary  in  size  from  ^  to  3  mm.,  and  irregular  bulliE,  the  size  of  a  walnut 
or  larger,  may  project  from  the  free  margins.  The  best  idea  of  the  ex- 
treme rarefaction  of  the  tissue  is  obtained  from  sections  of  a  lung  dis- 
tended and  dried.  At  the  anterior  margins  the  structure  may  form  an 
irregular  series  of  air-chambers,  lesembling  the  frog's  lung.  On  careful 
inspection  with  the  hand-lens,  remnants  of  the  interlobular  septa  or  even 
of  the  alveoli  may  be  seen  on  these  large  em])hysematous  vesicles.  Though 
general  thronghout  the  organs,  the  distention  is  more  marked,  as  a  rule, 
at  the  anterior  margins,  and  is  often  specially  developed  at  the  inner  sur- 
face of  the  lobe  near  the  root,  where  in  extreme  cases  air-spaces  as  large 
as  an  e^g  may  sometimes  be  found.  Microscopically  there  is  seen  atrophy 
of  the  alveolar  walls,  by  which  is  ])roduced  the  coalescence  of  neighboring 
air-cells.  In  this  process  the  ea])illary  network  disappears  before  the 
walls  are  com])letcly  atrophied.  T^^'^  loss  of  the  elastic  tissue  is  a  special 
feature.     It  is  stated,  indeed,  that  in  certain  cases  there  is  a  congenital 


1 


(iairdnor. 

iiml  coiu- 

4    un(|U('>- 

■(.'iiiii,   l»iit 

luk'T   Cdll- 

ikU'IssoIiii 
•toiy  way. 
s  isi  closL'd 
s,  so  that 
ed,  as  thu 
e  cmphy- 
lally  yield 
es,  pushed 
cartilages 
there  is  a 
volume  to 

ant.  The 
)\vers,  and 
)ing-cou;^h 
igLS  Avhieli 
attacks  ol' 

rel-shaped, 
,e  anterior 
lungs,  and 
large  and 
he  thorax 
often  an 
Ihinism  of 
feel,  and 
ires.      Be- 
|en.     They 
a  walnut 
of  the  ex- 
lung  dis- 
fonn  an 
n  careful 
a  or  even 
Though 
as  a  rule, 
inner  sur- 
s  as  largo 
n  atrophy 
ghboring 
efore   tho 
a  special 
congenital 


EMPHYSEMA. 


057 


II 


defect  in  the  development  of  tins  tissue.  The  epithelium  of  the  air-cells 
undergoes  a  fatty  change,  hut  the  large  distended  air-spaces  retain  a  pave- 
ment layer. 

The  lironchi  show  important  changes.  In  the  larger  tultes  the  mucous 
nu'nd)rane  may  l)e  rough  and  tliickencd  from  chronic  l)r()nchitis;  often  the 
longitudinal  lines  of  suhmucous  elastic  tissue  stand  out  prominently,  in 
(lie  advaiu'cd  cases  many  of  the  snuUler  tuhes  are  dilated,  partic'ularly 
wiu'ii,  in  addition  to  emphysema,  there  are  peri-bronciiial  fil)roid  changes, 
lironchiectasis  is  not,  however,  an  invarialile  accompaniment  of  emphy- 
sema, hut,  as  Laennec  remarks,  it  is  dilllcult  to  understaiul  why  it  is  not 
more  common.  Of  associated  morbid  changes  the  most  important  are 
fouu<l  in  the  heart.  The  right  chambers  are  dilated  and  hyperlrophied, 
tiie  tricuspid  orilice  is  large,  aiul  the  valve  segments  are  often  thickened 
at  the  edges.  In  advanced  cases  the  cardiac  hypertroi)hy  is  general.  The 
])uhnonary  artery  and  its  branches  may  be  wide  and  show  marked  atherom- 
atous changes. 

The  changes  in  the  other  organs  are  those  commonly  associated  with 
prolonged  venous  congestion. 

SymptoiDS. — The  disease  may  be  tolerably  advanced  before  any  spe- 
cial symptoms  develop.  A  child,  for  instance,  may  be  somewhat  short  of 
breath  on  going  up-stairs  or  may  be  unable  to  run  and  i)lav  as  other  chil- 
dren without  great  discomfort;  or,  j)erhaps,  has  attacks  of  slight  lividity. 
Doubtless  much  depends  upon  the  completeness  of  cardiac  compensation. 
When  this  is  perfect,  there  may  l)e  no  special  interruption  of  the  pulmonary 
circulation  and,  except  with  violent  exertion,  there  is  no  interference  with 
the  aeration  of  the  blood.  In  well-develo])ed  cases  the  following  are  the 
most  important  symptoms:  Dyspiiwa,  which  may  l)e  felt  only  on  slight 
exertion,  or  may  be  persistent,  and  aggravated  by  intercurrent  attacks  of 
bronchitis.  The  respirations  are  often  harsh  and  wheezy,  and  expiration 
is  distinctly  prolonged. 

Cyaiiusis  of  an  extreme  grade  is  more  common  in  emphysema  than  in 
other  affections  \  ith  the  exception  of  congenital  heart-disease.  S(j  far  as  I 
know  it  is  the  only  disease  in  which  a  patient  may  be  able  to  go  about  and 
even  to  walk  into  the  hospital  or  consulting-room  with  a  lividity  of  star- 
tling intensity.  The  contrast  between  the  extreme  cyanosis  and  the  com- 
parative comfort  of  the  patient  is  very  striking.  In  other  alfections  of  the 
heart  and  lungs  associated  with  a  similar  degree  of  cyanosis  the  patient  is 
invariably  in  bed  and  usually  in  a  state  of  orthopno\a.  One  condition  must 
he  here  referred  to,  viz.,  the  extraordinary  cyanosis  in  cases  of  poisoning 
by  aniline  products,  whicli  is  in  most  part  due  to  the  conversion  of  the 
luemoglobin  into  luethirmoglobin. 

Bronchitis  with  associated  cough  is  a  frequent  symptom  and  often  the 
direct  cause  of  the  pulmonary  distress.  The  contrast  between  emphy- 
sematous patients  in  the  winter  and  summer  is  marked  in  this  res])ect. 
Tn  the  latter  they  may  be  comfortal)le  and  able  to  attend  to  their 
Mork,  but  with  the  cold  and  changeable  weather  they  are  laid  u]i  with 
attacks  of  bronchitis.  F'nally,  in  fact,  the  two  conditions  become  in- 
separable and  the  patient  has  persistently  more  or  ]r     cough.     The  acute 


C5S 


DISKASES  OP  THE  llESPIUATOUY   SYSTJIM. 


lii'uiicl'ilis  iiuiy  ]»r<)(liici'  nlliicks  not  unlike  ii>tliiiiii.  In  soiiu!  insliiiioos 
this  it)  IniL'  sjiiisiiiodic  ii>tliiiiii,  with  wliicli  ('iii[ilivs('iii;i  is  jr(.',|iu'iitiy  hn-o- 
ciatt'd. 


As  iific  iidviinccs. 


iiiul  witii  successive  jittiicUs  ol'  hroiifliltis,  the  condi- 


tion gets  shjwiy  worse.  \n  hos|)it!d  practice  it  is  coniinon  to  adnnt  i)a- 
tients  over  sixty  with  well-iniirked  si;;ns  (d'  advanced  enipliysenia.  The 
alVeelion  can  genei'ally  he  tokl  at  a  ghiiiee — the  rounded  shoiddws,  barrel 
chest,  the  thin  yet  oftentimes  muscular  form,  and  sometimes,  1  thiidv,  a  very 
characteristic  facial  expression. 

There  is  another  ;^rou|»,  however,  of  youn^'er  ])atieids  from  tweniy-live 
to  forty  years  of  aj^c  who,  winter  after  wintei',  have  attacks  of  intense  cya- 
nosis in  consequence  of  an  aggravated  bronchial  catarrh.  On  iiujuiry  we 
find  that  thest'  patients  have  been  short-breathed  from  iirfancy,  aiul  lliey 
belong,  1  believe,  to  a  categ(jry  in  which  there  has  been  a  primary  defect 
(d'  sliMictui'e  in  the  lung  tissue. 

Physical  Signs.-— I nsjiciiiun. — The  thorax  is  markedly  altered  in  shape; 
tJie  antero-|)osterior  dianieler  is  increased  and  luiiy  be  even  greater  than 
the  lateral,  so  that  the  chest  is  barrel-shaped.  The  ap[)earance  is  some- 
what as  if  the  chest  was  in  a  i)ermanent  ins|iiratoi'y  position.  'J'ho  sternum 
and  costal  cartilages  are  ])rominent.  The  lower  /.one  of  the  thorax  looks 
large  and  the  intercostal  sjjaces  are  much  widened,  i)articularly  in  the  liypo- 
thondriac  regions.  The  sternal  fossa  is  deej),  the  clavicles  stand  out  with 
great  prominence,  and  the  neck  looks  shortened  from  the  elevation  of  the 
thorax  and  the  sternum.  A  zoiu'  of  dilated  venules  may  be  seen  along  the 
line  of  attachment  of  the  diai)hragm.  Though  this  is  common  in  enij)hy- 
sema,  it  is  l>y  no  means  ])t'cnliar  to  it  or  indet'd  to  any  s[)ecial  ail'ection. 
Andrew,  of  lUirtholomew's  Hospital,  and,  according  to  Duckworth,  Laycock 
called  atteidion  to  it. 

The  curve  of  the  sjjinc  is  increased  and  the  back  is  renuirkably  rounded, 
so  that  the  scapube  seem  to  be  almost  horizontal,  ^lensuration  shows  the 
rounded  form  of  the  chest  and  the  very  slight  expansion  on  deep  inspira- 
tion. The  respiratory  movements,  which  may  look  energetic  and  forcible, 
exercise  little  or  no  influence.  The  (diest  does  not  ex])and,  but  there  is  a 
general  elevation.  The  inspiratory  etl'ort  is  short  and  (piick;  the  expiratory 
movement  is  prolonged.  There  nuiy  be  retraction  instead  ol  distention 
in  the  up])er  abdominal  region  during  inspiration,  and  there  is  sometimes 
seen  a  transverse  curve  crossing  the  abdomen  at  the  level  of  the  twelftli 
rib.  The  apex  beat  of  the  heart  is  not  visible,  and  there  is  usually  marked 
pulsation  in  the  e])igastric  region.  The  cervical  veins  stand  out  promi- 
nently and  may  pulsate. 

Palpation. — The  vocal  fremitus  is  somewhat  enfeebled  but  not  lost. 
The  apex  beat  can  rarely  be  felt.  There  is  a  marked  shock  in  the  lower 
sternal  region  and  very  distinct  pulsation  in  the  epigastrium.  Permission 
gives  greatly  increased  resonance,  full  and  drum-like — what  is  sometimes 
called  hyperresonance.  The  note  is  not  often  distinctly  tympanitic  in 
quality.  The  percussion  note  is  greatly  extended,  the  heart  dulness  may 
be  obliterated,  the  up])er  limit  of  liver  dulness  is  greatly  lowered,  and  the 
resonance  may  extend  to  the  costal  margin.     Behind,  a  clear  percussion  note 


EMPHYSEMA. 


♦my 


instances 
iitly  usso- 

llf    Cdiuli- 

iidiiiit  [lii- 
nia.  The 
ii'A,  barrel 
Ilk,  ii  very 

wcnty-live 
ten.se  cya- 
ii(|iiiiT  we 
and  I  hey 
ary  defect 

in  sliiipc; 
.'ater  than 
J  is  some- 
le  sternuni 
orax  hjoks 

tlie  liypo- 
1  ont  with 
ion  of  the 

along  tlie 
in  empliy- 

alTectioii. 
1,  Laycoek 

roiinded, 

shows  the 

1  inspira- 

forcihlc. 

lieve  is  a 
■xpiratoi'y 

listcntion 

sometimes 

le  twelftli 

y  marked 

ut  pronii- 

not  lost, 
lie  lower 
ercussion 
omctimoR 
)anitic  in 
ness  may 
,  and  the 
Bsion  note 


extends  to  a  nuich  lower  level  than  normal.  The  level  of  splenic  dulnesd, 
too,  may  he  lowered. 

On  uiisciilhilidii  (he  breath-sounds  are  usually  enfeebii'd  and  may  be 
lllil^ke(l  by  bronehilic  rah's.  Thi'  most  characterist  ie  fenture  is  the  pru- 
|(iii;Aation  of  the  expiration,  ami  tiie  iKH'ina!  I'atio  uiay  bi'  reversed — 1  to  1 
instead  of  1  to  1.  it  is  often  whee/.y  and  harsii  anil  associated  with  coarse 
lules  and  sibihmt  rhonclii.  It  is  said  timt  in  interstitial  empliysema  tiieri; 
may  l)e  a  friction  sound  heard,  not  iiidike  that  of  ph'urisy.  The  hcnri- 
>ounds  are  usually  (dear;  hut  in  advanced  cases,  when  there  is  marked 
cyanosis,  a  tricuspid  rcixur^itant  murmur  may  bo  hearch  Aci  enluation  of 
ihc  pnhnoiiiny  sceond  M»und  is  proent. 

'i'he  (•(iiirse  of  the  disea  'i  is  .<low  l)ut  pro«.M'essive,  the  recurring"  attacks 
(if  bronchitis  a<^';ravatinii'  the  condition.  Deatii  nuiv  occur  from  intercur- 
lent  pncuuKiuia,  cither  lobar  or  iohuhir,  and  dropsy  may  supcrvcijc  from 
eartiiac  failure'.  Occasionally  ileatli  results  from  o\erdisteiitioii  of  the  henri, 
with  t'.xlrcme  cyanosis.  Ouckworth  has  called  attention  to  the  oecasiomil 
uccurrence  of  fatal  lueniorrhage  in  emphysema.  In  an  old  emphysematous 
patient  at  the  Montreal  Oeneral  llos|)ilal  eleath  followed  the  ei'osion  of  a 
nuiin  branch  of  the  jjulmonary  artery  by  an  ulcer  near  the  bifurcation  of  the 
trarhca. 

Treatment. — rractically,  the  mca-mres  mentioned  in  connection  witli 
hronchilis  should  be  employt'd.  In  children  with  asthma  and  developing 
emphysema  the  nose  should  be  carefully  examined.  No  remedy  is  known 
which  has  any  inlhu'nie  over  tlu'  progress  of  the  condition  itself,  bron- 
chitis is  the  great  danger  of  these  patients,  and  thei'efore  when  possible  they 
should  live  in  an  c(piable  climate.  In  conse((uence  of  the  venous  engorge- 
ment they  are  liable  to  gastric  and  intestinal  disturbance,  and  it  is  ])ar- 
ticularly  im[)ortant  to  keep  the  bowels  regulated  and  to  avoid  llatulency 
which  often  seriously  aggravates  the  dyspnu'a.  Patients  who  come  into  the 
hospital  in  a  state  of  urgent  (lys|)n(ea  and  lividi^v.  with  great  engorgement 
(if  the  veins,  i)articularly  if  they  are  young  ana  vigorous,  should  be  bled 
freely.  On  nuire  than  one  occasion  1  have  saved  the  lives  of  jx'rsons  in  this 
condition  by  venesection.  Inhalation  of  oxygen  may  l)e  used  and  the  reme- 
dies given  already  mentioned  in  connection  with  bronchitis.  Strychnine 
will  be  found  S})ecially  useful.     • 

III.  AxKormc  Emphyskma. 

This  is  really  a  senile  change  and  is  called  by  Sir  William  Jenner  small- 
lunged  emphysema.  It  is  really  a  primary  atro])hy  of  the  lung,  coming 
on  in  advanced  life,  and  scarcely  constitutes  a  special  allVction.  It  occurs 
in  "withered-looking  old  ])ersons  "  who  may  jjcrhap-^  have  had  a  winter 
cough  and  shortness  of  breath  for  years.  In  striking  contrast  to  the  essen- 
tial or  hypertro])hie  em]diyscma,  the  chest  in  this  form  is  small.  '^I'he  ribs 
are  obliquely  ])laced,  the  decrease  in  the  diameter  being  d;'e  to  greatly  in- 
creased oblirpiity  in  the  position  of  the  ribs.  The  thoracic  nnisclc-;  are 
usually  atrojjhied.  In  advanced  cases  of  this  affection  tlie  lung  pic-'ciils  a 
remarkable  appearance,  being  converted  into  a  series  of  large  vesicles,  on 


GOU 


DISKASIOS  OP  THE   KKSI'IUATORY  SYSTKM. 


the  walls  of  wliicli  tlu;  rcmimiits  of  air-cells  may  be  seen.     It  is  a  condition 
for  wliicli  iiolliiii;,'  tan  l)c  dom.'. 


/ 


IV.  Acute  Vksicllau  Emi'Iivsioma. 

Wlion  (lentil  occurs  from  broiicliitis  of  the  smaller  tiil)es,or  from  cyanosig 
when  stron;;'  inspiratory  clforts  have  been  made,  the  lun<;s  are  lariic  in  vol- 
innu  and  the  air-cells  arc  much  distended.  Cliiucally,  this  condition  nuiy 
dcvclo[)  ra|)i(lly  in  cases  of  cardiac  astluna  and  an^dmi  pectoris.  The  lungs 
are  voluminous,  the  area  of  puhnonary  resonance  is  nnuh  increased,  and  on 
auscultation  there  are  heard  everywhere  pijiinj;  rales  aiul  prolonjfed  expira- 
tion. It  is  the  condition  to  which  von  Hasch  has  given  the  nanu'S  Ltiiu/rn- 
schirclliinf/  and  Lumjenslarrhcit.  A  similar  condition  nuiy  follow  pressure 
on  the  vagi. 

V.  I.vTicitsTiTiAL  Emphysema. 

In  this  form  beads  of  air  are  seen  in  the  interlobidar  and  subpleural 
tissue;  sometimes  they  form  large  bulla!  beneath  the  i)leura.  A  rare  event 
is  ru|tture  close  to  the  root  of  the  lung,  and  the  passage  of  air  along  the 
trachea  into  the  subcutaneous  tissues  of  the  neck.  xVfter  tracheotomy  just 
the  reverse  may  occur  and  the  air  may  pass  from  the  tracheotomy  wound 
along  the  wind-])i])e  and  bronchi  ami  appear  beneath  the  surface  of  the 
jjleura.  From  this  interstitial  emphysema  spontaneous  pneumothorax  may 
arise  in  healthy  persons. 


VI.    GANGRENE    OF   THE    LUNG. 

Eltiology. — (iangrcne  of  the  lung  is  not  an  alTection  per  se,  but  occurs 
in  a  variety  of  conditions  when  necrotic  areas  undergo  putrefaction.  It 
it  not  easy  to  say  why  sphacelus  should  occur  in  one  case  and  not  in  an- 
other, as  the  germs  of  ])utrefaction  are  always  in  the  air-])assages,  and  yet 
necrotic  territories  rarely  become  gangrenous.  Total  obstruction  of  a  pul- 
monary artery,  as  a  rule,  causes  infarction,  and  the  area  shut  oil'  does  not 
often,  though  it  may,  sphacelate.  Another  factor  would  seem  to  be  neces- 
sar}' — probably  a  lowered  tissue  resistance,  the  result  of  general  or  local 
causes.  It  is  met  with  (1)  as  a  sequence  of  lobar  pneumonia.  This  rarely 
occurs  in  a  })reviously  healthy  person — more  commonly  in  the  debilitated 
or  in  the  diabetic  subject.-  {'i)  Gangrene  is  very  prone  to  follf  sv  the  as- 
piration pneumonia,  since  the  foreign  particles  rapidly  undergo  putrefac- 
tive changes.  Of  a  similar  nature  are  the  cases  of  gangrene  due  to  perfora- 
tion of  cancer  of  the  (esophagus  into  the  lung  or  into  a  bronchus.  (3)  The 
])utrid  contents  of  a  bronchiectatic,  more  commonly  of  a  tuberculous,  cav- 
ity may  excite  gangrene  in  the  neighboring  tissues.  The  pressure  bronchi- 
ectasis following  aneurism  or  tumor  may  lead  to  extensive  sloughing.  (4) 
Gangrene  may  follow  simple  embolism  of  the  pulmonary  artery.  More 
commonly,  however,  the  embolus  is  derived  from  a  part  which  is  morti- 
fied or  comes  Irom  a  focus  of  bone  disease.     In  typhus  and  in  typhoid  fever 


OANGRENR  OF  TFIK   lil'XO. 


661 


C'ouditiuii 


Qi  cyanosis 
1'^^'  in  vol- 
ution may 
Tliu  lungs 
cd,  and  on 
[I'd  expira- 
'S  LutKjvn- 
\y  pressure 


suljpleural 
rare  event 
along  the 
itomy  just 
my  wound 
ute  of  the 
liorax  may 


but  occurs 
ction.  It 
lot  in  an- 
s,  and  yet 

of  a  pul- 

does  not 

be  ncces- 
1  or  local 
his  rarely 

ebilitated 
w  the  as- 

putrefac- 
0  perfora- 
(3)  The 
lous,  eav- 

hronchi- 
nng.  (4) 
7.     More 

is  morti- 
loid  fever 


i 


^ningrcnc  ol'  ttic  lung  may  follow  lliriunhtisis  of  one  of  the  larger  branched 
(if  the  pulmonary  artery.  A  case  occurred  in  my  wards  in  October,  1S1)7, 
ill  eoniu'ction  with  a  typhoid  septica'iiiia.  'i'yphoid  l)ii(illi  were  isolated 
from  the  lung,  iiastly,  gangrene  of  the  lung  may  occur  in  conditions  of 
(lehilily  (luring  convalescence  from  protracted  fever — oi'casionally,  indeed, 
without  our  being  able  to  assign  any  reasonable  cause. 

Morbid  Anatomy. — Lacnncc,  who  lirst  accurately  described  jml- 
iiKUiary  gangrene,  ri'cogiiized  a  dilVuse  and  a  circumscrilied  fi)nn.  The  for- 
mer, though  rare,  is  sometimes  seen  in  connection  with  pneumonia,  more 
rarely  after  obliteration  of  a  large  branch  of  the  jjulmonary  artery.  Jt  may 
involve  tbc  greater  part  of  a  lobe,  and  the  lung  tissue  is  converted  into  a  hor- 
ril)ly  oircnsive  greenish-black  mass,  torn  and  ragged  in  the  centre.  \\\  the 
circumscrilK'd  form  there  is  well-marked  limitation  between  the  gangrenous 
iirca  and  the  surrounding  tissue,  'i'he  focus  may  be  single  or  there  may  be 
two  or  more.  The  lower  lobe  is  more  commonly  alfected  than  the  upper, 
iind  the  peripheral  more  than  the  central  portion  of  the  lung.  A  gan- 
grenous area  is  at  first  uniformly  greenish  brown  in  color;  but  softening  ra]i- 
idly  takes  place  with  the  formation  of  a  cavity  with  shreddy,  irregular  walls 
and  a  greenish,  olfensive  lluid.  The  lung  tissue  in  the  immediate  neigh- 
iiorhood  shows  a  zone  of  deep  congestion,  often  consolidation,  and  outside 
tiiis  an  intense  (edema.  In  the  embolic  cases  the  i)luggcd  artery  can  some- 
times be  found.  When  rapidly  extending,  vessels  may  i)e  opene(l  and  a 
(■(>|»ious  lucmorrliage  ensue.  Perforation  of  tiie  jilcura  is  not  uncommon. 
The  irritating  decomi)osing  material  usually  excites  the  most  intense  bron- 
chitis. Embolic  processes  are  not  infrecpient.  There  is  a  remarkable  asso- 
ciation in  some  cases  between  circumscribed  gnngrene  of  tlie  lung  and 
abscess  of  the  brain.  It  has  been  referred  to  under  the  section  on  bron- 
cliiectasis. 

Symptoms  and  Course. — I'sualiy  definite  symptoms  of  local  pul- 
monary disease  precede  the  characteristic  features  of  gangrene.  These,  of 
course,  are  very  varied,  depending  on  the  nature  of  the  trouble.  The  s])utuin 
is  very  characteristic.  It  is  intensely  fetid — usually  profuse — and,  if  ex- 
jiectorated  into  a  conical  glass,  separates  into  three  layers — a  greenish-brown, 
licavy  sediment;  an  intervening  thin  li(piid,  which  sometimes  has  a  greenish 
or  a  brownish  tint;  and,  on  to]),  a  thick,  frothy  layer.  Spread  on  a  glass 
|ilate,  the  shreddy  debris  of  lung  tissue  can  readily  be  picked  out.  Even 
large  fragments  of  lung  may  be  coughed  u]).  Ko])ertson,  of  Onancock, 
\'a.,  sent  me  one  several  centimetres  in  length,  which  had  l)ecn  expecto- 
rated by  a  lad  of  eighteen,  who  had  severe  gangrene  and  recovered,  ^[i- 
croscopically,  elastic  fibres  are  found  in  abundance,  with  granular  matter, 
|iigmcnt  grains,  fatty  crystals,  bacteria,  and  leptothrix.  It  is  stated  that 
clastic  tissue  is  sometimes  absent,  but  I  have  never  met  with  such  an  in- 
stance. The  peculiar  plugs  of  sputum  which  occur  in  bronchiectasy  are  not 
found.  lUood  is  often  present,  and,  as  a  rule,  is  much  altered.  The  spu- 
tum has,  in  a  majority  of  the  cases,  an  intensely  fetid  odor,  which  is  com- 
municated to  the  breath  and  may  permeate  the  entire  room.  It  is  nuich 
more  offensive  than  in  fetid  bronchitis  or  in  abscess  of  the  lung.  The 
fetor  is  particularly  marked  when  there  is  free  communication  between  the 


fifia 


DISEASES  OK  TIIK   UESl'IUATOllY  SYSTEM. 


/ 


jiaii;;rcii()iis  (iivilits  mid  llif  liroiiclii.  On  scvcrul  occiiHions  1  1iqv(!  foiiml, 
||<|^t  iiiiiili'iii.  I<p(iili/('(|  niiiiMniic,  wliicli  liiul  l)(('ii  iiiisus|i('ftc(l  (liii'iiig  liio, 
tiiul  ill  wliicli  llicrc  liiid  hccii  net  iVlor  ul'  llii'  hri-atli. 

Tilt'  plivsiciil  sijrns,  when  cxtensiivL'  (li'.struction  lias  occiirn'd,  arc  tlioso 
(iT  (iivitv,  l)iit  I  lie  limited  cinimiscrilK'd  areas  niav  lie  dilliiidl  to  detect, 
lirdiicliilis  is  alwnvs  preseiil. 

Aimtnj;  the  general  s_vni|>lniiis  imiy  he  iiieiitiniied  lever,  usiudly  of  mod- 
erate <ira(h';  the  |>ulse  is  ra|tid,  and  very  (dteii  the  constitutional  dtitressioii 
is  severe.  Ihit  the  only  special  i'l'atures  indicative  of  j;an;<rene  aro  the 
sputa  and  the  I'etur  ul'  the  breath.  The  patient  generally  sinks  I'runi  exhaus- 
tion.     I''iitiil  hieiiiorrhni^c  may  ensue. 

Treatment. — The  tri'atmeut  of  ^^au^i'ene  is  very  unsatisfactory,  'i'he 
indications,  of  course,  are  to  disinlect  the  gan^^renuus  area,  but  this  is  ufleii 
impossilile.  .\ii  antiseptic  spray  of  ciiiholic  aciil  mny  lie  employed,  A 
j^odd  plan  is  for  the  patient  to  use  over  the  nmuth  and  nose  an  inhaler, 
which  may  he  char^^ctl  with  a  solution  of  ciirliolic  ac'd  or  with  jiuaiacol; 
the  latter  dni^i'  has  also  heeii  Wf^vt]  hypodermicMlly,  with,  it  is  said,  happy 
results  ill  reiiio\  inn- the  odor.  If  t lie  sii^iis  of  cavity  are  distini't  an  attempt 
should  he  inaik'  to  cleanse  it  liy  direct  injections  of  an  antiseptic  solution. 
i(  the  patient's  condition  is  i^ood  and  the  ;rau;4i'enous  U'^ioii  can  be  local- 
ized, sui';^ical  interference  may  he  indicatetl.  Successful  cases  have  been 
reported.  The  j;enei'al  conditimi  of  the  [tatient  is  always  such  to  demand 
the  greatest  care  in  the  matter  (d'  diet  and  nursing. 


VII.    ABSCESS    OF   THE    LUNG. 


Etiology. — Suppurai.  n  occurs  in  the  lung  umh'r  the  following  con- 
diti(>ns:  (1)  As  a  sequeiu-e  of  intlammation,  either  lobjir  oi'  lobular.  Apart 
from  the  |)urulent  iiililtratioii  this  is  untpiestionably  rare,  and  even  in 
lobar  jinetnuonia  the  abscesses  are  of  small  size  and  usually  invt)lve,  as 
Addison  remarked,  several  points  at  the  same  time.  On  the  other  hand, 
abscess  formation  is  extremely  frc(pient  in  the  deglutition  and  aspiration 
forms  of  lobular  i)n:'um()nia.  After  wounds  of  the  neck  (jr  operations 
u])on  the  throat,  in  suppurative  ilisease  of  the  nose  or  larynx,  occasionally 
even  of  the  car  (\'olkmann),  infective  jiarticles  reach  the  bronchial  tubes 
by  aspiration  and  excite  an  intense  inllammation  which  often  ends  in 
abscess.  Cancer  of  the  (esophagus,  ])erlorating  the  root  of  the  lung  or  info 
the  l)ronchi.  may  ])roduce  extensive  sup|)uration.  The  abscesses  vary  in 
size  from  a  walnut  to  an  orange,  and  have  ragged  and  irregular  walls,  and 
purulent,  sometimes  necrotic,  contents. 

(2)  Knd)olic,  so-called  metastatic,  abscesses,  the  result  of  infectious 
emboli,  are  extremely  common  in  a  large  ])ro])ortion  of  all  eases  of  pyaemia. 
They  nuiy  occur  in  enormous  numbers  and  ])resent  very  definite  char- 
actiTS.  As  a  rule  they  ai'e  sujierficial,  beneath  the  ])leura,  and  often 
wedgc-sha]ied.  At  first  firm,  grayish  red  in  color,  and  surrounded  by  a 
zone  of  intenso  hypera'uiia.  suppuration  soon  follows  with  the  forma- 
tion of  a  definite  a1)scess.     The  ])leura  is  nsually  covered  with  greenish 


NKW  OIIOWTIIS   IN  THE   lA'NGS, 


063 


w  I'tiiiiul, 
irin^'  lilo, 

lU'l'     tlltlHL' 

Id  detoft. 

;  of  inod- 
l(  [)r('.s.si(iii 
J  are  lliu 
u  uxlmus- 

)ry.  Till" 
IS  is  ortcii 
()>•(•(  1.     A 

I  inliaU'i', 
^niiiiiicol; 
id,  liii|)|)y 

II  attompt 
t'oliitioii. 
lie  locid- 

1M\L'     l)(.'l'll 

(>  dt'iliaild 


l-^l 


vin<,'  coii- 

1'.     Apart 

(•veil   in 

volw,  as 

ler  Jiand. 

)ii'atii)ii 

H'l'ations 

asionally 

ial  tuborf 

ends    in 

<:,  or  into 

vary  in 

alls,  and 

nfuetioiis 
pya'nua. 
ito  char- 
nd  often 
lied  l)y  a 
e  I'ornia- 
U-rccnisli 


lymph,  and    perforation  ^oinetiiiies   takes   ])laee   witli    the    production    id' 
pneiitiiothorax. 

(.'{)  Terforation  of  the  Inn;,'  from  uithont,  loil;;inent  of  forei;-!!  hodies, 
and,  in  the  ri^dit  inn;,',  perforation  from  ahseess  of  I'le  liver  or  u  suppiirat- 
in;^  eehinoi'oeeiis  cyst  are  occasional  caiisi's  of  pulmonary  ahscess. 

(I)  Suppurative  processes  play  an  inipniijint  part  in  chronic  [lulmonary 
tuliercidosis,  numy  of  the  symptoms  of  which  are  due  to  them. 

Symptoms.— Ahscess  followin;,'  pneumonia  is  easily  ri'co^'ni/ed  hy 
an  a;;;;!  a  \  at  ion  of  the  ^^'Ueral  sympton..  and  l)y  tlu'  physical  si^'us  oi  cavity 
and  the  iharacli'rs  of  the  expectoration.  Mndxtlic  alocesscs  cannot  often 
ho  recoj,'ni/.e(l,  and  the  local  symptoms  are  ^'eiierally  maskccj  in  the  gen- 
eral pya'uue  manifestations.  The  chara<'lers  of  the  sputum  are  of  >.':real 
importance  in  deterniiniu;,^  the  presenci'  of  ahscess.  The  odor  is  olTciisivc, 
yet  it  rarely  has  the  horrihle  fetor  of  gan;irene  oi'  oi  putrid  hronchitis. 
In  the  pus  fra^^nieiils  of  luny  tis>ue  can  he  seen,  and  the  elastic  tissue  may 
he  very  idMiiidant.  The  presence  of  this  uith  the  physical  si^^ns  rart  ._ 
leaves  any  cpiestion  as  to  the  luiture  (d'  the  trouiile.  I'indiolic  cases  u.-iially 
run  a  fatal  course.  Ileeovei'y  oecasioiudly  occurs  after  pneumonia.  In  a 
ease  following  typhoid  fever  uliich  I  saw  at  the  (iarlield  Hospital,  Kcri' 
removed  two  rihs  an<l  found  free  in  the  pus  of  a  localized  empyema  a 
secpu'st  rated  piece  of  lun;;,  the  size  of  the  palm  of  the  hand,  which  had 
slouched  oil'  clearly  fr(»m  the  lower  lohi'.  I'lie  patient  maile  a  good  re- 
covery. 

Medicinal  ti'ealment  is  of  little  avail  in  ahscess  of  the  lung.  When 
Well  delined  and  superlicial,  an  attempt  should  always  he  maile  to 
open  and  drain  it.  A  numhei'  (d'  i-ucccssful  cases  have  already  heeii 
treated  in  this  way. 


VIII.    NEW    GROWTHS    IN    THE    LUNGS. 

Etiology  and  Morbid  Anatomy. — A\hile  primary  tunu)rs  are 
rare,  secondary  growths  are  not  •uncomnmn. 

The  i)riniary  growths  of  the  lung  are  either  encephaloid.  scirrhus  or 
epithelioma.  L'ecent  observations  show  that  the  last  is  the  most  common 
form.  Sarcoma  also  is  occasionally  found  as  a  pi'imary  growth,  and  still 
more  rarely  encliondroma. 

The  secondary  growths  nuiy  be  of  various  forms.  Most  commonly  they 
follow  tumors  in  the  digestive  or  geidto-urinary  organs;  not  infre(picntly 
also  tunu)rs  of  the  bone.  There  may  be  encephaloid,  scirrhus.  epithelioma, 
colloid,  melano-sarcoma,  encliondroma,  or  osteoma. 

Primary  cancer  or  sarcoma  nsually  involves  only  one  lung.  '^rh(>  sec- 
ondary gi'owtbs  are  distributed  in  boilv  The  jji'lmary  growth  generally 
forms  a  large  mass,  wbich  may  occupy  ibe  greater  ])art  of  a  lung.  Occasion- 
ally the  secondary  growths  are  solitary  and  confined  chieily  to  the  ])leura. 
The  metastatic  growtbs  are  nearly  always  disseminated.  Occasionally  they 
oecnpy  a  large  portion  of  the  pnlmonary  tissne.  In  a  case  of  ccdloid  cancer 
secondary  to  cancer  of  the  pancreas,  I  found  both  lungs  vo'    ,ninous.  heavy 


GU 


DISEASES  OP  TUE  KESPlIlATUllY  SYSTEM. 


/ 


only  slightly  t'rc'i)itaiit,  aiid  occupit'd  by  circular  translucent  masses,  vary- 
ing in  si/e  li'oin  a  pcu  to  a  large  walnut. 

There  are  numerous  accessory  lesions  in  the  pulmonary  new  growths. 
There  may  he  pleurisy,  either  cancerous  or  sero-iibrinous.  The  oH'nsion 
may  be  ha'uutrrhagic,  but  in  ;:iOU  cases  of  cancer,  primary  or  secondary,  oi' 
tlie  lungs  and  pleura  analyzed  by  .Moutard-.Martin,  lucniorrhagic  etl'usion 
occurred  in  only  12  per  cent.  The  tracheal  and  l)ronchial  glands  are  usu- 
ally ail'ected,  the  cervical  glands  not  infrequently,  and  occasionally  even 
the  inguinal. 

The  disease  is  most  common  in  the  middle  period  of  life,  'l^le  pri- 
mary f(»rni  ail'ectu  the  sexes  equally,  but  secondary  cancer  is  nnicli  more 
frecpient  in  women  than  in  men.  The  conditions  which  j)redisp()se  to  it 
are  quite  unknown.  Jt  is  a  remarkable  fact  that  the  workers  in  the 
Schneeberg  cobalt  mines  are  very  liable  to  jn'imary  cancer  of  the  lungs. 
It  is  stated  that  in  this  region  a  considerable  pro])ortion  of  all  deaths  in 
l>ersons  over  forty  are  due  to  this  disease. 

Symptoms. — The  clinical  features  of  neoidasms  of  the  lungs  are  by 
no  means  distinctive,  i)articularly  in  the  case  of  primary  growths.  The 
patient  may,  indeed,  as  noted  by  "Walshe,  i)resent  no  symptoms  ])ointing 
to  intrathoracic  disease.  Among  the  more  important  symptoms  are  i)ain, 
particularly  when  the  pleura  is  involved;  dyspntea,  which  is  apt  to  be 
paroxysmal  when  due  to  pressure  U])on  the  trachea;  cough,  which  may  be 
dry  and  jjainful  and  accompanied  by  the  expectfViation  of  a  dark  mucoid 
s|)utum.  This  so-called  prune-juice  expectoration,  which  was  ])resent  10 
times  in  18  cases  of  })rinuiry  cancer  of  the  lung,  was  thought  by  Stokes 
to  be  of  great  diagnostic  value. 

In  many  instances  there  are  signs  of  comj)rcssion  of  the  large  veins, 
producing  lividity  of  the  face  and  ui)per  extremities,  or  occasionally  of 
only  one  arm.  Com])ression  of  the  trachea  and  bronchi  may  give  rise  to 
urgent  dyspna'a.  The  heart  may  be  jjushed  over  to  the  ojjposite  side. 
The  ])ncunu)gastric  and  recurrent  laryngeal  nerves  are  occasionally  in- 
volved in  the  growth. 

Physical  Signs. — 'i'ho  ])ati('nt,  according  to  AValsho,  usually  lies  on 
the  atfectcd  side.  On  inspection  this  side  may  be  enlarged  and  immo- 
bile and  the  intercostal  s])aces  are  obliterated.  This  is  more  commonly 
due  to  the  effusion  tlian  to  the  growth  itself.  'JMie  external  lymi)h- 
glands  may  be  enlarged,  ])articularly  the  clavicular.  The  signs,  on  per- 
cussion and  auscultation,  arc  varied,  depending  much  u|)on  the  pres- 
ence or  al)sence  of  fluid.  Signs  of  consolidation  are,  of  course,  present; 
the  tactile  fremitus  is  absent  and  the  breath-sounds  are  usually  dimin- 
ished in  intensity.  Occasionally  there  is  ty[)ical  bronchial  breathing. 
Among  other  sym])toms  may  be  mentioned  fever,  which  is  ])resent 
in  a  certain  number  of  cases.  Thnaciation  is  not  necessarily  extreme. 
The  duration  of  the  disease  is  from  six  to  eight  months.  Occasion- 
ally it  runs  a  very  acute  course,  as  noted  by  Carswell.  Cases  are  rc- 
])orted  in  which  death  occurred  in  a  month  or  six  weeks,  and  in  one  in- 
stance (Jaccoud)  the  ])atient  died  ''n  a  week  from  the  onset  of  the  symp- 
toms. 


ACUTE  PLEURISY. 


605 


OS,  vary- 

growtlis. 
c'lVusioii 
idury,  oi' 
eirusioii 
are  iisu- 
lly  even 

l^ic  pi'i- 
c'li  more 
ose  to  it 
3  in  the 
ic  lungs, 
leatlis  in 

;s  are  l)y 
IS.  The 
jjointing 
ire  pain, 
l)t  to  bo 
L  may  bo 
:  mucoid 
osont  10 
y  Stokes 

:;o  veins, 
inally  of 
0  rise  to 

to  side. 

ally  in- 

lies   on 
innno- 
inmonly 
]yini)li- 
on  per- 
10    pros- 
present; 
dimin- 
athing. 
])resent 
extreme. 
)('Ciision- 
are   re- 
one  in- 
V  sy nip- 


Diagnosis.— I  n  seeondary  growths  this  is  not  dilficult.  The  develop- 
luciit  ol'  ])ulnK)nary  symptoms  within  a  year  or  two  aJ'ter  (iio  removal  of 
a  I'aueer  of  the  breast,  or  after  tlie  amputation  of  a  liml)  for  osteo-sarcoma, 
or  the  onset  of  similar  symptoms  in  eonnootion  with  cancer  of  the  liver, 
(ir  of  the  uterus,  or  of  the  rectum,  would  be  exlremely  suggestive.  In 
piimary  cases  the  unihiteral  involvement,  tiio  anomrJ'Uis  character  of  tiu' 
]tliysical  signs,  the  occurrence  of  prune-juice  expectoration,  the  progressive 
wasting,  and  the  secondary  involvement  of  the  cervical  glands  are  the  im- 
portant points  in  the  diagnosis. 

New  growths  are  occasionally  primary  in  the  pleura  (Harris,  Journal 
of  Pathology,  vol.  ii). 


V.    DISEASES  OF  THE   PLEURA. 
I.    ACUTE    PLEURISY. 

Aratomically,  the  cases  may  be  divided  into  dry  or  adhesive  pleurisy 
and  })leurisy  with  elfusion.  Another  classilication  is  into  primary  or  sec- 
ondary forms.  According  to  the  course  of  the  disease,  a  division  may  bo 
made  into  acute  ami  chronic  })leurisy,  and  as  it  is  ini])ossible,  at  })resont, 
to  group  the  various  forms  etiologically,  this  is  ])orhai)s  the  most  satisfac- 
tory division.    The  following  forms  of  acute  ])leurisy  may  be  considered: 

I.  FiiJHiN'ors    ou    I'l.vstic    I'lkuhisy. 

In  this  the  jdoural  meml)rane  is  covered  by  a  sheeting  of  lymph  of 
variable  thickness,  which  gives  it  a  turbid,  granular  appearance,  or  the 
fibrin  may  exist  in  distinct  layers.  It  occurs  (1)  as  an  independent  atl'ec- 
tion,  following  cold  or  ex])osure.  This  form  of  acute  ])lastic  pleurisy 
without  fluid  exudate  is  not  connnon  in  ])erfectly  healthy  individuals. 
Cases  are  met  with,  however,  in  which  the  disease  sets  in  with  the  usual 
symptoms  of  pain  in  the  side  and  slight  fever,  and  there  are  the  physical 
signs  of  ])leurisy  as  indicated  by  the  friction.  After  ])ersisting  for  a  few 
days,  the  friction  murnnu'  disa])])ears  and  no  exudation  occurs.  Union 
takes  ])lace  between  the  mend)ranes,  aiul  ])()ssibly  the  pleuritic  adhesions 
which  are  found  in  such  a  largo  percentage  of  all  bodies  examined  after 
death  originate  in  these  slight  fibrinous  ])leurisies. 

Fil)rinous  ])lourisy  occtirs  (2)  as  a  secondary  jirocess  in  acute  diseases 
of  the  lung,  such  as  jmeumonia,  which  is  always  accompanied  by  a  certain 
amount  of  ])lcurisy,  usually  of  tliis  form.  Cancer,  abscess,  and  gangrene 
also  cause  ])lastic  pleurisy  when  the  surface  of  the  lung  becomes  involved. 
This  condition  is  sjiccially  associated  in  a  large  nuinber  of  cases  with 
tuberculosis.  Pleural  pain,  stitch  in  the  side,  and  a  dry  cough,  with 
marked  friction  sounds  on  auscultation  are  the  initial  ])henonu'na  in 
many  instances  of  ])hthisis.  The  signs  are  usually  basic,  but  Purney  Yeo 
has  recently  called  attention  to  the  frequency  with  which  they  occur  at 
the  ajiex. 


C66 


DISEASES  OF  THE  RESPIliATORY  SYSTEM. 


II.  SERO-FiBniNOUs    Plkuiusy. 


.  \ 

/ 


In  a  majority  of  cases  of  inflammation  of  tlic  pleura  there  is,  with  the 
fihriii,  a  variable  amount  of  iluid  exudate,  wliich  produces  the  condition 
known  as  ])leurisy  with  elfusion. 

Etiology. — l''or  generations  physicians  have  considered  cold  the 
l)otent  factor  in  inducing  pleurisy.  This  m.iy  be  true  in  many  cases,  but 
nujdern  views  of  serous  inllannnations  scarcely  recognize  cold  as  auytiiiug 
more  than  a  ])i'('(lisposing  iigcnt,  which  jjcrmits  liie  action  of  various  micro- 
organisms. We  iiave  Jiot  yet,  however,  brouglit  all  the  acute  iileurisies  into 
the  category  of  niicrobic  all'ections,  and  the  fact  remains  that  pleurisy 
does  follow  witli  great  rapidity  a  sudden  wetting  or  a  chill.  Of  late 
years  an  attempt  has  heen  made,  ])articularly  by  French  writers,  to  show 
that  the  nuijority  of  acute  [)leurisies  are  tuberculous.  In  this  connection 
the  following  facts  may  be  admitted:  (1)  Jn  a  large  number  of  cases 
of  pleurisy  coming  on  abruptly  in  healtliy  ])ersons  the  disease  has  been 
shown — [ii)  by  ])ost-mortem,  in  cases  of  accidental  or  sudden  death,  {b)  by 
the  suljseipient  history — to  be  tuberculous;  {'i)  in  a  larger  ])rop()i'tion  of 
those  cases  which  come  on  insidiously  in  jjcrsons  who  have  been  in  failing 
health  or  who  are  delicate  the  disease  is  tubereulons  from  the  outset;  (3) 
the  acute  pleurisy,  which  occurs  as  a  secondary,  often  a  terminal,  event  in 
chi-onic  all'ections,  snch  as  cirrhosis  of  the  liver,  Bright's  disease,  and  Ciwi- 
cer,  is  very  fretpiently  tuberculous.  I  confess  that  the  more  carefully  I 
have  studied  the  (piestion  the  larger  does  the  jiroportion  ajipear  to  be  of 
primary  plenrisies  of  tubereulons  origin.  '^I'he  sid)sequent  history  of  cases 
of  acute  pleurisy  forces  ns  to  conclude  that  in  at  least  two  thirds  of  tlie 
cases  it  is  a  cnral)le  all'ection.  This  may  well  be  so,  according  to  our  ])res- 
ent  ideas  of  local  tuberculous  disease.  Several  years  ago  I  looked  over 
the  post-mortem  records  of  101  successive  cases  which  had  died  in  my  wards 
vith  pleurisy — fibrinous, scro-fibrinous,  hannorrhagic,or  purulent.  Of  these, 
^here  were  only  32  in  which  the  ])leurisy  was  definitely  tuberculous.  One 
of  the  most  interesting  contrilnitious  to  this  question  has  been  made  from 
the  records  of  Henry  I.  fJowditch,  of  Uoston.  to  whom  we  are  indebted  for 
so  many  important  additions  to  our  knowledge  of  pleurisy.*  Of  90  cases 
of  acute  ])]eurisy  which  had  been  under  observation  between  1849  and 
18T9,  32  died  of  or  had  phtliisis — a  jjercentage  large  enough  to  indicate 
what  an  important  role  tul)erculosis  plays  in  the  etiology  of  this  disease. 

Bactcriohifjy  of  Aculc  Pleurisi/. — From  a  bacteriological  standpoint  we 
may  recognize  three  groups  of  cases  of  acute  pleurisy:  the  tuberculous,  the 
pneumococcus,  and  the  streptococcus. 

The  hnrillvs  tvhrrculnsis  is  ]irepent  in  a  very  large  proportion  of  nil 
cases  of  jn-imary  or  so-called  idiojiathic  ])leurisy.  The  exudate  is  usually 
sterile  on  cover-slips  or  in  the  culture  and  inoculation  tests  made  in  thn 
ordinary  way.  as  the  bacilli  are  very  scanty.  Tt  has  been  demonstrated 
clearly  that  a  large  amount  of  tlic  exudate  must  be  taken  to  make  the  test 
complete,  cither  in  cidturcs  or  in  the  inoculation  of  animals.     Eichhorst 


Vincent  V.  Bowditch,  in  Boston  Mcilical  and  Surgical  Journal,  1889. 


ACUTE   TLEURISY, 


GG7 


1  of  all 
usually 

iu    tl!'> 

istrated 
the  test 
leliliorst 


found  tliat  more  that  G'i  per  cent  were  demonstrated  as  tuberculous  when 
as  mucli  as  15  ce.  of  tlie  e\u«hite  was  inoculated  into  test  animals,  wiiile 
less  than  10  i)er  cent  of  the  cases  showed  tnhiTculosis  when  only  1  cc.  of  the 
exudate  was  used.  This  is  a  ])oint  to  which  observers  should  j)ay  very 
special  attention.  J^e  Damany  has  recently  in  55  prinuiry  ])leiirisies  demon- 
strated the  tuberculous  character  of  all  but  4.  lie  has  used  large  quantities 
of  the  iluid  for  his  inoculation  exiteriments. 

The  pneumococcus  pleurisy  is  almost  always  secondary  to  a  focus  of 
inllammation  in  the  lung.  It  may,  however,  be  primary.  The  exudate  is 
usually  purulent  and  the  outlook  is  very  favorable. 

The  strei)tococcus  pleurisy  is  the  typical  septic  form  which  nuiy  occur 
cither  from  direct  infection  of  the  i)leura  through  the  lung  in  broncho- 
pneumonia, or  in  cases  of  streptococcus  ])neumonia;  iji  other  instances  it 
I'ollows  infection  of  more  distant  ]>arts.  The  acute  streptococcus  pleurisy  is 
the  most  serious  and  fatal  of  all  forms. 

Among  other  bacilli  which  have  l)een  found  ai'e  the  staphylococcus, 
Frit'dliindcr's  bacillus,  the  ty[)hoid  bacillus,  and  the  diphtheria  bacillus. 

Morbid  Anatomy. — In  sero-fibrinous  ])leurisy  the  serous  exudate  is 
abmidant  and  the  fibrin  is  found  on  the  ])leural  surfaces  and  scattered 
'rough  the  fluid  in  the  form  of  flocculi.  The  pro])ortion  of  these 
.nstituents  varies  a  great  deal.  In  some  instances  there  is  very  little 
jnembraiu)us  fibrin;  in  others  it  forms  thick,  creamy  layers  and  exists 
ill  tlie  de])endent  ])art  of  the  fluid  as  whitish,  curd-like  masses.  The 
fluid  of  sero-fibrinous  ])leurisy  is  of  a  lemon  color,  either  clear  or  slightly 
turbid,  depending  on  the  number  of  formed  elements.  In  some  instances 
it  has  a  dark-brown  color.  The  microscopical  examination  of  the  fluid 
shows  leucocytes,  occasional  swollen  cells,  which  may  possibly  be  derived 
from  the  ])leural  endothelium,  shreds  of  fibrillated  fibrin,  and  a  variable 
number  of  red  blood-corpuscles.  On  boiling,  the  fluid  is  found  to  be  rich 
in  albumin.  Sometimes  it  coagulates  spontaneously.  Its  composition 
closely  resembles  that  of  blood-serum.  C'holesterin,  uric  acid,  and  sugar 
are  occasionally  found.  The  anu)unt  of  the  effusion  varies  from  ^  to  4 
litres. 

The  lung  in  acute  sero-fibrinous  p.eurisy  is  more  or  less  compressed.  If 
the  exudation  is  limited  the  lower  lobe  alone  is  atelectatic;  but  in  an  exten- 
sive effusion  which  reaches  to  the  clavicle  the  entire  lung  will  be  found 
lying  close  to  the  s]tine,  dark  and  airless,  or  even  bloodless — i.  e.,  car- 
nified. 

In  large  exudations  the  adjacent  organs  are  dis])laced.  In  large  right- 
sided  ]deurisies  the  liver  is  much  de])ressed.  IJather  varying  statements 
are  made  with  reference  to  the  position  of  the  heart  and  as  to  whether  or 
not  it  rotates  on  its  axis.  In  a  number  of  ])ost-mortems  I  have  carefully 
studied  its  position,  both  in  ]meumothorax  and  in  large  elfusions,  a'^l  can 
s|:eak  with  some  degree  of  certainty  on  the  following  ])oints:  (1)  Even  in 
the  most  extensive  left-sided  exudation  there  is  no  rotation  of  the  apex 
of  the  heart,  which  in  no  case  was  to  the  right  of  the  mid-sternal  line; 
(2)  the  relative  position  of  the  apex  and  base  is  iisually  maintained;  in 
some  instances  the  apex  is  lifted,  in  others  the  whole  heart  lies  more  trans- 


I 


/ 


M 


668 


DISEASES  OP  THE  IlESPIRATORY  SYSTEM. 


vorsely;  (3)  the  ri},Iit  cIii;iiil)iTs  of  tlic  licart  occu})}'  tlu;  ^n'cator  portion  of 
the  front,  so  that  the  displaccniont  is  ratlicr  a  dclinito  dislocation  of  tho 
niL'diastiniini,  with  the  pericardium,  to  the  right,  tlian  any  special  twisting 
of  tlie  heart  itself;  (4)  the  kink  or  twist  in  tiie  inferior  vena  cava  described 
by  JJartels  was  not  i)rcsent  in  any  of  the  cases. 

Symptoms. — Prodromes  are  not  uncommon,  but  the  disease  may  set 
in  al)ruptly  with  a  chill,  followed  by  fever  and  a  severe  pain  in  the  side. 
In  very  many  cases,  however,  the  onset  is  insidious.  Washbourn  has  called 
attention  to  the  frequency  with  which  the  ])neumococcus  pleurisy  sets  in 
with  the  features  of  ])neumonia.  The  pain  in  the  side  is  the  most  distress- 
ing symj)tom,  and  is  usually  referred  to  the  nipple  or  axillary  regions.  It 
must  be  remembered,  however,  that  ])leuritic  ])ain  may  be  felt  in  the  abdo- 
men or  low  down  in  the  back,  ])articularly  when  the  diai)hraglnatic  sur- 
face of  the  pleura  is  involved.  It  is  lancinating,  sharp,  and  severe,  and  is 
aggravated  liy  cough.  At  this  early  stage,  on  auscultation,  sometimes  in- 
deed on  pal])ation,  a  dry  friction  rub  can  be  detected.  The  fever  rarely 
rises  so  rapidly  as  in  pneumonia,  and  does  not  reach  the  same  grade.  A 
temperature  of  from  102°  to  103°  is  an  average  pyrexia.  It  may  drop  to 
normal  at  the  end  of  a  week  or  ten  days  without  the  a])pearance  of  any 
definite  change  in  the  physical  signs,  or  it  may  persist  for  several  weeks. 
The  temperature  of  the  affected  is  higher  than  that  of  the  sound  side. 
Cough  is  an  early  symptom  in  acute  pleurisy,  but  is  rarely  so  distressing  or 
so  frequent  as  in  pneumonia.  There  are  instances  in  which  it  is  absent. 
The  expectoration  is  usually  slight  in  amount,  mucoid  -n  character,  and 
occasionally  streaked  with  blood. 

At  the  outset  there  may  be  dyspnoea,  due  partly  to  the  fever  and  partly 
to  the  pain  in  the  side.  Later  it  results  from  the  compression  of  the  lung, 
particularly  if  the  exudation  has  taken  place  rapidly.  "When,  however, 
the  fluid  is  effused  slowly,  one  lung  may  be  entirely  compressed  without 
inducing  shortness  of  breath,  except  on  exertion,  and  the  patient  will  lie 
quietly  in  bed  without  evincing  the  slightest  respiratory  distress.  "When  the 
effusion  is  large  the  patient  usually  prefers  to  lie  upon  the  affected  side. 

Physical  Signs. — Inspection  shows  some  degree  of  immobility  on  the 
affected  side,  dejwnding  upon  the  amount  of  exudation,  and  in  large  effu- 
sions an  increase  in  volume,  wiiich  may  appear  to  be  much  more  than  it 
really  is  as  determined  by  mensuration.  The  intercostal  spaces  are  obliter- 
ated. In  right-sided  effusions  the  apex  beat  may  be  lifted  to  the  fourtli 
interspace  or  be  pushed  beyond  the  left  nipple,  or  may  even  be  seen  in  tho 
axilla.  When  the  exudation  is  on  the  left  side,  the  heart's  impulse  may 
not  be  visible;  but  if  the  effusion  is  large  it  is  seen  in  the  third  and  fourth 
spaces  on  the  right  side,  and  sometimes  as  far  out  as  the  nipple,  or  even 
beyond  it. 

Palpation  enables  us  more  successfully  to  determine  the  deficient  move- 
ments on  the  affected  side,  and  the  obliteration  of  the  intercostal  spaces, 
and  more  accurately  to  define  the  position  of  the  heart's  impulse.  In  sim- 
ple sero-fibrinous  effusion  there  is  rarely  any  oedema  of  the  chest  walls. 
It  is  scarcely  ever  possible  to  obtain  fluctuation.  Tactile  fremitus  is  greatly 
diminished  or  abolished.     If  the  effusion  is  slight  there  may  be  only  en- 


ii'tion  of 

n  of  tho 

twisting 

lose  ri  bed 


may  set 
the  side. 
as  called 
y  sets  in 

distress- 
ions.  It 
he  abdo- 
atic  sur- 
e,  and  is 
times  in- 
er  rarely 
rade.  A 
'  drop  to 
e  of  any 
al  weeks, 
ind  side, 
■essing  or 
is  absent, 
cter,  and 

id  partly 

he  lung, 

however, 

without 

will  lie 

hen  the 

I  side. 

on  tho 

Hi  effu- 

than  it 

obliter- 

fourth 

In  in  the 

Ise  may 

fourth 

or  even 

It  movo- 
spacos, 

I  In  sim- 

[t  walls, 
greatly 

Inly  en- 


ACUTE  PLEUUISY. 


669 


fecblement.  The  absence  of  the  voice  vibrations  in  effusions  of  any  size 
constitutes  one  of  the  most  valuable  of  i)hysical  signs.  In  children  there 
may  be  much  elfusion  witli  retention  of  fremitus.  Jn  rare  cases  the  vilira- 
tions  may  be  communicated  to  the  chest  walls  through  localized  pleural 
adhesions. 

Mensitralion. — With  the  cyrtometer,  if  the  effusion  is  excessive,  a  dif- 
ference of  from  half  an  inch  to  an  inch,  or  even,  in  large  ell'usions,  an 
inch  and  a  half,  may  be  found  between  tho  two  sides.  Allowance  must 
bo  made  for  the  fact  that  the  right  side  is  naturally  larger  than  the  left. 
With  the  saddle-tai)e  the  dill'orence  in  expansion  between  the  two  sides 
can  be  conveniently  measured. 

Percussion. — Early  in  tho  disease,  when  the  i)ain  in  the  side  is  severe 
and  the  friction  murmur  evident,  there  may  be  no  alteration,  but  with 
the  gradual  accumulation  of  the  iluid  the  resonance  becomes  defective, 
and  finally  gives  place  to  absolute  flatness.  From  day  to  day  the  gradual 
increase  in  height  of  the  fluid  may  be  studied.  In  a  pleuritic  elfusion 
rising  to  the  fourth  rib  in  front,  the  percussion  signs  are  usually  very 
suggestive.  In  the  subclavicular  region  the  attention  is  often  aroused  at 
once  by  a  tympanitic  note,  the  so-called  Skoda's  resonance,  which  is  heard 
perhaps  more  commonly  in  this  situation  with  pleural  effusion  than  in 
any  other  condition.  It  shades  insensibly  into  a  flat  note  in  the  lower 
mammary  and  axillary  regions.  Skoda's  resonance  may  be  obtained  also 
behind.  Just  above  the  limit  of  effusion.  The  dulness  has  a  peculiarly 
resistant,  wooden  quality,  differing  from  that  of  pneumonia  and  readily 
recognized  by  skilled  fin^rers.  It  has  long  been  known  that  when  the 
jtationt  is  in  the  erect  posture  the  upper  line  of  dulness  is  not  horizontal, 
Init  is  higher  behind  than  it  is  in  front,  forming  a  parabola.  The  curve 
marking  the  intersection  of  the  plane  of  contact  of  lung  and  fluid  with 
the  chest  wall  has  been  variously  described.  The  "  Ellis  line  of  flatness," 
which  Garland  has  verified  clinically  and  by  animal  experiments,  is  per- 
liaps  the  most  characteristic.  With  medium-sized  effusions  "  this  line  begins 
lowest  behind,  advances  upward  and  forward  in  a  letter-S  curve  to  the 
axillary  region,  whence  it  proceeds  in  a  straight  decline  to  the  sternum." 
Such  a  curve  is  present  only  when  the  patient  is  in  the  erect  position, 
when  the  lung  is  in  fairly  normal  condition,  since  then  by  its  elastic  ten- 
sion it  controls  the  position  and  shape  of  the  mass  of  iluid,  even  supporting 
the  entire  weight  of  a  consideralde  exudate,  and  when  the  pleurae  are  free 
from  adhesions.  With  larger  exudates  the  curve  flattens  much,  but  the  S  can 
be  detached  with  the  fluid  as  high  as  the  third  rib.  Garland  emphasizes 
that  the  line  can  be  accurately  determined  only  by  light  percussion.  (Gar- 
land's exhaustive  work  on  Pneumo-dynamics.) 

On  the  right  side  the  dulness  passes  without  change  into  that  of  the 
liver.  On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate 
Traube's  semilunar  space.  If  the  effusion  is  moderate,  the  phenomenon 
of  movable  dulness  may  be  obtained  by  marking  carefully,  in  the  sitting 
IKisture,  the  upper  limit  in  the  mammary  region,  and  then  in  the  recum- 
bent posture,  noting  the  change  in  the  height  of  dulness.  This  infallible 
sign  of  fluid  cannot  always  be  obtained.     In  very  copious  exudation  the 


G70 


DISEASES  OP  THE  RESPIRATOllY  SYSTEM. 


/ 


(liiliicss  iiuiy  ix'iuli  till!  cliiviclc  and  even  extend  beyond  the  bt  r.iui  margin 
oi'  tlie  opposite  side. 

Ausailtdtiuii. — Karly  in  tlie  disease  a  friction  rub  can  usually  be  lieard, 
wliicii  disappears  as  the  ihiid  aeeuniulates.  Jt  is  u  to-and-l'i'o  dry  rub,  close 
to  the  eai',  and  has  a  leatiiery,  creaking  character.  There  is  another  pleural 
friction  sound  which  closely  resembles,  and  is  scarcely  to  be  distinguished 
IVoin,  the  line  crackling  crepitus  of  pneumonia.  This  may  bo  heard  at  the 
cniiiiiu'ncement  of  the  disease,  and  also,  as  pointed  out  in  JSI  1  by  ^Lu'- 
honnell,  Sr.,  of  ^lojdreal,  when  the  ell'usion  has  receded  and  the  pleural 
Liyei's  com(!  togetlier  again. 

\\'ith  even  a  slight  exudation  there  is  weakened  or  distant  breathing. 
Often  inspiration  and  expiration  are  distinctly  audible,  though  distant,  and 
Jiave  a  tubular  (piality.  Sometimes  oidy  a  ])uning  tubular  expiration  is 
heard,  which  may  have  a  metallic  or  amphoric  (juality.  J^oud- resonant 
rales  accompanying  this  may  forcibly  suggest  a  cavity.  These  i)seudo- 
cavernous  signs  are  met  with  more  frequently  in  children,  and  often  lead 
to  error  in  diagnosis.  Above  the  line  of  dulness  the  breath-sounds  are  usu- 
ally harsh  and  exaggerated,  and  nuiy  have  a  tubular  quality. 

The  vocal  I'csoiumce  is  usually  diuunished  or  absent.  The  whispered 
voice  is  said  to  be  transnutted  through  a  serous  and  not  through  a  puru- 
lent exudate  (Baceelli's  sign).  This  author  advises  direct  auscultation  in 
the  antero-lateral  region  of  the  chest.  There  may,  however,  Ije  intensifica- 
tion— bronchophony.  The  voice  sometimes  has  a  curious  nasal,  s([ueaking 
chai'acter,  which  was  tei'uied  ]jy  J^aennec  wnophuiuj,  from  its  sui)posed  re- 
semblance to  the  bleating  of  a  goat.  In  typical  form  this  is  not  common, 
but  it  is  by  no  means  rare  to  hear  a  curious  twang-like  quality  in  the  voice, 
l)articularly  at  the  outer  angle  of  the  scapula. 

In  the  exanuiuditni  of  the  heart  in  cases  of  })leuritic  effusion  it  is  well 
to  bear  in  mind  that  wlien  the  i\\)ex  of  the  heart  lies  beneath  the  sternum 
there  may  l)e  no  impulse.  The  determination  of  the  situation  of  the  organ 
may  rest  with  the  jx'i^ition  of  nuiximum  loudness  of  the  sounds.  Over  the 
dis])laced  organ  a  systolic  murniur  inay  1)e  heard.  When  the  lappet  of  lung 
over  the  pericardium  is  involved  on  either  side  there  may  be  a  pleuro-peri- 
cardial  friction.     A  leucoeytosis  is  usually  present. 

The  coKisc  of  acute  sero-fibrinous  jjleurisy  is  very  variable.  After  per- 
sisting for  a  week  or  ten  days  the  fever  suljsides,  the  cough  and  ])ain  dis- 
appear, and  a  slight  effusion  may  be  quickly  absorbed.  In  cases  in  which 
the  efl'usion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
]\[any  instances  come  under  observation  for  the  first  time,  after  two  or  three 
weeks'  indis]iosition,  with  the  fluid  at  a  level  with  the  clavicle.  The  fever 
may  last  from  ten  to  twenty  days  without  exciting  anxiety,  though,  as  a 
rule,  in  ordinary  ])leurisy  from  cold,  as  we  say,  the  temperature  in  cases  of 
moderate  severity  is  normal  within  eight  or  ten  days.  Left  to  itself  the 
luitural  tendency  is  to  resor])tion;  but  this  may  take  place  very  slowly. 
With  the  absorption  of  the  fluid  there  is  a  redux-friction  crepitus,  either 
li'atliory  and  creaking  or  crackling  and  rale-like,  and  for  months,  or  even 
longer,  the  defective  resonance  and  feeble  breathing  are  heard  at  the  base. 
Rare  modes  of  termination  are  perforation  and  discharge  through  the  lung, 


margin 


(•  hoard, 
lb,  elo^c 
■  pleural 
ij^uislii'd 
d  at  the 
by  ^Lk- 
pleiiral 

■ealhin•,^ 
ant,  ami 
ration  irf 
resonant 

pseudo- 
"ten  lead 

are  usii- 

■hispered 
a  puru- 
tation  in 
tensiiiea- 
(iueakinj^ 
)osed  re- 
eomnion, 
he  voice. 


ACUTE  PLEURISY. 


071 


is  well 
sternum 
e  organ 
vcr  the 
of  Inuii" 
ro-peri- 

tor  per- 
ain  dis- 
1  wliieli 

slower, 
or  throt! 
le  fever 
'h,  as  a 
cases  of 
self  the 

slowly. 

,,  either 

or  even 

he  base. 

he  lung, 


and  externally  through  the  chest  wall,  examples  of  which  have  been  re- 
corded by  Sahli. 

A  sero-filjrinous  exudate  may  i)ersist  for  months  without  change,  ]iar- 
ticularly  in  tuberculous  cases,  and  will  sonu'times  reaccumulate  ai'ter  aspi- 
lation  and  resist  all  treatment.  After  persistence  for  more  than  twelve 
months,  in  spite  of  repeated  tapping,  a  serous  eil'usion  was  cured  by  iiu'i- 
>i(in  without  deformity  of  the  chest  (S.  West).  The  change  of  the  exudate 
into  pus  will  be  spoivcn  of  in  connection  with  em[)yema.  Death  is  a  rare 
tcruunation  of  sero-tlbrinous  elfusion.  When  one  pleura  is  full  and  the 
heart  is  greatly  dislocated,  the  condition,  although  in  a  majority  of  cases 
producing  remarkably  little  disturbance,  is  not  without  risk.  Sudden  dcaih 
\\Vi\y  occur,  and  its  possibility  iiuder  these  circumstances  should  always  be 
( ousidered.  1  have  seen  two  instances — one  in  right  and  the  other  in  left 
sided  elfusion — both  due,  apparently,  to  syncope  following  slight  exertion, 
such  as  getting  out  of  bed.  In  neither  case,  however,  was  the  amount  of 
thud  excessive.  Weil,  who  has  studied  carefully  this  accident,  concludes 
as  follows:  (1)  That  it  may  be  due  to  thrombosis  or  eml)olisni  of  the  heart 
or  pulmonary  artery,  (edema  of  the  opposite  lung,  or  degeneration  of  tlio 
heart  muscle;  {'i)  such  alleged  causes  as  mechanical  impediment  to  the  cir- 
culation, owing  to  dislocation  of  the  heart  or  twisting  of  the  great  vessels, 
require  further  investigation.  Death  may  occur  without  any  premonitory 
symptoms. 

III.  PuRULKXT  I'leuuisy  {E mpyoim). 

Etiology. — Pus  in  the  pleura  is  met  with  nnder  the  following  condi- 
tions: {a)  As  a  sequence  of  acute  sero-fibrinous  pleurisy.  It  is  not  always 
easy  to  say  why,  ''n  certain  cases,  the  exudate  becomes  purulent.  It  rarely 
does  so  in  the  .jute  pleurisies  of  healthy  individuals.  In  children  many 
cases  are  probably  purulent  from  the  onset.  Aspiration,  which  is  said  to 
favor  the  occurrence  of  emj)yema,  in  my  experience  does  so  very  rarely. 
(b)  Purulent  ])leurisy  is  common  as  a  secondary  inflammation  in  various 
infectious  diseases,  among  which  scarlet  fever  takes  the  first  place.  It  has 
long  been  known  that  the  pleurisy  supervening  in  the  convalescence  of  this 
disease  is  almost  always  purulent.  It  should  be  remembered  that  it  is  latent 
in  its  onset,  and  that  there  may  be  no  pulmonary  symi)toins.  The  ])leurisy 
following  tyjihoid  fever  is  also  usually  purulent.  Other  infectious  diseases 
— measles  and  whooping-cough — are  more  rarely  followed  Ijy  this  compli- 
cation. Of  late  years  especial  attention  has  been  i)aid  to  the  connection 
of  pneumonia  with  empyema,  and  it  has  been  shown  that  very  many  cases 
come  on  insidiously  either  in  the  course  of  or  during  convalescence  from 
this  disease;  and,  lastly,  a  limited  number  of  tuberculous  ])leurisies  early 
become  purulent,  {c)  Empyema  results  from  local  causes — fracture  of  the 
lil).  penetrating  wounds,  malignant  disease  of  the  lung  or  asophagus,  and, 
perhaps  most  frequently  of  all,  the  perforation  of  the  pleura  by  tuberculous 
cavities. 

The  bacteriology  of  empyema  is  of  great  importance.  A  sterile  exudate 
suggests  tuberculosis.  In  many  cases  the  pneumococci  are  present, and  these 
cases,  as  a  rule,  run  a  verv  favorable  course.  The  streptococci  are  found 
43 


072 


DISEASES  OP  TllK  IlESIMUATOllY  SYSTEM. 


/ 


most  commonly  in  llic  sccoiidnrv  cnscs  in  connoction  witli  septic  processes. 
]n  a  few  instil iKTS  psorosiJi'rnis  have  been  present. 

Morbid  Anatomy. — On  openiiifx  an  empyema  post  mortem,  we  usu- 
nlly  lind  tliat  tlie  ell'iision  has  separated  into  a  clear,  jfreenish-yeilow  serum 
above  and  tiie  lliit-k,  ereani-lil<e  pus  l)eh)\v.  The  lluid  nmy  be  scarcely 
nuire  than  turbid,  with  tloceuli  of  fibrin  tiirouudi  it.  In  tlie  pneumoeoeeus 
em])yeiMa  tlie  pus  is  usually  thick  aiul  creamy.  It  usually  has  a  heavy, 
sweetish  odor,  but  in  some  instances — particularly  those  following;  wounils 
— it  is  fetid.  In  cases  of  t;anjj;rene  of  the  lun«i  or  pleura  the  pus  has  a 
horribly  stinkiu^^  odor.  Microscopically  it  has  the  characters  of  ordinary 
pus.  The  pleural  membranes  are  greatly  thickened,  and  present  a  jj;rayisli- 
whitc  layer  from  I  to  3  mm.  in  thickness.  On  the  costal  pleura  there  may 
be  erosions,  and  in  old  ca.ses  fistulous  communications  are  conunon.  The 
lunj;  nuiy  be  compressed  to  a  very  snuill  limit,  and  the  visceral  pleura  also 
nuiy  show  perforations. 

Symptoms. — I'urulent  pleurisy  may  begin  abruptly,  with  the  symp- 
toms already  described.  More  fre(iuently  it  comes  on  insidiously  in  the 
course  of  other  diseases  or  follows  an  ordinary  sero-fibrinous  pleurisy.  There 
may  l)e  no  ])ain  in  the  chest,  very  little  cough,  and  no  dyspnoea,  unless  the 
side  is  very  full.  Sym})toms  of  septic  infection  are  rarely  wanting.  If 
in  a  child,  there  is  a  gradually  develo])ing  i)allor  and  weakness;  sweats  occur, 
and  there  is  irregular  fever.  A  cough  is  by  no  means  constant.  The  leu- 
cocytes are  usually  much  increased;  in  one  fatal  case  they  numbered  315,- 
OUO  ]ier  cubic  millimetre. 

Physical  Signs. — Practically  they  are  those  already  considered  in  pleu- 
risy with  effusion.  There  are,  however,  one  or  two  additional  points  to  be 
mentioned.  In  empyenui,  i)articularly  in  children,  the  disproportion  be- 
tween the  sides  may  be  extreme.  The  intercostal  si)aces  may  not  only  be 
obliterated,  but  may  bulge.  Not  infrequently  there  is  (edema  of  the  chest 
walls.  The  network  of  subcutaneous  veins  may  be  very  distinct.  It  must 
not  be  forgotten  that  in  children  the  breath-sounds  may  be  loud  and  tiibuhir 
over  a  purulent  effusion  of  considerable  size.  Whispered  ])ectoriloquy  is 
usually  not  heard  in  empyema  (iiaccelli's  sign).  Tin  dislocation  of  the 
heart  and  the  dis]ilacement  of  the  liver  are  more  marked  in  emjiyema  than 
in  sero-fibrinous  effusion — probably,  as  Senator  suggests,  owing  to  the 
greater  weight  of  the  fluid. 

A  curious  phenomenon  associated  generally  with  empyema,  but  which 
may  occur  in  the  sero-fibrinous  exudate,  is  pulsating  pleurisi/,  first  described 
by  ;MacUonnell,  Sr.,  of  Montreal.  Of  42  cases  39  occurred  on  the  left  side. 
In  all  but  one  case  the  fluid  was  purulent.  Pneumothorax  may  be  present. 
There  are  two  groups  of  cases,  the  intrapleural  pulsating  pleurisy  and  the 
pulsating  empyema  necessitatis,  in  which  there  is  an  external  pulsating 
tumor.  Xo  satisfactory  explanation  has  been  offered  how  the  heart  im- 
pulse is  thus  forcibly  communicated  through  the  effusion. 

Empyema  is  a  chronic  affection,  Avhich  in  a  few  instances  terminates 
naturally  in  recovery,  but  a  majority  of  cases,  if  left  alone,  end  in  death. 
The  following  are  some  modes  of  natural  cure:  (a)  By  absorption  of  the 
fluid.     In  small  effusions  this  may  take  place  gradually.     The  chest  Mall 


1 

I 


pr 


UCOStfCS. 


,  we  \isu- 
u\v  soriim 
!  scarcely 
inococcus 

a  licavv, 
jf  wounds 
[)U3  has  a 

ordinary 
a  grayisli- 
tlicro  niav 
ion.  Tho 
(Icura  alijo 

the  symp- 
jly  in  tho 
ly.  There 
unless  tlie 
nting.  It" 
eats  occur, 
The  leu- 
)ered  115,- 

d  in  plou- 

lints  to  ho 

ortion  he- 

;  only  ho 

the  chest 

It  must 

I  tubular 

>riloquy  is 

on  of  the 

^oma  than 

to   the 

3ut  which 
lescrihed 
left  side. 

)e  present. 
'  and  tho 
pulsating' 

heart  im- 

terminatos 
in  death, 
on  of  tho 
chest  wall 


ACUTE  PLEURISY. 


073 


)in 


tiidvs.  Tho  pleural  layers  heconie  {.'reatly  Ihickened  and  enclose  l)etween 
tlieni  the  inspissated  pus,  in  which  lime  salts  are  gradually  de|»osited.  Sueli 
a  condition  nuiy  he  sci'ii  once  or  twice  a  year  in  the  ixist-niorteni  room  of 
any  larg'e  hospital.  (/>)  \\\  perforation  of  the  lung'.  Although  in  this 
event  death  may  take  place  rapi<lly,  by  sulVoi-ation,  as  .\ret:eus  says,  yet 
ill  cases  in  which  it  occurs  liradually  recovery  nuiy  follow.  SiiU'o  l.s7;5, 
when  1  saw  a  case  of  this  kind  in  Trauhe's  clinic,  and  heard  his  remarks 
(111  the  suhject,  I  have  seen  a  iiumher  of  instances  (»f  the  kind  and  can 
corrohorate  his  statement  as  to  the  I'avorahle  termination  of  many  of  them. 
I'.iiipycma  may  discharge  either  by  o[iening  into  tho  hronchus  and  forming 
a  listula,  or,  as  Trauhe  pointed  out,  by  jirodueing  necrosis  of  the  pulmonary 
pleura,  sullieient  to  allow  the  soakage  of  the  pus  through  the  s^xingy  lung 
tissue  into  the  hronchi.  In  the  first  way  juieumothorax  usually,  though 
not  always,  develops.  Jn  the  second  way  the  i)us  is  discharged  without 
formation  of  pneumothorax.  ]']ven  with  a  bronchial  fistula  recovery  is  pos- 
sil)le.  (c)  By  jierforation  of  the  chest  wall — empyema  necessitatis.  This 
is  by  no  means  an  unfavorable  method,  as  many  cases  recover.  The  i)er- 
loration  nuiy  occur  anywhere  in  the  chest  wall,  hut  is,  as  C'ruveilhier  re- 
marked, more  common  in  front.  It  nuiy  be  anywhere  from  the  third  to 
the  sixth  interspace,  usually,  according  to  ^Marshall,  in  the  fifth.  It  may 
jierforate  in  more  than  one  i)lace,  and  there  may  be  a  fistulous  comnuinica- 
tiou  which  oi)ens  into  the  ])leura  at  some  distance  from  the  external  orifice. 
The  tumor,  when  near  the  heart,  may  ])ulsato.  The  discharge  may  jiorsist 
for  years.  In  Copeland's  Dictionary  is  mentioned  an  instance  of  a  l>a- 
varian  physician  who  had  a  pleural  fistula  for  thirteen  years  and  enjoyed 
fairly  good  health. 

An  emjiyema  may  perforate  the  neighboring  organs,  the  cesophagns, 
])eritona'um,  pericardium,  or  the  stomach.  Very  remarkable  cases  are  those 
which  ])ass  down  the  spine  and  along  the  psoas  into  the  iliac  fossa,  and 
simulate  a  psoas  or  lumbar  abcess. 

IV.  Tuberculous  Pleurisy. 

This  has  already  been  considered  (p.  284),  and  the  symptoms  and  phys- 
ical signs  do  not  require  any  description  other  than  that  already  given  in 
connection  with  the  sero-fibrinous  and  pnmlent  forms. 

V.  Other  Varieties  of  Pleurisy. 

HaBmorrhagic  Pleurisy. — A  bloody  ofTusion  is  mot  with  under  the  fol- 
lowing conditions:  (a)  In  the  ])leurisy  of  asthenic  states,  such  as  cancer, 
ISright's  disease,  and  occasionally  in  tho  malignant  fevers.  It  is  interest- 
ing to  note  the  frequency  with  which  hannorrhagic  pleurisy  is  found  in 
cirrhosis  of  the  liver.  It  occurred  in  the  very  patient  in  whom  Laonnoc 
iirst  accurately  described  this  disease.  While  this  may  be  a  simjdc  luemor- 
I'liagic  pleurisy,  in  a  majority  of  the  cases  which  I  have  seen  it  has  boon 
tuberculous,  (b)  Tuberculous  pleurisy,  in  which  the  bloody  effusion  may 
result  from  the  rupture  of  newly  formed  vessels  in  the  soft  exudate  aceom- 


074 


DISEASES  OE  THE   UESIMUATOIIY  SYSTEM. 


/ 


imnvinf;  the  cruijtion  of  miliary  liibert-k's,  (ir  it  mny  coiiio  from  more  slowly 
foriiu'd  tiihiTcli'S  ill  n  iilciirisy  sccoiKJury  to  cxtt'iusivo  piiliiiniiary  ilisoiix. 
{(•)  ('luiccrniis  |ii('iiri.sy,  wlictlicr  priiiiary  or  sccomlnry.  is  fn't|ii(,'Mtly  lui'iimr- 
rliii>;ic.  ((/)  Oicasioiially  iia'iiioi  rlia,i:ic'  oxiidatioii  is  mot  witli  in  iii'rl'cftiy 
hcallliy  imlividiiuls,  in  whom  tlicru  is  not  lliu  sli^xlitt'st  suspicion  of  tul)cr- 
fiil(jsis  01  canc'cr.  In  one  such  case,  a  lar^'c,  ahU'-hodicd  man,  the  puticiit 
was  to  my  knowh'duc  iicahhy  and  strong;'  ci;;lit  years  afterward.  And, 
lastly,  it  must  he  remendjcred  that  during'  aspiration  llu'  lun,!,'  may  hi' 
wounded  and  hlood  in  this  way  get  mixed  with  the  sero-iil)i'inous  exnchitc. 
The  condition  of  luumorrhagic  pleurisy  is  to  be  dititinguished  from  ha.'mu- 
thorax,  due  to  tiie  rupture  of  aneurism  or  tlie  pressure  of  a  tunu)r  on  the 
thoracic  veins. 

Diaphragmatic  Pleurisy.— The  inllammation  may  he  linnted  partly  nr 
chielly  to  the  diaphragmatic  surface.  This  is  often  a  dry  ])leurisy,  hut 
there  nuiy  be  eifusion,  either  sero-flbrinous  or  purulent,  which  is  eircum- 
scrihcd  on  the  diaphragnuitie  surface,  in  these  cases  the  ])ain  is  low  in 
the  /.one  of  the  diaphragm  and  may  siiuulate  that  of  acute  abdominal  dis- 
ease. It  may  be  intensified  by  pressure  at  the  point  of  insertion  of  the 
dia|)hragm  at  the  tenth  rib.  The  diaphragm  is  lixed  and  the  res])iratioii 
is  thoi'acic  and  short.  Andral  noted  in  certain  cases  severe  dys[)n(ea  ami 
attacks  simulating  angina.  As  mentioned,  the  eifusion  is  usually  ])lasti(', 
not  serous.  Serous  or  purulent  elfusions  of  any  size  limited  to  the  dia- 
phragnuitic  surface  are  extremely  rare.  Intense  subjective  with  trilling 
objective  features  are  always  suggestive  of  diaphragmatic  ])leurisy. 

Encysted  Pleurisy. — The  eifusion  may  be  circumscribed  by  adhesions  or 
sei)aratcd  into  two  or  more  [)ockets  or  loculi,  vhieh  communicate  with  each 
other.  This  is  most  couimon  in  emi)yema.  In  these  cases  there  have 
usually  been,  at  dilferent  i)arts  of  the  pleura,  multiple  adhesions  by  which 
the  lluid  is  linnted.  In  other  instances  the  recent  false  mend)ranes  may 
encai)sulate  the  exudation  on  the  dia])hragmatic  surface,  for  example,  or  tlic 
part  of  the  i)leura  })osterior  to  the  mid-axillary  line.  The  condition  may 
be  very  puzzling  during  life,  and  i)resent  special  dilFiculties  in  diagnosis. 
In  some  cases  the  tactile  fremitus  is  retained  along  certain  lines  of  adhe- 
sion.    The  exploratory  needle  should  be  freely  used. 

Interlobar  Pleurisy  forms  an  interesting  and  not  uncommon  variety. 
In  nearly  every  instance  of  acute  ]deurisy  the  interlobular  serous  surface- 
are  also  involved  and  closely  agglntinated  together,  and  sometimes  the  fluid 
is  encysted  between  them.  In  this  ])osition  tuljcrclcs  are  to  be  carefully 
looked  for.  Ii;  a  case  of  this  kind  following  pneumonia  there  was  between 
the  lower  and  Tipper  and  middle  lobes  of  the  right  side  an  enormons  puru- 
lent collection,  which  looked  at  first  like  a  large  abscess  of  the  lung.  These 
collections  may  perforate  the  bronchi,  and  the  cases  present  special  dilli- 
culties  in  diagnosis. 

Diagnosis  of  Pleurisy, — Acute  i)lastic  pleurisy  is  readily  recog- 
nized. In  the  diagnosis  of  pleuritic  eifusion  the  first  question  is.  Docs  a 
fluid  exudate  exist?  the  second.  What  is  its  nature?  In  large  effusion^ 
the  increase  in  the  size  of  the  affected  side,  the  immobility,  the  absence  nf 
tactile  fremitus,  together  with  the  displacement  of  organs,  give  infallible 


lore  slowly 
rv  ilisc'iisf. 
:ly  liu'iiiiir- 
i  pi'i'lVftlv 
1  ol'  lulu'r- 
tlie  putit'iil 
urd.  Anil, 
ig  may  bo 
lis  exudate, 
•um  iiujniu- 
iior  ou  the 

1  partly  or 
eiirisy,   hut 

is  cireuni- 
1  is  luw  ill 
oiniual  (lis- 
tioii  uf  the 

resi)iraliim 
,-si)U(joa  ami 
illy  j)lasti(', 
to  the  (lia- 
itli  trilling 

|S.y. 

(Ihesions  or 
e  with  caeh 
there  have 
s  by  which 
branes  may 
nple,  or  tlu' 
idition  may 
1  diajiuosis. 
es  oi'  adhe- 

on  variety, 
us  surface- 
es  the  iluiil 
)e  carefully 
as  between 
mous  puni- 

r.      Tlu-r 

)ecial  dilli- 

dily  recoi:- 
is,  Does  a 

JO  effusion- 
absence  of 

c  infallible 


ACUTK   rLKl'IlISY. 


indications  of  the  presence  of  lliiid.  The  chief  diiriciilty  arises  in  edusions 
(if  moderate  e.\tent,  when  the  ilulnrs.x,  the  preseiu-e  of  bronchophony,  anil, 
pci'haps,  tubular  brcatliiii<r  may  siiiuilal(!  jiitvuinonin.  The  chief  points  to 
ill'  borne  in  mind  are:  {a)  l)iiferences  in  the  onset  and  in  the  >;cneral  ebar- 
iicters  of  the  two  aU'eetions,  more  jtarticularly  the  initial  chill,  the  hi;,dier 
iVver.  more  ur;;ciit  dysi)n(c;i,  and  the  rusty  expectoration,  which  charac- 
terize pneumonia.  As  already  mentioned,  some  of  the  ca>es  of  pneunio- 
coccus  pleurisy  set  m  like  pneumonia.  {!>)  Certain  physical  signs — the  more 
uDoden  character  of  the  dulncss,  the  greater  resistance,  and  the  marked 
iliiiiiiiiitioii  or  the  absence  of  tactile  fremitus  in  pleurisy.  The  aiixiillattiry 
-igns  may  be  deceptive.  It  is  usually,  indeed,  the  persistence  of  tubular 
lireathing,  particularly  the  high-pitched,  even  amphoric  expiration,  heard 
in  some  cases  of  ph'Urisy,  which  has  raised  the  doubt.  The  intercostal 
spaces  are  more  connnonly  c.hliti'rateil  in  pleui'itic  etfusion  than  in  piieii- 
iiioiiia.  As  already  mentioned,  the  displacement  of  organs  is  a  very  valuable 
,-i"n.  Xowadavs  with  the  hvpodermic  needle  the  (lucstion  is  easilv  sctlleil. 
A  separali!  small  syringe  with  a  capacity  of  two  drachms  should  be  reserved 
ior  exploratory  purposes,  and  the  needle  should  be  longer  and  lirmer  than 
in  the  ordinary  liy[)odermic  instrument.  With  careful  preliminary  disin- 
fection the  instrument  can  hi'  used  with  impunity,  and  in  cases  of  doubt 
llie  exploratory  puncture  should  be  madi'  without  hesitation.  I'neiimo- 
tliorax  is  an  occasional  sei[uence.  The  hypodermic  needle  is  es|)ecially 
u>eful  in  those  cases  in  which  there  are  |)seu'do-cavernous  signs  at  the  ])ase. 
In  cases,  too,  of  massive  pneumonia,  in  which  tlu'  bronchi  are  plugged  with 
lilirin,  if  the  patient  has  not  been  seen  from  the  outset,  the  diagnosis  may 
lie  impossible  without  it. 

On  the  h'ft  side  it  may  he  dilllcult  to  did'erentiate  a  very  large  jieri- 
ciirdial  from  a  ph'iiral  etfusion.  The  retention  of  resonance  at  the  base, 
the  presence  of  Skoda's  resonance  toward  the  axilla,  the  absence  of  dis- 
location of  the  hcart-la'at  to  the  right  of  the  sternum,  the  feebleness  of 
the  pulse  and  of  the  heart-sounds,  and  the  urgency  of  the  dyspmea,  out 
of  all  pr()i)ortion  to  the  extent  of  the  elfusion,  are  the  chief  i)oints  to  be 
considered.  I'nilateral  hydrothorax,  which  is  not  at  all  iinconiiiioii  in 
heart-disease,  ])resents  signs  identical  with  those  of  sero-iilji'inous  etfusion. 
(Vrtain  tumors  within  the  chest  may  simulate  ])leural  elfusion.  It  should 
be  ]'ememb{'re(l  that  many  intrathoracic  growths  iire  accompanied  by  exu- 
dation. .Malignant  disease  of  the  lung  and  of  the  ])h'ura  and  hydatids  of 
tlie  ])leura  produce  extensive  dulness,  with  sup])ression  of  the  breath-sounds, 
simulating  closely  elfusion. 

On  the  right  side,  abscess  of  the  liver  and  hyd;itid  cysts  may  rise  high 
into  the  pleura  and  produce  dulness  and  enfeebled  l)reathing.  Often  in 
these  cases  there  is  a  friction  sound,  which  should  excite  suspicion,  and 
the  up]»er  outline  of  the  duhiess  is  sometimes  pl;;iidy  convex.  In  a  casi'  (d' 
cancer  of  the  kidney  the  growth  involved  the  diaphragm  very  early,  and  for 
months  there  were  signs  of  pleurisy  before  our  attention  was  directed  to  the 
kiiliiey.     Ill  all  these  instances  the  exploratory  ])uncture  should  be  made. 

The  second  question,  as  to  the  nature  of  the  fluid,  is  quickly  decided 
by  the  use  of  the  needle.     The  i)ersistent  fever,  the  occurrence  of  sweats, 


t57»5 


DISKASKS  OF  TIIK   UKSIMIIATOUY  SVSTKM. 


n  l('iU'ocyt<»sis.  nml  llic  iiicrcnsc  in  the  inillor  sn^'post  iho  prrsonri'  nf  |iiis. 
Jii  chililiiii  till'  iiiiiiplcxidii  is  ol'ti'ii  Milluw  ami  carlliy.  In  itrutiiuU'd  lasis, 
fvcii  in  ( liilili'i'n,  when  tlio  p'ni'ial  hyniptonis  and  tlio  aiiiiraranct'  of  the 
jiatii'nt  has  Ixcn  nidst  stron^^ly  su^^'i'Hlivo  (if  pUH.  the  syriii^'i'  has  withdrawn 
I'k'ar  thiid.  On  IIm'  dlhcr  iinnd.  I'll'iisitms  nt'  shdit  duratiiin  may  hv  puru- 
lent, I'vcn  when  tlic  ^'I'ncral  sym|itonis  dd  mit  sii;.^ifi'st  it.  'i'hc  fdllowinj,' 
statt'incnl  may  lii'  niiuh'  with  rctVifncc  td  thi'  prd^indstii'  inipdrt  df  tiic  liat- 
ti'ridhi^'ical  cxamiinitidii  of  the  aspirated  tluid:  The  pri'senec  ui*  the  pneuino- 
fdceuti  is  ui  favorahle  si^iiilieanee,  as  sueh  eases  usually  get  well  rapidly, 
evt'U  with  a  sin;:l('  aspiiatidu.  The  streptocdccus  empyema  is  the  nmst 
seridus  fiirm,  and  even  after  u  free  (lraina;;e  the  patient  may  suecund)  tti  a 
p'lieral  septieu'mia.  A  sterile  lluiil  indicates  in  a  majority  of  instances  a 
tnhereuldus  (iri^-in. 

Treatment. — At  the  duset  the  severe  pain  may  deimind  leeches,  which 
usually  ^ivi'  relief,  hut  a  hy|iddermic  df  morphia  is  more  cU'ectiNe.  'riic 
I'aipielin  cautery  may  lie  li;,ditly  hut  freely  applied.  It  is  well  to  admini-;- 
tei'  a  mercurial  or  saline  purj^e.  Fixing  the  side  by  careful  strapping  with 
long  strips  of  adhesive  plaster,  which  sluiuld  jiass  well  over  the  middle  line, 
drawn  tightly  and  evenly,  gives  great  relief,  and  1  can  corrohorate  the 
titatemenl  of  F.  T.  Koherts  as  to  its  ellicacy.  Cupping,  wet  or  dry,  is  now 
seldom  employed.  Blisters  are  of  no  special  service  in  the  acute  stages, 
although  they  relieve  the  pain.  The  ice-hag  may  be  used  as  in  pneumonia. 
The  geiu'ral  treatnu'ut  at  the  early  stage  should  he  rest  in  bed  and  a  liipiid 
diet.  Medicines  are  rarely  re(pure(l.  A  Dover's  powder  may  be  given  at 
night.     Mercurials  are  not  indicated. 

When  the  cITusion  has  taken  ])lace,  nnistard  jilasters  or  iodine,  ])ro- 
ducing  slight  counter-irritation,  ajijiear  useful,  particularly  in  the  later 
stages.  The  following  rational  ]>lan  is  successful  'a  sonu'  cases.  It  is  Ijased 
upon  the  idea  that  if  the  blooil  serum  is  depleted  or  if  it  is  kept  concen- 
trated, the  licpiid  will  be  absorbed  from  the  lymph  si)aces,  of  which  the 
pleura  is  one,  to  cffualize  the  loss.  To  do  this  the  patient  should  have  the 
daily  anumnt  of  licpiid  food  greatly  restricted.  If  there  is  no  fever,  a  meat 
diet,  with  an  egg  and  dry  bread  and  S  to  10  ounces  of  liquid  in  the  form  of 
milk  or  water,  should  be  given.  Salt  articles  of  food  nmy  be  used,  but  I 
do  not  think  it  necessary  to  give,  as  some  do,  doses  of  salt.  The  second 
element  in  the  treatment  is  the  active  dei)Ietion  of  blood  serum,  which  is 
effected  in  the  way  introduced  by  Matthew  Hay.  J^very  morning,  if  the 
jiatient  is  robust,  otherwise  every  second  morning,  from  half  an  ounce  to 
an  ounce  and  a  half  of  Epsom  salts  is  given  an  hour  before  breakfast,  in  as 
concentrated  n  form  as  is  possible.  This  produces  copious  liquid  discharges. 
I  have  seen  large  exudations  disa]i]iear  ra])idly  when  this  plan  was  fol- 
lowed. Uy  acting  upon  the  skin  and  kidneys,  the  same  end  may  be  ob- 
tained, but  with  much  less  certainty.  The  vapor  or  hot  bath  may  bo 
used  and  an  occasional  dose  of  pilocarpin.  Diuretics,  such  as  digitalis, 
siiuills,  and  acetate  of  potash,  may  sometimes  be  required.  I  rarely  resort, 
however,  to  diuretics  or  diaphoretics  in  the  treatment  of  jileurisy  with  ciTu- 
siou.  Iodide  of  j)otassium  is  of  doubtful  benelit.  By  some  the  salicylates 
are  believed  to  be  of  special  efficacy. 


ACUTM    IM.KUUIHV. 


077 


icc  tii'  \n\«. 
ictt'tl  cajti'U, 

net'   of    tilt' 

withdraw  Ik 
V  1)1'  piiru- 

'    rnllo\vill>,' 

ul'  tlio  biU'- 
10  pncnmo- 
■U  ni[»i»lly, 
i  the  most 
!cuml)  to  a 
iii8taiii-t>d  a 

•lies,  which 
:tivu.  Tlu- 
:o  adiiiinis- 
ppiiij;  with 
liddlc  liin', 
)l)orate  the 
Iry,  is  now 
iitc  sta^U'S, 
)iU'iniioiiia. 
lid  a  li(iiiid 
)e  given  at 

)diiu\  ])ro- 
the  latiT 
It  is  based 
»t  concen- 
wliich  the 
1  have  the 
IT,  a  meat 
le  form  of 
sed,  but  I 
Mie  second 
,  which  is 
n<r,  if  the 
1  ounce  to 
fast,  in  as 
lischarges. 
1  was  fol- 
lay  be  ol)- 
1  may  bo 
dijxitalis. 
ly  resort, 
with  elTu- 
salicvlatcs 


Aspiration  <d"  the  lluid  is  the  most  thornii;rh  and  satisfactory  method 
and  should  be  resorted  to  wlu-Ui'ver  the  eiriision  becomes  large  or  if  it  re- 
sists the  ordinary  niclhods  of  treatment.  Tin  credit  of  introdneing  aspi- 
ration in  pleuritic  ell'usions  is  due  to  .Morrill  Wyman,  at  Cambridgi',  .Mass., 
and  llinry  I.  llowditih,  of  Uostor.  Years  prior  to  hii'ulal'oy's  work,  as- 
piration was  in  constant  uso  ut  o  Alassaeiiusetttt  General  IIosi)ital  and 
was  advocated  repeatedly  l»y  Howditch.  As  the  ([uestion  is  one  of  bome 
historical  interest,  I  give  Uowditch's  conclusions  cttiiccrning  aspiration, 
expressed  nearly  lifty  years  ago,  and  which  practically  represent  the  opinion 
(d"  to-day;  *'  (1)  The  o|>eration  is  perfectly  simple,  but  slightly  painful,  and 
can  be  done  with  case  upon  any  patient  in  however  advanced  a  stage  of 
the  disease,  {'i)  it  should  be  performed  forthwit'-.  in  till  cases  in  whit  h 
tlu're  is  ct)mplcte  lilling  up  of  one  side  t)f  the  chest.  (."!)  He  had  deti'r- 
niini'd  t»)  use  it  in  ain/  case  of  even  tnodcrale  ell'iision  lasting  more  than  n 
few  weeks  and  in  which  there  should  seem  to  be  a  disposition  to  resist 
ordinary  modes  of  treatment.  (4)  Jle  urged  this  practice  upon  the  pnifes- 
sion  as  a  very  important  measure  in  practical  medicine;  believing  that  by 
this  method  tleatli  may  fretjuently  be  prevented  from  ensuing  either  by 
sudden  attack  of  dyspntea  or  subsetpient  |)lithisis,  and,  fimilly,  from  the 
gradual  wearing  out  of  the  powers  of  life  or  inability  to  absorb  the  fluid. 
(.'))  He  bi'lieved  that  this  operation  woultl  sometimes  prevent  t'  "  occurrence 
tif  tht)se  teilious  casi'S  of  s|)ontanetius  evacuation  of  |uirulent  ihi  aul  those 
great  contractions  of  the  chest  which  occur  after  long-ct)ntiniied  cfTusion 
and  the  sulistHjuent  discharge  or  absorption  of  a  tluid." 

There  is  scarcely  anything  to  be  added  to-day  to  these  observations. 
When  the  fluid  reaches  tt)  the  clavicle  the  indication  for  asjiiratioii  is  im- 
perative, even  though  the  i)atient  be  comfortable  and  i)rescnt  no  signs  tif 
l)u!monary  distress.  The  presence  of  fever  is  not  a  contra-indication;  in- 
deed, sometimes  with  serous  exudates  the  temperature  falls  after  aspiration. 

The  ()])eration  is  e\  'iiicly  simple  and  is  practically  witht)ut  risk.  The 
spot  selected  for  ))uncture  should  be  either  in  the  seventh  interspace  in  the 
mill-axilla  or  at  the  outer  angle  of  the  sca])ula  in  the  eighth  interspace. 
The  arm  of  the  ])aticnt  should  be  l)rouglit  forward  with  the  hand  on  the 
t>pposite  shoulder,  so  as  to  widen  the  intersjjaces.  The  needle  slumld  be 
thrust  in  close  to  the  upper  margin  of  the  rib,  so  as  to  avoid  the  intercostal 
artery,  the  wounding  of  which,  however,  is  an  excessively  rare  accident. 
The  fluid  should  be  withdrawn  slowly.  The  amount  will  de[)end  on  the 
size  of  the  exudate.  If  the  fluid  reaches  to  the  clavicle  a  litre  or  more  may 
l)e  witlitlrawn  with  safety.  In  chronic  cases  of  serous  pleurisy  after  re- 
peated tappings  S.  West  has  shown  the  great  value  of  free  incision  and 
drainage.  He  has  rei)orted  cases  of  recovery  after  eifusions  of  fifteen  and 
eighteen  months'  standing. 

Symptoms  and  Accidents  during  Paracentesis. — Pahi  is  usually  com- 
[tlained  of  after  a  certain  amount  t)f  fluid  has  liecn  withdrawn;  it  is  sharp 
and  cutting  in  character.  (\nnjh\u(i  occurs  toward  the  close,  and  may  be 
severe  and  paroxysmal.  Piicuniolhorax  may  follow  an  exploratory  puncture 
with  a  hypodermic  needle;  it  is  rare  during  aspiration.  Svhrutaneous  em- 
physema may  develop  from  the  point  of  puncture,  without  the  production 


678 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


li 


i! 


(»f  ]tiicMiiiU)lli()nix.  Albiiiitiiwus  cxpccloralion  is  a  rcinarkablo  phonnmonoii 
dcscrilu'd  by  i-'roiu'li  writers.  It  usiiiilly  (Icvclops  ai'leT  tlio  tapping,  is  assu- 
riatcil  with  dyspim'a,  and  many  \ixo\m  siiddt'idy  iatal.  Cerebral  sympluins. 
— J'"ainliicss  is  not  uiiconiinon.  Ei)ilci)tic  convulsions  may  occur  eitiicr 
during  tlu;  w  itlidi'awal  or  while  irrigating  tiic  pleura.  1  liave  seen  but  a 
singk'  instance.  They  arc  very  dillicult  to  explain  and  arc  regarded  by  most 
authors  as  of  rellex  origin;  and  lastly  sudden  dcalh  may  occur  cither  from 
syncope  or  during  the  convulsions. 

EiiiptjeDia  is  really  a  surgical  nlTeetion,  and  I  shall  make  oidy  a  few- 
general  remarks  njton  its  treatment.  When  it  has  been  determined  by 
exjiloratory  ])uncture  that  the  lluid  is  i)urulent,  aspiration  should  not  be 
jierfoiined,  except  as  preliminary  to  operation  or  as  a  temporary  ineasure. 
r('riui]ts  it  is  better  not  to  have  an  cxcei)tion  to  this  rule,  although  the 
empyemas  of  children  and  the  ])neumonic  empyema  occasionally  get  well 
rapidly  alter  a  single  tapping.  It  is  sad  to  think  of  the  number  of  lives 
which  are  sacridced  annually  by  the  failure  to  recognize  that  em])yema 
should  be  treated  as  an  ordinary  abscess,  by  free  incision.  The  operation 
dates  I'rom  the  time  of  lIij)pocrates  aiul  is  by  no  means  serious.  A  ma- 
jority of  the  cases  get  well,  i)roviding  that  free  drainage  is  obtained,  and 
it  makes  no  dill'erence  ])ractically  what  measiires  are  folhnved  so  long  as 
this  indication  is  met.  The  good  results  in  any  method  depend  iijjou 
the  thoroughness  with  which  the  cavity  is  drained.  Irrigation  of  the 
cavity  is  rarely  necessary  unless  the  contents  are  fetid.  In  the  sul)S(>(pient 
treatment  a  ])()int  of  great  im])()rtance  in  facilitating  the  closure  of  the 
cavity  is  the  distention  of  the  lung  on  the  aH'ceted  side.  This  nuiy  be 
acconi])lished  by  the  method  advised  by  Halston  James,  which  has  been 
]n-actised  with  great  success  in  the  surgical  wards  of  the  Johns  Hopkins 
Hospital,  '^^riie  ])atient  daily,  for  a  certain  length  of  time,  increasing  gradu- 
ally with  the  increase  of  his  strength,  transfers  by  air-pressure  water  from 
one  bottle  to  another.  The  bottles  should  be  large,  holding  at  least  a  gallon 
each,  and  by  the  arrangement  of  tid)es,  as  in  the  Wollf's  bottle,  an  expira- 
tory etfort  of  the  ])aticnt  forces  the  water  from  one  bottle  into  the  other. 
In  this  way  expansion  of  the  conrpresscd  lung  is  systematically  practised. 
The  al)scess  cavity  is  gradually  closed,  ])artly  by  the  falling  in  of  the  chest 
wall  and  ])artly  by  tlie  expansion  of  the  lung.  In  some  instances  it  is 
necessary  to  resect  ])ortions  of  one  or  more  ribs. 

'V\\Q  ])hysician  is  often  asked,  in  cases  of  empj'cma  with  emaciation, 
hectic  and  feeble  rapid  ])ulse,  whether  the  Patient  eonld  stand  the  opera- 
tion. Even  in  the  most  desperate  cases  the  surgeon  should  never  hesitate 
to  nuike  a  free  incision. 


II.    CHRONIC    PLEURISY. 


This  afTection  occurs  in  two  forms:  (1)  Chronic  plcnrmj  icith  effusion, 
in  which  the  disease  may  set  in  insidiously  or  inay  follow  an  acute  scro- 
fibrinons  ])lenrisy  There  are  cases  in  Avhich  the  liquid  ]iersists  for  months 
or  even  years  without  undergoing  any  special  alteration  and  without  bccom- 


nomenon 
,  is  asso- 

IllipldlllS. 

ir  t'ilher 
L'li  but  a 
.  by  most 
lu'i'  rnuii 

ly  a  few 
iiiiu'd  by 
il  not  bo 
moasuro. 
DUgh  tho 
gL't  woll 
r  of  lives 
(Mni)yoma 
operation 
,  A  ma- 
ined,  and 
3  long  as 
nid  ujjou 
n  of  the 
ibse<[nent 
ru  of  the 
3  may  l)e 
has  been 
Hopkins 
ig  gradu- 
iter  from 

a  gallon 
n  expira- 

e  other, 
iractised. 

le  chest 
lees  it  is 

aciation, 
10  o])ora- 
hesitate 


CI  IRONIC  TLEURISy. 


679 


effusion, 
nto  sero- 
'  months 
t  becom- 


ing pnndent.  Such  cases  havi'  tho  cliarai-ters  whidi  we  have  described 
uiuh'r  j)k'iirisy  witii  ell'iisioii.  {'i)  Clironir  dnj  plnirisi/.  Tiu'  cases  are  met 
witii  ('0  as  a  se(Hiciice  of  ordinary  ]ih'unil  elfiision.  When  the  exudate  ].i 
aiisorbed  and  tlie  layers  of  tiie  pleura  come  together  there  is  It't't  bi'tween 
tlieni  a  variable  amount  of  lil)rinous  material  which  gradually  undergoes 
organization,  and  is  converted  into  a  laver  of  firm  connective  tissue.  This 
])rocess  goes  on  at  Hie  base,  and  is  represented  clinieally  by  a  slight  grade  of 
llatteiiing,  delicient  expansion,  defective  resonance  on  percussion,  and  en- 
feebled breathing.  After  recovery  from  cmpyenui  the  Ilattening  and  re- 
traction may  be  still  more  nuu'ked.  Jn  both  cases  it  is  a  condition  which 
can  be  greatly  benelited  by  ])ulmonary  gymnastics.  Jn  these  iirm,  librous 
membranes  calcilication  may  occur,  ]iarticularly  after  empyema.  It  is 
not  very  uncommon  to  find  between  the  false  mendn'anes  a  small  pocket 
of  lluid  forming  a  sort  of  ])leural  cyst.  Jn  the  great  majority  of  these 
cases  the  condition  is  one  which  need  not  causi'  anxiety.  There  may  be 
an  occasional  dragging  |)ain  at  the  base  of  the  lung  or  a  stitch  in  the  sine, 
but  patients  may  remain  in  perfectly  good  health  fen-  years.  The  most 
advanced  grade  of  Ibis  secondary  dry  jileurisy  is  seen  in  those  cases  of  em- 
jiyema  which  have  been  left  to  themselves  and  have  perforated  and  ulti- 
mately healed  by  a  gradual  absorption  or  discharge  of  the  pus,  with  retrac- 
lion  of  the  side  of  the  chest  and  pi'rmanent  carnilicat i(Ui  of  the  lung. 
Traumatic  lesions,  such  as  gunshot  wounds,  may  be  followed  by  an  identical 
condition.  Post  mortem,  it  is  quite  im])ossible  to  sepai'ate  the  layers  of  the 
]»leura,  which  are  greatly  thickened,  ]tarticularly  at  the  base,  and  surround 
a  com|)ressed,  airless,  iibi'oid  lung,  bronchiectasis  may  gradually  develop, 
and  in  one  remarkable  case  which  1  have  seen  on  several  occasions  with 
])r.  JUackader,  of  ]\l(mtreal,  not  only  on  the  ail'ected  side,  but  also  in  the 
lower  lobe  of  the  other  lung. 

(h)  Primitive  clrt/  pleurisi/.  This  condition  may  directly  follow  the 
acute  plastic  ])leurisy  already  described;  but  il  may  set  in  witlumt  any 
acute  symptoms  whatever,  and  the  patient's  attention  nuiy  be  called  to  it 
by  feeling  the  jdcural  friction.  A  constant  eU'ect  of  this  primitive  dry 
pleurisy  is  the  adhesion  of  the  layers.  This  is  jirobably  an  invariable  result, 
whether  the  pleurisy  is  ])rimary  or  secondary.  The  organization  of  the  thin 
layer  of  exudation  in  a  ]>neumonia  will  unite  the  two  surfaces  ])y  delicate 
bands.  J^U'ural  adhesions  are  extremely  common,  and  it  is  rare  to  examine 
a  body  entirely  free  from  them.  They  may  be  limited  in  extent  or  univer- 
sal. Thin  fibrous  adhesions  do  not  produce  any  alteration  in  the  ])ercussion 
characters,  and,  if  limited,  there  is  no  sjiecial  change  heard  on  ausculta- 
tion. When,  however,  there  is  general  synechia  on  lioth  sides  the  ex])ansile 
movement  of  the  lung  is  considerably  iin])aired.  We  should  naturally 
think  that  universal  adhesions  would  interfere  materially  with  the  func- 
tion of  the  lungs,  but  ]iractically  we  see  many  instances  in  which  there 
has  not  been  the  slightest  disturbance.  The  ])hysical  signs  of  total  adhe- 
sion are  by  no  means  constant.  It  has  been  stated  that  there  is  a  marked 
disproportion  between  the  degree  of  expansion  of  the  chest  walls  and  the 
intensity  of  tlie  vesicular  murmur,  but  tlie  latter  is  a  very  variable  factor, 
and  under  jierfectly  normal  conditions  the  breath-sounds,  with  very  full 


GSO 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


.  \ 
/ 


chest  expansion,  iiiny  be  extremely  I'eeljle.  'JMie  diaplimgiu  j)lienoiueiioii — 
Litteu's  sign — is  absent. 

Is  there  a  primitive  dry  pleurisy  Avhicli  gradually  leads  to  great  thick- 
ening of  the  membranes,  and  which  ultimately  may  invade  the  lung  and 
induce  cirrhotic  change?  U})on  this  question  neither  patliologists  nor 
clinicians  agree.  1  think  that  Sir  Andrew  Clark,  in  his  Lumleian  lectures 
at  the  Eoyal  College  of  IMiyKicians  (1S85),  has  made  good  his  claim  that 
such  a  disease  does  exist.  Clinically  the  cases  are  of  great  interest,  and 
should,  I  think,  be  se|)arated,  on  the  one  hand,  from  the  condition  which 
follows  a  healed  emi)yema  or  old  i)leurisy  with  elTusion,  and,  on  the  other, 
from  the  rare  instances  of  ])rimitive  cirrhosis  of  the  lung.  However,  in  all 
three  states  there  may  ultimately  be  an  almost  identical  clinical  picture. 
Anatomically  in  these  pleuritic  cases  the  pleura,  particularly  that  surroujid- 
ing  the  lower  lobe,  sometimes  the  entire  membrane,  is  thickened,  the  two 
layers  are  intinuitely  united,  and  fibrinous  bands  passing  from  the  pleura 
traverse  the  lung  tissue,  sometimes  dividing  it  in  a  remarkable  way  into 
sections.  The  bronchi  may  present  marked  dilatations,  thougn  this  is 
not  always  the  case,  and  the  lung  tissue  is  more  or  less  sclerosed.  The 
cases  belong  to  the  group  of  chronic  jjueumonias  called  by  Charcot  pleu- 
rogenous. 

Lastly,  there  is  a  primitive  dry  pleurisy  of  tuberculous  origin.  In  it 
both  parietal  and  costal  layers  are  greatly  thickened — perhaps  from  2  to 
3  mm.  each — and  present  firm  fibroid,  caseous  masses  and  snuill  tubercles, 
while  uniting  these  two  greatly  thickened  layers  is  a  reddish-gray  fibroid 
tissue,  sometimes  infiltrated  with  serum.  This  may  be  a  local  process  con- 
fined to  one  pleura,  or  it  may  be  in  both.  These  cases  are  sometimes  associ- 
ated with  a  similar  condition  in  the  pericardium  and  peritonaeum. 

Occasionally  remarkaljle  vaso-motor  phenomena  occur  in  chronic  pleu- 
risy, M-hether  simple  or  in  connection  with  tuberculosis  of  an  apex.  Flush- 
ing or  sweating  of  one  cheek  or  dilatation  of  the  pupil  are  the  common 
manifestations.  They  appear  to  be  due  to  involvement  of  the  first  thoracic 
ganglion  at  the  top  of  the  pleural  cavity. 


III.    HYDROTHORAX. 

Ilvdrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into 
the  ])]eural  cavities,  and  occurs  as  a  secondary  process  in  many  affections. 
The  fluid  is  clear,  without  any  flocculi  of  fibrin,  and  the  membranes  are 
smooth.  Tt  is  mot  with  more  iinrticularly  in  connection  with  general 
dropsy,  cither  renal,  cardiac,  or  ha^mic.  It  may,  however,  occur  alone,  or 
with  only  slight  avlema  of  the  feet.  A  child  was  admitted  to  the  Mont- 
real General  ITos]iital  with  urgent  dyspncra  and  cyanosis,  and  died  the 
night  after  admission.  She  had  extensive  bilateral  hydrothorax,  which 
had  come  on  early  in  the  nei)hritis  of  scai'let  fever.  In  renal  disease  hydro- 
thorax  is  almost  always  bilateral,  but  in  heart  affections  one  pleura  is  more 
commonly  involved.  The  physical  signs  are  those  of  pleural  effusion,  but 
the  exudation  is  rarely  excessive.    In  kidney  and  heart-disease,  even  when 


nicnou — 

'lit  thick- 
lung  and 
gists  nor 
1  k'cturos 
laim  that 
irost,  and 
on  which 
;he  other, 
rer,  in  all 

I  picture, 
surround- 
,  the  two 
he  pleura 
way  into 

II  this  is 
;ed.  The 
root  pleu- 

in.  In  it 
'rom  3  to 
tubercles, 
\y  fibroid 
jcess  con- 
ies associ- 
1. 

inic  plen- 
Flush- 
common 
thoracic 


PNEUMOTHORAX. 


C81 


uid  into 
ections. 

anes  are 
general 
lone,  or 
Mont- 

:lied  the 
which 

e  hydro- 
is  more 

ion,  but 

Dn  when 


there  is  no  general  dropsy,  the  occurrence  of  dyspnwa  should  at  once 
dLrect  attention  to  the  jjlcura,  since  many  imtients  are  carried  oil'  by  u 
rai)id  ell'usion.  rost-mortem  records  show  tlie  I'reiiueiu'y  with  which  this 
condition  is  overlooked.  The  saline  i)urges  will  in  many  cases  rajjidly 
reduce  the  ell'usion,  but,  if  necessary,  aspiration  should  repeatedly  be 
practised. 


IV.    PNEUMOTHORAX   {Ilydro-Pneumothorax  and  ryo-Pmumothorax), 

xVir  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is 
strictly  apidicable,  is  an  extremely  rare  condition.  It  is  almost  invariably 
associated  with  a  serous  fluid — hydro-pneumothorax,  or  with  pus — pyo- 
pneumothorax. 

Etiology. — There  exists  normally  within  the  pleural  cavity  of  an  adult 
a  negative  pressure  of  several  millimetres  of  mercury,  due  to  the  recoil  of 
the  distended,  perfectly  elastic,  lung.  Hence  through  any  opening  con- 
necting the  pleural  cavity  with  the  external  air  we  should  expect  air  to 
rush  in  until  this  negative  pressure  is  .relieved.  To  exi)lain  the  absence  of 
])neumothorax  in  a  few  cases -in  which  it  would  be  expected,  S.  West  has 
assumed  the  existence  of  a  cohesion  l)etween  the  pleura?  Avhich  overcomes 
the  tendency  of  the  chest  to  this  condition,  but  this  force  has  not  as  yet 
been  satisfactorily  demonstrated. 

In  a  ease  of  pneumothorax,  if  the  opening  causing  it  remain  patent, 
the  intrathoracic  pressure  will  be  that  of  the  atmosphere,  the  lung  will  be 
found  to  have  collapsed  by  virtue  of  its  own  elastic  tension,  the  intercostal 
grooves  obliterated,  the  heart  displaced  to  the  other  side,  and  the  diaphragm 
lower  than  normal,  because  the  negative  pressure  by  reason  of  which  these 
organs  are  retained  in  their  ordinary  position  has  been  relieved.  If  the 
opening  becomes  closed  the  intrathoracic  pressure  may  rise  above  the  at- 
mospheric and  the  above-mentioned  displacements  be  much  increased. 
Some  of  the  reasons  for  this  rise  of  pressure  are,  the  valvular  action  of  the 
opening  during  violent  expiratory  efPorts,  the  rise  of  temperature  of  the  ihi- 
])risoned  gas,  and  the  compression  of  the  air  by  the  usual  effusion  into  the 
cavity. 

Pneumothorax  arises:  (1)  In  perforating  wounds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It 
has  followed  exploratory  puncture.  Herman  Biggs  has  reported  two  cases 
and  I  have  seen  it  twice.  Pneumothorax  rarely  follows  fracture  of  the  rib, 
even  though  the  lung  may  be  torn.  (2)  In  ^perforation  of  the  pleura 
through  the  diaphragm,  usually  by  maliiinant  disease  of  the  stomach  or 
colon.  The  pleura  may  also  be  perforated  in  cases  of  cancer  of  the  oesoph- 
agus. (3)  When  the  lung  is  perforated.  This  is  by  far  the  most  com- 
mon cause,  and  may  occur:  {a)  In  a  normal  lung  from  rupture  of  the 
air-vesicles  during  straining  or  even  when  at  rest.  Special  attention  has 
been  called  to  this  accident  by  S.  West  and  He  H.  Hall.  The  air  may  be 
absorbed  and  no  ill  effect  follows.  It  does  not  necessarily  excite  ])leurisy, 
as  pointed  out  many  years  ago  by  Gairdncr,  but  inflammation  and  effusion 


682 


DISEASES  OP  THE  RESi'lllATOllY  SYSTEM. 


arc  tlio  usual  result.  In  a  rcci'iit  case  llio  fonditiuii  devflopod  as  the  pa- 
tient was  going  down-stairs;  no  ell'usion  followed;  he  did  not  react  to 
tuberculin,  (h)  From  [jerforation  due  to  local  tlisease  oi'  the  lung,  either 
the  softening  of  a  caseous  focus  or  the  breaking  of  a  tuberculous  cavity. 
According  to  S.  West,  i)0  per  cent  of  all  the  cases  are  due  to  this  cause. 
Less  coiniuon  arc  the  cases  due  to  sejjtic  broncho-pneumonia  and  to  gan- 
grene. A  rare  cause  is  the  breaking  of  u  luemorrhagic  infarct  in  chronic 
heart-disease,  of  which  I  met  an  instance  a  i^vw  years  ag(j.  (r)  I'erfora- 
tiort  of  the  lung  from  the  ])leura,  which  arises  in  certain  cases  of  empyema 
and  ])roduces  a  ])leuro-bronchial  listula.  (</)  S[)ontaneously,  by  the  de- 
veloiunent  in  pleural  exudates  of  the  gas  bacillus  {IJ.  acrogcnes  cai)salaliis 
Welch). 

Pneumothorax  occurs  chiefly  in  adults,  though  cases  are  met  with  in 
very  young  children.     It  is  more  fre(juent  in  males  than  in  females. 

Morbid  Anatomy. — If  a  trocar  or  blow-pipe  is  inserted  between 
the  ribs,  there  may  be  a  jet  of  air  of  sutHcieni  strength  to  blow  out  a 
lighted  match.  On  o]iening  the  thorax  tlie  mediastinum  and  pericardium 
are  seen  to  be  pushed,  or  rather,  as  l)o\iglas  Powell  pointed  out,  drawn 
over  to  the  opi)Osite  side;  but,  as  befoi'e  mentioned,  the  heart  is  not 
rotated,  and  the  relation  of  its  parts  is  maintained  much  as  in  the  normal 
condition.  A  serous  or  ])urulent  fluid  is  usually  present,  and  the  mem- 
branes are  inilamed.  The  cause  of  the  pneumothorax  can  usually  l)e 
found  without  dilliculty.  In  the  great  majority  of  instances  it  is  the 
])erforation  of  a  tuberculous  cavity  or  a  breaking  of  a  sui)erficial  caseous 
focus.  The  orifice  of  rupture  may  be  extremely  small.  In  chronic  cases 
there  may  be  a  fistula  of  considerable  size  communicating  with  the  bron- 
chi.   The  lung  is  usually  compressed  and  carnified. 

Symptoms. — The  onset  is  usually  sudden  nnd  characterized  by  severe 
pain  in  the  side,  urgent  dyspnoea,  and  sigr  ,  of  general  distress,  as  indicated 
by  slight  lividity  and  a  vci'y  rapid  and  feeble  pulse.  There  may,  however, 
be  no  urgent  symptoms,  particularly  in  cases  of  long-standing  ])lithisis. 
On  more  than  one  occasion  I  have  found,  post  mortem,  a  imeumothorax 
which  was  unsuspected  during  life.  "West  states  that  even  in  healthy 
adults  this  latent  pneumothorax  may  occasionally  occur. 

A  remarkable  recurrent  variety  has  been  described  by  S.  "West,  Good- 
hart,  and  Furney.  In  Coodhart's  case  the  pneumothorax  developed  first 
in  one  side  and  then  in  the  other. 

The  pliysical  sir/ns  are  very  distinctive.  Inspeciion  shows  marked  en- 
largement of  the  affected  side  with  immobility.  The  heart  impidse  is 
usually  much  displaced.  On  palpation  the  fremitus  is  greatly  diminished 
or  more  commonly  abolished.  On  prmission  the  resonance  may  be  tym- 
panitic or  even  have  an  anii)horic  quality.  This,  however,  is  not  always 
the  case.  It  may  he  a  flat  tympany,  resembling  Skoda's  resonance.  In 
some  instances  it  may  he  a  full,  hyperresonant  note,  like  emphysema: 
while  in  others — and  this  is  very  deceptive — there  is  dulness.  These 
extreme  variations  deix'ud  douhtless  u]ion  the  degree  of  intra]deural  ten- 
sion. On  several  occasions  I  have  known  an  error  in  diagnosis  to  result 
from  ignorance  of  the  fact  that,  in  certain  instances,  the  percussion  note 


the  pa- 
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PNEUMOTIIOR.  X. 


683 


may  bo  "  miinied,  toneless,  almost  dull  "  (Walshe).  There  is  usually  dul- 
ness  at  tlu'  base  from  elliiscd  Ihiid,  which  ciiu  readily  ijo  matle  to  ehanjie 
tiie  level  by  altci'iii^  the  position  of  tlie  patient.  Movalile  duiness  can 
be  obtained  much  more  readily  in  [du'iiinothorax  than  in  a  simple  pleu- 
risy. On  (iihsctilldlion  the  hreath-sounds  are  suppressed.  Sometimes 
thci'e  is  only  a  distant  feeble  inspiratory  murmur  of  marked  amphoric 
(piality.  Tlio  contrast  between  the  loud  exaggerated  breath-sounds  on 
the  noi'inal  side  and  the  absence  of  the  breath-sounds  on  the  other  is 
very  suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on 
coughing  or  dee[)  insi)iration  there  may  l»e  what  Jiaennec  termed  the 
metallic  tinkling.  The  voice,  too,  has  u  curious  metallic  echo.  What  is 
sometimes  called  the  coin-sound,  ternu'd  hy  Trousseau  the  J)niit  d'liirnin, 
is  very  characteristic.  To  ol)tain  it  the  auscultator  should  ])lace  one  ear 
on  the  back  of  tiie  chest  wall  while  the  assistant  taps  one  coin  on  another 
on  the  front  of  the  chest.  The  metallic  echoing  sound  which  is  produced 
in  this  way  is  one  of  the  most  constant  and  characteristic  signs  of  pneumo- 
thorax. And,  lastly,  the  Ilipi)()cratic  succussion  may  1)0  obtained  when 
the  auscultator's  head  is  j)laced  upon  the  chest  while  the  jiatient's  body  is 
shaken.  A  splashing  sound  is  produced,  which  may  be  audible  at  a  dis- 
tance. A  ])atieiit  may  himself  notice  it  in  making  alirupt  changes  in 
jiosture.  Ot*  other  symptoms  displaciMnent  of  organs  is  most  constant. 
As  already  mentioned,  the  heart  may  be  drawn  over  to  the  o[)i)osite  side, 
and  the  liver  greatly  displaced,  so  that  its  upper  surface  is  below  the  level 
of  the  costal  margin,  a  degree  of  dislocation  never  seen  in  simple  elfusion. 

The  c]ia(jn()i<is  of  j)neuniotliorax  rarely  offers  any  diifieulty,  as  the  signs 
are  very  characteristic.  In  cases  in  which  tlie  percussion  note  is  dull  the 
condition  may  be  mistaken  for  effusion.  I  made  this  mistake  in  a  case  of 
])ulsating  pleurisy,  in  which  the  pneumothorax  followed  heavy  lifting,  and 
it  was  not  until  several  days  later,  after  some  of  the  fluid  had  been  with- 
drawn, that  a  tympanitic  note  devel()])ed.  Diaphragmatic  hernia  follow- 
ing a  crush  or  other  accident  may  closely  simulate  })neiimothorax. 

In  cases  of  very  large  phthisical  cavities  with  tymi)anitic  percussion 
resonance  and  rales  of  an  am])lioric,  metallic  quality,  the  question  of  pneu- 
mothorax is  sometimes  raised.  \n  those  rare  instances  of  total  excava- 
tion of  one  lung  the  am])horic  and  metallic  phenomena  may  bo  most  in- 
tense, but  the  ab.sence  of  dislocation  of  the  organs,  of  the  succussion  splash, 
and  of  the  coin-sound  suflice  to  differentiate  this  condition.  While  this  is 
true  in  the  great  majority  of  cases,  I  have  recently  heard  the  bruit  d'airain 
over  large  cavities  of  the  right  up])er  lobe.  The  condition  of  pyo-pneu- 
mothorax  sul)])hrenicus  may  simulate  closely  true  pneumothorax. 

The  prof/nosis  in  cases  of  pneumothorax  depends  largely  u])on  the  cause. 
S.  "West  gives  a  mortality  of  70  per  cent.  The  tuberculous  cases  usually 
die  within  a  few  weeks.  Of  39  cases,  29  died  within  a  fortnight  (West); 
10  patients  died  on  tlio  first  day,  2  within  twenty  and  thirty  minutes  re- 
spectively of  the  attack.  I^ieumothorax  devt'loping  in  a  healthy  individual 
often  ends  in  recovery.  There  are  tuberculous  cases  in  which  the  pneu- 
mothorax, if  occurring  early,  seems  to  arrest  the  progress  of  the  tubercu- 
losis.   This  appeared  to  be  the  case  in  a  man  with  chronic  pneumothorax 


GS'A 


DISEASl'LS  OK  TIIK  IIESPIRATOIIY  SYSTEM. 


.  \ 
/ 


who  wns  under  iny  care  in  riiiliulclpliia  for  between  three  and  lour  }Lai,s. 
It  may  bo  a  chronic  condition,  as  in  tlie  case  just  mentioned,  and  a  fair 
measure  oi'  health  nuiy  he  enjoyed. 

Treatment. — Practically  these  cases  sliould  he  dealt  witli  as  ordinary 
j)leurisy  with  ell'iision.  Of  course,  when  pneumothorax  develops  in  ad- 
vanced phthisis  the  indication  is  to  relieve  the  pain  and  distress  either  by 
mor[)hia  or  chloroform;  hut  in  cases  which  develop  early  the  lluid  should 
be  withdrawn  by  aspiration,  or,  if  ])urulent,  i)ermanent  drainage  should  l.r 
obtained.  Kven  when  the  condition  has  seemed  to  be  most  desperate  1 
have  known  recovery  to  take  place  after  thorough  drainage  of  the  sac. 
Portions  of  ribs  may  have  to  bo  excised,  and  during  convalescence  it  is 
well  for  the  j)atient  to  i)ractise  expansion  of  the  lung  in  the  numner 
already  mentioned.  There  are  eases  of  pneumothorax  in  phthisis  in  which 
the  general  condition  is  so  good  and  the  inconvenience  so  slight  that  to 
let  well  eiu)ugh  alone  seems  the  best  course.  In  such  an  occasional  as- 
piration may  be  performed  if  the  fluid  increases.  In  some  of  the  in- 
stances the  mere  tapping  of  the  chest  with  a  fine  needle,  so  as  to  allow 
the  escape  of  some  of  the  air,  seems  to  give  relief  by  reducing  the  intra- 
thoracic ])ressure.  Good  results  are  stated  to  have  f(jllowed  the  method 
introduced  by  Potain,  of  rei)lacing  the  air  and  fluid  within  the  thorax  by 
sterilized  air. 


V.    AFFECTIONS   OF  THE   MEDIASTINUM. 

(1)  Simple  Lymphadenitis. — In  all  inflammatory  afTections  of  the 
bronchi  and  of  the  lungs  the  groups  of  lymph-glands  in  the  mediastinum 
become  swollen.  In  the  bronchitis  of  measles,  for  example,  and  in  simple 
broncho-pneumonia  the  bronchial  glands  are  large  and  infiltrated,  the 
tissue  is  engorged  and  edematous,  sometimes  intensely  hypera^Muic.  Much 
stress  has  been  laid  by  some  writers  on  this  enlargement  of  the  glands  in 
the  posterior  mediastinum,  and  De  Mussy  held  that  it  was  an  im])ortant 
factor  in  inducing  paroxysms  of  whooping-cough.  They  may  attain  a 
size  suificient  to  induce  dulness  beneath  the  manubrium  and  in  the  upper 
part  of  the  interscajmlar  regions  behind,  though  this  is  often  difficult  to 
determine.  In  reality  the  glands  lie  chiefly  upon  the  s])ine,  and  unless 
those  which  are  deep  in  the  root  of  the  lung  are  large  enough  to  induce 
compression  of  the  adjacent  lung  tissue,  I  doubt  if  the  ordinary  bronchial 
adenopathy  ever  can  be  determined  by  percussion  in  the  upper  interscapu- 
lar region.  I  have  never  met  with  an  instance  in  which  the  compression 
of  either  bronchus  seemed  to  have  resulted  from  the  glands,  however  large. 
Tul)erculous  affection  of  these  glands  has  already  been  considered. 

(2)  Suppurative  Lymphadenitis. — Occasionally  abscess  in  the  bronchial 
or  tracheal  lym])h-glands  is  found.  It  may  follow  the  simple  adenitis,  but 
is  most  frequently  associated  Avith  the  ])rcs('nce  of  tubercle.  The  liquid 
portion  may  gradually  become  absorbed  and  the  inspissated  contents  un- 
dergo calcification.  Serious  accidents  occasionally  occur,  as  perforation 
into  the  oesophagus  or  into  a  bronchus,  or  in  rare  instances,  as  in  the  case 


AFFECTIONS   OF   TllK   MKDI AST1XI\M. 


ns5 


large. 


mchial 
is,  but 
liquid 
ts  un- 
ration 
e  case 


reported  by  Sidney  I'billiiis,  peri'orntiim  ol'  the  aorta,  as  well  as  a  brouelius, 
which,  it  is  reiiiarl<al)le  to  say,  did  not  prove  fatal  rapidly,  but  caused  re- 
peated attacivs  of  iuein()j)tysis  during  a  pi'riod  of  sixteen  inontiis. 

(3)  Tumors ;  Cancer  and  Sarcoma. — in  Hare's  ehdjorate  study  of  5-^0 
cases  of  disease  of  the  mediastinum  *  there  were  IJJ-t  eases  of  cancer,  1»(S 
eases  of  sai'coma,  :^1  cases  of  lymphoma,  7  cuses  of  fil)roma,  11  cases  of 
dermoid  cysts,  S  cases  of  hydatid  cysts,  and  instances  of  lipoma,  gumnui, 
and  enclu)ndroma.  From  this  we  see  tluit  cancer  is  the  most  common 
form  of  growth.  The  tumor  occurred  in  the  anterior  mediastinum  alone 
in  48  of  the  cases  of  cancer  and  in  33  of  the  cases  of  sarcoma.  There  are 
three  chief  ])oints  of  origin,  the  thymus,  the  lym[»b-glands,  and  tlie  pleura 
and  lung.  Sarcoma  is  nuire  frecpiently  primary  than  cancer,  ^lales  are 
nu)re  frequently  aifected  than  females.  The  age  of  onset  is  most  eom- 
moidy  between  thirty  and  forty. 

Symptoms. — The  signs  of  mediastinal  tumor  are  those  of  intra- 
thoracic i)ressure.  Dyspiuva  is  one  of  tlie  earliest  and  most  constant 
sym])toms,  and  may  be  due  either  to  pressure  on  the  trachea  or  on  the 
recurrent  laryngeal  nerves.  It  may  indeed  be  cardiac,  due  to  pressure 
upon  the  heart  or  its  vessels.  In  a  few  cases  it  results  from  the  pleural 
effusion  wliich  so  frequently  accompanies  intrathoracic  growths.  Asso- 
ciated with  the  dysjuKea  is  a  cough,  often  severe  and  paroxy.smal  in  char- 
acter, with  the  brazen  quality  of  the  so-called  aneurismal  cough  when  a 
recurrent  nerve  is  involved.  The  voice  may  also  be  atrected  from  a  simi- 
lar cause.  Pressure  on  the  vessels  is  common.  The  superior  vena  cava 
may  l)e  compressed  and  obliterated,  and  when  t!ie  ])rocess  goes  on  slowly 
the  collateral  circulation  may  be  com])letely  eil'ected.  Less  commonly  the 
inferior  vena  cava  or  one  or  other  of  the  subclavian  veins  is  compressed. 
The  arteries  are  much  less  rarely  obstructed.  It  is  remarkable  how  little 
the  aorta  may  be  involved,  though  entirely  surrounded  by  a  sarcomatous 
or  cancerous  mass.  There  may  be  dysphagia,  due  to  com])ression  of  the 
a>sophagus.  In  rare  instances  there  are  pupillary  changes,  either  dilatation 
or  contraction,  due  to  involvement  of  the  sympathetic. 

Physical  Signs. — On  inspection  there  may  be  orthopnea  and  marked 
cyanosis  of  tlie  upper  part  of  the  l)ody.  In  such  instances,  if  of  long 
duration,  there  are  signs  of  collateral  circulation  and  the  sui)erficial  mam- 
mary and  e])igastric  veins  are  enlarged.  In  these  cases  of  chronic  oljstruc- 
tion  the  finger-tips  may  be  clubbed.  There  may  be  bulging  of  the  ster- 
num or  the  tumor  may  erode  the  bone  and  form  a  jirominent  subcutaneous 
growth.  The  rapidly  growing  lymjihoid  tumors  more  commonly  than 
others  perforate  the  chest  wall.  In  4  of  13  cases  of  Ilodgkin's  disease, 
there  was  mediastinal  growth,  and  in  3  instances  the  sternum  was  eroded 
and  perforated.  The  ])erforation  may  be  on  one  side  of  the  breast-bone. 
The  projecting  tumor  may  ]iulsate;  the  heart  may  be  dislocated  and  its 
ini])ulse  much  out  of  place.  Contraction  of  one  side  of  the  thorax  has  been 
noted  in  a  few  instances.  On  palpation  the  fremitus  is  absent  wherever 
the  tumor  reaches  the  chest  wall.     If  ])ulsating,  it  rarely  has  the  forcible, 

*  Fothcrgillian  Prize  Essay  of  the  Medical  Society  of  London,  Philadelphia,  1889. 


(ISO 


DISKASES   OF   TIIK   KKSI'IItAToRY   SYSTEM. 


/ 


liciiviii^  iiiiimlsi'  III'  ail  aniMiri.'iiuil  Siic  ()ii  aiisciillatinii  llicrc  is  \isiially 
."-ik'ncc  over  the  (lull  rcjiio:'.  Tlio  licart-finiiiKls  nw  iioi  t  I'an.-inittctl  and 
the  rcs|Mi'at<)i'V  iminniir  is  IVolilc  or  iiiaiidiMc,  rarely  liroiicliial.  N'ncal 
rt'sonaiico  i.s,  as  a  rule,  altscnt.  Siiiiis  of  pleural  eU'u.siou  occur  in  a  great 
many  instances  ol"  mediastinal  j^rowtli,  and  in  doulitl'nl  cases  the  aspirator 
needle  should  he  used. 

Tumors  of  the  anterior  mediastinum  orij^inate  usually  in  the  thymus; 
the  sternum  is  pushed  forward  and  often  erotled.  Tlio  groAVtli  may  be 
felt  in  the  suprastenud  i'(issa;  the  cervical  glands  are  usually  involved. 
'J'he  pressure  symptoms  are  chictly  upon  the  venous  trunks,  Dyspuiea  is 
a  l»romini'nt  feature. 

Intrathoracic  tumors  in  the  middle  and  posterior  nu'diastinnm  originati; 
most  commonly  in  tlie  lymiih-glands.  Tlio  symptoms  are  out  of  all  ])ro- 
portion  to  till'  jihysical  si;^iis;  there  is  urgent  dyspmea  and  cough,  which 
is  sometimes  loud  and  ringing.  The  pressure  symi)toms  are  chictly  upon 
the  gullet,  the  recurrent  laryngeal,  and  sinnetimes  upon  the  azygos  vein. 

In  a  third  group,  tum.n's  originating  in  the  pleura  and  the  lung,  the 
l)ressure  sym[)toms  arc  not  so  marked.  I'leural  exudate  is  very  much 
more  common;  the  ])atient  becomes  ana'nuc  and  emaciation  is  ra[)id. 
There  may  he  secondary  involvement  of  the  lym|)h-glands  in  the  neck, 
i-'or  a  discussion  of  the  symptomatology  of  these  dill'erent  groui)s,  see 
Pepper  and  Stengel,  Transactions  of  the  Association  of  American  I'liysi- 
cians,  vol.  x. 

The  di(i;/ii(!sis  of  mediastinal  tumor  from  aneurism  is  sometimes  ex- 
tremely dilllcult.  An  interesting  case  reported  and  figured  by  Sokolosski, 
in  I'xl.  I'J  of  the  Dentsches  Archiv  fiir  klinische  Modicin,  in  which 
Oppolzer  diagnosed  anenrism  and  Skoda  mediastinal  tumor,  illustrates 
how  in  some  instances  the  most  skilful  of  observers  may  be  unable  to 
agree.  Scarcely  a  sign  is  found  in  aneurism  which  may  not  be  duplicated 
in  mediastinal  tumor.  This  is  not  strange,  since  the  symptoms  in  both 
are  largely  due  to  pressure.  The  time  element  is  important.  If  a  case 
has  persisted  for  more  than  eighteen  months  the  disease  is  ])rol)ably  aneu- 
rism. There  are,  however,  exce])tions  to  this.  By  far  the  most  valualile 
mign  of  aneurism  is  the  diastolic  shock  so  often  to  be  felt,  and  in  a  majority 
of  cases  to  be  heard,  over  the  sac.  This  is  rarely,  if  ever,  present  in  medias- 
tinal growths,  even  when  they  perforate  the  sternum  and  have  communi- 
cated i)ulsation.  Tracheal  tugging  is  rarely  ]iresent  in  tumor.  Another 
point  of  importance  is  that  a  tumor,  advancing  from  the  mediastinum, 
eroding  the  sternum  and  appearing  externally,  if  aneurismal,  has  forci1)le, 
heaving,  and  distinctly  expansile  jmlsations.  The  radiating  ])ain  in  the 
i>ack  and  arms  and  neck  is  rather  in  favor  of  aneurism,  as  is  also  a  bene- 
ficial influence  on  it  of  iodide  of  ]iotassium. 

The  freipiency  of  jjleural  effusion  in  connection  with  mediastinal  tuuKn- 
is  to  be  constantly  borne  in  mind.  It  may  give  curiously  complex  char- 
acters to  the  physical  signs — characters  which  are  profoundly  modified 
after  aspiration  of  the  li(pii(L 

(4)  Abscess  of  the  Mediastinum. — Hare  collected  11.5  cases  of  medi- 
astinal abscess,  in  77  of  which  there  were  details  sudicient  to  permit  the 


•i  usually 
ttt'd  ami 
\'i)Oal 
:i  II  ^•iTiiL 
u.spiraliir 

thymus; 
L  may  Ijo 
involved. 
•spiKini  is 

ori<:;iiuit(! 
I'  all  i)ro- 
>:h,  which 
otly  upon 
js  vein, 
lung,  tho 
jry  much 
is  rapid, 
the  ucck. 

•OU[)S,    SCO 

an  I'hvsi- 

itimos  ex- 

okolosski, 

in    which 

illustrates 

naljle  to 

I  plica  ted 

in  both 

a  case 

)ly  anen- 

valuahle 

majority 

medias- 

oinmuni- 

Aiu)ther 

astinum, 

forcilde, 

n  in  the 

a  bene- 

al  tumor 
'X  char- 
modified 


AFFIXTIONS  OF  THE  MEDIASTINUM. 


r.S7 


analysis.  Of  thopc  cases  tiie  great  majority  occurred  in  nuiles.  Forty-four 
were  instances  of  acute  abscess,  'i'he  anterior  nu'diastinum  is  most  coni- 
numly  the  seat  of  tlu-  suppuration.  The  cases  are  most  freipu-ntiy  associated 
with  trauma.  Sonu'  have  followed  I'rysipelas  or  occurred  in  association 
with  eruptive  le\ers.  .Many  cases,  particularly  the  chronic  ahscesses,  are 
of  tuberculous  origin.  Of  sijiniiloiiis,  pain  behind  the  sternum  is  the  most 
common.  It  may  be  of  a  throbbing  character,  iiml  in  the  acute  cases  is 
associated  with  i'evcr,  sometimes  with  chills  and  sweats.  If  the  abscess  is 
large  there  may  be  dyspmea.  The  i>us  may  burrow  into  the  abdomen, 
|ierfoi'ate  through  an  intercostal  space,  or  it  may  erode  the  sternum.  In- 
>tances  are  on  record  in  which  the  abscess  has  discharged  into  the  trachea 
111'  (esophagus.  In  many  cases,  i)articularly  of  chronic  abscess,  the  pus 
iteconu'S  inspissated  and  ])roduces  no  ill  eU'ect.  'I'he  ])ln/sir(il  ftii/ns  may 
he  very  indeiinite.  A  [)ulsating  and  tluctuating  tumor  may  ajtpear  at  the 
border  of  the  sternum  or  at  the  sternal  notch.  The  absence  of  bruit,  of 
the  diastolic  shock,  and  of  the  expansile  pulsation  usually  enables  a  cor- 
rect diagnosis  to  be  made.  Wiien  in  doubt  a  fine  hypodermic  needle  may 
be  in.<erted. 

(5)  Indurative  Mediastino-Pericarditls. — Harris  has  recently  reviewed 
the  subject,  in  one  form  there  is  adherent  pericardium  and  great  increase 
in  the  fibrous  tissues  of  the  mediastinum;  in  another  there  is  adherent  peri- 
cardium with  union  to  surrounding  parts,  but  Aery  little  me(liastinitis;  in 
a  third  the  pericardium  may  Ite  uninvolved.  The  disease  is  rare;  of 
•.*•.*  cases  17  were  in  males;  only  2  were  above  thirty  years  of  age.  The 
syni])toms  are  essentially  those  of  that  form  of  adhesive  pericardium  which 
is  associated  Avith  great  hypertrophy  and  dilatation  of  the  heart,  and  in 
which  the  ])atients  present  a  picture  of  cyanosis,  dysimcpa,  anasarca,  etc. 
The  i)ulsus  jtaradoxus,  described  by  Kussmaul,  is  not  distinctive.  Occa- 
sionally thei'c  is  also  a  ])roliferative  peritonitis,  ^lediastinal  friction  is 
sometimes  heard  in  patients  with  adhesive  mediastino-])ericarditis — dry, 
coarse,  crackling  rales  heard  along  the  sternum,  ])articularly  when  the 
arms  are  raised. 

(6)  Miscellaneous  Affections.— In  Hare's  monogra])h  there  were  7  in- 
stances of  fibroma,  11  cases  of  dermoid  cyst,  8  cases  of  hydatid  cyst,  and 
cases  of  lipoma  and  gumma. 

(7)  Emphysemaof  the  Mediastinum.— Air  in  the  cellular  tissues  of  the 
mediastinum  is  nu't  with  in  cases  of  trauma,  and  occasionally  in  fatal  cases 
of  di])htheria  and  in  whooping-cough.  It  may  extend  to  the  subcutaneous 
tissues.  Champneys  has  called  attention  to  its  frequency  after  tracheotomy, 
in  which,  be  says,  the  conditions  favoring  the  production  are  division  of  the 

ep  fascia,  o1)struction  in  the  air-passages,  and  inspiratory  efforts.  Tho 
ej)  fascia,  he  says,  should  not  be  raised  from  the  trachea.  It  is  often 
associated  with  pneumothorax.  The  condition  seems  by  no  means  uncon- 
mon.  Angel  :Money  found  it  in  IG  of  28  cases  of  tracheotomy,  and  in  2 
"f  those  pneumothorax  also  was  present. 


(i( 
(1( 


of  mcdi- 
rmit  the 


48 


SECTION   VII. 
DISEASES  OF  THE  OIPvCULATORY  SYSTEM. 


/ 


I.    DISEASES   OF  THE   PERICARDIUM. 
1.    PERICARDITIS. 

Pericahditis  is  the  result  of  iiil'et'tivc  processes,  ])rininr)'  or  secondary, 
or  arises  l)y  extension  oi'  iiiUaniniation  from  t-onti^nious  or^nms. 

Etiology. — I'liiiiari/,  so-called  i(li<)|tatliic,  iiillanimation  of  this  niem- 
braiH'  is  rare;  hut  cases  arc  nu't  with,  luost  comniouly  in  cliildrcn,  in  whicli, 
there  is  no  evidence  of  rhcunuitisni  or  of  other  conditions  with  which  the 
disease  is  usually  associated. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surgeon 
in  connection  with  the  i)riniary  wound.  Interesting  cases  are  those  in 
which  the  traumatism  is  i'roni  within,  due  to  the  passage  of  some  foreign 
body — such  as  a  needle,  a  pin,  or  a  bone — through  the  cjesophagus  into  the 
pericardium. 

As  a  secondari/  process  ])ericarditis  is  met  with  in  the  following  affec- 
tions: (a)  A  majority  of  the  cases  occur  in  connection  with  rheumatisui. 
The  percentage  given  by  diiferent  authors  ranges  from  thirty  to  seventy. 
The  articidar  trouble  may  be  slight  or,  indeed,  the  disease  may  be  asso- 
ciated with  acute  tonsillitis  in  rheumatic  subjects.  Cases  are  recorded  iii 
which  the  ]iericarditis  has  ])reccded  the  articular  disease,  (h)  Septic  pro- 
cesses rank  next  to  rheumatism.  In  the  acute  necrosis  of  ])one  and  i)uer- 
peral  fever  it  is  not  uncommon,  (c)  Tuberculosis,  in  which  the  disease  may 
be  primary  or  ]iart  of  a  general  involvement  of  the  serous  sacs  or  associated 
with  extensive  ])ulmonary  disease,  (d)  Eruptive  fevers.  In  children,  the 
disease  is  not  infre(pient  after  scarlatina.  It  is  rarely  met  with  in  menshs. 
small-pox,  or  tyjjhoid  fever.  In  other  infective  diseases,  such  as  diphtheria 
and  ])neumonia,  it  is  rare.  Pericarditis  sometimes  complicates  chorea;  it 
was  present  in  10  of  73  autopsies  Avhich  I  collected;  in  only  8  of  these  was 
arth.itis  present,  (r)  Certain  altered  conditions  of  the  system  seem  to 
render  the  pericardium  more  susceptible  to  infection.  Of  these  gout  takes 
the  first  ]ilace.  Tn  chronic  Ptright's  disease  pericarditis  is  by  no  means  rare. 
The  pcrirarchlr  hrif/hfic/ve  of  the  French  forms  one  of  the  most  important 
groups  of  the  disease  in  persons  over  fifty  years  of  age,  most  frequently 
6PS 


PERK'AUniTl!''. 


nsD 


TEM. 


iccondary, 

his  nicm- 
,  ill  wliic'li. 
which  the 

[o  surgeon 
hose  ill 
i'oreigu 
into  the 

ng  alTec- 
uiiuitisin. 
seventy- 
be  asso- 
ordod  ill 
)tic  pro- 
ud i)uer- 
ease  may 
ssoeiatcd' 
Iren,  tlic 
nieasU's, 
iplithcria 
hoiva:  it 
these  \va> 
soem  to 
out  tala'^ 
\ans  rare, 
mportnnt 


rcquen 


th 


accompanying  the  chronic  interstitial  I'onu  of  nephritis.  Pericarditis  has 
lufii  met  with  also  in  scurvy  and  diahctcs. 

rcricurditix  hi/  v.ilciisiini  of  disease  from  contiguous  organs.  In  pleiiro- 
piiciiiiioiiia  it  forms  one  of  tiie  most  serious  com|tli(  atioMs,  and  was  present 
in  ■)  cases  of  l(M»  |tnst  moilcms  in  tliis  (liscaM-  which  I  iiukU'  at  liic  Mont- 
real (ieneral  Hospital.  It  is  most  often  met  with  in  tlu'  plcnro-pneumonia 
of  cliildrcn  and  of  alcoholics.  The  association  with  simple  pleurisy  is  much 
li'ss  ciiinmnn.  In  ulcerative  endocarditis,  pundcnt  myocarditis,  and  in 
aneurism  of  tlu'  a<irta  pericarditis  is  oeeasionally  fuiind.  It  may  also  rcsidt 
l.'om  extension  of  disease  from  the  hronchial  glands,  tlic  rihs,  sternum,  verte- 
hre,  and  even  from  the  abdominal  viscera.  Of  100  consecutive  cases  at  the 
J5<  ston  City  Hospital  analyzed  hy  Sears,  in  o-l  the  exudate  was  dry,  in  11 
sc/ous,  in  I  ha'inorrhagic,  and  in  T)  purulent,  'i'hirty-four  casi's  showed 
(-igns  of  old  valvular  disease;  rheumatism  was  a  factor  in  ."il;  pneumonia 
in  IS;  and  in  7  chronic  ne|»hritis.    Of  the  loo  cases  43  died. 

IVricarditis  occurs  at  all  ages.  Cases  are  reported  in  tlu-  ftetus.  In 
the  new-horn  it  may  result  from  septic  infection  through  the  navel. 
Tliroughout  childhood  the  incidence  of  rheumatism  and  scarlet  fever  makes 
it  a  fret|uent  all'ection,  whereas  late  in  life  it  is  most  often  associateil  with 
luhcrculosis,  Uright's  disease,  and  gout.  Males  are  somewhat  more  fre- 
(pieutly  attacked  than  females.  Climatic  and  seasonal  iniluences  have  hcen 
mentioned  hy  some  writers.  The  so-called  epidemics  of  pericarditis  have 
been  outbreaks  of  pntMiUKMiia  with  this  as  a  fre((ucnt  complication. 

Anatomically  as  well  as  clinically  the  disease  may  be  considered  under 
the  following  divisions: 

1.  Acute,  plastic,  or  dry  ])ericardit is. 

2.  Pericarditis  with  ell'usion — sero-dbrinous,  ha'inorrhagic,  or  |)uruli'nt. 

3.  Chronic  adhesive  pericarditis  (adherent  pericardium). 

Acute  Plastic  Pericarditis. — This,  the  most  common  form,  occurs  usu- 
ally as  a  secondary  ])roci'ss,  and  is  distinguished  by  the  small  amount  of 
lluid  exudation,  which  does  not,  as  in  the  next  variety,  give  special  charac- 
ters to  the  disease.    It  is  a  benign  form  and  never  of  itself  ])roves  fatal. 

Anatomically  it  may  be  ])artial  or  general.  In  the  mildest  grade:  the 
serous  membrane  looks  lustreless  and  roughened.  This  is  due  to  the  pres- 
ence of  a  thin  fibrinous  sheeting,  which  can  be  lifted  with  the  knife,  showing 
the  membrane  beneath  to  be  injected  or  in  ])laces  ecchymotic.  As  the 
iibrinous  slieeting  increases  in  thickness  the  constant  movement  of  the 
adjacent  surfaces  gives  to  it  sometimes  a  ridge-like,  at  others  a  honey- 
(•niid)cd  appearance.  With  more  abunchuit  fibrinous  exudation  the  mem- 
branes ])resent  an  a])])earance  resembling  buttered  surfaces  which  have  been 
drawn  ajiart.  The  fibrin  is  in  long  shreds,  and  the  heart  presents  a  curiously 
shaggy  appearance — the  so-called  hairy  heart  of  old  writers — cdv  rillnsum 

In  mild  grades  the  subjacent  muscle  looks  normal:  but  in  the  more 
jirolongcd  and  severe  cases  there  is  myocarditis,  and  for  2  or  3  inni.  be- 
neath the  visceral  layer  the  muscle  ]u-esents  a  jiale,  turbid  ai)])earanco. 
Many  of  these  acute  cases  are  tuberculous:  covered  by  the  layers  of  lymph 
ilie  iiriMiulations  are  easily  overlooked  in  a  superficial  examination. 


p^ 


1 


(, 


ouo 


DlSKASKS  OF  THE  f lUCL'LAToUY  SYSTK.M. 


S!i«,'lit  lliiitl  I'Midatioii  in  iiiviirinhly  present,  fiilaii;:l('(l  in  tlu'  incslu's 
ol'  liliiiii,  liiit  tin  re  iiiiiv  lu-  Very  tliick  libiiiioiis  layors  willioiit  inucli  hltuuh 

t'll'usidll. 

SymptomB.— 'I'lio  inajorit}'  of  cat^cH  of  siniplo  pluHtic  pt'ricanlili.s,  like 
tliot^e  of  t^iiiiplt'  L'lidocardilis,  pri'.st'iit  no  tiyniptoins,  and  unli'SH  sought  fur 
tluTc  arc  no  ofjjcctivc  si;,Mis  indicatinf;  its  (.'xistcncc  In  llic  posl-uiorti'ni 
room  it  is  not  uMcnMiinun  to  lind  it  in  cased  in  wluch  its  prcscncu  luis  bt'ca 
uiisuspi'C'ti'd  during  life. 

I'ain  is  a  variable  syniptonj,  not  usually  intense,  and  in  this  form  rarely 
exeitcd  l»y  pressure.  It  is  nmre  luarketl  in  the  early  stage,  and  may  he 
referred  either  to  the  pra-eurdia  or  to  the  region  of  the  .xiphoid  cartilage. 
Instances  are  recorded  of  pain  of  an  aggravated  and  most  distressing  char- 
neter  resend)ling  angina.  Fever  is  usually  present,  hut  it  is  not  always  easy 
to  say  how  much  depends  upon  the  primary  febrile  atl'eetion,  and  how  mueli 
upon  the  pericarditis.  Jt  is  as  a  ride  not  high,  rarely  exceeding  1()'^..">'. 
In  rhcumiitic  cases  hyperpyrexia  has  been  observed. 

Physical  Signs. — Inspection  is  negative;  piilpntinn  may  reveal  the  pres- 
ence of  u  distinct  fremitus  caused  by  the  rubbing  of  the  rougheiu'd  peri- 
cardial surfaces.  This  is  usually  best  nwirked  over  the  right  ventricle.  It 
is  not  always  to  be  felt,  even  when  the  friction  sound  on  auscultation  is 
loud  and  ch'ar.  Aiisrnlldlion :  The  friction  sound,  due  to  the  movement 
of  the  ])erieardial  surfaces  upon  each  other,  is  one  of  the  most  distinctive 
of  physical  signs.  It  is  double,  corres|»onding  to  the  systole  and  diastole; 
but  the  synchronism  with  the  heart-sounds  is  not  accurate,  and  the  to-and- 
fro  mui'iiiur  usually  outlasts  the  tinu'  occu|»icd  by  the  lirst  and  second 
sound.  In  rare  instances  the  friction  is  single;  more  freiiuently  it  ap- 
pears to  be  triple  in  character — a  siu't  of  canter  rhythm.  The  sounds  have 
a  pt'culiar  I'ubbing,  grating  (piality,  characteristic  when  oiu-e  recogni/cd. 
and  rarely  simulated  by  endocardial  murmurs.  Sonu'tinu'S  insteail  nf 
grating  there  is  a  creaking  (piaiity — the  hniil  tic  cnir  nciif — the  new-leather 
murmur  of  the  French.  The  pericardial  friction  appears  superficial,  very 
close  to  the  ear,  and  is  usually  intensified  by  pressure  with  tin;  stethosco]ie. 
It  is  best  heard  over  the  right  ventricle,  the  part  of  the  heart  which  is  most 
closely  in  contact  with  the  front  of  the  chest — that  is,  in  tlu;  fourth  and 
fifth  interspaces  and  adjacent  portions  of  the  sternum.  There  are  instances 
in  which  the  friction  is  most  marked  at  the  base,  over  the  aorta,  and  at 
the  superior  rctlecti(Ui  of  the  jiericardium.  Occasionally  it  is  best  heard 
''^"  the  apex,  it  may  be  limited  and  heard  over  a  very  narrow  area,  or  it 
l)e  transmitted  U])  and  down  the  sternum.  There  are,  however,  im 
tinite  lines  of  transnii.ssion  as  in  the  en(h)cardial  muimur.  An  important 
point  is  the  variability  of  the  sounds,  both  in  ])osition  and  quality;  they  mny 
be  heard  at  one  visit  and  not  at  another.  The  maximum  of  intensity  will 
1)6  fonnd  to  vary  with  position. 

Diagnosis. — There  is  rarely  any  ditTiculty  in  determining  the  ]ircs- 
ence  of  a  dry  i»ericarditis,  for  the  friction  sounds  are  distinctive.  '^I'ln' 
double  murmur  of  aortic  incom])etency  may  simulate  closely  the  to-and- 
fro  pericardial  rul).  I  recall  one  instance  at  least  in  which  tliis  mistake  w.is 
made.    The  constant  character  of  the  aortic  murmur,  flic  direction  of  trans- 


rKniCARIHTIS. 


•un 


ho  mcslu's 
\U'li  Horuus 

nlili.-,  liUo 
soiijflil  t'ur 
)st-m()rti'in 
c  lias  bt'on 

iorni  rarely 
ii\  may  be 
I  cart  il ago. 
ssiii^,'  cliar- 
ilwiiys  I'asy 
how  imu'li 
iiiK  102.5°. 

il  tlic  i)rcs- 

iciu'd  pt'i'i- 

ntrick'.     it 

.'ultation  is 

inovL'iiic'iil 

(listiiK'tivc 

1(1  (liastolo; 

the  to-aiul- 

111(1  second 

iilly  it  ap- 

miids  have 

:'('C()giiiz('d, 

instead    nf 

'w-lcathcr 

icial,  very 

t'tllOSCOJlC. 

icli  is  most 
'oiirtli  ami 

instances 

•ta,  and  at 

)cst  heard 

area,  or  it 

Dwcver,  no 

important 

they  m;iy 
ensity  will 

jlie  ]ires- 
tivc.  The 
lie  lo-and- 
listakc  Wits 
n  of  trans- 


iids.Nioii,  (lie  phciioiiu'iia  in  tlu'  arteries,  and  the  n.-^sociatcd  conditions  of 
ilic  disease  wlionid  he  sntlicicnt  to  prevent  this  error 

1  have  never  kni»wn  an  instance  in  which  pericarditis  was  mistaken  for 
iHiile  endocarditis,  thou^di  writers  refer  to  sueh,  and  give  tiie  dilVerciitial 
dia"ii()sis  in  the  two  idVeeiioiis.  The  oidy  possible  mistake  could  be  made 
Ml  those  rare  instances  of  single  soft,  systolic,  pericariliai  friction. 

I'lciiro-pei'irardidl  (rirtion  is  very  common,  and  may  be  a.ssociate(i  with 
eiido-pericarditis,  partieidarly  in  cases  of  pleiiro-pneiiinoiiia.  It  is  fre- 
(pient,  too,  in  phthisis.  It  is  best  beard  over  the  left  bolder  (tt  the  heart, 
and  is  iiiiich  alVeeted  by  the  respiratory  movcnient.  Ibdding  the  l»realli 
or  taking  a  deep  inspii'at»ion  may  annihilate  it.  The  rhythm  is  not  the  sim- 
ple to-and-fro  diastolic  and  systolic,  but  the  res|»iratory  rhythm  is  super- 
iidded,  usually  intensifying  the  murmur  during  expiration  and  lessening 
it  on  ins'tiratioii.  In  phthisis  there  are  instances  in  which,  with  the  fric- 
tion, a  loud  .'iystolic  click  is  heard,  due  to  the  compression  (d'  a  thin  layer 
(d'  lung  and  the  expulsion  of  a  bubble  (d'  air  from  a  small  softening  focus 
or  from  a  bronchus. 

And,  lastly,  it  is  not  very  uncommon,  in  the  r-'gion  of  the  apex  beat,  to 
liear  a  series  of  fine  crepitant  sounds,  systolic  in  time,  often  very  distinct, 
su''i:estivc  of  pericardial  adhesions,  bid  heard  too  frciiiieiitlv  for  this  cause. 

Course  and  Tcniiiiuiliiiii. — Simple  tibrinous  pericarditis  never  kills,  but 
it  occurs  so  often  in  connection  with  serious  aUVctions  that  we  have  fre- 
((iictd  opportunities  to  see  all  stages  of  its  |trogress.  In  the  majority  (d' 
ciises  the  inllammation  subsides  and  the  thin  lilninous  lamina'  gradually 
become  converted  into  connective  tissue,  which  unites  the  pci'icardial  leaved 
liniily  together,  in  otlu'r  instances  the  inllamiiiiitioii  progresses,  nitli  in- 
crease of  the  exudation,  and  the  condition  is  changed  from  a  "dry"  to  a 
"  moist  "  pericarditis,  or  the  pericarditis  with  elVusion. 

Ill  a  lew  instances — prol)ably  always  tuberculons — the  simidc  ]ilastic 
pericarditis  becomes  chronic,  and  great  thickening  of  b(dh  visceral  and 
parietal  layers  is  gradually  induced. 

Pericarditis  with  Eirusion. — 'IMiongh  commonly  a  direct  se(picnce  of 
the  dry  or  ])lastic  pericarditis,  of  which  it  is  sometimes  called  the  second 
stage,  this  form  presents  s])ecial  features  and  deserves  separate  considera- 
tion. It  is  found  most  frcipiciitly  in  association  with  acute  rlu'umatism, 
tuberculosis,  and  se])ticaMnia,  and  sets  in  nsnally  with  the  symptoms  above 
described,  namely,  piwcordial  pain,  with  slight  fever  or  a  distinct  chill. 

In  children  the  disease  nuiy,  like  ])leurisy,  come  on  without  local  symp- 
toms, and,  after  a  week  or  two  of  failing  healtli,  slight  fever,  shortness  of 
breath,  and  increasing  jiallor,  the  physician  may  iind,  to  his  astonishment, 
signs  of  most  extensive  ]H'ricardial  clfusion.  These  latent  causes  are  often 
tuberculous.  "\Y.  Kwart  lias  called  special  attention  to  latent  and  eph(^meral 
pci'icardial  effusions,  which  he  thinks  are  oft(^n  of  short  duration  and  of 
moderate  size,  with  an  absence  of  the  painful  features  of  pericarditis.  I'lio 
effusion  may  he  scro-fil)rinous,  luemorrliagic,  or  purulent.  The  amount 
varies  from  200  or  300  cc.  to  2  litres.  In  the  cases  of  sero-fibriiioiis  exuda- 
tion the  pericardial  membranes  are  covered  with  thick,  creamy  fibrin,  which 


/ 


C[)2 


DISEASES  OF  THE  CIllCULATOIlY  SYSTEM. 


iiuiy  bo  in  ri(l<;i's  or  honuyfonibt'il,  or  may  })R'.<ent  Inii^^,  villous  extensions, 
'riio  ])iiriL'tal  layer  may  bo  several  millimetres  in  tliiekness  and  may  I'oriii 
'n  lirni,  leathery  membrane.  The  luemorrhagie  exudation  is  usually  associ- 
ated with  tuberculous,  or  with  cancerous  pericartlitis,  or  with  the  disease 
in  the  aged.  The  lyuiph  is  less  abundant,  but  both  surfaces  are  injected 
aud  ol'ten  show  nuuierous  luemorrhages.  Thick,  curdy  nuisses  of  lymph 
are  usually  I'ouud  iu  the  dependent  part  of  the  sac.  In  the  purulent  eH'u- 
sion  the  lluid  has  a  creamy  consistency,  i)articularly  in  tuberculosis.  In 
many  cases  the  ell'usion  is  really  sero-purulent,  a  thin,  turbid  exudation  con- 
tainiug  llocculi  oi'  iibrin. 

'J'he  pericardial  layers  are  greatly  thickened  ajul  covered  with  fibrin. 
"When  the  lluid  is  pus,  they  }»resent  a  grayish,  rough,  granular  surface. 
Souietimes  there  are  distinct  erosions  on  the  visceral  membrane.  The 
heart  muscle  in  these  cases  becomes  involved  to  a  greater  or  less  extent, 
and  on  section,  the  tissue,  for  a  dej)th  of  from  2  to  3  mm.,  is  pale  and 
turbid,  and  shows  evidence  of  fatty  and  granidar  change.  Endocarditis 
coexists  frecpiently,  but  rarely  results  from  the  extension  of  the  inllannnii- 
tion  through  the  wall  of  the  heart. 

Symptoms. — Even  with  co])ious  elfusion  the  onset  and  course  may 
be  so  insidious  that  no  suspicion  of  the  true  nature  of  the  disease  is  aroused. 

As  in  the  simple  i)ericarditis,  pain  may  be  present,  either  sharp  and 
stabbing  or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region.  It 
is  more  fre(|uent  with  elfusion  than  in  the  plastic  form.  Pressure  at  the 
lower  end  of  the  sternum  nsually  aggravates  it.  Dyspntua  is  a  common 
and  im])ortant  sym])tom,  one  which,  perhai)s,  more  than  any  other,  excites 
sns])icion  of  grave  disorder  and  leads  to  careful  examination  of  heart  and 
lungs.  The  ])atient  is  restless,  lies  npon  tlu'  left  side  or,  as  the  ell'usion 
increases,  sits  up  in  bed.  Associated  with  the  dyspntjoa  is  in  many  cases  a 
peculiarly  dusky,  anxious  countenance.  The  pulse  is  rapid,  small,  some- 
tinj^s  regular,  and  may  present  the  characters  known  as  pulsus  paradoxus, 
in  which  during  each  inspiration  the  pulse-beat  becomes  very  weak  or  is 
lost.  These  sym])toms  are  due,  in  great  part,  to  the  direct  mechanical 
olfect  of  the  lluid  within  the  pericardium  M-hicli  embarrasses  the  heart's 
action.  Other  ])ressure  elfects  are  distention  of  the  veins  of  the  neck, 
dys])hagia,  which  may  lie  a  marked  symptom,  and  irritative  cough  from 
com])ression  of  the  trachea.  Aphonia  is  not  uncommon,  owing  to  comjires- 
sion  or  irritation  of  the  recurrent  laryngeal  as  it  winds  round  the  aorta. 
Another  inijiortant  pressure  effect  is  exercised  npon  the  left  lung.  In 
massive  effusion  the  pericardial  sac  occupies  such  a  largo  portion  of  the 
antero-lateral  region  of  the  left  side  that  the  condition  has  frequently  been 
mistaken  for  ])leurisy.  Even  in  moderate  grades  the  left  lung  is  somewliat 
coiu])ressed.  This  is  an  additional  element  in  the  production  of  the 
dyspnoea. 

Great  restlessness,  insomnia,  and  in  the  later  stages  low  delirium  and 
couia  are  symptoms  in  the  more  severe  cases.  Delirium  and  marked  cere- 
bral sym])toms  are  associated  with  the  hyperpyrexia  of  rheumatic  eases, 
but  a])art  from  the  ordinary  delirium  there  may  be  peculiar  mental  symp- 
toms.    The  patient  may  become  melancholic  and  show  snicidal  tendencies. 


extensions, 
may  I'orni 
illy  associ- 
lie  diijcaso 
V  injected 
of  lynij)h 
Lilent  eirii- 
ilosis.  In 
ation  con- 

ith  fibrin. 
ir  surface, 
uie.  The 
.'.ss  extent, 
1  pale  and 
idocarditis 
inilannna- 

Durse  may 

IS  aroused. 

sharp  and 

egion.     It 

-ire  at  tlie 

I  common 

jr,  excites 

heart  and 

ell'iision 

y  cases  a 

11,  somc- 

arado.vus, 

eak  or  is 

echanical 

i  heart's 

le  neck, 

gh  from 

comjires- 

le  aorta. 

In 

n  of  the 

ly  been 

nnewliat 

of   the 


PERICARDITIS. 


608 


it 


um  and 
ed  cere- 
ic  cases. 
1  symp- 
flencies. 


In  otlier  cases  tlio  condition  resembles  closely  delirium  tremens.  Sibson, 
who  has  sjjecially  described  this  condition,  states  that  the  majority  of  such 
cases  recover,  t'horca  may  also  occur,  as  was  pointed  out  by  liright.  Epi- 
lepsy is  a  rare  comi)lication  which  iuis  occurred  during  ])aracentesis. 

Physical  Signs. — lusjicrllun. —  In  children  the  pra'cordia  bulges  aiul 
with  c(»pious  exudation  the  antero-lateral  region  of  the  left  chest  becomes 
enlarged,  ^i'he  intercostal  s])aces  are  ])rominent  and  there  may  be  marked 
(edcna  of  the  wall.  The  epigastrium  may  be  more  prominent.  I'erfora- 
tion  externally  through  a  space  is  very  rare.  Owing  to  the  comi)ression 
of  the  lung,  the  expansion  of  the  left  side  is  greatly  diminished.  The  dia- 
phragm and  left  lobe  of  the  liver  nuiy  be  pushed  down  and  may  produce 
a  distinct  prominence  in  the  epigastric  region. 

Pal  pal  ion. — A  gradual  diminution  and  final  ol)literation  of  the  cardiac 
shock  is  a  striking  feature  in  j)rogressive  effusion.  The  position  of  the 
a|)ex  beat  is  not  constant.  In  large  effusions  it  is  usually  not  felt.  In  chil- 
ihvn  as  the  fluid  collects  the  i)ulsation  may  be  best  seen  in  the  fourth  space, 
but  this  nuiy  not  be  the  ajiex  itself.  Kwart  maintains  that  the  position  of 
the  apex  beat  is  unaltered,  or  even  depressed.  The  i)ericardial  friction  nuiy 
lessen  with  the  effusion,  though  it  often  persists  at  the  base  wiien  m)  longer 
pal|)able  over  the  right  ventricle,  or  may  be  felt  in  the  erect  and  not  in  the 
recumbent  posture.    Fluctuation  can  rarely,  if  ever,  l)e  detv'cted. 

Fcrcussion  gives  most  imjjortant  indications.  The  gradual  distention 
of  the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large 
area  comes  in  contact  with  the  chest  wall  and  gives  a  greatly  increased 
percussion  dulness.  The  form  of  this  dulness  is  irregularly  })ear-shaped; 
the  base  or  broad  surface  directed  downward  and  the  stem  or  a])ex  directed 
;.pward  toward  the  manubrium.  A  valuable  sign,  to  which  Kotch  called 
attention,  is  the  absence  of  resonance  in  the  right  fifth  intercostal  space. 
In  the  left  infrasca])ular  area  there  may  be  a  patch  of  diminished  resonance 
or  even  flatness  (Kwart). 

Auscullalion. — The  friction  sound  heard  in  the  early  stages  may  dis- 
<'ip])ear  when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at 
the  limited  area  of  the  ai)ex.  It  may  be  audible  in  the  erect  and  not  in 
the  recumbent  ])osture.  With  the  absorption  of  the  fluid  the  friction  re- 
turns. One  of  the  most  important  signs  is  the  gradual  weakening  of  the 
heart-sounds,  which  with  the  increase  in  the  elfusion  may  become  so  muf- 
fled and  indistinct  as  to  be  scarcely  audible.  The  heart's  action-  is  usually 
iiu-reased  and  the  rhythm  disturbed.  Occasiomdly  a  systolic  endocardial 
murmur  is  heard.  Early  and  ])ersisteiit  accentuation  of  the  i)ulmonary 
second  sound  may  be  present  (Warthin). 

Important  accessory  signs  in  large  effusion  are  due  to  pressure  on  the 
left  lung.  The  antero-lateral  margin  of  the  lower  lobe  is  ])ushed  aside  and 
in  some  instances  com])ressed,  so  that  percussion  in  the  axillary  region, 
in  and  just  below  the  transverse  ni])])le  line,  gives  a  modified  ])ercussion 
note,  usually  a  flat  tympany.  Variations  in  the  position  of  the  patient 
may  change  materially  this  modified  ])ercussi(ni  area,  over  which  on  auscul- 
latic  1  there  is  either  feeble  or  tubular  breathing. 

Course. — Cases  vary  extremely  in  the  rapidity  with  which  the  effusion 


G94 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


/ 


tako8  jtlace.  In  every  instance,  when  a  i)ericarilial  friction  murmur  has 
Ijcen  tietected,  the  jinietitioner  sliould  immediately  outline  with  care — 
using  the  aniline  pencil  or  nitrate  oi'  silver — the  upper  and  lateral  limits 
oi'  cardiac  (hihie.ss,  since  he  will  in  this  way  have  certain  i)ositive  guides  in 
determining  the  rate  and  grade  oi'  the  ellusion.  In  many  instances  the 
exudation  is  sliglit  in  amount,  reaches  a  maximum  witiiin  i'orty-eigiit  hours, 
and  then  gradually  suhsidcs.  In  other  instances  the  accumulation  is  more 
gradual  ami  j)rogressive,  iiu'reasiug  for  several  weeks.  To  such  eases  the 
term  ehronic  has  Ix'cn  applied.  The  rapidity  with  whieh  a  sero-librinous 
ell'iision  may  be  absorbed  is  surju-ising.  The  possibility  of  the  absorption 
of  a  purulent  exudate  is  shown  l)y  the  cases  in  which  the  pericardium  con- 
tains semi-solid  grayish  nuisses  in  all  stages  of  calcilication.  With  sero- 
libi'inous  ell'iision,  if  moderate  in  amount,  recovery  is  the  rule,  with  in- 
evitable union,  however,  of  the  jjcricardial  layers.  In  some  of  the  septic 
cases  there  is  a  rapid  formation  of  pus  and  a  fatal  residt  may  follow  in  three 
or  four  days.  More  commonly,  when  death  occurs  with  large  elfusion,  it  is 
not  until  tlie  second  or  third  week  and  takes  ])lace  by  gradual  asthenia. 

Prognosis. — In  the  sero-librinous  elfusions  the  outlook  is  good,  and 
a  large  majority  of  all  the  rheumatic  cases  recover.  The  ])urulent  elfusiojis 
are,  of  course,  more  dangerous;  the  septic  cases  are  usually  fatal,  and  re- 
covery is  rare  in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked 
hy  the  practitioner,  i'ost-mortem  experience  shows  how  often  i)ericarditis 
is  not  recognized,  or  goes  on  to  resolution  and  adliesion  without  attracting 
notice.  In  a  case  of  rheumatism,  watched  from  the  outset,  with  the  atten- 
tion directed  daily  to  the  heart,  it  is  one  of  the  simplest  of  diseases  to  diag- 
nose; hut  when  one  is  called  to  a  case  for  the  first  time  and  finds  ])erhaps  an 
increased  area  of  i)riccordial  dulness,  it  is  often  very  hard  to  determine  with 
certainty  whether  or  not  elfusion  is  present. 

The  dilRculty  usually  lies  in  distinguishing  between  dilatation  of  the 
heart  and  pericardial  elfusion.  Although  the  dilferential  signs  are  simple 
enough  on  ])aper,  it  is  notoiiously  dillicult  in  certain  cas' s,  particularly  in 
stout  jiersons,  to  say  which  of  the  conditions  exists.  The  points  which 
deserve  attention  are: 

(d)  The  character  of  the  impulse,  which  in  dilatation,  particularly  in 
thin-chested  iieo])le,  is  commonly  visible  and  wavy. 

(/;)  The  shock  of  the  cardiac  sounds  is  more  distinctly  palpable  in  dila- 
tation. 

{(•)  The  area  of  dulness  in  dilatation  rarely  has  a  triangular  form; 
nor  does  it,  except  in  cases  of  mitral  stenosis,  reach  so  high  along  the  left 
sternal  margin  or  so  low  in  the  fifth  and  sixth  inters])aces  wilhoid  visible  or 
pnlpahlc  impulse.  An  upper  limit  of  dulness  shifting  with  change  of  posi- 
tion speaks  strongly  for  effusion. 

(d)  In  dilatation  the  heart-sounds  are  clearer,  often  sharp,  valvular, 
or  foetal  in  character;  whereas  in  effusion  the  sounds  are  distant  and 
muffled. 

(e)  IJarely  in  dilatation  is  the  distention  sufficient  to  compress  the  lung 
and  produce  the  tymi)anitic  note  in  the  axillary  region. 


mur  has 
li  care — 
■al  limits 
s^uidt'ti  in 
incus  the 
ht  hours, 
1  is  more 
cases  the 
-librinous 
hsorption 
ium  con- 
'itli  sern- 

Avith  in- 
;he  septic 
\-  in  three 
sion,  it  is 
enia. 
^ood,  and 

eliusions 
I,  and  re- 

verlooked 
3ricarditis 
attracting 

he  atten- 
to  diag- 

rhaps  an 
nine  with 

)n  of  the 
re  simple 
ularly  in 
ts  which 

ularly  in 

in  dila- 

iir  form; 

the  left 
visible  or 

of  posi- 

rahndar, 
ant  and 

;hc  lunc: 


PERICARDITIS. 


695 


The  number  of  excellent  observers  who  have  acknowledged  that  they 
have  failed  sometimes  to  discriminate  between  these  two  conditions,  and 
who  have  indeed  performed  jiaracentesis  cunlis  instead  of  paracentesis  peri- 
cardii, is  perhaps  the  best  comment  on  the  dillicuities. 

Massive  (1^  to  2  litre)  exudations  have  been  confounded  with  a  i)leural 
elfusion.  On  more  than  one  occasion  the  i)ericardium  has  been  tapped 
under  tlie  impression  that  the  exudate  was  i)leuritic.  Tlie  Hat  tympany 
in  the  infrascapidar  region,  the  absence  of  well-deliued  movable  dulness, 
and  the  feeble,  niulUed  sounds  are  indicative  points.  If  the  case  has  been 
followed  from  day  to  day  there  is  rarely  much  dilUculty;  but  it  is  dilferent 
when  a  case  presents  a  large  area  of  dulness  in  the  antero-lateral  region 
of  the  left  chest,  and  tiiere  is  no  to-and-fro  pericardial  friction  nmrmur. 
Many  of  the  cases  have  been  regarded  as  enca[)sulated  i)leural  elfusions. 

The  nature  of  the  fluid  cannot  positively  be  determined  without  aspira- 
tion; but  a  fairly  accurate  opinion  can  be  formed  from  the  nature  of  the 
primary  disease  and  the  general  condition  of  the  patient.  In  rheumatic 
cases  the  exudation  is  usually  sero-iibrinous;  in  septic  anil  tuberculous 
cases  it  is  often  purulent  from  the  outset;  in  senile,  nephritic,  and  tuber- 
culous cases  the  exudation  is  sometimes  lucmorrhagic. 

Treatment. — The  patient  should  have  absolute  quiet,  mentally  and 
bodily,  so  as  to  reduce  to  a  minimum  the  lu'art's  action.  Drugs  given  for 
this  purpose,  such  as  aconite  or  digitalis,  are  of  douljtful  utility.  Local 
bloodletting  by  cupping  or  leeches  is  certainly  advantageous  in  robust 
subjects,  particularly  in  the  cases  of  extension  in  pleuro-jmeumonia.  The 
ice-bag  is  of  great  value.  It  may  be  a])])lied  to  the  pnccordia  at  first  for  an 
hour  or  more  at  a  time,  and  then  continuously.  It  reduces  the  frequency 
of  the  heart's  action  and  seems  to  retard  the  progress  of  an  elfusion.  Blis- 
ters are  not  indicated  in  the  early  stage. 

AVhen  elfusion  is  present,  the  following  measures  to  ]n-onujte  absorption 
may  be  ado})ted:  lUisters  to  the  pra^cordia,  a  practice  not  so  much  in  vogue 
now  as  formerly.  It  is  suri)rising,  however,  in  some  instances,  how  quickly 
an  effusion  will  snl)side  on  their  ajjplication.  If  the  ])atient's  strength  is 
good,  a  purge  every  other  morning  may  be  given.  The  diet  should  be  light, 
dry,  and  nutritious.  In  cases  in  which  the  pulse  is  strong  and  the  consti- 
tutional disturbance  not  great,  iodide  of  potassium  may  be  of  service,  and 
the  action  of  the  kidneys  may  be  promoted  by  the  infusion  of  digitalis  and 
acetate  of  potash. 

AVhen  the  effusion  is  largo,  as  soon  as  signs  of  serious  imi)airment  of 
tlio  heart  occur,  as  indicated  by  dysjuuea,  small  rapid  pidse,  dusky,  anxious 
countenance,  surgical  measures  should  be  resorted  to,  and  paracentesis,  or 
incision  of  the  pericardium,  at  once  be  i)erformed.  With  the  sero-rd)rinous 
exiulate,  such  as  commonly  occurs  after  rheumatism,  asjiiration  is  sulli- 
cient;  but  when  the  exudate  is  purulent,  the  pericardium  should  be  freely 
incised  and  freely  drained.  The  puncture  may  be  made  in  the  fourth  inter- 
space, either  at  the  left  sternal  margin  or  2..j  cm.  (an  inch)  from  it.  If 
made  in  the  fifth  interspace  it  is  well  to  jiuncturc  an  inch  and  a  half  from 
the  left  sternal  margin.  In  large  cfl'usions  the  pericardium  can  also  be 
readily  reached  without  danger  by  thrusting  the  needle  upward  and  back- 


090 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


/ 


wiii'd  close  to  llic  cnstiil  marjiin  in  the  left  oosto-xiphoid  angle.  The  re- 
sults of  }mrac'entesiti  of  the  pericardium  have  so  far  not  heen  satisfactory. 
With  an  I'arlier  t)peration  in  many  instances  and  a  more  radical  one  in 
others — a  free  incision  and  not  aspiration  when  the  lluid  is  purulent — the 
percenta.iic  of  recoveries  will  be  greatly  increased.  Uf  35  cases  of  suppura- 
tive pericarditis  treated  hy  incision  15  recovered  and  20  died  (Jioberts,  Am. 
Jr.  ?ded.  Sciences,  Dec,  ISDT). 

Chronic  Adhesive  Pericarditis  {Adherent  Pericardium). — Two  groups 
of  cases  may  he  recognized: 

{a)  Simple  adhesion  of  the  peri-  and  epicardial  layers.  This  is  a  com- 
mon sequence  of  pericarditis,  and  is  frequently  met  with  post  mortem  as 
an  accidental  lesion.  It  is  not  necessarily  associated  with  disturbance  in 
the  function  of  the  heart,  and  in  a  large  proportion  of  the  eases  there  is 
neither  dilatation  nor  hypertrophy. 

{!))  xVdherent  pericardium  with  chronic  mediastinitis  and  union  of  the 
outer  layer  of  the  pericardium  to  the  pleura  and  to  the  chest  walls.  This 
constitutes  one  of  the  most  serious  forms  of  cardiac  disease,  particularly  in 
early  life,  and  may  lead  to  an  extreme  grade  of  hypertrophy  and  dilatation 
of  the  heart.  Even  with  partial  adhesion  hetween  the  epicardium  and 
pericardium  there  may  be  enormous  hypertrophy  under  the  conditions  just 
mentioned.  The  symptoms  of  adherent  pericardium  are  uncertain  and  in- 
definite. In  the  second  grou}>  the  features  are  those  of  hypertrophy  and 
dilatation  of  the  heart,  later  cardiac  insufhciencj',  and  in  a  few  instances 
signs  of  extension  of  the  mediastinitis  to  the  peritonieum,  causing  chronic 
proliferative  peritonitis,  Avith  perihepatitis  and  perisplenitis.*  Sudden 
deatli  may  occur  after  an  unusual  exertion  or  during  parturition  (Reynolds 
Wilson). 

The  following  are  important  points  in  the  diagnosis:  Inspection. — A 
majority  of  the  signs  of  value  come  under  this  heading,  (a)  The  prnecordia 
is  prominent  and  there  may  he  marked  asymmetry,  owing  to  the  enormous 
■enlargement  of  the  heart,  (b)  The  extent  of  the  cardiac  impulse  is  greatly 
increased,  and  may  sometimes  he  seen  from  the  third  to  the  sixth  inter- 
si)aces,  and  in  extreme  cases  from  the  right  parasternal  line  to  outside  the 
left  nipple,  (c)  The  character  of  the  cardiac  inqjulse.  It  is  undulatory, 
wavy,  and  in  the  apex  region  there  is  marked  systolic  retraction,  (d)  Dia- 
])hragm  ]ilienonicna.  J.  W.  Broadhent  has  called  attention  to  a  very  valu- 
able sign  in  adherent  pericardium.  When  the  heart  is  adherent  over  a  large 
area  of  the  diaphragm  there  is  with  each  pulsation  a  systolic  tug,  which 
may  he  communicated  through  the  diaphragm  to  the  points  of  its  attach- 
ment on  the  wall,  causing  a  visible  systolic  tugging.  This  has  long  been 
recognized  in  the  region  of  the  seventh  or  eighth  ribs  in  the  left  parasternal 
line,  but  Dr.  Broadhent  called  attention  to  the  fact  that  it  was  frequently 
best  seen  on  the  left  side  behind,  between  the  eleventh  and  twelfth  ribs. 
With  each  systole  there  may  be  here  a  distinct,  visible  retraction  of  the  chest 
wall.  This  is  a  very  valuable  and  quite  common  sign.  Sir  William  Broad- 
bent  calls  attention  also  to  the  fact  that  owing  to  the  attachment  of  the 

*  For  illustrative  cases  see  Arch,  of  Pediatrics,  1896. 


OTHER  AFFECTIONS  OP  THE  PERICARDIUM. 


097 


The  ro- 
rilactory. 
1  onu  in 
I'ut — tho 
suppura- 
.Tts,  Am. 

0   groups 

is  a  com- 
lortem  as 
•bance  in 
i  there  is 

m  of  the 

Is.     This 

Hilarly  in 

ililatation 

lium  and 

tions  just 

a  and  in- 

ophy  and 

instances 

g  chronic 

Sudden 

Reynolds 

Hon. — A 
praecordia 
'normous 
IS  greatly 
Ith  inter- 
tside  the 
jdulatory, 
((/)  Dia- 
|ory  valu- 
'v  a  large 
;,  which 
Is  attach- 
bng  been 
irasternal 
roquently 
fth  ribs. 
;he  chest 
11  Broad- 
it  of  the 


heart  to  the  central  (riidoii  of  tlie  diaphragm  this  part  does  not  descend 
■\vitli  insj)iration,  (hiring  wliicli  act  there  is  not  the  visible  movement  in  the 
epigastrium,  (r)  Diastolic  collapse  of  the  cervical  veins,  the  so-calletl  Tried- 
reiclTs  sign,     ^riiis  is  not  ol'  much  moment. 

ralpaliun. — The  apex  heal  is  fixed,  and  turning  the  i)ati('nt  on  the  left 
side  docs  not  alter  its  i)osition.  This  1  have  found,  however,  somewhat  un- 
certain. On  ])lacing  the  hand  over  the  heart  there  is  felt  a  diastolic  shock 
^)r  rebound,  which  some  have  regarded  as  the  most  reliable  of  all  signs  of  ad- 
herent pericardium. 

Percussion. — The  area  of  cardiac  dulness  is  usually  nnich  increased.  In 
a  majority  of  instances  there  are  adhesions  between  the  i)lcura  and  the  peri- 
cardium, and  the  limit  of  cardiac  dulness  above  and  to  the  left  may  be 
fixed  and  is  uninlluenced  by  d„jp  inspiration.  This,  too,  is  an  uncertain 
sign,  inasmuch  as  there  may  be  close  adhesions  between  the  ])leura  and  the 
pericardium  and  between  the  jjleura  and  the  chest  wall,  which  at  the  same 
.time  allow  a  very  considerable  degree  of  mobility  to  the  edge  of  the  lung. 

Aiiscullalion. — The  i)lienomena  are  variable  and  uncertain.  In  the 
cases  in  children  with  a  history  of  riieumatism,  endocarditis  has  usually 
been  present.  Even  in  the  absence  of  chronic  endocarditis,  when  the  dila- 
tation rearhes  a  certain  grade  there  are  murmurs  of  relative  insufficiency, 
which,  as  in  one  case  I  have  recorded,  may  be  ])rescnt  not  only  at  the  mitral 
but  also  at  the  tricusjjid  and  pulmonary  orifices.  Hale  White  has  called 
attention  to  the  fact  that  there  may  be  a  well-marked  presystolic  murmur 
in  connection  with  adherent  pericardium.  This  was  ])resent  in  one  of  my 
<cases. 

The  ])ulsus  paradoxus,  in  which  during  inspiration  the  pulse-wave  is 
small  and  feeble,  is  sometimes  present,  but  it  is  not  a  diagnostic  sign  of 
either  simple  pericardial  adhesion  or  of  the  cicatricial  mediastino-peri- 
carditis. 

In  children,  chronic  adhesive  pericarditis  and  nicdiastinitis  may  ])e  asso- 
ciated with  proliferative  i)eritonitis,  pcrihe])atitis,  and  perisi)lenitis,  in 
which  condition  ascites  may  recur  for  months,  or  even  for  years. 


II.    OTHER    AFFECTIONS   OF    THE    PERICARDIUM. 

(1)  Hydrop'Ticardium. — Xaturally  there  are  in  the  pericardial  sac  a  few 
•cubic  centinuiies  of  clear,  citron-colored  fluid,  which  [)rol)ably  re^jresents 
a  post-mortem  transudate.  In  certain  conditions  diiring  life  there  may  be 
a  large  secretion  of  scrum  forming  what  is  known  as  dropsy  of  the  peri- 
cardium. It  occurs  usually  in  connection  with  general  dropsy,  due  to  kid- 
ney or  heart  disease;  more  commonly  the  former.  It  rarely  of  itself  proves 
fatal,  though  when  the  effusion  is  excessive  it  adds  to  the  embarrassment  of 
the  heart  and  the  lungs,  particularly  when  the  ])loural  cavities  are  the  scat 
of  similar  exudation.  There  are  rare  instances  in  which  effusion  into  the 
jiericardium  occurs  after  scarlet  fever  with  few,  if  any,  other  dropsical 
symptoms.  The  physical  signs  are  those  already  referred  to  iu  connection 
-with  pericarditis  with  effusion.    It  is  frequently  overlooked. 


698 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


/ 


In  rare  cases  the  siTum  has  a  milky  character — chylo-pericanliiuu. 

(2)  HaBmo-pericardium. — This  coiHlitiou,I)y  no  means  uncommon,  is  met 
with  in  aneurism  of  tlie  lirst  part  of  the  aorta,  of  the  cardiac  wall,  or  of  the 
coronary  arteries,  and  in  rui)ture  and  wounds  of  the  heart.  Death  usually 
follows  before  there  is  time  for  the  production  of  syni[)tonis  other  than 
those  of  rapid  heart-failure  due  to  compression.  I'articularly  is  this  the 
case  in  aneurism.  In  rupture  of  the  heart  the  patient  may  live  for  many 
hours  or  even  days  with  symptoms  of  progressive  heart-failure,  dyspna^a, 
and  the  physical  signs  of  eirusion. 

As  already  mentioned,  the  inilammatory  exudate  of  tubercle  or  cancer 
is  often  ])lood-stained.  The  same  is  true  of  the  ell'usiou  in  the  pericarditis 
of  iiright's  disease  and  of  old  }>eople. 

(;3)  Pneumo-pericardium. — (Jas  is  rarely  found  in  tlie  pericardial  sac, 
and  is  due,  as  a  rule,  to  i)erforation  from  without,  as  in  the  case  of  stab 
wouiuls,  or  is  the  result  of  i)erforation  from  the  lungs,  (rso])hagus,  or  stom- 
ach. Perforation  from  a  tuberculous  cavity  is  a  not  unconnnon  cause.  In 
those  cases,  formerly  so  puzz]"-\ir,  in  which  the  gas  is  ])resent  shortly  after 
death  (a  few  liours),  the  gas  bacillus  (/>.  aih-ot/cncs  aipsiihtliis)  will  bo  found. 
In  a  case  at  the  Koyal  Victoria  llos[)ital,  in  wliich  the  gas  bacillus  was 
isolate<l,  the  diagnosis  was  made  during  life  (Nicholls).  As  a  result  of  per- 
foration, acute  pericarditis  is  always  excited,  and  the  effusion  rapidly  be- 
comes purulent.  The  ])liysical  signs  are  remarkable.  When  the  elTusion 
is  copious  the  tin; J  and  gas  together  give  a  movable  area  of  percussion  dul- 
ness  Avith  marked  tym])any  in  the  region  of  the  gas.  On  auscultation,  re- 
markable splashing,  churning,  metallic  ])hcnomena  are  heard  with  friction 
and  ])ossibly  feeble,  distant  heart-sounds.  Death  follows  rajiidly,  even  in 
thirty-six  hours,  as  in  a  case  (tlie  only  one  which  I  have  seen)  of  perforation 
of  tlie  pericardium  in  cancer  of  the  stouuieh.  Except  as  a  result  of  injury, 
the  condition  is  not  one  for  which  treatment  is  available.  In  a  case  of 
perforation  from  without  with  signs  of  elfusion,  to  enlarge  the  wound  by 
free  incision  would  be  justifiable. 


II.    DISEASES   OF  THE  IIEAET. 


I.     ENDOCARDITIS. 


Inflammation  of  the  lining  memhrane  of  the  heart  is  usually  confined  to 
the  valves,  so  that  the  term  is  practically  synonymous  with  valvular  endo- 
carditis. It  occurs  in  two  forms — acute,  characterized  hy  the  presence  of 
vegetations  with  loss  of  continuity  or  of  substance  in  the  valve  tissues; 
chronic,  a  slow  sclerotic  change,  resulting  in  thickening,  puckering,  and  de- 
formity. 

xVcuTE  Endocarditis. 

This  occurs  in  rare  instances  as  a  primary,  independent  affection;  but 
in  the  great  majority  of  cases  it  is  an  accident  in  various  infective  processes, 
so  that  in  reality  the  disease  does  not  constitute  an  etiological  entity. 


mm. 

n,  is  mot 
or  of  tlie 
1  usually 
her  thau 
this  the 
for  many 
Llyspna'a, 

3r  cancer 
ricardilis 

•dial  sac, 
L^  ol'  stab 
or  stom- 
luse.  Ill 
i-tly  al'ter 
le  found, 
illus  was 
It  of  per- 
pidly  ])e- 

ell'usion 
sion  dul- 
ation,  re- 
i  friction 

even  in 
rf oration 
f  injury, 

case  of 
ound  by 


ifined  to 
ir  endo- 
sence  of 

tissues; 

and  de- 


on;  but 
•ocesscs. 


ENDOCARDITIS. 


C09 


For  convenience  of  d"scription  we  speak  of  a  sini])le  or  beni<jn,  and  a 
mali^'nant  or  ulcerative  endocarditis,  between  which,  however,  there  is  no 
essential  anatomical  dill'ercme.  as  all  <;radations  can  be  traced,  and  they 
Tcpri'sent  but  diU'erent  decrees  of  intensity  of  the  same  process. 

£tiology. — iSi //(/>/«  cndacanlitis  does  not  constitute  a  disease  of  itself, 
but  is  invai'ial)ly  found  with  8ome  other  affection.  The  general  experience 
of  the  profession  has  conlirmed  the  orij^inal  observation  of  J>ouillaud  as  to 
the  fi'ctpu'ncy  of  association  of  simple  endocarditis  with  acute  articular 
riieumalisni.  I'ossibly  it  is  nothing  in  the  disease  itself,  but  simply  an 
altered  state  of  the  lluid  media — a  reduction  perhaps  of  the  lethal  intlu- 
cnces  which  they  normally  exert — permitting  the  invasion  of  the  blood  by 
certain  micro-organisms.  Tonsillitis,  which  in  some  forms  is  regarded  as 
a  rheumatic  all'ection,  may  be  complicated  with  endocarditis.  Of  the  spe- 
cific diseases  of  childhood  it  is  not  uncommon  in  scarlet  fever,  while  it  is 
rare  in  measles  and  chicken-pox.  In  diphtheria  simple  endocarditis  is  rare. 
In  small-pox  it  is  not  common.  In  typhoid  fever  1  have  met  with  it  twice 
in  SO  autopsies. 

In  i)neujnonia  both  simple  and  malignant  endocarditis  are  common. 
In  lUO  autopsies  in  this  disease  made  at  the  Montreal  General  Hospital  there 
were  5  instances  of  the  former.  Acute  endocarditis  is  by  no  means  rare  in 
])hthisis.    I  have  met  with  it  in  1"3  cases  in  21G  ])0st  mortems. 

In  chorea  simple  warty  vegetations  are  found  on  the  valves  in  a  large 
majority  of  all  fatal  cases,  in  <62  of  73  cases  collected  by  me.  There  is  no 
disease  in  which,  post  mortem,  acute  endocarditis  has  been  so  frequently 
found.  And.  lastlv,  simple  endocarditis  is  met  with  in  diseases  associated 
with  loss  of  tlesli  and  progressive  debility,  as  cancer,  and  such  disorders  as 
gout,  diabetes,  and  Uright's  disease. 

A  very  common  form  is  that  which  occurs  on  the  sclerotic  valves  in  old 
heart-disease — the  so-called  recurring  endocarditis. 

Mdlii/nant  endocardilis  is  met  with:  (a)  As  a  primary  disease  of  the 
lining  membrane  of  the  heart  or  of  its  valves. 

(b)  As  a  secondary  all'ection  in  acute  rheumatism,  pneumonia,  and  in 
various  specific  fevers;  or  as  an  associated  condition  in  septic  processes. 

It  is  also  known  by  the  names  of  ulcerative,  infectious,  or  di])litheritic 
endocarditis,  but  the  term  malignant  seems  most  appropriate  to  charac- 
terize the  essential  clinical  features  of  the  disease. 

The  existence  of  a  primary  endocarditis  has  been  doubted;  but  there 
are  instances  in  which  persons  previously  in  good  health,  without  any  his- 
tory of  affections  with  which  endocarditis  is  usually  associated,  have  been 
attacked  with  symptoms  resembling  severe  typhus  or  typhoid.  In  one  case 
which  I  saw,  death  occurred  on  the  sixth  day  and  no  lesions  were  found 
other  than  those  of  malignant  endocarditis. 

The  simple  endocarditis  of  rheumatism  rarely  develops  into  the  malig- 
nant form.  In  only  2-4  of  20!.>  cases  the  symptoms  of  severe  endocarditis 
arose  in  the  progress  of  acute  or  subacute  rlanimatism.  In  only  3  of  my 
^lontreal  cases  was  there  a  history  of  rheumatism  either  before  or  during 
the  attacks. 

Malignant  endocarditis  is  extremely  rare  in  chorea.     Of  all  acute  dis- 


700 


DISRASES  OF  THE  CIRCrLATOUY  SYSTEM. 


/ 


Hi 


cast's  (•om[)liciiti'(l  with  sevoro  endocarditis  piiounionia  |)r<)l)al)ly  heads  the 
list.  This  fact,  whidi  had  l)ucn  referred  to  by  several  of  the  older  writers, 
was  broii^dit  out  in  a  strii<iM<f  manner  l)y  the  li«,nires  on  wiiich  my  Gul- 
stonian  lectures  were;  based,  in  11  of  the  l'.'{  Montreal  cases  the  disease  came 
on  with  lobar  pneumonia,  while  it  developed  with  this  disease  in  51  of  the 
5i(i!)  cases  analyzed — indeed,  the  endocarditis  which  occurs  in  jnieunionia 
seems  to  be  of  an  unusually  niali<i;nant  type,  as  in  l(i  cases  of  my  100  autop- 
sies in  this  disease  in  which  this  lesion  was  present,  11  were  of  this  form. 
This  has  been  conlirnied  by  Xetter,  Kanthack,  and  others.  .Menin«,Mtis  was 
associated  with  endocarditis  in  25  of  the  2{)[)  cases,  and  in  15  there  was  also 
])neum()nia. 

The  all'ection  may  complicate  erysipelas,  septicivmia  (from  whatever 
cause)  and  ])uerperal  fever  and  jionorrlura.  ^lalijiiiant  endocarditis  is  very 
rare  in  tuljcrculosis,  typhoid  fever,  and  diphtheria. 

It  has  been  stated  by  many  writers  that  endocarditis  occurs  in  ague. 
With  the  unusual  facilities  for  the  study  of  this  disease  which  I  have  had 
in  the  past  nine  years  1  have  not  yet  met  with  an  instance.  Uiuiuestion- 
al)ly,  in  the  nuijority  of  these  cases,  the  intei'mittent  pyrexia,  which  has 
been  re<iarded  as  characteristic  of  the  ajiiie,  has  depended  upon  the  endo- 
carditis. Jn  dysentery  cases  have  been  described.  In  snuiU-jJox  and  scarlet 
fever,  with  which  simple  endocarditis  is  not  infrequently  complicated,  the 
malignant  form  is  extrenu>ly  rare. 

Morbid  Anatomy  of  Simple  and  Malignant  Endocarditis. — Simple  endo- 
cardilis  is  characterized  l)y  the  presence  on  the  valves  or  on  the  lining  mem- 
brane of  the  chambers  of  minute  vegetations,  ranging  from  1  to  4  mm. 
in  diameter,  with  an  irregular  and  fissured  surface,  giving  to  them  a  warty 
or  verrucose  ai)pearance.  Often  these  little  caulillower-like  excrescences  are 
attached  by  very  narrow  ])edicles.  They  are  more  connnon  on  the  left  side 
of  the  heart  than  the  right,  and  occur  on  the  mitral  valves  more  often  than 
on  the  aortic.  The  vegetations  are  usually  above  the  line  of  closure  of  the 
valves.  It  is  rare  to  see  any  swelling  or  macrosco))ic  evidence  of  infiltration 
of  the  endocardiuiu  in  the  neighborhood  of  even  the  smallest  of  the  granu- 
lations, and  redness,  indicative  of  distention  of  the  vessels,  is  uncommon, 
even  when  they  occur  upon  valves  already  the  seat  of  sclerotic  changes,  in 
which  capillary  vessels  extend  to  the  edges.  "With  time  the  vegetations  may 
increase  greatly  in  size,  but  in  what  may  be  called  simple  endocarditis  the 
size  rarely  exceeds  that  mentioned  al)ove. 

The  earliest  vegetations  consist  of  elements  derived  from  the  blood,  and 
are  com])osed  of  blood  jdatelets,  leucocytes,  and  fibrin  in  varying  propor- 
tions. At  a  later  stage  they  appear  as  small  outgrowths  of  connective  tissue. 
The  transition  of  one  form  into  tlie  other  can  often  be  followed.  The 
process  consists  of  a  proliferation  of  the  endothelial  cells  and  the  cells  of 
the  subendothelial  layer  which  gradually  invade  the  fresh  vegetation,  and 
ultimately  entirely  rejdace  it.  The  blood-cells  and  fil)rin  undergo  disinte- 
gration and  gradually  they  are  removed.  The  whole  ])roccss  has  received 
the  name  of  ''  organization."  Even  when  the  vegetation  has  been  entirely 
converted  into  granulations  or  connective  tissue  it  is  often  found  at  autopsy 
to  be  cajiped  with  a  thin  layer  of  fibrin  and  leucocytes. 


lends  the 
r  writers, 

my  (Jiil- 
.'tisc  caiiit' 
54  of  the 
leuinoniii 
)(>  aiitop- 
liis  lorm. 
igitis  was 

was  also 

whatever 
is  is  very 

ill  a;,nie. 
have  luul 
incstion- 
hieh  has 
he  endo- 
d  sear let 
iited,  the 

}Je   endo- 

iig  inem- 

)  4  mm. 

a  warty 

iices  are 

lel't  side 

en  than 

of  the 

ration 

granu- 

Dmmon, 

igos.  in 

ins  may 

itis  the 


d,  and 
)ropor- 
tissiie. 
The 
s  of 
n.  and 
isinte- 
ceived 
ntirely 
utopsy 


•e 


ENDOCARDITIS. 


701 


Miero-organisms  are  generally,  even  if  not  invariably,  found  associated 
witli  the  vegetations.  'I'iiey  tend  to  he  entangled  in  tlii'  granular  and 
lihrillated  liljrin  or  in  the  older  ones  to  eap  the  a[)ices. 

In  hoth  man  and  animals  there  is  a  form  of  climnir  rri/rhtlirr  cikIh- 
ciinlilis  in  whieh,  without  much  or  any  loss  of  sid)stance,  the  valves  and 
chorda'  temlineie  are  covered  with  large,  iirm  outgrowths,  in  several  cases 
(if  this  kind  the  clinical  history  has  heeii  characterized  by  a  protracted  fever 
of  a  nuirked  remittent  or  even  intermittent  tyi)e. 

tSubf<C(iiiciif  ('lianf/es. — (1)  The  vegetations  may  become  organized  and 
the  valve  restored  to  a  normal  state  (?).  ('i)  The  process  may  extend,  and  a 
simple  may  become  an  ulcerative  endocarditis.  {'.))  The  vegetations  may  bo 
hrolvcn  oir  and  carrii'd  in  the  cireulation  to  distant  parts.  (4)  The  vegeta- 
tions become  organized  and  disappear,  but  they  initiate  a  nutritive  change 
in  the  valve  tissue  which  ultimately  leads  to  sclerosis,  thickening,  and  de- 
formity.  The  danger  in  any  case  of  simi)le  emlocaijjlitis  is  not  immediate, 
hut  remote,  and  consists  in  this  ])erversion  of  the  nornuU  jjrocesses  of  nutri- 
tion which  results  in  sclerosis  of  the  valves. 

A  gradual  transition  from  the  simple  to  a  more  severe  all'ection,  to  which 
the  name  vialiijnant  or  vicerative  cndocurdilix  has  been  given,  nuiy  be  traced. 
Practically  every  case  of  ulcerative  endocarditis  is  attended  by  vegetations. 
In  tliis  form  the  loss  of  sul)stance  in  the  valve  is  more  })ronounced,  the  de[)- 
osition — thrombus  fornuition — from  the  blood  is  nu)re  extensive,  and  the 
micro-organisms  are  present  in  greater  number  and  often  show  increased 
virulence.  Ulcerative  endocarditis  is  often  fouiul  in  connection  with  heart 
valves  already  the  scat  of  chronic  ])roliferative  and  sclerotic  changes. 

]n  nuilignant  endocarditis  there  is  distinct  loss  of  substance  in  the  heart 
valve.  This  loss  nuiy  be  su])erficial  ami  limited  to  the  endocardium,  or, 
what  is  more  common,  it  involves  deei)er  structures,  and  not  very  infre- 
(piently  leads  to  perforation  of  a  valve,  a  septum,  or  even  of  the  heart  itself. 

I'pon  microscopical  examination  the  aU'eeted  valve  shows  necrosis,  with 
more  or  less  loss  of  substance;  the  necrotic  tissue  is  devoid  of  preserved 
nuclei  and  ])rcsents  a  coagulated  ai)]iearance.  Upon  it  a  mixture  of  blood 
platelets,  fibrin — granular  or  fibrillated — and  leucocytes  enclosing  masses 
of  micro-organisms  are  met  with.  The  subjacent  tissue  often  shows  scle- 
rotic thickening  and  always  infiltration  with  exuded  granulation  tissue-cells, 

Paris  affected. — The  following  figures,  taken  from  my  Gulstonian  lec- 
tures at  the  Eoyal  College  of  Physicians,  give  an  ap])roximate  estimate  of 
the  fre(|uency  with  which  in  '^09  cases  ditl'erent  ])arts  of  the  heart  were 
alTected  in  malignant  endocarditis-  Aortic  and  mitral  valves  together,  in 
41;  aortic  valves  alone,  in  53;  niii.al  valves  alone,  in  77;  tricus])id  in  ti); 
the  jiulmonary  valves  in  ^■)•,  and  the  heart  walls  in  ;].').  Tn  0  instances  the 
right  heart  alone  was  involved,  in  most  cases  the  auriculo-vei.tricular  valves, 

Plural  endocarditis  is  seen  most  often  at  the  u])])er  jiart  of  the  septum 
of  the  left  ventricle.  Next  in  order  is  the  end-x-arditis  of  the  left  auricle 
on  the  postero-extcrnal  wall.  The  vegetations  may  extend,  as  in  a  recent 
case  in  my  Avards,  along  the  intinia  of  the  ])ulmonary  artery  into  the  hiluni 
of  the  lung.  The  ulcerative  changes  may  lead  to  ])erl'oration  of  a  valve  seg- 
ment, erosion  of  the  chorda?  tendinca%  })erforation  of  the  septum,  or  even 


/ 


702 


msEASRS  OK  TIIK  flRrrriATOHY  SYSTEM. 


of  tlic  licnrt  itnt'll'.  A  cnimiion  result  of  (he  uU'orntion  is  the  production  of 
viilvulnr  HtK'uriHni.  In  tiut'o  fuurtlis  oi'  tho  cases  the  aH'cctcd  viilvcs  present 
old  sclerotic  clumgcs.  The  jjtoccss  niny  extend  to  the  aorta,  producinj:,  as 
in  one  of  my  ciises,  extensive  enchirtei  itis  witli  inulti|)le  acute  aneurisms. 

Assiiriiilcd  Lcsiiins. — The  associati'd  patinilti;4ical  changes  are  partly 
those  of  the  prinuiry  disease  to  which  the  endocarditis  is  secondary  and 
partly  those  due  to  endxilism.  In  the  endocarditis  of  8e[)tic  processes  there 
is  the  local  lesion — an  acute  lU'crosis,  a  suppurative  wound,  or  puerperal  dis- 
ease. Jn  many  cases  the  lesions  are  those  of  pneumonia,  rhcuiuatisiii,  or 
other  fehrile  processes.  The  changes  duo  to  cmholism  constitute  the  most 
striking  features,  l)Ut  it  is  remarkahle  that  in  sonu'  instaiu-es,  even  with 
endocai'ditis  of  a  markedly  ulcerative  character,  there  may  he  no  trace  of 
einholic  processes. 

The  infarcts  may  l)e  few  in  numher — only  one  or  two,  ])erhaps,  in  tlu' 
spleen  or  kidney — or  they  may  exist  in  hundreds  througlunit  the  various 
parts  of  the  body.  They  may  i)resent  the  ordinary  appearance  of  red  or 
white  infarcts  of  a  suppurative  character.  They  are  iiuist  common  in  the 
spleen  ami  kidneys,  though  they  may  he  numerous  in  the  hrain,  and  in 
many  cases  are  very  abundant  in  the  intestines.  In  right-sided  endocar- 
ditis there  may  be  infarcts  in  the  lungs.  In  many  of  the  cases  there  are 
innumerable  miliary  abscesses.  Acute  supi)urative  meningitis  was  met 
with  in  5  of  "^'3  of  the  ^Montreal  cases,  and  in  over  10  j)cr  cent  of  the  ^O'J 
cases  analyzed  in  the  literature.  Acute  suppurative  parotitis  also  nuiy 
occur. 

liarleriolof/j/. — No  distinction  in  tho  micro-organisms  found  in  tho  two 
forms  of  endocarditis  can  be  nuide.  In  both  the  pyogenic  cocci — strepto- 
cocci, staphylococci,  ])ncumococci,  and  gonococci — are  the  most  frcipieut 
bacteria  nu't  with.  ^lore  rarely,  especially  in  the  simple  vegetative  endo- 
carditis, the  bacilli  of  tuberculosis,  tyi)hoid  fever,  and  anthrax  have  been 
encountered.  The  bacillus  coli  communis  has  also  been  found,  and  IJowaid 
has  descrii)cd  a  case  of  malignant  endocarditis  due  to  an  attenuated  form 
of  the  diphtiiei'ia  bacillus.  Flexner  *  has  analyzed  34  cases  of  acute  endo- 
carditis associated  with  chronic  renal  and  cardiac  disease,  and  found  the 
micrococcus  lanceolatxis  and  the  stre])tococcus  ])yogenes  present  each  twelve 
times,  the  sta])bylococcus  three  times.  Other  bacteria  encountered  were 
bacillus  pyocyaueus,  coli,  and  influenza',  and  the  gonococcus. 

Symptoms. — Xeither  the  clinical  course  nor  the  ])hysical  signs  of 
simple  endocardififi  are  in  any  respect  characteristic.  The  great  majority 
of  the  cases  are  latent  and  there  is  no  indication  whatever  of  cardiac  mis- 
chief. F]xporicnco  has  taught  ns  that  endocarditis  is  frequently  found  i)ost 
mortem  in  persons  in  whom  it  was  not  sus])ected  during  life.  There  arc 
certain  features,  however,  by  which  its  presence  is  indicated  with  a  degree 
of  probability.  The  ])atient,  as  a  rule,  does  not  complain  of  any  pain  or 
cardiac  distress.  In  a  case  of  acute  rheumatism,  for  example,  the  symptoms 
to  excite  sns])icion  would  be  increased  ra])idity  of  the  heart's  action,  per- 
haps slight  irregnlarity,  and  an  increase  in  the  fever  without  aggravation 


♦  Journal  of  Experimental  Medicine,  1890,  i,  p.  559. 


Inctioii  (if 
08  present 
ilii(iii<j:,  as 
.'uridiiis. 
no  i)nrtly 
idary  iiiul 
.'ssc's  the IV 
r|)('rnl  (lin- 
iiiilisiii,  ur 
I  the  most 
even  with 

()   tnU'O   nf 

pa,  ill  the 

10  various 

of  red  or 

ion  ill  the 

n,  tiiid  ill 

[  endocnr- 

there  are 

was   met 

)i'  the  2(yj 

alno   may 

n  the  two 

— stro[)to- 

rro(Hiont 

ivo  ondo- 

lave  been 

1  JTowaid 

Mod  form 

lite  endo- 

ound  the 

•li  twelve 

rod  were 

signg  of 
I  majority 
iliac  mii'- 
lund  post 
rhore  are 
I  a  degree 
pain  or 

mptoms 
lion,  pcr- 

ravation 


KNnoCAUDITIS. 


703 


(if  the  joint  trouble.  Uowh  of  tiny  vogi'talioiirt  on  tiio  milral  or  on  tiie  aortic 
MgnienlH  Hoem  a  1  rilling  matter  to  excite  fever,  and  it  is  ditliciilt  in  the 
(  iidoearditiH  of  lVI)ril(.'  processes  to  say  (h'liiiiloiy  in  every  instance  that  an 
iiKrcase  in  tlie  fever  (h'pcnds  upon  tlie  endocardial  coniplicalion.  i>iit  u 
M iidy  of  tlie  recurring  t'luhxiii'ditis — wliicli  is  of  tlie  warty  variety,  con- 
.-i>tiiig  of  minute  beads  on  old  sclerotic  valves — shows  that  this  process  nuiy 
lie  associated,  for  days  or  weeks  at  a  time,  with  slight  fevi'r  ranging  from 
111(1°  to  lO'v'i".  Talpitatioii  may  be  a  marki'd  feature  and  is  a  symjitoMi  u|ion 
which  certain  authors  lay  great  stress. 

The  diaijnusis  of  the  condition  rests  upon  physical  signs  which  an; 
notoriously  uncertain.  Tlu'  presence  of  a  murmur  at  one  or  other  of  the 
cardiac  areas  in  a  case  of  fever  is  often  regarded  as  indicative  of  the  exist- 
ence of  endocarditis.  This  o.xtremcly  coniiiio!i  mistake  has  arisen  from  the 
fact  that  the  hriiit  dc  soii//le  or  bellows  muriiiur  is  coninion  to  endocarditis 
and  a  numlxM'  of  other  conditions  wliieli  have  nothing  to  do  with  it.  .\t 
tirst  there  may  be  only  a  slight  rougheniiig  of  the  llr^t  sound,  which  may 
gradually  develop  into  a  distinct  murmur,  'i'akeii  a!;)iio,  it  is,  however,  a 
very  uncertain  and  fallacious  sign. 

It  is  dilHcult  to  give  a  satisfactory  clinical  ])i('ture  of  iiKiliijiKtiil  vihId- 
lardilis  because  the  modes  of  onset  are  so  varied  and  the  symptoms  so 
diverse.  Arising  in  the  course  of  some  other  di.sease,  thcri'  may  be  simjily 
an  intensilication  ol'  the  fever  or  a  change  in  its  character.  In  a  majority 
<if  the  cases  there  are  present  certain  general  features,  such  as  irregular 
|iyre.xia,  sweating,  delirium,  and  gradual  failure  of  strength. 

Embolic  processes  may  give  special  characters,  such  as  delirium,  coma 
or  ]»aralysis  from  involvement  of  the  brain  or  its  momhranos,  pain  in  the 
(■ido  and  local  ])eritonitis  from  infarction  of  the  s])leen,  bloody  urine  from 
implication  of  the  kidneys,  impaired  vision  from  retinal  Inemorrliage,  and 
suppuration,  and  even  gangrene,  in  various  parts  from  the  distribution  of 
the  emboli. 

Two  sjiecial  types  of  the  disease  have  been  recognized — the  sejitic  or 
pviomic  and  the  typhoid.  Other  cases  closely  resemble  true  intermittent 
lever.  In  .some  the  cardiac  symptoms  are  most  ])rominent,  while  in  others 
again  the  main  symptoms  may  be  those  of  an  acute  all'ection  of  the  cerebro- 
spinal system. 

The  seplir  li/pc  is  met  with  usually  in  connection  with  an  external 
wound,  the  ])uerperal  jirocess,  or  an  acute  necrosis.  There  are  rigors,  sweats, 
irregular  fevers,  and  all  of  the  signs  of  sojitic  infection.  The  heart  synip- 
tdiiis  may  be  com])letely  masked  by  the  general  condition,  and  attention 
called  to  them  only  on  the  occurrence  of  embolism.  In  a  most  remarkable 
sub-grou])  of  this  tyjio  the  disease  may  simulate  a  ipiotidian  or  a  tertian 
ague.  The  syni])toms  may  develop  in  persons  with  chronic  heart-disease 
without  any  external  lesions.  These  cases  may  be  much  prolonged — for 
three  or  four  months,  or  oven  longer,  as  in  one  of  Bristowe's.  The  ex- 
istence in  some  of  those  instances  of  a  previous  genuine  nuilaria  has  been 
a  very  puzzling  circumstance. 

The  iyphoid  type  is  by  far  the  most  common  and  is  characterized  by 
an  irregular  temperature,  early  prostration,  delirium,  somnolence,  and  coma, 
44 


704 


DISKASl'X  OF  TFIK  CIIU'l'LATOllY  SYSTKM. 


ri'liixcd  howi'ls,  swcutiiijr,  which  imiy  Itc  <»f  a  most  (licncliin^  chamcter, 
pi'tt'fhial  and  other  rasht's,  and  occa.sioimlly  parotitis.  Thu  heart  Hynii)tonis 
may  ho  coniplcti'ly  ovcrhiokcd,  and  in  sonio  instances  the  most  careful 
examination  has  I'aiU-d  to  discover  a  murmur. 

I'nder  the  ciinlinr  (jniup,  as  sn^fj^cslcd  hy  Uniinwell,  may  he  consid- 
ered tliose  cases  in  wiiich  patients  wilii  ehronic  valve  disease  are  attacked 
with  nuirked  lever  and  evi(h'nee  of  recent  endocarditis.  Many  such  cases 
present  symptoms  of  the  pya'nii(!  and  typhoid  character  and  may  rnn  a 
most  acute  course.  In  othi-rs  the  course  is  chronic,  hislinj,'  for  weeks  or 
months.  I  have  ri'portcd  two  ca.^es  of  tiiis  clironic  ve^'etalive  en(h)carditis. 
with  intermittent  fever,  one  of  more  than  a  year's  duration.  Tiie  autopsies 
showed  extensive  vej,'etative  and  uh'crative  disease  of  the  mitral  valves. 

There  are  cases  in  which  it  is  often  diilicult  to  decidti  whetiier  malijf- 
nant  endocarditis  is  present  or  jiot.  'I'hus,  a  patient  with  aortic  valve  dis- 
ease is  under  treatment  for  failing'  compt-nsation  and  I)i'<^ins  to  have  irregu- 
hir  fever  with  restlessness  and  cardiac  distress;  end)olie  phenomena  may 
develoj)— sudden  hcmiplej^ia,  ])ain  in  the  region  of  the  spleen,  or  bloot^ 
rine,  or  perhaps  peripheral  embolism.  There  may  I)e  a  low  delirium  an( 
the  case  may  run  a  tolerably  acute  conr.se;  but  in  other  instances  the  fever 
subsides  and  recovery  occurs. 

In  what  nuiy  be  termed  the  rerchrnl  group  of  cases  the  clinical  pictnre 
may  simulate  a  meiungitis,  either  basilar  or  cerebro-s])inal.  There  may 
l)e  acute  delirium  or,  as  in  three  of  the  Montreal  cases,  the  patient  may  be 
brought  into  the  hos[)ital  unconscious,  Jleineman  reports  an  instance,  with 
autopsy,  in  which  t'ne  clinical  picture  was  that  of  an  acute  cerebro-8i)in!d 
meningitis. 

Certain  special  symptoms  may  he  mejitioncd.  The  fever  is  not  always 
of  a  remittent  type,  ])ut  may  be  high  and  continuous.  Petechial  rashes 
are  very  cr.  :imon  and  render  the  similarity  very  strong  to  certain  cases  of 
tyi)hoid  and  cerebro-spinal  fever.  In  one  case  the  disease  was  thought 
to  he  liu'inorrhagic  small-])ox.  Erythenuitous  rashes  are  not  uncommon. 
The  sM'cating  may  he  most  profuse,  even  exceeding  that  wliich  occurs  in 
])hthisis  and  ague.  Diarrlnea  is  not  necessarily  as,sociated  with  embolic 
lesions  in  the  intestines.  Jaundice  has  been  observed  and  cases  are  on 
record  which  were  mistaken  for  acute  yellow  atro])liy. 

The  heart  sym])toms  may  be  entirely  latent  and  are  not  found  unless  a 
careful  senrcli  be  made.  l*'ven  on  examination  there  may  be  no  murmur 
])resent.  Instances  are  recorded  by  careful  observers,  in  which  the  examina- 
tion of  the  heart  has  been  negative.  Cases  with  chronic  valve  disease  usu- 
ally present  no  dilTiculty  in  diagnosis. 

The  course  of  the  di.^ease  is  varied,  depending  largely  upon  the  nature 
of  the  i)rimary  trouljle.  Except  in  the  disease  grafted  upon  chronic  valvu- 
litis tlie  course  is  rarely  extended  beyond  five  or  six  weeks.  As  already 
mentioned,  tliere  are  instances  in  which  the  disease  is  prolonged  for  months. 
Tlie  most  ra])idly  fatal  case  on  record  h  described  by  Eberth,  the  duration 
of  wliich  Avas  scarcely  two  days. 

Diagnosis.' — Tn  many  cases  the  detection  of  the  disease  is  very  diffi- 
cult; in  others,  with  marked  embolic  symptoms,  it  is  easy.     From  sinii)li> 


ENDOCAUDITIS. 


705 


t'huractor, 

Hyini)toni.s 

uut  cui'fi'ul 

1)0    COUHUl- 

re  uttac'kt'd 
HiiL'li  t'uat's 
limy  run  a 
r  wi'oks  or 
ulocarditis, 
e  iiutopsio.s 

viilvos. 
hor  iiuilig- 
i  valve  dis- 
avo  irregii- 
tiiK'iia  niiiy 

or  l)l()o(' 
liriuiu  aiK 
fs  the  fevor 

cal  ])ic'tiin' 
TluM'o  may 
I'lit  may  Ix- 
tance,  with 
el)ro-8i)inal 

not  always 
lial  raslu's 
in  cases  of 
19  thou<j;lit 
mcommon. 
occurs  ill 
h  emboli(.' 
SOS  are  on 

(1  unless  a 
)  murmur 
examina- 
■isease  usu- 

he  nature 
nic  valvu- 
Vs  already 
)r  months. 
2  duration 

very  difTi- 
)m  simi)l<' 


ondocarditirt  it  is  n-adily  distiiij,Miisli('d,  (hoii^'h  confusion  occasionally 
(icciirrt  in  the  transitional  sta^'c,  when  a  simple  is  developing'  into  a  malig- 
nant I'orm.  'I'lie  const  it  lit  ioinil  syiiiptoms  arc  of  a  graver  type,  the  fever 
IS  iiigher,  rigors  are  common,  and  scjitic  and  typhoid  symptoms  ilevi-lop. 
Teriiaps  a  majority  of  the  cases  not  associated  with  puerperal  processes  or 
hone-disease  uro  confounded  with  typhoid  fever.  A  ditl'erenlial  diaguosia 
iiiay  even  he  impossihle,  pnrtieiiiarly  when  we  consider  that  in  typiioid 
I'ever  inl'arctions  and  parotitis  may  occur.  The  diarrlnea  and  alidoininal 
teii(h'riiess  may  also  he  present,  which  with  tlii;  stupor  and  progressive 
asthenia  make  a  pictuii'  not  to  he  distinguished  from  this  diseasi'.  Points 
which  may  guide  us  are:  The  more  ahrupt  onset  in  endocarditis,  the  ah- 
seiice  ()['  any  regularity  of  the  pyrexia  in  the  early  stage  of  the  disuse,  anil 
the  cardiiU!  pain.  Oppression  and  slutrtncss  of  breath  may  he  early  symp- 
toms in  malignant  endocarditis.  Rigors,  too,  are  not  uncommon.  There 
is  a  marked  leiicocytosis  in  infective  endocarditis.  lU'tween  pyicmia  and 
nialignant  endocarditis  tlieri'  are  practically  no  dill'erential  features,  for 
the  disease  really  constitutes  an  arlvridl  jii/fnuid  (W  ilks).  In  the  lU'utc  ciise^i 
resemhling  malignant  fevers,  the  diagiuxis  is  usually  made  of  typhus, 
typhoid,  cerehro-spinal  fever,  or  even  of  hiemorrhagic  small-po.x.  The  in- 
termittent pyrexia,  occurring  for  weeks  or  months,  has  led  in  some  cases 
*"  the  diagnosis  of  malaria,  hut  this  disease  could  now  he  positively  excluded 
hy  the  hlood  examination. 

The  cases  usually  terminate  fatally.  IMie  instances  of  recovery  are  those 
more  suhacute  forms,  the  so-called  recurring  endocarditis  developing  on 
old  sclerotic  valves  in  cases  of  chronic  heart-disease. 

Treatment. — We  know  no  measures  hy  which  in  rheumatism,  chor'.,:, 
or  the  eruiitive  fevers  the  onset  of  endocarditis  can  he  ]ireventc<l.  As  it  is 
prohahle  that  many  cases  develop,  ])articnlarly  in  chihlren,  in  mild  forms 
of  these  diseases,  it  is  well  to  guard  the  jmticnts  against  taking  cold  and 
insist  upon  rest  and  quiet,  and  to  hear  in  mind  that  of  all  complications 
an  acute  endocarditis,  though  in  its  immediate  cIVects  harndess,  is  per- 
haps the  most  serious.  This  statement  is  enforced  by  the  observations  of 
Sihson  that  on  a  system  of  absolute  rest  the  pro])ortion  of  cases  of  rheu- 
matism attacked  by  endocarditis  was  less  than  of  those  who  were  not  so 
treated. 

It  is  doubtful  whether  the  salicylates  in  rheumatism  have  an  intluenco 
in  reducing  the  liability  to  endocarditis.  When  the  endocarditis  is  present 
we  know  no  remedii's  which  will  definitely  intliience  the  valvular  lesions. 
If  there  is  much  vascular  excitement  aconite  may  be  given  and  an  ice-ljag 
jilaccd  over  the  lieart. 

The  salicylates  are  strongly  advised  by  some  writers  and  the  sul]dio- 
carbolatos  havo  been  recommended  by  Sansom.  In  the  severer  cases  of 
nialignant  endocarditis  the  treatment  is  practically  that  of  septicaemia. 

rirT?0\ir    EXDOCATJDITIS. 

This  condition,  which  is  a  sclerosis  of  the  valve,  may  be  primary,  but  is 
oftener  secondary  to  acute  endocarditis,  particularly  the  rheumatic  form. 


706 


DISEASES  OP  THK  CIRCULATORY  SYSTEM. 


/ 


It  is  essentially  n  slow,  insidious  process  whicli  leads  to  deformity  of  the 
valve  segment  and  is  the  foundation  of  chronic  valvidar  disease. 

Certain  poisons  np})ear  ca])able  of  initiating  the  change,  such  as  alco- 
hol, syphilis,  and  gout,  thougii  we  are  at  i)resent  ignorant  of  the  way  in 
wliicii  they  act.  A  very  im])<)rtant  factor,  |)articularly  in  the  case  of  the 
aortic  valves,  is  the  strain  of  ])rolonged  and  heavy  muscular  exertion.  In 
no  other  way  can  be  explained  the  occurrence  of  so  many  cases  of  sclerosis 
of  the  aortic  valves  in  young  and  middle-aged  men  whose  occupations  neces- 
sitate the  overuse  of  the  muscles. 

Morbid  Anatomy. — A'egetations  in  the  form  in  which  they  occur 
in  acute  endocarditis  are  not  i)resent.  In  the  early  stage,  which  we  have 
frequent  opi)ortunities  of  seeing,  the  edge  of  the  valve  is  a  little  thickened 
and  ])erlia])s  presents  a  few  small  nodular  ])rominences,  which  in  some 
cases  may  represent  tlie  healed  vegetations  of  the  acute  process.  Li  the 
aortic  valves  the  tissue  about  the  corpora  Arantii  is  first  aU'ected,  jn-oducing 
a  slight  thickening  with  an  increase  in  the  size  of  the  nodules.  The  sub- 
stance of  the  valve  may  lose  its  translucency,  and  the  only  change  noticeable 
be  a  grayish  oi)acity  and  a  slight  loss  of  its  delicate  tenuity.  In  the  auriculo- 
ventricular  valves  these  early  changes  are  seen  just  within  the  margin 
and  here  it  is  not  uncommon  to  find  swellings  of  a  grayish-red,  somewhat 
infiltrated  appearance,  almost  identical  with  the  similar  structures  on  the 
intima  of  the  aorta  in  arlerio-sclerosis.  Even  early  there  may  be  seen  yellow 
or  o[)a(pie-white  subintimal  fattily  degenerated  areas.  As  the  sclerotic 
■changes  increase,  the  fibrous  tissue  contracts  and  jn'oduces  thickening  and 
■deformity  of  the  segment,  the  edges  of  which  become  round,  curled,  and 
incapable  of  that  delicate  a])position  necessary  for  i)erfect  closure.  A  sig- 
moid valve,  for  instance,  may  be  narrowed  one  fourth  or  even  one  third 
across  its  face,  the  most  extreme  grade  of  insuthciency  being  induced  with- 
out any  special  deformity  and  withoiit  any  definite  narrowing  of  the  arterial 
orifice.  In  the  auriculo-ventricular  segments  a  sim})le  process  of  thicken- 
ing and  curling  of  the  edges  of  the  valves,  inducing  a  failure  to  close  with- 
out forming  any  obstruction  to  the  normal  course  of  the  blood-flow,  is  less 
common.  Still,  we  meet  with  instances  at  the  mitral  orifice,  particularly 
iu  children,  in  which  the  edges  of  the  valves  arc  curled  and  thickened, 
so  that  there  is  extreme  insuiliciency  without  any  material  narrowing  of  the 
oridce.  ^More  freipiently,  as  the  disease  advances,  the  chord<e  tendinea; 
become  thickened,  first  at  the  valvular  ends  and  then  along  their  course. 
The  edges  of  the  valves  at  their  angles  are  gradually  drawn  together  and 
there  is  a  definite  narrowing  of  the  orifice,  leading  in  the  aorta  to  more 
or  less  stenosis  and  in  the  left  auriculo-ventricular  orifice — the  two  sites 
most  fre(piently  involved — to  constriction.  Finally,  in  the  sclerotic  and 
necrotic  tissues  lime  salts  are  deposited  and  may  even  reach  the  deeper 
structures  of  the  fibrous  rings,  so  that  the  entire  valve  becomes  a  dense  cal- 
careous mass  with  scarcely  a  remnant  of  normal  tissue.  The  chordos  ten- 
dinea^  may  griidually  become  shortened,  greatly  thickened,  and  in  extreme 
cases  the  ])a])illary  muscles  are  im]ilanted  directly  upon  the  sclerotic  and 
deformed  valve.  The  apices  of  the  papillary  muscles  usually  show  marked 
fibroid  change. 


CUliONlO  Vi\JjVULAR  DISEASE, 


707 


ity  of  the 

li  as  alco- 
lio  way  in 
ase  of  the 
rtion.  In 
if  sclerosis 
ons  neces- 

hoy  occur 
1  wo  have 
thiclconcd 
L  in  some 
i.     In  the 
])rodiicing 
The  sul)- 
noticoable 
I  auriculo- 
le  margin 
somewliat 
•cs  on  the 
2on  yellow 
;  sclerotic 
ening  and 
irled,  and 
A  sig- 
one  third 
ced  witli- 
10  arterial 
thickon- 
ose  witli- 
)w,  is  less 
rticnlarly 
lickened, 
ng  of  the 
tcndinea; 
r  course, 
ither  and 
to  more 
two  sites 
•otic  and 
0  deeper 
ense  cal- 
rdo3  ton- 
extreme 
otic  and 
marked 


In  all  stages  of  the  process  the  vegetations  of  simple  endocarditis  may 
be  present,  and  upon  sclerotic  valves  we  tind  the  so  er,  ulcerative  form  of 
the  disease. 

Chronic  mural  endocarditis  produces  cieatricial-like  patches  of  a  gray- 
ish-white appearance  which  are  sometimes  seen  on  the  muscular  trabeculie 
(if  the  ventricle  or  in  the  auricles.  It  often  occurs  in  association  with  myo- 
carditis. 

The  frequency  with  which  chronic  endocarditis  is  met  with  may  be 
irathered  from  the  following  figures:  In  the  statistics,  amounting  to  from 
r3,UU0  to  1-1,000  autopsies,  reported  from  Dresden,  Wiirzburg,  and  Prague 
the  percentage  ranged  from  four  to  nine.  The  relative  freipiency  of  involve- 
ment of  the  various  valves  is  thus  given  in  the  collected  statistics  of  Parrot: 
The  mitral  orilice  was  involved  in  Q"Z\,  the  aortic  in  380,  the  tricuspid  in 
K),  and  the  ])ulnionary  in  11.  This  gives  57  instances  in  the  right  to  1,001 
in  the  left  heart. 

The  endocarditis  of  the  foetus  is  usually  of  the  sclerotic  form  and  in- 
volves the  valves  of    xe  right  more  frequently  than  tlu  se  of  the  left  side. 


II.    CHRONIC  VALVULAR    DISEASE. 

1.    GkXEKAL    IXTHODUCTIOX. 

The  inciileiire  of  valvular  lesions  may  be  gathered  from  the  following 
figures  compiled  l)y  CJillespie  from  the  records  of  the  Koyal  Infirmary,  Edin- 
bur'di:  Of  2,'3{)S  cases  with  cardiac  lesions,  valvular  disease  occurred  in  80.8 
per  cent;  endocarditis  and  ]iericarditis  in  5.3;  myocardial  lesions  in  11.9 
per  cent;  C)().2  ])er  cent  of  the  cases  were  in  males. 

Effects  of  Valve  Lesions. — The  general  influence  on  the  work  of  the 
heart  may  be  briefly  stated  as  follows:  The  sclerosis  induces  insuiriciency 
or  stenosis,  which  may  exist  se])arately  or  in  combination.  The  narrowing 
retards  in  a  measure  the  normal  outflow  and  the  insullicicncy  permits  the 
l)lood  current  to  take  an  al)!uu'inal  course.  In  both  instances  the  effect  is 
(lihitation  of  a  chamber.  Tiie  result  in  the  former  case  is  an  increase  in 
thi'  diniculty  which  the  chand)er  has  in  expelling  its  contents  through  the 
narrow  orifice;  in  the  other,  the  overfdling  of  a  chamber  hy  blood  flowing 
into  it  from  an  improper  source,  as,  for  instance,  in  mitral  insufficiency, 
when  the  left  auricle  receives  blood  both  from  the  pulmonary  veins  and 
from  the  left  ventricle. 

The  cardiac  mechanism  is  fully  ])re])ared  to  meet  ordinary  grades  of 
dilatation  Mhich  constantly  occur  during  sudden  exertion.  A  man,  for  in- 
stance, at  the  end  of  a  hundred-yard  race  has  his  right  chambers  greatly 
dilated  and  his  reserve  cardiac  power  worked  to  its  full  capacity.  The  slow 
progress  of  the  sclerotic  changes  brings  about  a  gradual,  not  an  abrupt,  in- 
sulTiciency,  and  the  moderate  dilatation  which  follows  is  at  first  overcome 
by  the  exercise  of  the  ordinary  reserve  strength  of  the  heart  muscle.  Grad- 
ually a  new  factor  is  introduced.  The  reserve  power  which  is  capal)le  of 
meeting  sv  '  "■  n  emergencies  in  such  a  remarkable  manner  is  unable  to  cojie 


" 


708 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


/ 


long  witli  a  ])rniiinH'iit  and  pcrliaps  increasing  dilatation.  ]\[oro  work  has 
to  be  done  and,  in  accordance  with  dclinite  ])hysiological  laws,  more  jjowcr 
is  given  l)y  increase  oi'  the  nuiscles.  Tiie  heart  iiypcrtropliies  and  liie  ell'ect 
of  the  valve  lesion  heconies,  as  we  say,  cumpcnsaled.  The  equilibrium  of 
the  circnlation  is  in  this  way  maintained. 

The  natnre  of  the  process  with  which  we  have  to  deal  is  graphically 
illustrated  in  the  acconi])anying  diagrams,  which  we  owe  to  ^Martins,  of 
Uostock.  The  i)eri)endicnlar  lines  in  the  tignres  represent  the  power  of 
work  of  the  heart.  While  the  muscle  in  the  healthy  heart  (Diagram  I)  has 
at  its  disposal  the  maximal  force,  a.,  it  carries  on  its  work  under  ordinary 
circumstances  (when  the  body  is  at  rest)  with  the  force  ah.  The  force  he 
is  reserve  force,  by  means  of  which  the  heart  accommodates  itself  to  greater 
exertion. 

If  now  there  be  a  gross  valvular  lesion,  the  force  required  to  do  the  ordi- 
nary work  of  the  heart  (at  rest)  becomes  very  much  increased  (Diagram  II). 
But  in  spite  of  this  enormous  call  for  force,  insuiTiciency  of  the  heart  muscle 
does  not  necessarily  result,  for  the  working  force  required  is  still  within  the 


1 

Cl. 

Reserve-force- 

i 

f 

Accommodation-  ' 
capacity 

} 

y 

c 

bi 

Reserve-force  — 

Accommodation-  < 

capacity 

y  Power  of  work 
(body  at  rest) 

• 

b                       1 

1*"" 

^  Power  of  work 
(body  at  rest) 

ai 

I.  Nor 

Tial  heart                     II.  Het-.i  in  valvular  disease  :;i 

stage  of  compensation 

( 

Z-RK 

BT    \ 

'fVi. 

Total  power  of  heart 
\  (ess  than  amount  needed 
when  the  body  is  at  rest. 
Insufficiency  of  the  heart 


III.  Heart  in  uncompensated 
valvular  disease 


limits  of  the  maximal  power  of  the  heart,  a^  h^,  being  less  than  a^  c^.  The 
muscle  accommodates  itself  to  the  new  conditions  by  making  its  reserve 
force  mobile  (cx])erimcnt  of  Rosenbach).  If  nothing  further  occurred, 
however,  this  condition  could  not  be  permanently  maintained,  for  there 
would  be  left  over  for  emergencies  only  the  small  reserve  force,  &i  y.  Even 
Avhen  at  rest  the  heart  would  be  using  continuously  almost  its  entire  maxi- 
mal force.  Any  slight  exertion  requiring  more  extra  force  than  that  repre- 
sented by  the  small  value  h^  y  (say  the  effort  required  on  walking  or  on 


work  lias 
ore  j)i)\vi'r 

the  el  Feet 
ibrium  of 

rapliically 
artius,  of 
power  of 
am  I)  has 
•  ordinary 
>  foi'ce  />  c 
to  greater 

i  the  ordi- 
gram  II). 
irt  niusele 
t'ithin  tlio 


CUIIONIC  VALVULAR  DISEASE. 


709 


lOwer  M  heart 
amount  needed 
body  Is  at  rest, 
ncy  of  the  heart 


lensated 


The 
1  reserve 
c'curred, 
or  there 
.  Even 
e  maxi- 
it  repre- 
g  or  ou 


going  njistairs)  would  bring  the  heart  to  the  limit  of  its  working  ])ower, 
,111(1  pali)itation  and  dyspmea  would  ai)pear.  Such  a  eonditiou  iloe.s  not 
last  long.  The  working  jjower  of  the  heart  gradually  inereat-es.  ^More  and 
more  exertion  can  be  borne  without  causing  dys])n(.en,  for  the  heaii  Injpcr- 
Iriijiliics.  Finally,  a  new,  more  or  less  ))ermanent  condition  is  attained,  iu 
that  the  hypertrophied  heart  i)ossesses  the  maximal  force,  (i,  c.  Owing  to 
the  increase  in  volume  of  the  heart  muscle,  the  total  force  of  the  heart  is 
greater  absohilcli/  than  that  of  the  normnl  heart  by  the  amount  /y,  c.  It  is, 
however,  rchilirelij  less  ellicient,  for  its  reserve  force  is  much  less  than  that 
(»f  the  healthy  heart.  Its  cai)acity  for  accommodating  itself  to  unusual  calls 
upon  it  is  accordingly  ]!ernuuiently  diminished. 

Turning  now  to  the  disturbances  of  compensation,  it  is  to  be  distinctly 
borne  in  mind  that  any  heart,  normal  or  diseased,  can  become  insullicient 
whenever  a  call  upon  it  exceeds  its  maximal  working  capacity.  The  liability 
to  such  disturbance  will  depend,  above  all,  upon  the  accommodation  limits 
of  the  heart — the  less  the  width  of  the  latter,  the  easier  will  it  be  to  go 
beyond  the  heart's  efliciency.  A  comparison  of  Diagrams  I  and  II  will  im- 
mediately make  it  clear  that  the  heart  in  valvular  disease  will  much  earlier 
become  insuilicient  tluiu  the  heart  of  a  healthy  individual.  If  the  heart 
muscle  is  comj)elled  to  do  maximal  or  nearly  maximal  work  for  a  long  time, 
it  becomes  exhausted.  It  is  obvious  that  the  heart  in  valvular  disease  has 
on  account  of  its  small  amount  of  reserve  force  to  do  maximal  or  nearly 
maximal  work  far  more  frequently  than  does  the  normal  heart.  The  power 
of  the  heart  may  become  decreased  to  the  amount  necessary  simjjly  to  carry 
on  the  work  of  the  heart  when  the  body  is  at  rest,  or  it  may  cease  to  be 
sulHcient  even  for  this.  The  reserve  force  gained  through  the  compensa- 
tory process  may  be  entirely  lost  (Diagram  III).  If  the  loss  be  only  tem- 
])orary,  the  exhausted  heart  muscle  quickly  recovering,  the  condition  is 
s])oken  of  as  a  "  disturbance  of  c()m])ensation."  The  term  "  loss  of  com- 
])cnsation  "  is  reserved  for  the  condition  in  which  the  disturbance  is  con- 
tinuous. 

2.  Aortic  IxcoMrETEXCY. 

Incompetency  of  the  aortic  valves  arises  either  from  inability  of  the 
valve  segments  to  close  an  abnormally  large  orifice  or  more  commonly  from 
disease  of  the  segments  themselves.  This  best-defined  and  most  easily 
recognized  of  valvular  lesions  was  first  carefully  studied  by  Corrigan,  whose 
name  it  sometimes  bears. 

Etiology  and  Morbid  Anatomy. — It  is  more  freqnent  in  males 
than  in  females,  affecting  chiefiy  able-bodied,  vigorons  men  at  the  middle 
period  of  life.  The  ratio  which  it  bears  to  other  valve  diseases  has  been 
variously  given  from  30  to  50  per  cent. 

Among  the  important  factors  in  producing  this  condition  are:  (a)  Con- 
genital malformation,  particularly  fusion  of  two  segments — most  com- 
monly those  behind  which  the  coronary  arteries  are  given  ofp.  It  is  prob- 
able that  an  aortic  orifice  may  be  com])etent  with  this  l)icnspid  state  of  the 
vidves,  but  a  great  danger  is  the  liability  of  these  malformed  segments  to 
sclerotic  endocarditis.     Of  17  cases  which  I  have  reported  all  presented 


710 


DISKASKS  OK  THE  CIRCCLATORY  SYSTEM. 


/ 


KC'ltTotir  clianfics,  and  the  iiiiijorily  <>l'  lliciii  luid,  (luring  life,  tlio  clinical 
J'oaturos  of  clironic  liciirt-discasc. 

{!))  vVciitc  endocarditis.  'I'liis  docs  not  |)rodMcc  aoi'tic  inconipclcncy 
unless  tlic  process  passes  on  to  ulceration  and  destruction,  under  which 
circumstances  it  is  often  found,  and  may  cause  a  rapidly  fatal  issue.  Sim- 
ple endocarditis  associated  with  the  spccilic  fevers  is  not  nearly  so  com- 
mon on  the  aortic  as  on  the  nntral  segments;  so  also  with  rheumatism, 
which  plays  a  less  important  rule  lu're  than  in  mitral  valve  disease. 

(<•)  \\\  far  the  most  fre([uenl  cause  of  insulliciency  is  a  slow,  progressive 
sclerosis  of  the  segments,  rcsidting  in  a  curling  of  the  edges,  which  lessens 
thi'  working  surface  of  the  valve.  This  may,  of  course,  follow  acute  endo- 
carditis, hut  it  is  so  often  met  with  in  strong,  ahlc-hodied  men  among  the 
working  classes,  without  any  history  of  rheumatism  or  sju'cial  fehrile  dis- 
eases with  which  endocarditis  is  commonly  assoeiati'd,  that  other  con- 
ditions must  he  songlit  for  to  explain  its  freciuency.  Of  these,  nmjuestion- 
ahly  strain  is  the  most  important — not  a  sudden,  forcible  strain,  but  a 
|)eisistent  increase  of  the  normal  tension  !o  which  the  segments  are  subject 
during  the  diastole  of  the  ventricle.  Of  circumstances  increasing  this  ten- 
sion, heavy  and  excessive  use  of  the  muscles  is  perha])s  the  most  important. 
So  often  is  this  form  of  heart-disca.^e  found  in  ])ers()ns  devoted  to  athletics 
that  it  is  sometinu's  called  the  "athlete's  i'  'art."  Alcohol  is  n  second  im- 
portant factor,  and  is  stated  to  raise  considerably  the  tension  iu  the  aortic 
system.  A  combination  of  these  two  causes  is  extremely  common.  A  third 
element  in  inducing  chronic  sclerotic  changes  in  these  valves  is  syi)hilis. 
Cases  are  rarely  seen  in  which  other  factors  must  not  be  taken  into  account, 
but  the  association  is  too  frciincnt  to  be  accidental.  That  syphilis  is  ca])a- 
ble  of  inducing  arterial  sclerosis  is,  I  think,  acknowledged,  although  the 
way  in  which  it  does  so  is  not  yet  clear.  It  is  interesting  to  note  with  what 
fre(|ucn(y  this  form  of  valve  disease  occurs  in  soldiers.  I  was  struck  with 
this  fact  in  the  I'hiladi'lphia  Hospital,  to  Mhich  so  many  veterans  of  the 
civil  war  are  admitted.  1  was  in  the  luibit  of  enforcing  U]Hm  my  students 
the  etiological  lesson  by  a  reference  to  Bacchus  and  A'ulcan,  at  whose 
shrines  a  majority  of  the  cases  of  aortic  insufficiency  have  w'orshipi)ed,  and 
not  a  few  at  those  of  INFars  and  Venus. 

The  condition  of  the  valves  is  such  as  has  already  been  described  in 
chronic  endocarditis.  It  may  be  noted,  however,  how  slight  a  grade  of 
curling  may  produce  serious  incompetency.  Associated  with  the  valve  dis- 
ease is,  in  a  nuijority  of  the  eases,  a  more  or  less  advanced  artcrio-sclerosis 
of  the  arch  of  the  aorta,  one  serious  effect  of  which  may  he  a  narrowing 
of  the  orifices  of  the  coronary  arteries.  The  sclerotic  changes  are  often 
combined  with  atheroma,  cither  in  the  fatty  or  calcareous  stage.  This  may 
exist  at  the  attached  margin  of  the  valves  without  iiulucing  insufficiency. 
In  other  instances  insulficiency  may  result  from  a  calcified  spike  projecting 
from  the  aortic  attachment  into  the  body  of  the  valve,  and  so  preventing 
its  proper  closure.  Some  writers  (Peter)  have  laid  great  stress  upon  the 
extension  of  the  endarteritis  to  the  valve,  and  would  separate  the  instances 
of  this  kind  from  those  of  simple  valvular  endocarditis.  I  must  say  that 
I  have  not  been  able  to  recognize  clinical  differences  between  these  two  con- 


CHRONIC  VALVULAR  DISEASE. 


Yll 


0  clinical 

inpetoucy 
IT  wliicli 
Lie.  Sim- 
'  so  t'om- 
'iiinatism, 


'ii  Icssuns 
uto  endo- 
rnong  liic 
'brilo  dis- 

lluT  C'OM- 
KlUL'Stioil- 

iii,  but  ii 

I'e  subject 

this  ten- 

iiportant. 

i  atiiletics 

'cond  iui- 

Lhe  aortic 

A  til  in] 

I  syi)liilis. 

account, 

s  is  ca])a- 

()ii<j:h  tlu; 

itii  Aviiiit 

K'k  with 

IS  of  the 

students 

it   wliosc 

|)cd,  and 

•ribcd  in 
Sirade  of 
alve  dis- 
-sclcrosis 
irrowini); 
PC  often 
'his  may 
ficiency. 
ojectin^'' 
ventinjj; 
pon  tlie 
nstancos 
say  that 
;vvo  con- 


ditions, tbouj^di  anatomically  we  may  separate  the  cases  into  two  groups — 
the  eiidocarditic  and  the  arterio-sclerotic. 

(</)  And,  lastly,  insiiHicicncy  may  be  induced  by  rupture  of  a  segment 
— a  very  rare  event  in  healthy  valves,  bnt  not  uncommon  in  disease,  either 
from  excessive  strain  during  heavy  lifting  or  from  the  ordinary  endarterial 
strain  in  a  valve  eroded  and  weakened  by  ulcerative  endocarditis. 

li'cldtirc  iiisKfJicictiC!/  of  the  sigmoid  valves,  due  to  dilatation  of  the 
aortic  ring,  is  a  rare  condition.  It  is  said  to  occur  in  extensive  arterial 
sclerosis  of  the  ascending  i)orti()n  of  the  arch  with  great  dilatation  just 
above  the  valves.  In  such  cases  the  valve  segments  are  usually  involved 
with  the  arterial  coats.  In  aneurism  just  above  the  aortic  ring,  relative  iii- 
sutliciency  of  the  valve  may  be  j)resent. 

It  would  appear  from  the  careful  measurements  of  Beneke  that  the 
aortic  orifice,  which  at  birth  is  '^0  nun.,  increases  gradually  with  the  growth 
of  the  heart  until  at  one-and-twenty  it  is  about  (iO  mm.  At  this  it  remains 
until  the  age  of  forty,  beyond  which  date  there  is  a  gradual  increase  in  the 
size  up  to  the  age  of  eighty,  when  it  may  reach  from  (58  to  70  mm.  There 
is  thus  at  the  very  jieriod  of  life  in  wliich  sclerosis  of  the  valve  is  most 
couinion  a  physiological  tendency  toward  tlu-  [)roduction  of  a  state  of  rela- 
tive insutlicieiicy. 

The  insulliciency  may  be  combined  with  various  grades  of  narrowing, 
but  the  majority  of  the  cases  of  aortic  insulliciency  present  no  signs  of 
stenosis.  On  the  other  hand,  cases  of  aortic  stenosis  almost  without  ex- 
cei)tion  are  associated  with  some  grade,  however  slight,  of  regurgitation. 

The  direct  ell'ect  of  aortic  insulliciciicy  is  the  regurgitation  of  blood 
from  the  artery  into  the  ventricle,  causing  an  overdistention  of  the  cavity 
and  a  reduction  of  the  blood  column;  that  is,  a  relative  aiuemia  in  the  ar- 
terial tree.  As  an  immediate  effect  of  the  double  hlood-flow  into  the  left 
vi'utricle  dilatation  of  the  chamber  occurs,  and  finally  hypertrophy.  Jn 
this  way  the  valve  defect  is  ccnnpensated  and  as  with  each  ventricular  sys- 
tole a  larger  amount  of  blood  is  propelled  into  the  arterial  system,  the  re- 
gurgitation of  a  certain  amount  during  diastole  does  not,  for  a  time  at  least, 
seriously  impair  the  nutrition  of  the  peripheral  ])arts.  In  this  valve  lesion 
dilatation  and  hypertrophy  reach  their  most  extreme  limit.  The  heaviest 
hearts  on  record  are  described  in  connection  with  this  affection.  The  so- 
called  bovine  heart,  cor  hovinum,  may  weigh  35  or  40  ounces,  or  even,  as 
in  a  case  of  Dulles's,  48  ounces.  The  dilatation  is  usually  extreme,  and  is 
in  marked  contrast  to  the  condition  of  the  chamber  in  cases  of  pure  aortic 
stenosis.  The  papillary  muscles  may  be  greatly  flattened.  The  mitral 
valves  are  usually  not  seriously  affected,  though  the  edges  may  present  slight 
sclerosis,  and  there  is  often  relative  incompetency,  owing  to  distention  of 
the  mitral  ring.  Dilatation  and  hypertro])hy  of  the  left  auricle  are  com- 
mon, and  secondary  enlargement  of  the  right  heart  occurs  in  all  cases  of 
long  standing.  The  myocardium  usually  presents  changes,  fibroid  or  fatty; 
more  commonly  the  former  in  association  with  disease  of  the  coronary  ar- 
teries. The  arch  of  the  aorta  may  ])resent  extensive  arterio-sclerosis  and 
dilatation.  In  the  endocarditic  cases,  particularly  those  following  rheu- 
matism, the  intima  is  perfectly  smooth,  and  the  arch  with  its  main  branches 


712 


DISKASES  OF  THE  CIRCULATORY  SYSTEM. 


/ 


iKit  (lilatod.  This  condition  niny  be  found  post  mortem  even  when  during 
life  there  have  l)een  tlie  most  eharaeteristie  signs  of  enlargement  of  the 
arch  ami  of  dilatation  of  the  innominate  and  right  carotid.  I  have  even 
known  the  condition  of  aneurism  to  he  diagncjsed  when  post  mortem  no 
trace  of  dilatation  or  sclerosis  was  found,  only  an  extreme  grade  of  insulli- 
ciency  with  enormous  dilatation  and  liyi)ertroi)hy.  The  coronary  arteries 
are  usually  involved  in  the  sclerosis,  and  their  orifices  may  he  much  mir- 
rowed.  Although  these  vessels  have  Ijcen  shown  by  Martin  and  Sedgwick 
to  he  filled  during  the  ventricular  systole,  the  circulation  in  them  must  be 
embarrassed  in  aortic  incompetency.  They  must  miss  the  elfeet  of  the 
blood-i)ressure  in  the  sinuses  of  Valsalva  during  the  elastic  recoil  of  the 
arteries,  which  surely  aids  in  keeping  tlic  coronary  vessels  full.  The  ar- 
teries of  the  body  usually  present  more  or  less  sclerosis  consequent  upon  the 
Btrain  which  they  undergo  during  the  forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  per- 
sons who  have  not  presented  any  features  of  cardiac  disease 

Headache,  dizziness,  flashes  of  light,  and  a  feeling  of  faintness  on  ris- 
ing quickly  are  among  the  earliest  symptoms.  Palpitation  and  cardiac 
distress  on  slight  exertion  are  common.  Long  before  any  signs  of  failing 
comi)ensation  pain  may  become  a  marked  and  troublesome  feature.  It  is 
extremely  variable  in  its  manifestations.  It  may  be  of  a  dull,  aching  char- 
acter confined  to  the  praecordia.  More  frequently,  however,  it  is  sharp 
and  radiating,  and  is  transmitted  iip  the  neck  and  down  the  arms,  particu- 
larly the  left.  Attacks  of  true  angina  pectoris  are  more  frequent  in  this 
than  in  any  other  valvular  disease.  Anaemia  is  also  common,  much  more  so 
than  in  aortic  stenosis  or  in  mitral  affections. 

More  serious  symptoms,  as  compensation  fails,  are  shortness  of  breath 
and  oedema  of  the  feet.  The  attacks  of  dyspnoea  are  liable  to  come  on  at 
night,  and  the  patient  has  to  sleep  with  the  head  high  or  even  in  a 
chair.  Cyanosis  is  rare.  It  is  most  commonly  due  to  complicating 
valve  disease,  or  it  is  stated  that  it  may  result  from  bulging  of  the 
septum  ventriciilorum  and  encroachment  upon  the  right  ventricle.  Of  re- 
spiratory symptoms  cough  may  develop,  due  to  the  congestion  of  the  lungs 
or  a'dema.  Haemoptysis  is  less  frequent  than  in  mitral  disease.  I  have 
reported  a  case  in  which  it  was  profuse  and  believed  to  be  due  to  tubercu- 
losis of  the  lungs,  inasmuch  as  the  patient  was  admitted  in  a  state  of  ema- 
ciation and  profound  exhaustion.  General  dropsy  is  not  common,  but 
oedema  of  the  feet  may  occur  early  and  is  sometimes  due  to  the  anaemia,  at 
others  to  the  venous  stasis,  at  times  to  both.  Unless  there  is  coexisting 
disease  of  the  mitral  valve,  it  is  rare  in  aortic  incompetency  for  the  patient 
to  die  with  general  anasarca.  Sudden  death  is  frequent;  more  so  in  this 
than  in  other  valvular  diseases.  As  compensation  fails  the  patient  takes 
to  bed  and  slight  irregular  fever,  associated  usually  with  a  recurring  endo- 
carditis, is  not  uncommon  toward  the  close.  Embolic  symptoms  are  not 
infrequent — pain  in  the  splenic  region  with  enlargement  of  the  organ, 
hamiaturia,  and  in  some  cases  paralysis.  Distressing  dreams  and  disturbed 
sleep  are  more  common  in  this  than  in  other  forms  of  valvular  disease. 

Here  may  appropriately  be  mentioned  the  connection  between  mental 


CnRONIC  VALVULAR  DISEASE. 


713 


ion  (luring 
Jilt  oi  tho 
have  t'VL'u 
iiortcm  MO 

of  iiisulli- 
vy  arteries 
uueh  nar- 

Sedgwick 

n  must  be 

'(•t  of  the 

oil  of  the 

The  ar- 

upon  the 
e. 
[y  in  per- 

'ss  on  ris- 
d  cardiac 
of  failing 
re.  It  is 
dng  char- 
is  sharp 
,  particu- 
it  in  this 
1  more  so 

)f  breath 

me  on  at 

en  in  a 

ilicating 

of   the 

Of  re- 

le  lungs 

I  have 

ubercu- 

of  ema- 

on,   but 

cmia,  at 

existing 

patient 

in  this 
it  takes 
g  endo- 
are  not 

organ, 
sturbed 

se. 

mental 


pymptoms  and  cardiac  disease,  as  they  are  oftenest  seen  with  this  lesion.  An 
jiduiirable  account  ol'  the  relations  between  insanity  and  disease  of  the  heart 
is  to  be  found  in  Mickle's  Gulstonian  lectures  for  IfSSS.  In  general  med- 
ical practice  we  seldom  find  marked  mental  symptoms,  except  toward  the 
close  of  the  disease,  when  there  may  be  delirium,  hallucinations,  and  mor- 
l)id  ini])u]ses.  It  is  to  be  remembered  that  in  many  heart  cases  this  ter- 
minal delirium  is  uni'inic.  The  irritability  and  peevishness  sometimes 
found  in  persons  the  subject  of  organic  heart-disease  cannot,  1  think,  be 
associated  with  it  in  any  special  manner.  We  do  meet  insanity,  breaking 
out  in  j)atients  with  aortic  and  mitral  disease,  in  the  stage  of  compensation, 
which  appears  to  be  related  definitely  to  the  cardiac  lesion.  It  is  imj)ortant 
to  bear  this  in  mind,  for  cases  occasionally  disj)lay  suicidal  tendencies.  I 
have  twice  had  ])atients  throvv  themselves  from  a  window  of  the  ward. 

Physical  Signs. — Inspediun  shows  a  wide  and  forcible  area  oF  cardiac 
impulse  with  the  apex  beat  in  the  sixth  or  seventh  intersi)ace,  and  perhaps 
as  far  out  as  the  anterior  axillary  line.  In  young  subjects  tlie  ijnecordia 
nuiy  bulge.  On  palpation  a  thrill,  diastolic  in  time,  is  occasionally  felt, 
l)ut  is  not  common.  The  impulse  is  usually  strong  and  heaving,  unless 
in  conditions  of  extreme  dilatation,  when  it  is  wavy  and  indefinite.  Occa- 
sionally two  or  three  interspaces  between  the  ni])i)le  line  and  sternum  will 
be  de])ressed  with  the  systole  as  a  result  of  atnu)splieric  jiressure.  rercussion 
shows  a  greater  increase  in  the  area  of  heart  dulness  than  is  found  in  any 
other  valvular  lesion.     It  extends  chiefly  downward  and  to  the  left. 

On  auscultation  there  is  heard  a  murmur  during  diastole  in  the  second 
right  interspace,  which  is  projjagated  with  intensity  toward  the  ensiform 
cartilage,  or  down  the  left  margin  of  the  sternum  toward  the  apex.  In 
the  majority  of  cases  it  is  a  soft,  long-drawn  hruit,  and  is  of  all  cardiac 
murmurs  the  most  trustworthy.  It  occurs  during  the  time  of,  and  is  pro- 
duced by,  the  reflux  of  blood  from  the  aorta  into  the  ventricle.  In  a  large 
proportion  of  the  cases  there  is  also  a  systolic  murmur  heard  at  the  aortic 
region,  usually  shorter,  often  rougher  in  quality,  and  which  may  be  propa- 
gated upward  into  the  neck.  A  common  mistake  is  to  regard  this  as 
indicating  stenosis,  whereas  in  the  great  majority  of  instances  of  aortic 
insufficiency  there  is  no  material  narrowing,  and  the  murmur  is  produced 
by  roughening  of  the  segments  or  of  the  intima  of  the  arch.  The  second 
■sound  is  usually  obliterated,  but  when  the  valves  are  only  slightly  curled  or 
if  one  cusp  only  is  involved  both  the  murmur  and  the  valvular  sound  may 
be  distinctly  heard.  At  the  apex  murmurs  are  also  heard,  either  transmitted 
from  the  aortic  orifice  or  produced  at  the  mitral.  In  the  majority  of  cases 
with  aortic  incompetency  of  high  grade,  the  mitral  orifice  is  dilated,  and 
there  is  relative  insufficiency  of  the  valves.  It  can  frequently  be  deter- 
mined that  the  systolic  murmur  at  the  apex  difl'ers  in  quality  from  that  at 
the  base.  A  second  murmur  at  the  apex,  probably  produced  at  the  mitral 
orifice,  is  not  uncommon.  Attention  was  called  to  this  by  the  late  Austin 
Flint,  and  the  murmur  usually  goes  by  his  name.  It  has  a  distinctly  rum- 
bling quality,  is  limited  in  area,  and  is  sometimes,  though  not  always,  ex- 
actly presystolic  in  time.  The  explanation  of  its  occurrence,  as  given  by 
Flint,  is  that  in  the  extreme  dilatation  of  the  ventricle  the  mitral  segments 


714 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


cniinot  (luririf^  diastole  be  forced  back  af,'ainst  the  wall,  and  tlioroforc,  rr- 
iiiaining  in  the  blood  current,  they  produce  a  sort  of  relative  narrowing, 
and  in  consecjucncc  a  vil)ratorv  niuruiur  not  unlike  in  quality  the  ))ri'sys- 
tolic  niurniur  of  mitral  stenosis.  IJroadhent,  on  the  other  hand,  suggests 
that  the  regurgitant  current  from  the  aorta  im])inging  u|)on  the  anterior  or 
aortic  fla])  of  the  mitral  nuiy  set  it  into  vibration  and  thus  produce  the 
niurniur.  This  apex  diastolic  murmur  of  aortic  insulViciency  occui-h  in  a 
consid('rabl(!  jirojiortion  of  all  cases.  It  is  variable,  and  may  disappear  as 
the  dilatation  of  the  ventricle  diminishes.  There  is  never  the  loud  systolic 
shock  which  follows  the  murmur  of  mitral  stenosis. 

■ 

The  examination  of  the  arteries  in  aortic  insulliciency  is  of  great  value. 
Visible  ])ulsation  is  more  commonly  seen  in  the  ])cripheral  vessels  in  this 
than  in  any  other  condition.  The  carotids  may  be  seen  to  throb  forcibly,, 
the  temporals  to  dilate,  and  the  brachials  and  radials  to  expand  with  each 
heart-beat.  With  the  ophthalmoscope  the  retinal  arteries  are  seen  to  pul- 
sate. Not  only  is  the  pulsation  evident,  but  the  characteristic  jerking  (pial- 
ity  is  apparent.  In  the  throat  the  throbbing  carotids  may  lead  to  the 
diagnosis  of  aneurism.  In  many  cases  the  jjulsation  can  be  seen  in  the  su- 
prasternal notch,  and  prominent,  forcibly-throbbing  vessels  beneath  the 
right  sterno-mastoid  muscle.  The  abdominal  aorta  may  lift  the  epigas- 
trium with  each  systole.  To  be  mentioned  with  this  is  the  capillary  pulse, 
met  very  often  in  aortic  insudiciciicy,  and  best  seen  in  the  finger-nails  or  by 
drawing  a  line  upon  the  forehead,  when  the  margin  of  hyperieinia  on  either 
side  alternately  blushes  and  pales.  In  extreme  grades  the  face  or  the  hand 
may  blush  visibly  at  each  systole.  It  is  met  with  also  in  profound  auiumia, 
occasionally  in  neurasthenia,  and  in  liealth  in  conditions  of  great  relaxa- 
tion of  the  peviiiheral  arteries.  Pulsation  may  also  be  present  in  the  periph- 
eral veins.  On  palpation  the  characteristic  water-hammer  or  Corrigan 
pulse  is  felt.  In  the  majority  of  instances  the  pulse  wave  strikes  the  finger 
forcibly  with  a  quick  jerking  impulse,  and  immediately  recedes  or  collapses. 
The  characters  of  this  are  sometimes  best  appreciated  by  grasping  the  arm 
above  the  wrist  and  holding  it  np.  Moreover,  the  piilse  of  aortic  regurgita- 
tion is  usually  retarded  or  delayed — i.  e.,  there  is  an  appreciable  interval 
between  the  beat  of  the  heart  and  the  jmlsation  in  the  radial  artery,  which 
varies  according  to  the  extent  of  the  incompetence.  On  auscultation  a 
double  murmur  may  be  heard  in  the  carotids  and  subclavians  when  it  h 
present  at  the  aortic  orifice.  Occasionally  in  the  carotid  the  second  sound 
is  distinctly  audible  when  absent  at  the  aortic  cartilage.  Indeed,  accord- 
ing to  Broadbent,  it  is  at  the  carotid  that  we  must  listen  for  the  second 
aortic  sound,  for  when  heard  it  indicates  that  the  regurgitation  is  small  in 
amount,  and  is  consequently  a  very  favorable  prognostic  element.  In  the 
femoral  artery  a  double  murmur  also  may  be  heard  sometimes,  as  pointed 
out  by  Durozicz. 

Aortic  insufficiency  may  for  years  be  fully  compensated.  Persons  do 
not  necessarily  suffer  any  inconvenience,  and  the  condition  is  often  found 
accidentally.  So  long  as  the  hypertrophy  just  equalizes  the  valvular  de- 
fect there  may  be  no  symptoms  and  the  individual  may  even  take  moder- 
ately heavy  exercise  without  experiencing  sensations  of  distress  about  the 


CDRONIC   VALVULAR   DISEASE. 


715 


lionrt.  The  cases  which  last  the  htn^'ent  are  those  in  which  the  insulTUiciuy 
I'dllows  {'iidocarditis  and  is  not  a  part  *  f  a  <,'cnt'ral  artcrio-sclci-osis.  'I'lio 
ii^'c  of  tiic  imticiit  too,  at  tlic  time  the  lesion  is  a((|uircd,  is  a  most  important 
( onsidcratioii,  as  in  youth  the  heart  is  much  more  jjrone  to  take  on  cum- 
|)ensatory  changes.  Coexistent  lesions  of  the  mitral  valves  tend  early  to  dis- 
turb the  compensation.  It  has  scarcely  been  sullieiently  recognized  hy  the 
profession  at  lar^^e  that  \n\vo  aortic  insulllciency  is  consistent  with  years  of 
avcrafjje  licahli  anil  with  a  tolerably  activi'  life,  i  know  several  physiiiuns 
with  aortic  insulliciencv  who  have  been  able  to  carry  on  for  years  larjfe  and 
somewhat  onerous  i)ractices.  One  of  them  since  the  establishment  of  in- 
siilliciency  has  ])assed  successfully  throu<,di  two  attacks  of  acute  rheuiiui- 
lism.  In  a  ]ar<,'e  hospital  ]iractice,  scarcely  a  nu)nth  ))asses  without  the  dis- 
covery of  a  case  of  aortic  insulliciency  in  connection  with  some  other  af- 
t'ccli(tn. 

With  the  onset  of  myocardial  cliangcs,  with  increasing  degeneration  of 
the  arteries,  ])articularly  with  a  ])r()gressive  sclerosis  of  the  arch  and  in- 
volvcmcnt  of  the  oriiices  of  the  coronary  arteries,  the  comi)ensation  becomes 
disturbed.  In  advanced  cases  the  changes  about  the  aortic  ring  may  be 
associated  with  alterations  in  the  cardiac  nerves  and  ganglia,  and  so  intro- 
duce an  important  factor. 


3.  AouTic  Stmnosis. 

Xarrowing  or  stricture  of  the  aortic  oritice  is  not  nearly  so  common  as 
insutliciency.  The  two  conditions,  as  already  stated,  may  occur  together, 
however,  and  ])robab]y  in  almost  every  case  of  stenosis  there  is  some  leakage. 

Etiol(^y  and  Morbid  Anatomy. — In  the  milder  grades  there  is 
adhesion  between  the  segments,  which  are  so  still'ened  that  during  systole 
tliey  cannot  be  pressed  back  against  the  aortic  wall.  The  process  of  cohe- 
sion between  the  segments  may  go  on  witluuit  great  thickening,  and  pro- 
duce a  condition  in  which  the  oriiice  is  guarded  by  a  comparatively  thin 
membrane,  on  the  aortic  face  of  which  may  bo  seen  the  primitive  raphes 
separating  the  sinuses  of  Valsalva.  In  some  instances  this  membrane  is 
so  thin  and  ])resents  so  few  traces  of  atheromatous  or  sclerotic  changes  that 
the  condition  looks  as  if  it  had  originated  during  fa-tal  life.  !More  com- 
monly the  valve  segments  are  thickened  and  rigid,  and  have  a  cartilaginous 
hardness.  In  advanced  cases  they  may  be  represented  by  stilf,  calcified 
masses  obstructing  the  orifice,  through  which  a  circidar  or  slit-like  ])assage 
can  be  seen.  The  older  the  patient  the  more  likely  it  is  that  the  valves 
will  be  rigid  and  calcified. 

AVe  may  spCak  of  a  relative  stenosis  of  the  aortic  orifice  when  with  nor- 
mal A'alves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated.  A 
stenosis  due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareoiis 
clianges  without  lesion  of  the  valves  is  referred  to  by  some  authors.  I  have 
never  met  with  an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result 
of  endocarditis  in  the  mitro-sigmoidean  sinus,  nsually  occurs  as  the  result  of 
fo'tal  endocarditis.  In  comparison  with  aortic  insufiiciency,  steriosis  is  a 
rare  disease.     It  is  usually  met  ..  ith  at  a  more  advanced  period  of  life  than 


YIO 


DISEASES  OP  THE  flRCULATOIlY  SYSTEM. 


/ 


iiisuliick'ncy,  niid  tlio  nioHt  typical  cases  of  it  arc  found  associated  witli 
extensive  calcareous  clianj^es  in  the  arterial  system  in  old  men. 

M'licn  ^M'aduiiily  produced  and  when  there  is  not  niucii  InsufTiciency 
the  (lihitalion  of  the  left  vcntrich'  may  l)e  snj,dit,  th()U;j;ii  I  think  that  in 
all  ca.se.s  it  does  occur.  The  walU  of  the  ventricles  heconu,'  iiypcrlropiiic(l, 
and  we  see  in  this  condition  tlu'  most  typical  instances  of  what  is  called 
concentric  hypertrophy,  in  which,  without  much,  if  any,  eidar^'cment  (»r 
the  cavity,  tlu'  walls  are  •,'reatly  thickeiu'd,  in  contradistinction  to  the  so- 
called  eccentric  hypertrophy,  in  which,  with  the  iiureuse  in  the  thickiu'ss 
of  the  walls,  the  clunnher  itself  is  j,'reatly  dilated.  There  niay  he  no  changes 
in  the  other  cardiac  cavities  if  compensation  is  well  maintained;  hut  with 
its  failure  come  dilatation,  impeded  auricular  dischar^re,  pulmonary  con- 
ffcstion,  and  increased  woik  for  the  ri<,dit  heart.  The  arterial  chanj^'cs  are. 
as  a  rule,  not  so  nuirked  as  in  aortic  insuihcicncy,  for  tlu;  walls  have  not 
to  withstand  the  impulse  of  a  greatly  increased  hlood-wave  with  each  sys- 
tole. On  the  contrary,  the  amount  of  hlood  propelled  through  the  narrow 
orifice  may  be  smaller  than  nornuil,  though  when  com})ensation  is  fully 
cstahlished  the  pulse-wave  may  he  of  medium  volume. 

Symptoms. — Physical  Signs. — Inspection  may  fail  to  reveal  any  area 
of  cardiac  impulse.  Tarticidarly  is  this  the  case  in  old  nu'n  with  rigid 
chest  walls  and  large  emphysematous  lungs.  Under  these  circumstances 
there  may  l)e  a  high  grade  of  hypertrophy  without  any  visible  impulse. 
Even  when  the  apex  beat  is  visible,  it  may  be,  as  Traube  i)ointed  out,  feeble 
and  indefinite.  In  many  cases  the  apex  is  seen  dis})laced  downward  and 
outward,  and  the  impulse  looks  strong  and  forcible. 

J'aljxifion  reveals  in  many  cases  a  thrill  at  the  base  of  the  heart  of 
maximum  force  in  the  aortic  region.  With  no  other  condition  do  we  meet 
with  thrills  of  greater  intensit}'.  The  apex  beat  may  not  be  ])ali)able  under 
the  conditions  above  mentioned,  or  there  may  be  a  slow,  heaving,  forcible 
impulse. 

Percussion  never  gives  the  same  wide  area  of  dulness  as  in  aortic  in- 
sufFiciency.  The  extent  of  it  depends  largely  on  the  state  of  the  lungs, 
whether  emphysematous  or  not. 

Auscultation. — A  systolic  murmur  of  maximum  intensity  at  the  aortic 
cartilage,  and  propagated  into  the  great  vessels,  is  present  in  aortic  stenosis, 
but  is  by  no  means  pathognomonic.  One  of  the  last  lessons  learned  by 
the  student  of  physical  diagnosis  is  to  recognize  the  fact  that  this  systolic 
murmur  is  only  in  comparatively  rare  cases  produced  by  decided  narrowing 
of  the  aortic  orifice,  toughening  of  the  valves,  or  the  intima  of  the  aorta, 
and  hjcmic  states  are  much  more  frequent  causes.  In  aortic  stenosis  the 
murmur  often  has  a  much  harsher  quaMty,  is  louder,  and  is  more  frequently 
musical  than  in  the  conditions  just  mentioned.  AVhen  compensation  fails 
and  the  ventricle  is  dilated  and  feeble,  tiie  murmur  may  be  soft  and  distant. 
The  second  sound  is  rarely  heard  at  the  aortic  cartilage,  owing  to  the  thick- 
ening and  stiffness  of  the  valve.  A  diastolic  murmur  is  not  uncommon, 
but  in  many  cases  it  cannot  be  heard.  Occasionally,  as  noted  by  V^^.  IT. 
Dickinson,  there  is  a  musical  murmur  of  greatest  intensity  in  the  region  of 
the  apex,  due  probably  to  a  slight  regurgitation  at  high  pressure  through. 


itod  witli 

iiiricioncv 

k  llial  ill 

•troplut'd, 

is  called 

Cllll'Ilt  (if 
O    tilt'    SD- 

(liickiicss 

0  eiuui^^'s 

hut  with 

mry  coii- 

iii<,'C'.s  inc. 

have  iidt 
each  sys- 
10  narrow 

1  is  fully 

any  area 
•ith  rifjid 
inistaiu'i's 

impulse. 
ut,  feehle 
ward  and 

heart  of 
we  meet 
e  under 
forcihle 

.ortic  in- 
le  lungs, 

le  aortic 
tenosis, 
rned  l)y 
systolic 
lirrowin.i: 
10  aorta, 
osis  the 
quently 
on  fails 
distant. 
0  thick- 
ommon, 
W.  IT. 
3gion  of 
;hrou<rh. 


ciiuonk;  valvulau  i>i.skasr. 


71' 


the  mitral  valves.     Tlie  pulse  in  pure  aortic  stenosis  is  small,  usually  of 
i,'oo(l  tension,  well  sustained,  re;,Milar,  and  perhaps  slower  than  normal. 

The  condition  may  he  hit<'iil  for  an  indelinite  period,  as  loii;^'  as  the 
|iypertro[tliy  is  maintained,  luirly  syniptoms  are  tliosi'  {\\u'  to  defective 
hlood-sujiply  to  the  bruin,  di//iness,  and  faintin^^  i'al|)itati(in,  pain  ahoiit 
tlie  heart,  and  anginal  symptoms  are  not  so  marked  iis  in  iiisulliciency. 
With  degeneration  of  the  lieart-iiiuscle  and  dilatation  relative  iii>iiHicien('y 
id'  the  mitral  valve  is  estahlished,  and  the  patient  may  jU'i'seiit  all  the  fea- 
tures of  engorgement  in  the  lesser  and  systemic  circulations,  with  dysiimea, 
cough,  rusty  e.vpi'ctoration,  and  the  signs  of  anasarca  in  the  lower  part  of 
the  hody.  Many  of  the  cases  in  old  people,  without  presi'iiting  any  drop.sy, 
have  symptoms  pointing  rather  to  general  arterial  disease.  Cheyne-Stokes 
breathing  is  not  uncommon  with  or  without  signs  of  ura-mia. 

Diag^nosis. — With  an  extremely  rough  or  musical  murmur  of  maxi- 
mum intensity  at  the  aortic  region  and  signs  of  hypertrophy  of  the  left 
veiitri(de,  a  thrill,  and  especially  a  hard,  slow  pulse  of  moderate  volume  and 
fairly  good  tension,  which  in  s[thygmographic  tracing  givi's  a  curve  of  slow 
rise,  a  broad  well-sustained  summit  and  slow  decline,  a  diagnosis  of  aortic 
stenosis  can  bo  made  with  some  degree  of  iirohability,  particularly  if  the 
subject  is  an  old  man.  ^Mistakes  are  common,  however,  and  a  roughened 
or  calcified  valve  segment,  or,  in  some  instances,  a  very  roughened  and 
prominent  calcitied  iilate  in  the  aorta,  and  hypertrophy  associated  with 
renal  disease,  nuiy  produce  sinular  symptoms. 

Let  me  repeat  that  a  murmur  of  maximum  intensity  at  the  aortic  car- 
tilage is  of  no  imi)ortaii'  e  in  itself  as  a  diagnostic  sign  of  stenosis,  tough- 
ening of  the  valve,  sclerosis  of  the  intima  of  the  arch,  and  aiiiemia  are  con- 
ditions more  frequently  associated  with  a  systolic  niurmur  in  this  region. 
Seldom  is  there  dilliculty  in  distinguishing  the  murmur  due  to  aniemia^ 
since  it  is  rarely  so  intense  and  is  not  associated  with  thrill  or  with  marked' 
hyi)ertrophy  of  the  left  ventricle.  In  aortic  iiisulliciency  a  systolic  mur- 
mur is  usually  present,  but  has  neither  the  intensity  nor  the  musical  ({ual- 
ity.  nor  is  it  accompanied  with  a  thrill.  With  roughening  and  dilatation 
of  the  ascending  aorta  the  murmur  may  be  very  harsh  or  musical;  but  the 
existence  of  a  second  sound,  accentuated  and  ringing  in  quality,  is  usually 
sullicieiit  to  differentiate  this  condition. 

4.  Mitral  Ixcompetexcy. 

Etiology. — InsufTicicncy  of  the  mitral  valve  results  from:  (a) 
Changes  in  the  segments  whereby  tliey  are  contracted  and  shortened,  usu- 
ally combined  with  changes  in  the  chorda;  tendinciv,  or  with  more  or  less 
narrowing  of  the  orifice,  (h)  As  a  result  of  changes  in  the  muscular  walls 
of  the  ventricle,  either  dilatation,  so  that  the  valve  segments  fail  to  close 
an  enlarged  orifice,  or  changes  in  the  muscular  substance,  so  that  the  seg- 
ments are  imperfectly  coapted  during  the  systole — muscular  incompetency. 
The  common  lesions  producing  insufficiency  result  from  endocarditis,  which 
causes  a  gradual  thickening  at  the  edges  of  the  valves,  contraction  of  the 
chorda?  tendinea?,  and  union  of  the  edges  of  the  segments,  so  that  in  a 


718 


DISKASKS  (H''  TIIK  (iUCULATOUY  HYSTFOM. 


/ 


i  r 


1  '• 

I? 


Tiiajorily  «»f  the  iiiHtiiiicos  IIutc  in  not  only  inHuHicii'iicy,  l)Ht  Honio  gnidc  (tf 
niiri'owin^'  uh  well.  Ivvccpt  in  chililri'n,  \vu  rarely  Hi't>  tliu  mitral  Ifatlctrt 
ciirlt'd  iiikI  piickcri'd  willioiil  iiiinuw  iii;^  of  llic  orillfc.  CnlciM't'oiiM  pliitcH 
at  tlic  liasc  (if  llu'  vulvo  may  jircvciil  pcrlccl  closiirc  ul'  ono  ul'  tlic  Hi'j^mcnts. 
ill  long-standing  vnnvA  the  cnlirt'  milral  Htructurcs  uri'  conviTtt-'d  into  a  lirm 
( idcart'oiiri  ring.  i''rom  this  valvular  insullicit'iify  the  other  cnndilion  of 
muscular  incompcti'ncy  must  he  carcl'ully  dislinguislu'd.  It  is  luct  with 
iu  all  coiidilidus  of  c.xtri'im'  dilalation  of  llii'  left  vcnlrlilc,  and  also  in 
wcidxcnin;;  of  llic  muscles  in  prolonged  fevers  and  in  ameuiia. 

Morbid  Anatomy. — The  t'll't'cta  of  ineompeti'tuy  of  the  mitral  seg- 
ment upon  tlu'  heart  and  circulation  arc  as  follows:  (d)  The  imperfect 
closure  allows  a  certain  amount  of  lilood  to  regurgitate  from  the  veiitriclt; 
iuto  the  auricle,  so  that  at  the  end  of  auricular  diastole  this  clunnher  con- 
tains not  only  the  hlood  which  it  has  received  from  the  lungs,  hut  also  that 
which  has  regurgitated  from  the  h'ft  ventricle.  This  nocessitates  dilata- 
tion, ami.  as  increased  work  is  thrown  upon  it  in  expelling  the  augmented 
contents,  h\[>ertrophy  as  well. 

(h)  With  I'ach  systole  of  the  left  auricle  a  larger  volume  of  blooil  is 
forced  into  the  left  ventricle,  which  also  dilates  and  8ubse([uently  becomes 
hyjji'rtrophied. 

{(■)  During  the  diastole  of  the  left  auricle,  as  blood  is  regurgitated  into 
it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  emptied. 
In  conse(jucnce  the  right  ventricle  ex))els  its  contents  less  freely,  and  in 
turn  becomes  dilated  and  hyi)ertroj)hied. 

{(I)  l"'inally,  the  right  auricle  also  is  involved,  its  chamber  is  enlarged, 
and  its  walls  are  increased  in  thickness. 

(r)  The  cH'cct  upon  the  puhnonary  vessels  is  to  produce  dilatation  botli 
of  the  arteries  and  veins — often  iu  long-stamling  cases,  athoronnitous 
changes;  the  capillaries  are  distended,  and  ultinuitely  the  condition  of 
l)r()wii  induriition  is  produced.  I'ei'fect  compensation  may  be  ell'ectcd, 
chiclly  through  the  hypertrophy  of  both  ventricles,  and  the  I'U'ect  npou 
the  peripheral  circulation  may  not  be  numi tested  for  years,  as  a  ntjrmal 
volume  of  blood  is  discharged  from  tiie  h'ft  heart  at  each  systole.  The 
time  conu's,  however,  when,  owing  either  to  increase  in  the  grade  of  the 
incompetency  or  to  failure  of  the  compensation,  the  left  ventricle  is  iinable 
to  send  out  its  m)rmal  volun\e  into  the  aorta.  Then  there  is  overlilling  of 
the  left  auricle,  engorgement  in  the  lesser  circulation,  embarrassed  action 
of  the  right  heart,  and  congestion  in  the  systemic  veins.  For  years  this 
somewhat  congested  condition  may  1)e  limited  to  the  lesser  circulation,  but 
finally  the  right  auricle  becomes  dilated,  the  tricuspid  valves  incomi)elent, 
and  the  systemic  veins  are  engorged,  '^^riiis  gradually  leads  to  the  condi- 
tion of  cyanotic  induration  in  the  viscera  and,  when  extreme,  to  dropsical 
effusion. 

]\Iuscubir  incompetency,  due  to  impaired  nutrition  of  the  mitral  and 
papillary  muscles,  is  rarely  followed  by  siu-h  perfect  compensation.  There 
may  be  in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of 
the  left  ventricle  with  relative  incom])etency  of  the  mitral  segments,  great 
dilatation  of  the  left  auricle,  and  intense  engorgement  of  the  lungs,  under 


iiiiife 


CIIUONK;   VAIiVULAU  DISHASK. 


ID 


pnidc  of 
il  Icallcts 
lis  plnlcH 

H'J,'tlU'lll.-l. 

ito  11  iiriii 
ililiuii  III' 
iiicl  with 
l1  also  ill 

ilriil  soj,'- 
impcrrt'c  I 
Vfiitriclc 
iiIrt  com- 
ahu  tiial 
'S  (liliitii- 
ignicnk'il 

blood  is 
bcconu's 

ated  into 

oinplic'd. 

',  and  ill 

I'lihir'^'d, 


loll    lllltll 

oiiiatDUs 
itioii  of 
cirt'ctcd, 
ct  upon 
iionii.-il 

V.        TIlL' 

r  of  tlie 
s  iiiialjio 
illiii^'  (if 
d  ai'tioii 
■ars  tliis 
ion,  hut 
iipi'ti'iit, 
I'  condi- 
ro]»sii-al 

ral  and 

itioii  of 
s,  firoat 
!,  under 


uliirh  circuinsliinrrs  profuse  liii'iiiorrliap'  iniiy  rosiill.  In  llicso  cnsc^  tliiTO 
i>  link'  clianct'  fur  ilir  c^tnliiisliint'iil  of  coiiipciisat  inn.  In  ciiscrt  of  liy[»t'r- 
li'ophy  iind  diliilnlion  of  the  lirart,  without  vaiviihir  h'siotis,  Ixit  associatcil 
with  heavy  work  and  ahidml,  the  in-iiirioiciiry  (if  the  inili.il  valve  niav  lie 
exlri'int'  and  U'lid  to  ^wnl  pulmonary  (Min^icHtion,  cn^forjieincnt  of  tint  hva- 
teiiiii;  veins,  and  a  condition  of  cardiae  dropsy,  which  cannot  he  distin- 
■Mii.'hed  hy  any  fcatiiic  from  that  of  mitral  incompetency  due  to  lesion  of 
I  he  valve  itself.  In  (lironic  Uri;,dit's  disease  the  hypertrophy  of  the  left 
M'litrielo  may  j,'riidiially  fail,  leadiii",'.  in  the  later  stiif':cs,  to  relative  in- 
-iiHieieiicy  of  the  iiiiti'iil  valve,  and  the  production  of  a  condition  of  pul- 
iiioiiiiry  and  systemic  congestion,  similar  to  that  induced  hy  the  most  ev- 
ireine  jirade  of  lesion  of  the  valve  itself.  Adherent  pericardium,  especially 
in  children,  may  lead  to  like  results. 

Oymptoms. — Duiin;;'  the  development  of  the  lesion,  nnh^ss  the  in- 
eompeteiicy  comes  on  acutely  in  conseipieiice  of  rupture  (d'  the  valve  se;^- 
iiieiit  or  of  ulceration,  the  compensatory  clian;^'es  j^o  hand  in  hand  with  the 
defect,  and  there  are  no  suhjeelive  symptoms.  So,  also,  in  tin;  stage  of 
perfect  compensation,  there  may  he  the  most  evtreme  jiiade  of  mitral 
iiisiiHiciency  with  enormous  hypertrophy  of  the  heart,  yet  the  patient  may 
not  he  aware  of  the  existence  of  heart  troiihle,  and  may  siilTer  no  iiicon- 
M'liienee  except  ]»erliaps  a  little  shortness  of  hreath  on  exertion  or  on  j^'oin;^' 
upstairs.  It  is  only  when  from  aiu  cause  the  compensation  has  not  heeii 
perfectly  eU'eeted,  or,  liaviii<4'  heeii  so,  is  hndvcn  ahriiptly  or  {^'radiially,  that 
the  patients  he(.'in  to  he  Iroiihled.  The  symptoms  may  he  di\i(h'd  into  two 
;.rroiips: 

(ii)  The  luiiior  manifestations  while  compen.sition  is  still  (food.  I'a- 
lii'iits  with  extreme  incoinpetcncy  often  have  a  eongesteil  appearance  of 
the  face,  the  lips  and  cars  have  a  Idiiisli  tint,  and  the  venules  on  the  cheeks 
may  he  enlariicd,  w  liicli  in  many  cases  is  very  suji'tiestive.  In  lonj^-standing 
cases,  particularly  in  children,  the  linj^crs  may  he  cluhhed,  and  there  is 
shortness  of  hrealh  on  exertion.  This  is  one  of  the  most  constant  features 
ill  mitral  insnllicieney,  and  may  exist  for  years,  even  when  the  compensu- 
tioii  is  perfect.  f)win;f  to  the  somewhat  coiif^ested  condition  of  the  liinfj^3 
these  jiatients  have  a  tendency  to  attacks  of  hroiichitis  or  ha'iiioptysis. 
There  may  also  he  jialpitation  of  the  heart.  As  a  laile,  however,  in  well- 
halanced  lesions  in  adults,  this  period  of  full  compensation  or  latent  stage 
is  not  associated  with  symptoms  which  call  the  attention  to  an  allection 
of  the  heart,  and  with  care  the  patient  may  reach  old  age  in  comparative 
comfort  Avithont  being  coiniielled  to  curtail  seri(Uisly  his  plea.sures  or  liiri 
work. 

(Il)  Sooner  or  later  conios  a  ])eriod  of  disturbed  or  bnd'Cen  eomjiensa- 
'ion,  in  which  the  most  intense  symptoms  are  those  of  venous  engorgement. 
Tliere  are  palpitation,  weak,  irregular  action  of  the  heart,  and  signs  of 
dilatation.  Dyspnoea  is  an  esitecial  feature,  and  there  may  be  cough.  A 
(lislressing  symptom  is  the  cardiac  "sleep-start,"  in  wliicli,  just  as  the  pa- 
tient falls  asleep,  he  wakes  gasping  and  feeling  as  if  tlu^  heart  was  stoi)]iing. 
There  is  nsnally  a  slight  cyanosis,  ar.d  even  a  jaundiced  tint  to  the  skin. 
The  most  marked  symjitoms,  however,  are  tb.ose  of  venous  sta.sis.  The 
45 


720 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


/ 


overiilliii'T  of  llic  itulmonnry  vessels  accounts  in  jtiirt  for  the  clyspnnoa. 
There  is  cough,  oi'ten  with  hh)0(ly  or  M'ntery  expectoration,  and  the  alveolar 
e]»itiu'liiin)  (•(•ntainiiig  hivnvn  uigiucnt-grains  is  abundant.  Dropsical  ell'u- 
sioii  usually  sets  in,  bc'-inninj^  in  the  leet  and  extending  to  the  body  and 
the  serous  sacS.  The  liver  is  enlarged,  and  there  are  signs  of  portal  con- 
gestion, gastric  irritation,  and  catarrh  of  tiie  stomach  and  intestines.  The 
urine  is  usually  scanty  and  albuminous,  and  contains  tube-casts  and  some- 
times blood-corpuscles.  With  judicious  treatment  the  comi)ensation  may 
be  restored  and  all  the  serious  symptoms  may  i)ass  away.  Patients  usually 
have  recurring  attacks  of  this  kind,  and  die  of  a  general  dropsy;  or  there 
is  progressive  dilatation  of  the  heart,  and  death  from  asystole.  Sudden 
death  in  these  cases  is  rare. 

Physical  Signs. — Inspection. — Tn  children  the  praecordia  may  bulge  and 
there  may  be  a  large  area  of  visible  pulsation.  The  apex  beat  is  to  the  left 
of  the  nii)ple,  in  some  cases  in  the  sixth  interspace,  in  the  anterior  axillary 
line.  There  may  ))e  a  wavy  impulse  in  the  cervical  veins  which  are  often 
full,  particidarly  when  the  i)atient  is  recumbent. 

Pcdpaiion. — A  tlirill  is  rare;  when  present  it  is  felt  at  the  apex,  often 
in  a  limited  area.  The  force  of  the  imjjulse  m.iy  depend  largely  upon  the 
stage  in  which  the  case  is  examined.  In  full  compensation  it  is  fccible 
and  heaving;  when  the  compensation  is  disturbed,  usually  wavy  and  feeble. 

Percussion. — The  dulness  is  increased,  particularly  in  a  lateral  direction. 
There  is  no  disease  of  the  valves  which  produces,  in  long-standing  cases, 
a  more  extensive  transverse  area  of  heart  dulness.  It  does  not  extend  so 
much  u])ward  along  the  left  margin  of  the  sternum  as  beyond  the  right 
margin  and  to  the  left  of  the  nip])le  line. 

Avscullatinn. — At  the  apex  tlieie  is  a  systolic  murmur  which  wholly 
or  partly  obliterates  the  first  sound.  It  is  loudest  here,  and  has  a  blowing, 
sor.ietinies  musical  char-^cter,  ]iarticidarly  toward  the  latter  part.  The 
murmur  is  transmitted  to  the  axilla  and  inay  be  heard  at  the  back,  in  some 
instances  over  the  entire  chest.  There  are  cases  in  which,  as  ])ointed  out 
by  Xaunyn,  the  murmur  is  heard  best  along  the  left  border  of  the  sternum. 
Usually  in  diastole  at  the  apex  the  loudly  transmitted  second  sound  may 
be  heard.  Occasionally  there  is  also  a  soft,  sometimes  a  rough  or  rumlding 
presystolic  murmur.  As  a  rule,  in  cases  of  extreme  mitral  insufficiency 
from  valvular  lesion  with  great  hypertrophy  of  both  ventricles,  there  is 
heard  only  a  loud  blowing  murmur  during  systole.  A  murmur  of  mitral 
insufficiency  may  vary  a  great  deal  according  to  the  position  of  the  patient, 
it  may  be  present  in  the  recumbent  and  absent  in  the  erect  posture.  In 
cases  of  dilatation,  particularly  when  dropsy  is  present,  there  may  be  heard 
at  the  ensiform  cartilage  and  in  the  lower  sternal  region  a  soft  systolic 
murmur  due  to  tricus])id  regurgitation.  An  imjiortant  sign  on  auscidta-i 
tion  is  the  accentuated  pulmonary  second  sound.  This  is  heard  to  the  left 
OL  the  sternum  in  the  second  interspace,  or  over  the  third  left  costal  car- 
tilage. 

The  pu''se  in  miiral  insufficiency,  during  the  period  of  full  compensa- 
tion, may  be  full  and  regular,  often  of  low  tension.  Usually  with  the  first 
onset  of  the  symptoms  the  pulse  becomes  irregular,  a  feature  which  then 


lyi:pnona. 
alvooliir 
ical  eiru- 
)0(ly  and 
rtal  con- 
es. Tlio 
lid  sonie- 
:ion  may 
8  iisually 

01'   tluM'C 

Suddeii 

)ulgo  and 
3  the  left 
r  axillary 
are  often 

icx,  often 
upon  tlic 
5  fo.ei1)lo 
id  feeble, 
direction, 
ing  cases, 
extend  so 
the  riglit 

h  wholly 

blowinii-, 

rt.     The 

,  in  some 

nted  out 

sternum. 

ind  may 

uinbling 

litftciency 

there  is 
f  mitral 
patient, 
ure.  Tn 
)e  heard 

systolic 
usculta- 

the  loft 
stal  car- 

[mpcnsa- 
Ithe  first 
Ich  then 


CIIllONIC  VALVULAR  DISEASE. 


721 


dominates  the  case  throughout.  There  may  be  no  two  beats  of  equal  force 
or  volume.  Often  after  the  disappearance  of  tlie  symjjtoms  of  failure  of 
compensation  the  irregularity  of  the  pulse  i)ersists. 

The  three  inii)ortant  i)liysical  signs  then  of  mitral  regurgitation  are*J 
(a)  Systolic  murmur  of  maximum  intensity  at  the  apex,  which  is  propa-1 
gated  to  the  axilla  and  heard  at  the  angle  of  the  scapula;  (b)  accentuation\ 


of  the  i)ulmonary  second  sound;  (r)  evidence  of  enlargement  of  the  heart,' 
particularly  the  increase  in  the  transverse  diameter,  due  to  hypertrophy 
of  both  right  and  left  ventricles. 

Diagnosis. — There  is  rarely  any  difTiculty  in  the  diagnosis  of  mitral 
iusullicicucy.  The  i)hysical  signs  just  referred  to  are  quite  characteristic 
and  distinctive.  Two  points  are  to  be  borne  in  nund.  First,  a  murmur, 
systolic  in  character,  and  of  maxiimim  intensity  at  the  apex,  and  propa- 
gated even  to  the  axilla,  does  not  necessarily  indicate  incompetency  of  the 
mitral  valve.  There  is  heard  in  this  region  a  large  group  of  what  are 
termed  accidental  murmurs,  the  precise  nature  of  which  is  still  doubtful. 
'J'iiey  are  probably  formed,  however,  in  the  ventricle,  and  are  not  associated 
with  hypertroi)hy,  or  accentuation  of  pulmonary  second  sound. 

Second,  it  is  not  always  possible  to  say  whether  the  insullicicncy  is  due 
to  lesion  of  the  valve  segment  or  to  dilatation  of  the  nutra!  ring  and  rela- 
tive incompetency.  Here  neither  the  character  of  the  murmur,  the  propa- 
gation, the  accentuation  of  the  pulmonary  second  sound,  nor  the  hyper- 
trophy assists  in  the  diil'erentiation.  The  history  is  sometimes  of  greater 
value  in  this  matter  than  the  ])]iysical  examiuation.  Tiie  cases  most  likely 
to  lead  to  error  are  those  of  the  so-called  idiopathic  dilatation  and  liy])er- 
trophy  of  the  heart  (in  which  the  systolic  murmur  may  be  of  the  greatest 
intensity),  and  the  instances  of  arterio-sclerosis  with  dilated  heart.  Balfour 
and  others,  however,  maiiitain  that  organic  disease  of  the  mitral  leaflets 
sulhcient  to  produce  incompetency  is  always  accompanied  with  a  certain 
degree  of  narrowing  of  the  orifice,  so  that  the  only  unequivocal  proof  of  tlio 
actual  disease  of  the  mitral  valve  is  the  presence  of  a  presystolic  murmur. 

5.  ]\riTRAL  Stenosis. 

Etiology. — Xarrowing  of  the  mitral  orifice  is  usually  the  result  of 
valvular  endocarditis  occurring  in  the  earlier  years  of  life;  very  rarely  it 
is  congenital.  It  is  very  much  more  common  in  women  than  in  men — in 
()3  of  80  cases  noted  by  Duckworth,  while  in  4,7i)l  auto])sies  at  Guy's  IIos- 
])ital  during  ten  years  there  were  li)6  cases,  of  which  107  were  females  and 
89  males  (Samways).  This  is  not  easy  to  ex])lain,  but  there  are  at  least  two 
factors  to  be  considered.  l?heumatism  ])revails  more  in  girls  than  in  boys 
and,  as  is  Avell  known,  endocarditis  of  tlie  nutral  valve  is  more  common 
in  rheumatism.  Chorea,  also,  as  suggested  by  Barlow,  has  an  important 
influence,  occurring  more  freiiuently  in  girls  and  being  often  associated 
with  endocarditis.  Of  140  cases  of  c^  ea  which  I  examined  at  a  period 
more  than  two  years  subsequent  to  ttack,  73  had  signs  of  organic 

heart-disease,  among  wliich  were  34  i.. stances  with  the  physical  signs  of 
mitral  stenosis.    Anannia  and  chlorcsis,  which  are  prevalent  in  girls,  have 


722 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


/ 


boon  regarded  as  possible  factors.  In  a  sur])risiiig  iiuinber  oi"  cases  no  recog- 
nizable etiological  factor  can  be  discovered.  This  has  been  regarded  by 
some  writers  as  favoring  the  view  that  many  cases  are  of  congenital  origin; 
but  it  is  not  imijrobable  that  with  any  of  the  febrile  aU'ections  of  childhood 
endocarditis  may  l)e  associated.  AVhooping-cougli,  too,  with  its  terrible 
strain  on  the  lieart-valves,  may  be  accountable  for  certain  cases.  Con- 
genital ad'ections  of  the  mitral  valve  are  notoriously  rare.  While  met  Mith 
at  all  ages,  stenosis  is  certainly  more  fre(|uent  in  young  j)ersons. 

Morbid  Anatomy.  —  in  a  majority  of  instances  with  the  stenosis 
there  is  some  incompetency;  indeed,  Jialfour  maintains  that  we  never  find 
mitral  stenosis  without  some  degree  of  reguigitation.  The  narrowing  re- 
sult.- from  thickening  and  contraction  of  the  tissues  of  the  ring,  of  the  valve 
segments,  and  of  the  chordiu  tendine:e.  The  condition  varies  a  good  deal 
according  to  the  amount  of  atheromatous  change.  In  many  cases  the  cur- 
tains are  so  welded  together  and  the  whole  valvidar  region  so  thickened  that 
the  oriiice  is  reduced  to  a  mere  chink — (.'orrigan's  button-hole  contraction. 
h\  other  cases  the  curtains  are  not  much  thickened,  but  narrowing  has 
resulted  from  gradual  adhesion  at  the  edges,  and  thickening  of  the  chordae 
temline.T,  so  that  from  the  auricle  it  looks  cone-like — the  so-called  funnel- 
sha])i'd  variety  of  stenosis.  The  instances  in  which  the  valve  segments  are 
very  slightly  deformed,  but  in  which  the  orifice  is  considerably  narrowed, 
are  regarded  by  some  as  ])ossilj]y  of  congenital  origin.  Occasionally  the 
curtains  are  in  great  ])art  free  from  disease,  but  the  narrowing  results  from 
large  calcareous  masses,  which  })rojcct  into  them  from  the  ring.  Tlie  in- 
volvement of  the  chorda>  tendincie  is  usually  extreme,  and  the  pai)illary 
muscles  may  l)e  inserted  directly  upon  the  valve.  In  moderate  grades  of 
constriction  the  orifice  will  admit  the  tip  of  the  index-finger;  in  more 
•extreme  forms,  the  ti])  of  the  little  finger;  and  occasionally  one  meets  with 
a  specimen  in  which  the  orifice  seems  almost  obliterated,  as  in  a  case  which 
came  under  my  notice,  which  only  admitted  a  medium-sized  Bowman's 
probe. 

The  hetfrt  in  mitral  stenosis  is  not  greatly  enlarged,  rarely  weighing 
more  than  14  or  15  ounces.  Occasionally,  in  an  elderly  j^orson,  it  may 
seem  only  slightly,  if  at  all,  enlaiged,  and  again  there  are  instances  in  which 
the  weight  may  reach  as  much  as  '^0  ounces.  The  left  ventricle  is  usually 
small,  and  may  look  very  small  in  comparison  with  the  right  ventricle, 
which  forms  the  greater  portion  of  the  apex,  in  cases  in  which  with  the 
narrowing  there  is  very  considerable  incomi)etency  the  left  ventricle  may 
Ijc  moderately  dilated  and  hypertro])hied. 

These  changes  gradually  induced  are  associated  with  scc^ondary  altera- 
tions of  great  importance  in  the  heart.  The  left  auricle  discharges  its  blood 
Avith  greater  diflficulty  and  in  conse(pience  dilates,  and  its  walls  reach  three 
or  four  times  their  normal  thickness.  Although  the  auricle  is  by  structure 
unfitted  to  compensate  an  extreme  lesion,  the  ])robability  is  that  for  some 
time  during  the  gradual  production  of  stenosis,  the  increasing  muscular 
])o\\o"  of  the  walls  is  sufTicient  to  counterbalance  the  defect.  Samways 
found  in  3(1  cases  of  well-marked  stenosis  the  auricle  hypertrophied  in  2t), 
dilatation  coexisting  in  1-1.    P'ventually  the  tension  is  increased  in  the  pul- 


no  rccog- 
iirdcd  by 
il  origin; 
•hildhood 
3  terriblo 
IS.  Con- 
nict  with 

i  stenosis 
levor  find 
:)\ving  re- 
thc  valve 
i^ood  deal 
5  tlie  cur- 
enod  that 
ntraction. 
iwing  lias 
ic  elioi'diu 
d  i'unnc'I- 
iiicnts  are 
narrowed, 
inally  the 
suits  from 

The  in- 
pai)illary 
grades  of 

in  more 
leets  witli 
ise  whicli 
jowman'ri 

weighing 
1,  it  may 
in  which 
is  usually 
:eiitricle, 
with  tlic 
■icle  may 

V  altera- 
ts  blood 
eh  three 
structure 
for  some 
muscular 
Samways 
d  in  2(). 
the  pul- 


CIIROXIC   VALVULAR  DISEASE. 


723 


monary'  circulation,  owing  to  impeded  outflow  from  the  veins.  To  over- 
<'Oine  this  tlie  right  ventricle  undergoes  dilatation  and  liy])ertroi)hy,  and 
upon  this  chandler  falls  the  work  of  I'qualizing  the  circulation.  Kelative 
inconij)etency  of  the  tricuspid  and  congestion  of  the  systemic  veins  at  last 
siiiiervene. 

It  is  not  uncommon  at  the  examination  to  find  white  thrombi  in  tlio 
.ip|)endix  of  the  left  auricle.  Occasionally  a  large  part  of  the  auricle  is 
(Kciipied  by  an  ante-mortem  thrombus.  Still  more  rarely  the  remarkable 
liall  thrombus  is  found,  in  which  a  globular  concretion,  varying  in  size  from 
,1  walnut  to  a  small  egg,  lies  free  in  the  auricle,  two  examples  of  which  have 
come  under  my  ol)servation. 

Symptoms. — Physical  Signs. — Inspect  inn. — In  children  the  lower 
sternum  and  the  fifth  and  sixth  left  costal  cartilages  are  often  prominent, 
owing  to  hypei-troi)hy  of  the  right  ventricle.  The  apex  beat  may  be  ill- 
defined.  I'sually,  it  is  not  dislocated  far  beyond  the  nipple  line,  and  the 
chief  impulse  is  over  the  lower  sternum  and  adjacent  costal  cartilages. 
Often  in  thin-chested  persons  there  is  ])vdsation  in  the  third  and  fourth 
left  interspaces  close  to  the  sternum.  When  compensation  fails,  the  pra3- 
cordial  impulse  is  much  feebler,  and  in  the  veins  of  the  neck  there  may  be 
marked  systolic  regurgitation. 

Palpal'wn  reveals  in  a  majority  of  the  cases  a  characteristic,  well-defined' 
fremitus  or  tlirill,  which  is  best  felt,  as  a  rule,  in  the  fourth  or  fifth  inter- 
space within  the  nipple  line.  It  is  of  a  rough,  grating  quality,  often  pecul- 
iarly limited  in  area,  most  marked  during  expiration,  and  can  be  felt  to 
terminate  in  a  sharj),  sudden  shock,  synchronous  with  the  impulse.  This 
most  characteristic  of  physical  signs  is  pathognomonic  of  narrowing  of  the 
mitral  orifice,  and  is  perhaps  the  only  instance  in  which  the  diagnosis  of 
a  valvular  lesion  can  be  made  by  |)al])ation  alone.  Tlie  cardiac  ini])ulse  is 
felt  most  forcibly  in  the  lower  sternum  and  in  the  fourth  and  fifth  left  in- 
terspaces. The  impulse  is  felt  very  high  in  the  third  and  fourth  inters])aces, 
or  in  rare  cases  even  in  the  second,  and  it  has  been  thought  that  in  the 
latter  interspace  the  impulse  is  due  to  ]nilsation  of  the  auricle.  It  is  always 
the  impulse  of  the  conus  arteriosus  of  the  right  ventricle;  even  in  the  most 
extreme  grades  of  mitral  stenosis,  there  is  never  such  tilting  forward  of  the 
auricle  or  its  appendix  as  would  enable  it  to  produce  an  impression  on  the 
chest  wall. 

Pcrcussinn  gives  an  increase  in  the  cardiac  dulness  to  the  right  of  the 
sternum  and  along  the  left  margin;  not  usually  a  groat  increase  beyond 
the  nipple  line,  except  in  extreme  cases,  wdien  the  transverse  dulness  may 
reach  from  5  cm.  beyond  the  right  margin  of  the  sternum  to  10  cm.  beyond 
the  nipple  line. 

Avsciilfation. — In  the  mitral  area,  usually  to  the  inner  side  of  the  apex 
beat  and  often  in  a  very  limited  region,  is  heard  a  rough,  vibratory  or  purr- 
ing murmur,  which  terminates  abruptly  in  the  first  sound.  By  combining 
palpation  and  auscultation  the  purring  murmur  is  found  to  be  synchro- 
nous with  the  thrill  and  the  loud  shock  with  the  first  sound.  This  is  the 
j)resystolic  murmur,  about  the  time  and  mode  of  production  of  which  so 
much  discussion  has  occurred.    I  hold  with  those  who  regard  it  as  occur- 


r24 


DISK  ASKS  OK   TIIK   CIUCULATOUY   SYSTEM. 


■/ 


ling  (lining, the  auricular  systole.  In  whatever  way  pruducecl,  it  remains 
one  of  tiie  most  distinctive  and  characteristic  ol"  murmurs  and  its  presence 
is  positively  indicative  of  narrowing  of  the  mitral  orifice.  The  sole  excep- 
tion to  this  statement  is  tlie  Flint  murmur  already  referred  to  in  aortic 
incompetency.  Once,  in  a  case  of  enormous  enlargement  of  the  spleen, 
with  dropsy,  in  wliich  the  heart  was  greatly  jjushed  up,  I  heard  a  presystolic 
murmur  of  rough  (piality,  and  the  mitral  valves  were  found  post  mortem 
to  be  normal.  Tlie  i)resystolie  nnirmur  may  occupy  the  entire  period  of  the 
diastole,  or  tlje  middle  or  oidy  the  latter  half,  corresponding  to  the  auricu- 
lar systole.  The  difference  may  sometimes  be  noted  between  the  first  and 
second  portions  of  the  nnirmur,  when  it  occu])ies  the  ent'rc  time.  Often 
there  is  a  ])eculiar  rumbling  or  echoing  quality,  which  in  some  instances 
is  very  limited  and  may  be  heard  only  over  a  single  bell-space  of  the  stetho- 
sco])e.  A  systolic  murmur  mav  be  heard  at  the  apex  or  along  the  left  sternal 
border,  often  of  extreme  softness  and  audible  only  when  the  breath  is  held. 
Sometimes  the  systolic  murmur  is  loud  and  distinct  and  is  transmitted  to 
the  axilla.  The  second  sound  in  the  second  left  interspace  is  loudly  accentu- 
ated, sometimes  reduplicated.  It  may  be  transmitted  far  to  the  left  and 
be  heard  with  great  clearness  beyond  the  apex.  In  uneom])licated  cases 
of  mitral  stenosis  there  are  usually  no  murmurs  audible  at  the  aortic  region, 
at  which  spot  the  second  sound  is  less  intense  than  at  tlie  pulmonary  area. 
In  the  lower  sternum  and  to  the  right  a  tricus])id  murmur  is  sometimes 
heard  in  advanced  cases.  Other  points  to  be  noted  are  the  following:  The 
unusually  sharp,  clear  first  sound  which  follows  the  presystolic  murmur, 
the  cause  of  which  is  by  no  means  easy  to  explain.  It  can  scarcely  be  a 
valvular  sound  produced  chiefly  at  the  mitral  orifice,  since  it  may  be  heard 
with  great  intensity  in  cases  in  which  the  valves  are  rigid  and  calcified. 
It  has  been  suggested  by  A.  E.  Sansom  and  others  that  it  is  a  loud 
"  snap  "  of  the  tricuspid  valves  caused  by  the  powerful  contraction  of  the 
greatly  hypertro])hied  right  ventricle.  Broadbent's  explanation  is  as  fol- 
lows: "  Owing  to  the  narrowing  of  the  mitral  orifice  there  is  not  time  in 
the  diastolic  interval  for  a  sufficient  amount  of  blood  to  flow  into  the  left 
ventricle  to  com])letely  fill  it.  At  the  commencement  of  systole,  therefore, 
the  ventricular  cavity  is  not  fully  distended  with  blood,  so  that  the  mus- 
cular walls  at  the  first  moment  of  their  contraction  meet  with  no  resist- 
ance; then  closing  down  rapidly,  they  are  suddenly  l)rought  up  and  made 
tense  as  they  encounter  the  contained  blood.  This  sudden  tension  and 
abbreviated  systole  may  thus  account  for  the  short  first  sound."  The 
valvular  sound  may  he  audible  at  a  distance,  as  one  sits  at  the  bedside  of 
the  jiatient  ((Jraves). 

These  ]ihysical  signs,  it  is  to  be  l)orne  in  mind,  are  characteristic  only 
of  the  stage  in  which  compensation  is  maintained.  Finally  there  comes  a 
period  in  which,  with  rupture  of  compensation,  the  ])resystolic  murmur 
disa])])cars  and  there  is  heard  in  the  a]icx  region  a  sharp  first  sovmd,  or 
sometimes  a  gallo])  rhythm.  The  marked  systolic  shock  may  be  present 
after  the  disappearance  of  the  thrill  and  the  characteristic  murmur.  Under 
treatment,  with  gradual  recovery  of  compensation,  probably  with  increas- 
ing vigor  of  contraction  of  the  right  ventricle  and  left  auricle,  the  pre- 


CHRONIC   VALVULAR  DISEASE. 


725 


it  remains 
s  prc'rit'iico 
olo  excep- 
iu  aortic 
lie  spleen, 
[)resyst()lio 
it  mortem 
iod  of  the 
lie  aiiricii- 
!  iirst  ami 
ic.     Often 
instances 
lie  stetho- 
L^ft  sternal 
:li  is  held, 
•niitted  to 
y  aceentu- 
}  left  and 
ited  cases 
:ic  region, 
nary  area, 
sometimes 
-ing:  The 
murmnr, 
cely  be  a 
be  heard 
calcified. 
s  a  loud 
m  of  the 
is  as  fol- 
time  in 
the  left 
lerefore, 
he  mus- 
10  resist- 
nd  made 
ion  and 
•'     The 
xlsidc  of 

stic  only 
comes  a 

murmur 

Dund,  or 

])resent 

Under 

increas- 

the  pre- 


-ystnlic  murmur  rca]i])ears.     In  cases  seen  at  this  stage  of  the  disease  the 
nature  of  the  valve  lesion  may  l)e  entirely  overlooked. 

Stenosis  of  the  mitral  valve  may  for  years  be  elTlciontly  compensated 
liy  the  hyi)ertrophy  of  the  right  ventricle.  ]\Iany  persons  with  the  char- 
acteristic i)hysical  signs  of  this  lesion  jtresent  no  symptoms.  They  may 
lor  years  i)erliai)s  be  short  of  breath  on  going  u])stairs,  but  are  able  to  i)asd 
through  the  ordinary  duties  of  life  without  discomfort.  The  i)ulse  is 
.-mailer  in  volume  than  normal,  but  may  be  perfectly  regular.  A  special 
(laiiger  of  this  stage  is  the  recurring  endocarditis.  Vegetations  may  be 
\\hipi)ed  olf  into  the  circulation  and,  blocking  a  cerebral  vessel,  may  cause. 
heniii)legia  or  ai)hasia,  or  both.  This,  unfortunately,  is  not  an  uncommon 
sequence  in  women.  Patients  with  mitral  stenosis  may  survive  this  acci- 
dent for  an  indefinite  period.  A  woman,  above  seventy  years  of  age,  died 
in  one  of  my  wards  at  the  Philadeljdua  Hospital,  who  had  been  in  the 
almshouse,  hemi})legic,  for  more  than  thirty  years.  The  heart  presented 
■in  extreme  grade  of  mitral  stenosis  which  had  probably  existed  at  the  time 
of  the  hemiplegic  attack. 

Pressure  of  the  enlarged  auricle  on  the  left  recurrent  laryngeal  nerve, 
causing  paralysis  of  the  vocal  cord  on  the  corresponding  side,  has  been 
described  by  Ortner  and  by  Ilerrick.  I  have  met  with  two  instances.  It 
is  a  point  to  be  borne  in  mind,  as  the  diagnosis  of  aneurism  of  the  arch  of 
the  aorta  may  be  made. 

Failure  of  comjiensation  brings  in  its  train  the  group  of  symptoms 
which  have  l)een  discussed  under  mitral  insufficiency.  Briefly  enumerated 
they  are:  Rapid  and  irregular  action  of  the  heart,,  shortness  of  breath, 
cough,  signs  of  pulmonary  engorgement,  and  very  frecjuently  ha}moptysis. 
Attacks  of  this  kind  may  recur  for  years.  Bronchitis  or  a  febrile  attack 
may  cause  shortness  of  breath  or  slight  blueness.  Inflammatory  affections 
iif  the  lungs  or  pleura  seriously  disturb  the  right  heart,  and  these  patients 
stand  pneumonia  very  badly.  ^lan}',  perha})S  a  majority  of  cases  of  mitral 
stenosis,  do  not  have  dropsy.  The  liver  may  be  greatly  enlarged,  and  in 
the  late  stages  ascites  is  not  uncommon,  particularly  in  children.  General 
anasarca  is  most  frequently  mot  with  in  those  cases  in  which  there  is  sec- 
ondary narrowing  of  the  tricuspid  orifice  (Broadbent). 

G.  TRicusriD  Valve  Disease. 

(a)  Tricuspid  Re,2;urgitatioil. — Occasionally  this  results  from  acute  or 
chronic  endocarditis  with  puckering;  more  commonly  the  condition  is  one 
(if  relative  insufficiency,  and  is  secondary  to  lesions  of  the  valves  on  the  left 
>ide,  particularly  of  the  mitral.  It  is  mot  with  also  in  all  conditions  of  the 
lungs  which  cause  obstruction  to  the  circulation,  such  as  cirrhosis  and 
emphysema,  particularly  in  combination  with  chronic  bronchitis.  The 
symptoms  are  those  of  obstruction  in  the  lesser  circulation  with  venous 
congestion  in  the  systemic  veins,  such  as  has  already  been  described  in  con- 
nection with  mitral  insufficiency.     The  signs  of  this  condition  arc: 

(1)  Systolic  regurgitation  of  the  blood  into  the  right  auricle  and  the,' 
transmission  of  the  pulse-wave  into  the  veins  of  the  neck.    If  the  regurgi-' 


72G 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


/ 


tation  is  sli<flit  or  tlio  contraction  of  the  ventricle  is  feeble  there  may  bo 
no  vi'iioiis  tlirol)l)iii^-,  but  in  other  canes  tiiere  is  nmrked  .systolic  pulsation 
in  the  cervical  veins.  That  in  the  rijiht  juj^nilar  is  more  forcible  than  that 
in  tlic  left.  It  may  be  secu  l)oth  in  tiie  iuterual  and  the  external  vein, 
])aiticularly  in  the  latter.  Marked  ])ulsati()n  in  llie.se  veins  occurs  only 
when  the  valves  guarding'  tlicni  become  incomj)etent.  Sli^dit  oscillations 
are  by  no  means  uncommon,  even  when  the  valves  are  intact.  The  dis- 
tention is  sonu'tinu's  enormous,  particularly  in  the  net  of  couj^-hin^,  when 
the  ri<;ht  jugular  at  the  root  of  the  neck  may  stand  out,  forming; 
•an  I'xlraordinary  prominent  ovoid  mass.  Occasionally  the  regurgitant 
])ulse-\vave  nuiy  be  widely  transmitted  and  be  seen  in  the  subclavian  and 
axillary  veins,  ami  even  in  the  subcutaneous  veins  over  the  shoulder, 
or,  as  in  a  case  recently  under  observation,  in  the  superficial  mammary 
veins. 

l{egurgitant  ])nlsation  through  the  tricusi)id  orifice  may  be  transmitted 
to  the  inferior  cava,  and  so  to  the  hepatic  veins,  causing  a  systolic  disten- 
tion of  the  liver.  This  is  best  a|)preciated  by  bimaniuil  palpation,  ])lacing 
one  hand  over  the  fifth  and  sixth  costal  cartilages  and  tlie  other  in  the 
lateral  region  of  the  liver  in  the  mid-axillary  line.  The  rhythnucal  ex- 
])ansile  ]iulsation  may  be  readily  distinguished,  as  a  rule,  from  the  systolic 
depression  of  the  liver  due  to  communicated  ])ulsation  from  the  left  ven- 
tricle. 

y  (2)  The  second  important  sign  of  tricuspid  regurgitation  is  the  occur- 
rence of  a  systolic  murmur  of  maximum  intensity  in  the  lower  sternum. 
It  is  usually  a  soft,  low  murmur,  often  to  be  distinguished  from  a  coexist- 
ing mitral  murmur  l)y  ditfcrences  in  (piality  and  pitch,  and  may  he  heard 
to  the  right  as  far  as  the  axilla.  Sometimes  it  is  very  limited  in  its  distri- 
bution. 

j  Together  these  two  signs  ])ositively  indicate  tricuspid  regurgitation. 
'In  addition,  the  percussion  usually  shows  increase  in  the  area  of  dulness 
to  the  right  of  the  sternum,  and  the  imjnilse  in  the  lower  sternal  region  is 
forcible.  Jn  the  great  majority  of  cases  the  symptoms  are  those  of  the 
associated  lesions.  In  cirrho.sis  of  the  lung  and  in  chronic  emphysema  the 
failure  of  compensation  of  the  right  ventricle  with  insufficiency  of  the  tri- 
cuspid not  infrequently  leads  either  to  acute  asystole  or  to  gradual  failure 
with  cardiac  dropsy. 

{!))  Tricuspid  Stenosis. — This  interesting  condition  may  he  either  con- 
genital or  ac(iuired.  The  congenital  cases  are  not  uncommon,  and  are 
associated  usually  Avith  other  valvular  defects  which  cause  early  death.  The 
acquired  form  is  not  very  infrequent.  Bedford  Fenwick  collected  46  ob- 
servations, of  which  41  were  in  women.  Leudet  *  has  analyzed.  117  cases. 
Of  101  of  these  in  which  the  ages  were  mentioned,  80  were  in  women  and 
21  in  men.  A  great  majority  of  the  cases  were  in  adults,  only  8  being 
between  the  ages  of  ten  and  twenty.  Its  rarity  as  an  isolated  condition 
may  be  gathered  from  the  fact  that  of  114  autopsies,  in  11  only  was  the 
lesion  confined  to  this  valve.     In  21  the  tricuspid,  mitral,  and  aortic  seg- 


*  Paris  Thesis,  1888. 


e  may  bo 

luilsulioii 
than  tliiit 

'Hill    Vl'ill, 

I'Urs  only 

'(Mllalions 

The  dis- 

n<f,  whi'ii 

yiirgitant 
ivian  and 
sliouhler, 
:nainniary 

msmittc'd 
ie  distcn- 
i,  placing 
er  in  the 
niical  cx- 
e  systolic 
left  vcn- 

he  occur- 
stornum. 
1  coexist- 
be  hoard 
its  distri- 

rgitation. 
1'  dulncss 
region  is 
ie  of  the 
sema  the 
[  the  tri- 
d  failure 

licr  con- 
and  are 

th.    The 

1  4G  ob- 

17  cases. 

men  and 
8  being 

ondition 
was  the 

rtic  seg- 


CllltONIC   VALVULAR   DISEASE. 


727 


nients  were  involved,  and  in  18  the  tricuspid  and  mitral,     rructieally  tho 
condition  is  almost  always  secondary  to  h'sions  of  the  left  heart. 

Tlio  piiysical  signs  are  sometimes  characteristic.  J'"or  instance,  a  pre- 
systolic tiirill  has  been  noted  by  several  observers.  'I'lie  percussion  shows 
(liihiess  to  be  increased,  particularly  to  the  right  of  tlie  sternum.  On  aus- 
cidtation  a  jiresystolic  murmur  has  been  deteiiiiined  in  certain  cases,  and 
is  jieard  best  at  the  root  of  tlie  ensiform  cartilage,  or  a  little  to  the  right 
of  it.  Of  general  symptoms,  cyanosis  of  the  face  and  lips  is  very  common, 
and  in  the  late  stages,  when  dropsy  suijcrvenes,  it  is  apt  to  be  intense.  Tho 
lesion  is  interesting  chielly  because  it  forms  one  of  the  most  serious  com- 
jiiicatious  of  mitral  stenosis. 

7.  I'li-monahy  Valvk  Dihkase. 

Murmurs  in  the  region  of  the  pulmonary  valves  are  extremely  common; 
lesions  of  tlie  valves  are  exceedingly  rare.  IJalfour  has  well  called  the  pul- 
monic area  the  region  of  romance.  A  systolic  murmur  is  heard  here  under 
many  conditions — (1)  very  often  in  health,  in  thin-chested  persons,  par- 
ticularly in  children,  during  ex|)iration  aiul  in  the  recumbent  posture;  {'I) 
when  the  heart  is  acting  ra[)id]y,  as  in  fever  and  after  exertion;  (3)  it  is  a 
favorite  situation  of  the  cardio-respiratory  murmur;  (4)  in  ana-mic  states; 
and  (5)  as  mentioned  previously,  the  systolic  murmur  of  mitral  insutliciency 
may  be  transmitted  along  the  left  sternal  margin.  xVctual  lesions  of  the 
valves  of  the  ])ulmonary  artery  are  rare. 

{a)  Stenosis  is  almost  invariably  a  congenital  anomaly.  It  constitutes 
one  of  the  most  important  of  the  congenital  cardiac  affections.  The  valve 
segments  are  usually  united,  leaving  a  small,  narrow  orifice.  In  the  adult 
oases  occasionally  occur.  In  Case  008  of  my  post-nu)rtem  records  there 
was  extreme  stenosis  in  a  girl  of  eighteen,  owing  to  great  thickening  and 
adhesion  of  the  segments,  and  there  were  also  numerous  vegetations.  The 
orifice  was  only  2  mm.  in  diameter.  The  congenital  lesion  is  commonly  asso- 
ciated with  ])atency  of  the  ductus  Botalii  and  imperfection  of  the  ventricu- 
lar septum.    There  may  also  be  tricuspid  stenosis. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systolic 
murmur  with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second 
intercostal  space.  This  murmur  may  be  very  like  a  murmur  of  aortic 
stenosis,  but  is  not  transmitted  into  the  vessels.  Xaturally  tlio  ])ulmonary 
second  sound  is  weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  mur- 
mur.   Usually  there  is  hypertrophy  of  the  right  heart. 

(b)  Pulmonary  Insufjicicncy. — This  rare  affection  is  occasionally  due  to 
congenital  malformation,  particularly  fusion  of  two  of  the  segments.  It  is 
sometimes  present,  as  Bramwell  has  shown,  in  cases  of  malignant  endocar- 
ditis.   Barie  has  collected  58  cases. 

The  physical  signs  are  those  of  regurgitation  into  the  right  ventricle, 
but,  as  a  rule,  it  is  difficult  to  differentiate  the  murmur  from  that  of  aortic 
insufficiency,  though  the  maximum  intensity  may  be  in  the  pulmonary 
area.  The  absence  of  the  vascular  features  of  aortic  insulTiciency  is  sug- 
gestive.   Both  Gibson  and  Graham  Stcell  have  called  attention  to  the  pos- 


728 


DISKASKS  OF  THE  CIRCULATORY  SYSTEM. 


i^ihility  of  Icakii^'o  tllI•()llJ^'ll  tlicsc  vuIvoh  in  cuhcs  of  grt-at  incM'cnso  of  proseuro 
ill  the  i)iiliiiomiry  nrtory,  and  lo  a  soft  diastolic  nuinmir  heard  under  these 
(■irciiiiislMnces,  wliich  Stccll  culls  "  tli(>  niiirmur  of  Iii«j;li  pressure  in  tin; 
])ulnionary  artery." 


/ 


8.  CoMnixKD  Valvular  Lksioxs. 

These  are  extremely  common.  The  mitral  and  aortic  pe<iments  may  he 
affected  to<i;etlier;  next  in  fre([iiency  comes  tiie  comhinatiou  of  mitral  and 
tricuspid  lesions;  and  then  of  aortic,  mitral,  and  tricuspid.  Aortic  insuf- 
ficiency or  aortic  stenosis  is  more  fre(piently  eomhined  with  mitral  incom- 
]ietency  than  aortic  stenosis  with  mitral  stenosis,  or  mitral  stenosis  with 
aortic  insiinieiency.  In  children  the  most  common  comhination  is  aortic 
and  mitral  insuiliciency.  In  adults,  mitral  insuiliciency  with  thickening 
of  the  aortic  valves  and  sli<;ht  narrowin^i;  is  perhaps  the  most  common. 

The  dia<?nosis  rests  uj)on  the  character  of  the  murmurs  and  the  state 
of  the  chamhers  as  repirds  hypertrophy  and  dilatation. 

Prognosis  in  Valvular  Disease. — The  cpiestion  is  entirely  one 
of  eilicient  coni])ensation.  So  long  as  this  is  maintained  the  patient  may 
suffer  no  inconvenience,  and  even  with  the  most  serious  forms  of  valve 
lesion  the  function  of  the  heart  may  he  little,  if  at  all,  disturhed. 

I'ractitioners  who  are  not  adepts  in  auscultation  and  feel  iinahle  to  esti- 
mate the  value  of  the  various  heart  murmurs  should  rememher  that  the 
best  judgment  of  the  conditions  may  be  gathered  from  inspection  and  pal- 
pation. With  an  apex  beat  in  the  normal  situation  and  regular  in  rhythm 
the  auscultatory  phenomena  may  be  ])ractically  disregarded. 

As  8ir  Andrew  Clark  states,  a  murmur  per  se  is  of  little  or  no  moment 
in  determining  the  prognosis  in  any  given  case.  There  is  a  large  grou]) 
of  patients  who  ])resent  no  other  symptoms  than  a  systolic  murmur  heard 
over  the  body  of  the  heart,  or  over  the  apex,  in  whom  the  left  ventricle  is 
not  hypertrophied,  the  heart  rhythm  is  normal,  and  who  may  not  have 
had  rheumatism.  Indeed^  the  condition  is  accidentally  discovered,  often 
during  examination  for  life  insurance.  I  know  cases  of  this  kind  which 
have  persisted  unchanged  for  more  than  fifteen  years.  Among  the  condi- 
tions intluencing  prognosis  arc: 

(a)  /if/6'. — Children  under  ten  are  bad  subjects.  Compensation  is  well 
effected,  and  they  are  free  from  many  of  the  influences  which  disturb  com- 
pensation in  adults.  The  coronary  arteries  are  healthy,  and  nutrition  of 
tlie  heart-muscle  can  be  readily  maintained.  Yet,  in  spite  of  this,  the  out- 
look in  cardiac  lesions  developing  in  very  young  children  is  usually  bad. 
One  reason  is  that  the  valve  lesion  itself  is  apt  to  be  rapidly  ])rogressive, 
and  the  limit  of  cardiac  reserve  force  is  in  such  cases  early  reached.  There 
seems  to  be  proportionately  a  greater  degree  of  hy]iertrophy  and  dilatation. 
Among  other  causes  of  the  risks  of  this  ]ieriod  are  to  be  mentioned  insuf- 
ficient food  in  the  poorer  classes,  the  recurrence  of  rheumatic  attacks,  and 
the  existence  of  pericardial  adhesions.  The  outlook  in  a  child  who  can  be 
carefully  supervised  and  prevented  from  damaging  himself  by  overexertion 
is  naturally  better  than  in  one  who  is  constantly  overtasking  his  muscles. 


CIIIIONIC   VALVULAR  DISKASE. 


i29 


f  prossiiro 
ulcr  thfsc 
re  in  tlio 


ts  mny  Itc 
iiitral  and 
•tic  insuf- 
•al  iiicoiii- 
losis  with 
I  is  aortic 
liickeninjj; 
lion, 
tlie  state 

tirely  one 
tiont  may 
i  oi'  valve 

)le  to  esti- 
■  tliat  tlu! 
1  and  pal- 
n  rliytlim 

moment 
fjo  grou]) 
ur  lieard 
ntricle  is 
not  liavo 
od,  often 
id  whicli 
le  eondi- 

n  is  well 
url)  coni- 
rition  of 
the  onf- 
all y  bad. 
i,<i'ressive, 
.'    Tliere 
latation. 
■d  insnf- 
eks,  and 
o  can  l)e 
■exertion 
muscles. 


The  vnlvnlar  lesions  which  devcIo|i  at,  or  suhscijiicnt  to,  the  period  of 
piihcrty  arc  more  likely  to  l)e  permanently  and  cllicicnlly  com|»ensated. 
Su(hlen  death  from  heart-disease  is  very  rare  in  children. 

{{))  ^V'.r. — Women  hear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fact  that  they  live  (piieter  lives,  partly  to  the  less  eoninion 
involvement  of  the  coronary  artei'ics,  and  to  the  ^q-eater  fretpiency  of  mitral 
lesions.  Pregnancy  and  parturition  are  disturbing  factors,  but  are,  1  think, 
less  serious  than  some  writers  would  have  us  believe. 

{(')  Valve  ajjevlcd. — The  relative  i)rognosis  of  the  dilTereiit  valve  lesions 
is  very  dilUcult  to  estimate.  Kach  case  must,  therefore,  be  judged  on  its 
own  merits.  Aortic  iiisulliciency  is  nn(|uestionably  the  nu>st  serious;  yet 
for  years  it  may  be  perfectly  com[)ensated.  Favorable  circumstances  in 
any  case  arc  the  moderate  grade  of  hypertrophy  and  dilatation,  the  absence 
f)f  all  symptoms  of  cardiac  distress,  and  the  absence  of  extensive  arterio- 
sclerosis and  of  angina.  The  ])rogn()sis  rests  in  reality  with  the  condition 
of  the  coronary  arteries.  Rheumatic  lesions  of  the  valves,  inducing  insuf- 
liciency,  are  less  apt  to  bo  associated  with  endarteritis  at  the  root  of  the 
aorta;  and  in  such  cases  the  coronary  arteries  may  escape  for  years.  I 
know  a  ])hysician,  now  about  forty-three  years  of  age,  who,  when  sixteen, 
had  his  iirst  attack  of  rheumatism,  which  involved  the  aortic  segments. 
lie  has  had  two  subsequent  attacks  of  rheumatism,  but  with  care  has  been 
able  to  live  a  comfortable  and  fairly  active  life.  On  the  other  hand,  when 
the  aortic  insnlhciency  is  only  a  part  of  an  extensive  arterio-sclerosis  at  the 
root  of  the  aorta,  the  coronary  arteries  are  almost  invariably  involved,  and 
the  outlook  in  such  cases  is  much  more  serious.  Sudden  death  is  not  un- 
common, either  from  acute  dilatation  during  some  exortion,  or,  more  fre- 
(piently,  from  blocking  of  one  of  the  branches  of  the  coronary  arteries. 
The  liability  of  this  form  to  be  associated  with  angina  ])ectoris  also  adds 
to  its  severity.  Aortic  stenosis  is  a  comparatively  rare  lesion,  most  com- 
monly met  with  in  middle-aged  or  elderly  men,  and  is,  as  a  rule,  well  com- 
pensated. In  Tlroadbent's  series  of  cases,  in  which  autopsy  showed  definite 
aortic  narrowing,  forty  years  was  the  average  age  at  death,  and  the  oldest 
was  Init  fifty-three. 

In  mitral  Icsicms  the  outlook  on  the  whole  is  much  more  favorable  than 
in  aortic  insufficiency.  ]\[itral  insuificiency,  when  well  compensated,  car- 
ries with  it  a  better  prognosis  than  mitral  stenosis.  Practically  it  is  the  only 
valvular  disease  we  meet  M'ith  in  patients  o^'er  threescore  years.  It  must 
he  borne  in  mind  that  the  cases  which  last  the  longest  are  those  in  which 
the  valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent.  There 
is,  in  reality,  no  valve  lesion  so  poorly  comi)ensated  and  so  rapiiily  fatal 
as  that  in  which  the  mitral  segments  are  gradually  curled  ami  puc^iered 
until  they  form  a  narrow  strip  around  a  wide  mitral  ring — a  condition  spe- 
cially seen  in  children.  There  are  many  cases  of  mitral  insufficiency  in 
which  the  defect  is  thoroughly  balanced  for  thirty  or  even  forty  years, 
without  distress  or  inconvenience.  Even  with  great  hy])ertrophy  and  the 
apex  beat  almost  in  the  mid-axillary  line,  there  may  be  little  or  no  distress, 
and  the  compensation  may  be  most  effective.  "Women  may  pass  safely 
through  repeated  pregnancies,  though  here  they  are  liable  to  accidents  asso- 


T30 


DISKASKS  OF  TIIK  CIIlCULATOllY  SYSTKM. 


/ 


(■iati'(l  with  the  severe  stniin.  I  luive  lunl  iimli  r  my  cnn'  I'nr  ni....y  ycarH 
a  patient  wlio  li.  I  lur  first  attack  <•!'  rheuinatism  at  the  a;^''  <>t'  llt'tt'eii,  wht'n 
hhe  already  had  a  weil-niarked  mitral  mnniuir.  She  first  eamo  uiuUir  my 
ohservalioii,  tuenty-rmii'  years  aj^o,  with  si;,MiM  of  hypertrnpliy  of  the  Irl'l 
veiitrich' and  a  iniid  systoUe  murmur.  She  juis  had  no  cardiac  disturlmnce 
wiuitever,  th()u;,di  she  has  lived  a  very  active  life,  has  heeii  unusually  vigor- 
ous, has  l)orne  I'leven  children,  and  has  passed  throu^^h  three  suhse<iuent  at- 
tacks of  rheumatism. 

Jn  mitral  stenosis  the  pro;,^ru»sis  is  usually  reirarded  as  less  favorahle. 
'My  own  experience  has  led  nu',  however,  to  place  this  lesion  almost  on  a 
level,  partii'ularly  in  women,  with  tlu!  nntral  insulllcicncy.  it  is  found 
very  often  in  persons  iu  perfect  health,  who  have  had  neither  palpitation 
nor  si^iiis  of  heart-failure,  ami  who  have  lived  lahorious  lives.  The  lijiurcs 
given,  too,  hy  jJroadhent  indicate  that  the  date;  of  death  in  mitral  stenosis 
in  comparatively  advanced.  Of  o.'J  cases  ahstracted  from  the  post-mortem 
records  of  St.  Mary's  Hospital,  tlurty-thrcc!  was  the  age  for  males,  and 
thirty-seven  or  thirty-eight  for  females.  These  women,  too,  pass  through 
repeated  |)regnancies  with  safety.  There  arc  of  course  those  too  common 
accidents,  the  ri'sult  of  cerehral  end)olism,  which  are  more  likely  to  occur 
in  this  than  in  other  forms. 

Hard  and  fast  lines  cannot  be  drawn  in  the  question  of  prognosis  in 
valvular  disease.  Kvery  case  must  he  judged  se])arately,  and  all  the  cir- 
cumstances carefully  balanced.  There  is  no  ([uestion  which  recpures  greatei' 
exjierience  and  more  mature  judgment,  and  even  the  most  experienced  are 
sometinu's  at  fault. 

The  following  l)ricf  summary  of  the  conditions  which  justify  a  favor- 
ahle prognosis  endxxlies  the  large  and  varied  clinical  experience  of  Sir 
Andrew  Clark;  Good  general  health;  just  habits  of  living;  no  exceptional 
liat)ility  to  rheumatic  or  catarrhal  all'ectious;  origin  of  the  valvular  lesion 
indei)endently  of  degeneration;  existence  of  the  valvular  lesion  without 
change  for  over  three  years;  sound  ventricles,  of  moderate  fre(picncy  and 
general  regularity  of  action;  sound  arteries,  with  a  normal  amount  of  bloud 
and  tension  in  the  smaller  vessels;  free  course  of  blood  through  the  cer- 
vical veins;  and,  lastly,  freedom  from  pulmonary,  hepatic,  aiul  renal  con- 
gestion. 

Treatment  of  Valvular  Lesions.— For  this  purpose  the  valvular 
lesion  may  be  divided  into  the  period  of  progressive  develo[)ment,  with  es- 
tablishment and  maintenance  of  hypertro])hy,  and  the  period  of  disturbed 
com]K>nsation. 

{cf)  Stage  of  Compensation. — :\redicinal  treatment  at  this  period  is  not 
necessary  and  is  often  hurtful.  A  very  common  error  is  to  administer 
cardiac  drugs,  such  as  digitalis,  on  the  discovery  of  a  murmur  or  of  hyper- 
tro])hy.  If  the  lesion  has  been  found  accidentally,  it  may  be  best  not  to 
tell  the  patient,  but  rather  an  intimate  friend.  Often  it  is  necessary,  bow- 
ever,  to  be  perfectly  frank  in  order  that  the  patient  may  take  certain  pre- 
ventive measures.  ITe  should  lead  a  quiet,  regidated,  orderly  life,  free  from 
excitement  and  worry,  and  the  risk  of  sudden  death  makes  it  imperative 
that  the  patient  suffering  from  aortic  disease  should  be  specially  warned 


CIIUONIC   VALVULAR   DISKASK. 


781 


■II,   wlll'H 

lultT  my 

till'    left 

turlmncc 
ly  vi^ior- 
|ucnf  !il- 

iivornl)lc'. 

lost  oil  il 
irt  found 
ilpitiitioti 

I  stenosis 

(-inorlciii 

iilcs,  iind 

tlir()ii};li 

common 

to  oi'cur 

l^nosirt  ill 
[  tlu'  fir- 
33  greater 
3nced  are 

a  I'avor- 

e  of  Sir 
eptioiiiil 

ar  lesion 
without 

:ncy  and 
of  blood 
the  eer- 

'iial  con- 
valvular 
with  es- 

listurhcd 

d  is  not 
minister 
f  hyper- 
\t  not  to 
ry,  how- 
ain  pro- 
:-ee  from 
perative 
warned 


iii,fainst  oven'vertion  nn<l  liiiiry.  An  ordinary  wholesome  diet  in  niodcralo 
i|iiMiitities  should  he  taken,  tohaeio  should  he  iiiterdieted,  and  slimulantti 
not  allowe(|.  Ivvereise  should  he  r(';,Milaled  entirely  by  tiie  feelin;;;s  of  the 
[latient.  So  long  as  no  canliae  distress  or  palpitation  follows,  moderate  cx- 
t  rcisi'  will  prove  very  henelieial.  The  skin  slmnld  he  kept  active  hy  a  daily 
liiitli.  Hot  haths  shoulil  he  avoided  and  the  Turkish  iiatli  should  h(^  inter- 
dicted, in  the  case  of  fnll-hlooded,  somewhat  corpulent  individuals,  iii\ 
(iccasiomil  saline  purge  should  he  taken.  Patients  with  valvular  lesions 
should  not  go  into  very  iiigli  altitudes.  The  act  of  coition  has  serious  risks, 
particularly  in  aortic  insullicieiicy.  Knowing  that  tin*  causes  which  most 
surely  and  powerfully  disturh  the  compensation  are  overexertion,  mental 
worry,  nnd  malnutrition,  the  physi(;ian  should  give  suitable  instructions  in 
each  case.  As  it  is  always  better  to  have  the  co-operation  of  an  intelligent 
patient,  he  should,  as  a  rule,  be  told  of  the  condition,  but  in  this  inatttir 
the  jiliysician  must  he  guided  by  cireumsta'ices,  iind  there  are  cases  in 
which  reticence  is  the  wiser  ])olicy. 

(/>)  Stage  of  Broken  Compensation.— The  hivak  may  be  immediate  and 
linal,  as  when  sudden  death  results  from  acute  dilatation  or  from  blocking 
of  a  branch  of  the  coronnry  artery,  or  it  may  be  gradual.  Among  the  first 
indications  are  shortness  of  hreath  on  exertion  or  attacks  of  noc:turnal  dysp- 
luea.  These  arc  often  associated  with  im])aired  nutrition,  ])artieularly 
with  amemia,  and  a  course  of  iron  or  chrnge  of  air  may  suilice  to  relieve  the 
.^yniploms. 

Irregularity  of  the  action  (tf  tlii'  heart  cannot  always  he  teriiu'd  an  in- 
dication of  failing  com[>ensation,  ])articiilarly  in  instances  of  mitral  disease. 
It  has  greater  significance  in  aortic  lesions.  Serious  failure  of  compensa- 
tion is  indicated  by  signs  tif  dilatation  of  the  heart,  marked  cyanosis,  the 
gallop  rhythm,  or  various  forms  of  arrhythmia,  witli  or  without  the  ex- 
istence of  dro|»sy.  L'lider  these  circumstances  the  following  measures  arc 
to  he  carried  out: 

(!)  J'rst. — Disturbed  compensation  may  be  completely  restored  by  rest 
of  the  body,  lioth  in  "Montreal  and  in  riiiladelphia  it  was  a  favorite  dem- 
onstration in  ])ractical  therapeutics  to  show  the  liem'gn  influence  of  com- 
plete rest  and  (piiet  on  the  cardiac  dilatation.  In  many  cases  with  tedema 
of  the  ankles,  moderate  dilatation  of  the  heart,  and  irregularity  of  the  pulse, 
the  rest  in  bed,  a  few  doses  of  the  compound  tincture  of  cardamoms,  aiul  a 
saline  ])urge  sufTice,  within  a  week  or  ten  days,  to  restore  the  compensation. 
One  patient,  in  Ward  11  of  the  ]\lontreal  General  Hospital,  with  aortic 
iiisutriciency  recovered  from  four  successive  attacks  of  failing  compensation 
with  these  measures  alone. 

i'i)  I'lie  relief  of  the  embarrassed  circulation. 

{(I)  Bij  VcncsccUoii. — In  cases  of  dilatation,  from  whatever  cause,  whether 
in  mitral  or  aortic  lesions  or  distention  of  the  right  ventricle  in  emphysema, 
when  signs  of  venous  engorgement  are  marked  and  when  there  is  orthopnooa 
with  cyanosis,  the  abstraction  of  from  20  to  30  ounces  of  blood  is  indi- 
cated. This  is  the  occasion  in  which  timely  venesection  may  saA'C  the 
])atient's  life.  It  is  a  condition  in  which  I  have  bad  most  satisfactory  re- 
sults from  blood-letting.    It  is  done  much  bettor  early  than  late.    I  have 


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23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


^"'^ 


6^ 


732 


DISEASES  OF  THE  CIRCULATORY  SYSTE.M. 


.  \ 
/ 


on  sovcr;il  occasions  rofrrottcd  its  postponement,  particularly  in  instances 
of  acute  dilatation  and  cyanosis  in  connection  with  emi)liyscnui.* 

(b)  By  Deplclion  ilirouijh  tltc  Jloircls. — Tliis  is  particularly  valuable  wlicu 
dropsy  is  ])resent.  Of  the  various  i)urges  the  salines  are  to  be  jjreferred. 
and  may  be  given  by  ^latthcw  J  lay's  method.  Half  an  hour  to  an  hour 
before  breakfast  from  half  an  ounce  to  an  ounce  and  a  half  of  Epsom  salts 
may  be  tiiven  in  a  concentrated  form.  This  usually  produces  from  three  to 
five  li(iuid  evacuations.  The  comi)ound  jalap  powder  in  half-drachm  doses, 
or  elaterium,  may  be  employed  for  the  same  pnrpose.  Even  when  the  pulse 
is  very  feeble  these  hydragogue  cathartics  are  well  borne,  and  they  dej)lete 
the  ])ortal  system  rapidly  and  cflicieiitly. 

(r)  The  Use  of  Itcmedirs  which  sliunilale  the  IlearCs  Action. — Of  these, 
by  far  the  most  important  is  digitalis,  which  was  introdnced  into  practice 
by  A\'ithering.  The  indication  for  its  use  is  dilatation;  the  contra-in  ^ica- 
tion  is  a  perfectly  balanced  compensatory  hy))ertr()phy,  such  as  we  see  in  all 
forms  of  valvular  disease.  IJroken  comj)ensation,  no  matter  what  the 
valve  lesion  may  be,  is  the  signal  for  its  use.  It  acts  upon  the  heart,  slow- 
ing and  at  the  same  time  increasing  the  force  of  the  contractions.  It  acts 
on  the  jieripheral  arteries,  raising  their  tension,  so  that  a  steady  and  equable 
ih)w  of  blood  is  maintained  in  tlic  cai)illaries.  wh!eu,  after  all,  is  tlie  prime 
aim  and  object  of  the  circulation.  The  beneticial  effects  are  best  seen  in 
cases  of  mitral  disease  with  small,  irregular  i)ulse  and  cardiac  dropsy.  Its 
effects  are  not  less  striking  in  the  dilatation  of  the  left  ventricle,  in  the 
failing  compensation  of  aortic  insulliciency  or  of  arterio-sclerosis.  On  theo- 
retical grounds  it  has  been  urged  that  its  use  is  not  so  advantageous  in 
aortic  insulTiciency,  since  it  prolongs  the  diastole  and  leads  to  greater  dis- 
tention. This  need  not  be  considered,  and  digitalis  is  just  as  serviceable 
in  this  as  in  any  other  condition  associated  with  ])rogressive  dilatation; 
larger  doses  are  often  required.  It  may  be  given  as  the  tincture  or  the  in- 
fusion. In  cases  of  cardiac  dro])sy,  from  whatever  cause,  15  minims  of  the 
tincture  or  half  an  ouiue  of  the  infusion  may  be  given  every  three  hours 
for  two  days,  after  which  the  dose  may  be  reduced.  8ome  prefer  the  tinc- 
ture, others  the  infusion;  it  is  a  matter  of  indifference  if  the  drug  is  good. 
The  urine  of  a  i)atient  taking  digitalis  slundd  be  carefully  estimated  each 
day.  As  a  rule,  when  its  action  is  beneficial,  there  is  within  twenty-four 
hours  an  increase  in  the  amount;  often  the  flow  is  very  great.  Under  its 
use  the  dyspnoea  is  relieved,  the  dropsy  gradually  disappears,  the  pulse  be- 
comes firmer,  fuller  in  volume,  and  sometimes,  if  it  has  been  very  inter- 
mittent, regular. 

Ill  effects  sometimes  follow  digitalis.  There  is  no  such  thing  as  a 
cumulative  action  of  the  drug  manifested  by  sudden  symptoms.  Toxic 
effects  are  seen  in  the  production  of  nausea  and  vomiting.  The  pulse  bo- 
comes  irregular  and  small,  and  there  may  be  two  beats  of  the  heart  to  one 
of  the  ])ulse,  which,  as  pointed  out  by  Broadbent,  is  found  particularly  in 
cases  of  mitral  stenosis  when  they  ai'c  under  the  influence  of  this  drug. 

*  For  illustrative  cases  from  my  wards  see  paper  by  II.  A.  Lafleur,  Medical  News, 
July.  1891. 


CHRONIC  VALVULAR  DLSEASE. 


733 


instances 

l)lo  wlicii 

an  hour 
som  salts 
I  thrt'o  to 
nil  (loses, 
the  \n\W 
'V  tk'iik'tL' 

-Of  thoso. 
1)  practice 
Ta-in  lea- 
see in  all 
what   the 
:art,  slow- 
;.     It  acts 
id  equable 
the  prime 
'st  seen  in 
■opsy.     Its 
:-le,  in  the 
On  tlieo- 
taiicous  ill 
reater  dis- 
crviccahlo 
ihitation; 
or  the  in- 
ms  of  the 
ree  hours 
llie  tinc- 
sr  is  good, 
ted  each 
ciity-four 
Uncler  its 
liulse  be- 
ery inter- 
ling  as  a 
IS.     Toxic 
pulse  be- 
>nrt  to  one 
icularly  in 
this  drug. 

cdical  News, 


ia1 


The  urine  is  reduced  in  amount.  These  symptoms  subside  on  the  with- 
(h'awal  of  the  digitahs,  and  are  rarely  seri(nis.  There  are  patients  who  take 
digitalis  uiiinterrui)tedly  for  years,  and  feel  i)alpitation  and  distress  if  the 
drug  is  omitted.  In  mitral  disease,  even  when  it  does  good  it  does  not  al- 
ways steady  the  pulse.  There  are  many  cases  in  which  the  irregularity  is 
not  affected  by  the  digitalis.  When  the  comiiensation  has  been  re-estab- 
lished the  drug  may  be  omitted.  When  there  is  (lysi)nu'a  on  exertion  and 
cardiac  distress,  from  5  to  lU  minims  three  times  a  day  may  be  advan- 
tageously given  for  prolonged  i)eriods,  but  the  elfects  should  be  carefully 
watclic;!.  In  cardiac  dropsy  digitalis  should  be  used  at  the  outset  with  a 
free  hand.  Small  doses  should  not  be  given,  but  from  the  first  half-ounce 
(loses  of  the  infusion  every  three  h(uirs,  or  from  15  to  :^0  minims  of  the 
tincture.     There  are  no  substitutes  for  digitalis. 

Of  other  remedies  strojihanthus  alone  is  of  service.  Given  in  doses  of 
from  5  to  8  minims  of  the  tincture,  it  acts  like  digitals.  It  ce.tainly  will 
sometimes  steady  the  intermittent  heart  of  m;tr=il  v-,'.lve  disease  when  digi- 
talis fails  to  do  so,  but  it  is  not  to  be  compared  with  this  drug  when  dropsy 
is  present.  C'onvallaria,  citrate  of  cail'eine,  and  (idnnis  rcnuiUs  and  spar- 
trine  are  warmly  recommended  as  substitutes  for  digitalis,  but  their  infe- 
riority is  so  manifest  that  their  use  is  rarely  indicated. 

There  are  two  valuable  adjuncts  in  the  treatment  of  valvular  disease — 
iidii  and  strychnia.  When  ana'iiiia  is  a  marked  feature  iron  should  be 
given  in  full  doses.  In  some  instances  (jf  failing  compensation  iron  is  the 
only  medicine  needed  to  restore  the  balance.  Arsenic  is  occasionally  an. 
excellent  substitute,  and  one  or  other  of  them  should  be  administered  iiii 
all  instances  of  heart-trouble  when  pallor  is  present.  Htrychnia  is  a  heart 
tonic  of  very  great  value.  It  may  be  given  alone  or  in  combination  with  the- 
■ligitalis  in  1  or  3  drop  doses  of  the  1-per-cent  solution.  Alcoholic  stimu- 
lants in  moderation  are  occasionally  useful,  especially  in  tiding  over  a  period 
of  acute  cardiac  weakness. 

Treatment  of  Special  Symptoms,  (a)  Dwpsij. — The  increased 
arterial  tension  and  activity  of  the  capillary  circulation  under  the  inilueiice 
of  digitalis  hastens  the  interstitial  lymph  flow  and  favors  resor])tion  of  the 
lluid.  The  hydragogue  cathartics,  by  rapidly  dei)leting  the  blood,  promote,, 
too,  the  absorption  of  the  fluid  from  the  lymph  spaces  and  the  lym])li  sacs. 
These  two  measures  usually  sufhce  to  rid  the  ])atieiit  of  the  dropsy.  In 
some  cases,  however,  it  cannot  be  relieved,  and  then  Southey's  tubes  may 
be  used  or  the  legs  jmnctured.  If  done  with  care,  after  a  thorough  wash- 
ing of  the  parts,  and  if  antisejitic  ])recautions  are  taken,  scarification  is  a 
very  serviceable  measure,  and  should  be  resorted  to  more  frequently  than  it 
is.     Canton  flannel  bandages  may  be  applied  on  the  cedematous  legs. 

(h)  Dyspna'a. — The  ]iatients  are  usually  unable  to  lie  down.  A  com- 
fortable bed-rest  should  therefore  be  provided — if  possible,  one  with  lateral 
projections,  so  that  in  sleeping  the  liead  can  be  supported  as  it  falls  over. 
The  shortness  of  breath  is  associated  with  dilatation,  chronic  bronchitis, 
di'  hydrothorax.  The  chest  should  be  carefully  examined  in  all  these  cases, 
a-;  hydrothorax  of  one  side  or  of  both  is  a  common  cause  of  shortness  of 
breath.     There  are  cases  of  mitral  re<rurgitation  with  recurring  hvdrothorax 


•34 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


.  \ 
/ 


lis  tlic  eule  di'dpsidil  syiiiptoin,  whicli  is  relicvod,  ucuk  liy  week  or  nuontli 
l)y  month,  by  tai>j)ing.  For  tlio  nocturnal  dysi)na'a,  particularly  when  com- 
hincd  with  restlessness,  nu3ri)hia  is  invaluable  and  may  be  given  without 
hesitation.  Tlie  value  of  the  calniinjf  iniluence  oi"  oi)ium  in  all  conditions 
oi'  cardiac  insulliciency  is  not  cnou<ih  reco;;iiized.  There  are  instances  of 
cardiac  dyspncea  unassociated  with  dropsy,  ])ai'ticularly  in  mitral  valve  dis- 
ease, in  which  iiitro<;iycerin  is  of  great  service,  if  given  in  the  1-per-cent 
solution  ill  increasing  doses.  Jt  is  especially  serviceable  in  the  cases  in 
^vhicIl  the  pulse  tension  is  high. 

{(■)  I'dlpildliDii  and  Cardiac  Dislrcss. — in  instances  of  great  liypertrophy 
and  in  the  throbbing  wliich  is  so  distressing  in  some  cases  of  aortic  in- 
suilicicncy,  aconite  is  of  service  in  doses  of  from  1  to  3  minims  every  twd 
or  three  liours.  An  ice-l)ag  over  tlie  heart  or  Letter's  coil  is  also  of  service 
in  allaying  the  rapid  action  and  the  throbbing.  For  tlie  nains,  whicli  are 
often  so  marked  in  aortic  lesions,  iodide  of  potassium  in  10-grain  doses, 
three  times  a  day,  or  the  nitroglycerin  may  ])e  tried.  Small  blisters  are 
sometimes  advantageous.  It  must  be  remembered  that  an  important  caus(! 
of  pal|)itation  and  cardiac  distress  is  flatulent  distention  of  the  stomach 
or  colon,  against  whicli  suitable  measures  must  be  directed. 

(d)  (laylric  Syinpfums. — The  cases  of  cardiac  insufliciency  which  dn 
badly  and  fail  to  resjiond  to  digitalis  are  most  often  those  in  which  nausea 
and  vomiting  are  jirominent  features.  The  liver  is  often  greatly  eiilargeil 
ill  these  cases;  there  is  more  or  less  stasis  in  the  liei)atic  vessels,  and  but 
little  can  be  expected  of  drugs  until  the  venous  engorgement  is  relieved. 
If  the  vomiting  persists,  it  is  best  to  stop  the  food  and  give  small  bits  of 
ice,  small  quantities  of  milk  and  lime  water,  and  etrervcscing  drinks,  such 
as  A])ollinaris  water  and  cliam])agne.  C'reasote,  hydrocyanic  acid,  and  the 
oxalate  of  cerium  are  sometimes  useful;  but,  as  a  rule,  the  condition  is  ob- 
stinate and  always  serious. 

(e)  C(ni(/h  and  Ila'nwpti/sis. — The  former  is  almost  a  neccssaiT  concomi- 
tant of  cardiac  insulliciency,  owing  to  engorgemetit  of  the  pulmonary  ves- 
sels and  more  or  less  bronchitis.  It  is  allayed  by  measures  directed  rather 
to  the  heart  than  to  the  lungs.  Ilauiioptysis  in  chronic  valvular  disease 
is  sometimes  a  salutary  symptom.  An  army  surgeon,  who  was  invalided 
during  the  late  civil  war  on  account  of  haemoptysis,  sujiposed  to  be  due 
to  tul)erculosis,  has  since  tliat  time  had,  in  association  with  mitral  insuffi- 
ciency  and  enlarged  heart,  many  attacks  of  lucmojitysis.  lie  assures  me 
that  his  condition  is  invariably  better  after  the  attack.  It  is  rarely  fatal, 
exce])t  in  some  cases  of  acute  dilatation,  and  seldom  calls  for  special  treat- 
ment. 

(/)  Sleeplessness. — One  of  the  most  distressing  features  of  valvular  le- 
sions, even  in  the  stage  of  compensation,  is  disturbed  sleep.  Patients  may 
Avake  suddenly  with  throbbing  of  the  heart,  often  in  an  attack  of  night- 
mare. Subseiiuently,  when  the  compensation  has  failed,  it  is  also  a  worry- 
ing symptDiu.  The  sleep  is  broken,  restless,  and  frequently  disturb vd  by 
frightful  dreams.  Sometimes  a  dose  of  the  s]urits  of  chloroform  or  of  ether, 
with  half  a  drachm  of  spirits  of  camphor,  given  in  a  little  hot  whisky,  will 
give  a  quiet  niglu.     The  compound  spirits  of  ether,  Hoffman's  anod^'ne, 


or  month 

illC'll    COlll- 

11  withoul 
conditions 
stancrs  of 
valve  diri- 

l-l)L'r-CLMlt 

3  cases  ill 

■pcrtropliy 
aortic  in- 
t'very  two 
ol"  service 
which  ar(; 
a  ill  doses, 
listers  are 
lant  cause 
e  stoniaeli 

whieli  do 
ich  nanscii 
V  enhirji"e(l 
■;,  and  but 
s  relieved, 
all  hits  of 
inks,  such 
1,  and  the 
tioii  is  oh- 

'  concomi- 
niary  ves- 
d  rather 
ir  disease 
invalided 
o  he  due 
il  insufTi- 
ssures  me 
■ely  fatal, 
eial  treat- 

Ivular  le- 
ients  may 
of  niglit- 

a  worry- 
urhii  hy 
•  of  ether, 
isky,  will 

anodvne, 


te 


IIVPERTROPIIY   AND   DILATATION. 


35 


ihough  very  unpleasant  to  lake,  is  fic(|urntly  a  great  hoon  in  the  inter- 
iiicdiate  period  when  conii)ensatioii  has  ])artially  faihd  and  the  [)atients 
■I'U'er  from  restless  and  slee])less  nights.  I'araldcliydc  and  aiuyleiie  hydrate 
;ii'e  sonietiincs  serviceable.  L'rethan,  sulplional,  and  ehloralamide  are  rarely 
illicacious,  and  it  is  hest,  after  a  few  trial.s,  j)articularly  if  the  paraldehyde 
iloi'S  not  answer,  to  resort  to  iiierpliia.  it  may  lie  given  in  (■(iniluiial  ion  with 
■itr(i|»iiie. 

((/)  Ji'ciKil  Si/iiipl(iiiis. — With  ru[)tured  compensation  and  lowering  of 
ihe  tension  in  the  aorta,  the  urinary  secretion  is  greatly  diminished,  and 
the  amount  may  sink  to  '>  or  (i  ouiu'cs  in  the  day.  Digitalis,  and  strophan- 
ihus  when  elhcient,  usually  increase  the  How.  A  hrisk  purge  may  he  fol- 
Idwed  hy  augmented  sei'i'ction.  The  comhiiiation  in  [till  form  of  digitalis, 
-(|uill,  and  the  l)lack  oxide  of  mercury,  will  semetimes  ])rove  ell'eetive  wlu'ii 
the  infusion  or  tincture  of  digitalis  alone  has  hiiled.  Calomel  acts  well  in 
M)me  cases,  given  in  ;5-grain  doses  even'  six  hours  for  three  or  four  (hiys. 

The  (liii  in  chronic  valve-diseases  is  often  very  dillicult  to  regulate. 
With  the  dilatation  and  vemnis  engorgement  come  nausea  and  often  a  great 
(hstaste  for  food.  The  amount  of  li(|uid  should  he  restricted,  and  milk, 
heef-juice.  or  egg  alhumeii  given  every  three  hours.  When  the  sei'ious 
syin|)toms  have  ])assed,  eggs,  scraped  meat,  lisli,  and  fowl  m;iy  lie  aUowea. 
Starchy  foods,  and  all  articles  likely  to  cause  ilatulency.  should  he  for- 
hidden.     Stimulants  are  usually  necessary,  either  whisky  or  brandy. 


III.     HYPERTROPHY    AND    DILATATION. 

TTv]iertrophy  is  an  enlargement  of  the  heart  due  to  an  increased  thick- 
ness, total  or  partial,  in  the  muscular  walls.  Dilatation  is  an  increase  in 
size  of  one  (U'  more  of  the  chambers,  with  or  without  thickening  of  Ihe  walls. 
The  ctmditions  usually  coexist,  and  could  be  more  correctly  described  to- 
gether under  the  term  enlargement  of  the  heart.  Simple  hy[)ertropliy,  in 
which  the  cavities  remain  of  a  normal  size  and  the  walls  are  increased, 
occurs,  but  simple  dilatation,  in  which  the  cavities  are  increased  and  tlie 
Willis  remain  of  a  normal  diameter,  ^u'obahly  does  not,  as  it  is  always  asso- 
ciated with  thinning  or  with  thickening  of  the  coats.  Commonly  we  have 
the  forms  of  siiii])le  hy|)ertropliy;  hy[)ertrophy  with  dilatation,  and  dilatation 
with  thinning  of  the  coats. 

TTYi'KUTHoi'nv  ot'^  Tiri';  TTkaut. 

There  are  two  forms — the  sini])le  liypertroi)hy.  in  which  the  cavity  or 
eavities  are  of  normal  size;  and  hypeitrophy  with  dilatation  (eccentric 
liy])ertroi)hy),  in  which  the  cavities  are  enlarged  and  the  walls  increased  in 
tliickness.  The  condition  formerly  spoken  of  as  concentric  hypertrophy, 
in  which  there  is  diminution  in  the  size  of  the  cavity  with  thickening  of 
the  walls,  is,  as  a  rule,  a  post-mortem  change. 

The  enlargement  may  aflPect  the  entire  organ,  one  side,  or  only  one 
chamber.  Naturally,  as  the  left  ventricle  does  the  chief  work  in  forcing 
46 


/ 


73G 


DISEASP^S  OF  THE  CIRCULATORY  SYSTEM. 


tlie  Mood   through  the  pystciiiic  arteries,  the  change  is  most   frequently 
found  in  it. 

Etiology. — Hypertrophy  of  the  lieart  loHows  the  law  governing  mus- 
cles, tliat  within  certain  limits,  if  the  nutrition  is  kept  up.  increased  worlv 
is  followed  hy  increased  size — i.e.,  hy])ertro])hy.  Hypertrophy  of  the  left 
ventricle  alone,  or  with  general  enlargemejit  of  the  heart,  is  hrought 
ahout  by — • 

Conditions  affecting  the  heart  itself:  (1)  Disease  of  the  aortic  valve; 
(2)  mitral  insulhciency;  (I?)  pericardial  adhesions;  (4)  sclerotic  myocarditis; 
(."))  disturbed  innervation,  with  overaction,  as  in  exophthalmic  goitre,  i;i 
long-continued  nervous  pal]»itation,  and  as  a  result  of  the  action  of  certain 
articles,  such  as  tea,  alcohol,  aiul  tobacco.  In  all  of  these  conditions  the 
work  of  the  heart  is  increased.  In  the  case  of  the  valve  lesions  the  increase 
is  due  to  the  increased  intraventricular  pressure;  in  the  case  oi;  the  adherent 
pericardium  and  myocarditis,  to  direct  interference  with  i,he  symmetrical 
and  orderly  contractior  of  the  chand)ers. 

Conditions  acting  upon  the  blood-vessels:  (1)  General  arterio-sclerosis,. 
with  or  without  renal  disease;  (2)  all  states  of  increased  arterial  tension 
induced  by  the  contraction  of  the  smaller  arteries  under  the  influence  of 
certain  toxic  substances,  which,  as  Jiright  suggested,  "  Ijy  aifecting  the 
minute  capillary  circulation,  render  greater  action  necessary  to  send  the 
blood  through  the  distant  subdivisions  of  the  A'ascular  system";  (3)  pro- 
longed muscidar  exertion,  wliich  enormously  increases  the  blood-pressure 
in  the  arteries;  (1)  narrowing  of  the  aorta,  as  in  the  congenital  stenosis. 

IIypertro})hy  of  the  right  ventricle  is  met  with  under  the  following 
conditions — 

(1)  Lesions  of  the  m.tral  valve,  cither  incompetence  or  stenosis,  which 
act  by  increasing  the  resistance  in  the  ])ulmonary  vessels.  (2)  Pulmonary 
lesions,  obliteration  of  any  number  of  blood-vessels  within  the  lungs,  such 
as  occurs  in  emphysema  or  cirrhosis,  is  followed  by  hypertrophy  of  the 
right  ventricle.  (3)  Valvular  lesions  on  the  right  side  occasionally  cause 
hypertro])hy  in  the  adult,  not  infrequently  in  the  fcetus.  (4)  Chronic 
valvular  disease  of  the  left  heart  and  pericardial  adhesions  are  sooner  or 
later  associated  with  hy])ertrophy  of  the  right  ventricle. 

In  the  auricles  simple  hypertrophy  is  never  seen;  it  is  always  dilata- 
tion M'ith  hy])ertrophy.  In  the  left  auricle  the  condition  develops  in  lesions 
at  the  mitral  orifice,  ])articularly  stenosis.  The  right  auricle  hypertropliics 
when  there  is  greatly  increased  blood-pressure  in  the  lesser  circulation, 
whether  due  to  mitral  stenosis  or  pulmonary  lesions.  Xarrowing  of  the 
tricuspid  orifice  is  a  less  frequent  cause. 

Morbid  Anatomy.- — Phe  heart  of  an  average-sized  man  weighs  about 
9  ounces  (280  grammes);  that  of  a  woman,  about  8  ounces  (250  grammes). 
In  case  of  general  hypertro])hy  the  heart  may  weigh  from  IG  to  20  ounces. 
Weights  above  25  ounces  are  rare.  So  far  as  I  know,  the  heaviest  heart 
on  record  is  one  of  53  ounces,  described  by  Beverly  Robinson.  Dulles 
has  reported  one  weighing  48  ounces.  The  measurement  of  the  thickness 
of  the  walls  is,  next  to  weighing,  the  best  means  of  determining  the  hyper- 
trophy.    In  extreme  dilatation  the  walls,  though  actually  thickened,  may 


IIYPEIlTROPIiy   AND   DILATATION. 


rcquently 

linjT  mii>- 
isL'd  work 
f  the  left 

l)l'()U<J,llt 

tic  valve; 
'ocanlitis; 
goitre,  in 
of  certain 
itions  the 
c  increast' 
'  adherent 
mmetrical 

)-sclerosis^ 
il  tension 
tluonce  of 
■cting  tlic 

send  the 
;  (3)  pro- 
d-pressure 
stenosis. 

following 

sis,  which 
ulmonary 
ngs,  such 
ly  of  the 

lly  cause 
Chronic 

ooner  or 

rs  dilata- 
in  lesions 
3rtrophies 
rculation. 
ig  of  the 

ghs  about 
framnies). 
0  oimces. 
lest  heart 
1^)111  les 
thickness 
le  hy per- 
iled, may 


look  thin.  \\'hen  riijnr  iiinrliN  is  present,  the  cavity  may  be  small  and  the 
walls  may  appear  greatly  tiiickened.  The  measurements  should  not  be 
made  until  the  heart  has  been  soaked  in  water  and  thoroughly  relaxed.  In 
ilie  lett  ventricle  a  thickness  of  ten  lines,  or  from  '2i)  to  'rio  mm.,  indicates 
liyiiertrophy.  The  right  ventricle  is  thinner  tluui  the  left,  and  has  an 
average  diameter  of  from  -1  to  T  mm.  In  hy[)ertrophy  it  may  measiiri'  from 
i;{  to  20  mm.  The  left  auricle  has  a  normal  thickness  of  about  3  mm., 
which  may  be  doubled  in  hypertrophy.  The  wall  of  the  right  auricle  is 
tliinner  than  that  of  the  left,  rarely  exceeding  2  mm.  in  diameter.  The 
appendices  of  the  auricles  often  present  marked  increase  in  thickness  and 
I  he  musculi  jjectinati  are  greatly  devel()j)ed. 

The  shape  of  the  heart  is  altered  in  hypertrophy;  with  gri-at  t'ldarge- 
uient  of  the  ventricles,  the  apex  is  broadened,  and  the  conical  shape  is  lo.st. 
In  the  enornu)Us  eidargement  of  aortic  insuilicieucy  this  rotundity  of  the 
apex  is  very  marked.  When  the  right  ventricle  is  cbielly  all'ected  it  occu- 
pies the  largest  share  of  the  apex.  In  mitral  stenosis  the  contrast  is  very 
striking  between  the  large,  broad  right  ventricle,  reaching  to  the  apex,  and 
the  small  left  chamber. 

The  hypertrophied  muscle  has  a  deep  red  color,  is  firm,  and  is  cut  with 
increasing  resistance.  The  right  ventricle,  as  Kokitansky  noted,  may  have 
a  peculiar  hard,  leathery  consistence.  In  simple  hypertro|)hy  of  the  left 
ventricle  the  papillary  mu.scles  and  the  columniL'  carncjo  nuiy  be  enlarged, 
hut  the  former  are  often  much  flattened  in  dilated  hypertrophy.  The 
muscular  trabecuhii  are  more  develoi)ed,  as  a  rule,  in  the  right  ventricle 
than  in  the  left. 

The  increase  in  size  of  the  heart  is  probably  due  to  a  definite  numerical 
increase,  resulting  from  develoi)ment  of  new  fibres. 

Symptoms. — Hypertrophy  is  a  conservative  process,  secondary  to 
some  valvular  or  arterial  lesion,  and  is  not  necessarily  accomi)anied  by 
symptoms.  So  admirable  is  the  adjusting  ])ower  of  the  heart  that,  for 
example,  an  advancing  stenosis  of  aortic  or  mitral  orifice  may  for  years  be 
perfectly  ecpudized  by  a  progressive  hypertroj-hy,  and  the  sid)ject  of  the 
affection  be  happily  unconscious  of  the  existence  of  heart  trouble.  ITyper- 
tropJiy  is  in  almost  all  cases  an  unmixed  good;  the  symptoms  which  arise 
are  usually  to  be  attributed  to  its  faihn-e,  or,  as  we  say,  to  disturbance  of 
com])ensation. 

Among  the  most  common  symptoms  are  unpleasant  feelings  about  the 
heart — a  sense  of  fulness  and  discomfort,  rarely  amounting  to  ])ain.  This 
may  be  Aory  noticea1)le  when  the  patient  is  recumbent  on  the  left  side. 
Actual  ])ain  is  rare,  exce])t  in  the  irritable  heart  from  tobacco  or  in  neur- 
asthenics. ral])itation  may  not  occur,  nor  do  patients  always  have  sensa- 
tions from  the  violent  shocks  of  a  greatly  bypertrojihied  organ.  There 
are  instances  in  whi  h  very  uneasy  feelings  arise  from  a  moderately  exag- 
gerated pulsation.  The  general  condition  has  much  to  do  with  this.  In 
health  we  are  not  conscious  of  the  heart's  pulsations,  but  one  of  the  first 
indications  of  exhaustion  from  excesses  or  overstudy  is  the  consciousness 
of  the  heart's  action,  not  necessarily  with  palpitation.  ITeadaches,  flush- 
ings of  the  face,  noises  in  the  ears,  and  flashes  of  light  may  be  present. 


T38 


DISKASKS  OP  THE  CIRCULATORY  SYSTIIM. 


/ 


Cci'tiiiii  iiiitowjinl  uH't'i'ls  of  loii^-t'oulimicd  liyiicrlro|»liy  ol'  ilio  U't'L 
vciitricK'  iiiiist  1j(!  iii('iiti(»iit'tl,  fliic'l'  aiiiuiiji;"  wliicli  is  the  pi'odiiftiou  of 
arterio-KfltTosis.  I'urticularly  is  this  tho  cusu  wht'ii  tlic  liy[K'rli'()pliy  icisiilis 
t'niiii  iiiciTiised  pcriplieral  rt'sistance.  Tiio  lici^ilili'iUMl  blood-pri'ssiirc  (ox- 
j»rcsist'd  l)y  tlio  word  .strain)  in  llic  arteries  ^n'adiinlly  indiiees  an  endarteritis 
and  a  si  ill",  inelastic  state  oli  those  vessels  most  exposed  to  it — viz.,  tin; 
aoria  and  its  primary  divisions.  In  overeomin^'  the  peripheral  ol)strn('lioii 
the  liyi  (  il  Kipliy  "  i'uins  the  artei'ies  as  a  scMjueitial  re.-nlt  "  (Kotlu'r;.,nll). 
]'r(don;.'(  d  niiisenlar  exertion  also  acts  injuriously  Iji  this  way. 

Another  (lan^^ci'  is  laipture  ol"  the  hlood-vessels,  particularly  those  of  the 
lirain.  In  ^ciu'ral  ai'terial  de^t'nei'ation  associated  with  contracted  kidneys 
and  hypertrophicd  hd'l  heart  apoplexy  is  common.  Indeed,  in  the  majority 
of  ca.^^es  (if  cerehral  ha'uiorrha^c  there  is  .sclcrosi.s  oi'  the  smaller  vessels, 
often  with  the  dcNclopment  of  nnliaiT  aneurisms,  and  the  ruptui'c  may  he 
caused  hy  the  I'oi'cihle  action  of  the  heart. 

Physical  Signs. —  Inspcrlidn  may  show  hul^in<,f  of  the  pi'a'coidia,  pi'o- 
ducin^'  in  children  marked  asymmetry  of  the  chest,  it  may  occur  with- 
out jjcricardial  adhesions,  which  Scliroetter  thinks  are  invariahly  asso(;iated 
with  this  condition.  The  intercostal  s|)aces  are  widi'iied,  and  the  area  of 
visihlc  impulse  is  much  increased.  On  inilpalioii  the  im|)u!se  is  t'orcihle 
and  heaving',  and  with  each  systole  the  hand  oi'  tlu'  ear  applieil  over  the 
heai't  may  he  visibly  raised.  A  slow,  heavin;^:  im])ulse  is  one  of  the  hest 
si;;ns  of  simple  hypertrophy.  With  lar<:e  diliited  hypertro])hy  tho  forcihle 
im|)ulse  is  often  uku'c  sudden  aiul  aljrupt.  A  second,  weaker  impulse  can 
sonu'timos  he  felt,  due  perhaps  to  a  rehound  from  the  aortic  valves  (CJowers). 
The  heat  may  he  felt  in  tho  sixth,  seventh,  or  eighth  inters])ace  from  1 
to  -■)  iiu'hes  outside  the  nipple.  '^Fhis  downward  dislocation  of  the  ajx'X 
is  an  important  sijiii  in  hypertrophy  of  tho  left  ventricle.  In  modoraU; 
^M'ades,  such  as  are  soon  in  chroid(!  JJri^ht's  disease,  the  impulse  nujy  be  in 
the  sixth  interspace  in  the  nipple  line,  or  a  little  outside  of  it. 

Percvs.sioii  reveals  iiu-reased  dulnoss,  which  in  the  ])arastenial  line  may 
heiriii  iit  tho  thinl  rih  or  in  the  sec(uid  iiderspace,  and  transversely  may 
extend  from  half  an  inch  to  2  inches  heyond  tho  inpple  line  and  an 
0(|ual  distance  beyond  tho  middle  lino  of  the  sternum.  Tho  dull  area  is 
more  ovoid  than  in  lu-altli.  A\']ien  carefully  delimited  the  colossal  hyper- 
trophy of  aortic  valve  disease  may  <,Mve  an  area  of  dulnoss  from  7  to  8 
inches  in  transverse  extent.  In  moderate  <rrados  a  transverse  dulnoss  of  4 
inches  is  not  nncommon. 

On  auxrulhii'uin  tho  sonnds,  wlion  tho  valves  are  healthy,  may  present 
no  s])ecial  chanfjos,  Liit  the  first  sonnd  is  often  ]irolonfrod  and  dull.  AYhen 
there  is  dilatation  as  well,  it  may  ho  very  clear  and  sharp.  Reduplication 
is  common  in  tS"  hyi)ertro])hy  of  renal  di.soaso.  A  ])oculiar  clink — the 
iiiitemput  mfloUuine  of  Boiiillaud — may  be  heard  jnst  to  the  right  of  the 
apex  heat.  The  second  sonnd  is  clear  and  lond,  sometimes  ringing  in  char- 
actor  or  rednplicatod.  With  valvnlar  lesions,  the  sounds,  of  course,  are 
much  altered,  and  arc  replaced  or  accompanied  hy  murmurs. 

In  simple  hy])ertrophy  not  dependent  on  valvular  lesions,  the  pulse 
is  usually  regular,  full,  strong,  and  of  high  tension.     It  may  he  increased 


UYPHUTllorUY  AND  J)1LATAT1()N. 


730 


the  left, 
iiftion  III' 
ly  results 
•siiri.'  (t'X- 
idartoritis 
-viz.,  flic 
)stniclinii 
)llicr^ill). 

OSU    of    till' 

(1  kidneys 
■  iiiiijorily 
■r  v(.'ssels, 
I'e  lUiiy  \n' 

rdiii,  prn- 

•eiir  Avitli- 

aaso(;iiited 

10  area  of 

is  forcihh! 

I  over  the 

r  the  best 

le  forcil)U> 

ipulse  eai\ 

((iowers). 

from  1 

the  a pox 

modera*e 

lay  be  in 

lino  may 
rsoly  may 
and  an 
1  area  is 
al  liypor- 
n  7"to  8 
noss  of  -i 


lY 
II. 


])resent 
AYlion 
iplication 
ink — tlie 
ht  of  the 
y  in  char- 
mvsQ,  are 

the  pnlsc 
increased 


I 


in  I'apidity,  liiit  is  often  noiniiil.  In  eccentric  hy|»ertropliy  the  pulse  i.i  full, 
liiit  softer,  and  iisiiiilly  more  rapid.  One  of  the  earliest  si^iis  of  failure  and 
dilatation  is  irrej^ularity  and  intermittencH'  of  the  [lulse. 

lly|'ertro|(liy  of  the  /■(///(/  vciilrirlc  in  the  adult  very  rarely  follows  valvu- 
lar disease  on  the  ri<;lit  side,  hut  results  from  increased  resistance  in  the 
luilmoiiary  circulation,  as  in  ciirliosis  of  the  Inn;;'  and  enipliysema,  or  in 
.-lenosis  of  the  mitral  orilice.  With  perfect  compensation,  which  fully 
maintains  the  (Mpiilihriiini  <d'  the  circulation,  there  are  no  syinptoins.  Mxtra 
exertion,  as  the  ascent  of  stairs  or  runniiit:-,  may  cau>e  >lioitiiess  of  hreatli, 
hill  in  many  ways  hy|)eri  ropliy  of  the  ri^iht  ventricle  is  the  mf).-t  cndurin;^ 
and  salutary  I'oriii  in  the  whole  cycde  of  c-ardiac  alVcctions.  Foi'  lon^ 
|iei'iods  of  years  the  olfects  of  mitral  stenosis  may  he  coiiiiterlialaneeil,  and 
only  sudden  death  hv  aecidont  or  an  acute  disease  reveal  the  I'xisteiice  of 
an  ii!isiis|ie(  ted  lesion.  In  the  liypert  rophy  secondary  to  eni[)hysema  or 
cirrhosis  of  the  lun^^s,  there  may  he  sensations  id"  distress  in  the  cardiac 
rc.uion,  with  eoii^di  and  shortness  of  hreatli:  hut  as  ion;:  as  the  dilatation 
is  moderate  the  symptoms  are  not  markeil.  With  i^reat  dilatation  and 
Iriciir-pid  leakaj^e  cctiiie  venous  en;for<fenient,  ledenia,  and  pulmonary  trou- 
liles.  The  increased  pres.-iiie  in  the  lesser  circulation  leads  to  sclerosis  of 
the  pulmonary  arteries  and  the  constant  en^oriicnieiit  id'  the  capillaries 
leads  ultimately  to  a  deposition  of  pi<;inent  and  increase  in  the  lihrous 
eleineiits  ill  the  liiii;^' — the  hrowii  induration.  Extreme  pulmonary  con- 
gestion and  apoplexy  are  more  often  associateil  with  dilalalidii.  Ihemop- 
lysis  may  result   from  ru|)ture  of  vessels  durinjjf  sudden  exertion. 

I'lii/sical  i^ii/iis. —  IWil^iiiu'  of  the  lower  ])art  of  the  sternum  and  left 
cartila<,H's  occuis.  The  apex  heat  is  forced  to  the  left,  hut  is  not  so  often 
displaced  downward,  '^riie  most  marki'd  impulse  may  he  in  the  aiiizle  ho- 
tween  the  eiisiform  cart  ilaiic  and  the  seventh  rih  or  heiiealh  the  cartilagea 
of  the  sixth  and  seventh  rihs.  The  pulsation  is  rather  diffuse,  not  punc- 
tate, ]iarticiilarly  if  there  is  much  dilatation.  In  thin-walleil  chests  thert;. 
may  he  luilsation  in  the  tliiid  and  fourth  ri,i:'hl  iiiters])aces.  The  cardiac 
diilness  is  increased  transversely  and  toward  tlu'  ri^iit;  it  may  extend  an 
inch  or  more  heyond  the  border  of  the  sternum.  On  auscultation  the  first 
M)iiiid  at  the  lower  jiart  of  the  sternum  is  louder  and  fuller  than  normal, 
but  the  dillerences  are  not  v  iT  marked  unless  there  is  much  'ilatation,. 
when  the  sound  is  eleari'r  and  sliarjier.  Accentuation  and  reduplication 
of  the  second  sound  are  heard  in  th(>  pulmonary  artery  on  account  of  the 
increased  tension.  The  ])ulse  at  tlie  wrist  is  usually  small.  Pulsation 
iiceiirs  in  the  juj^nlars  when  there  is  tricuspid  incompetence. 

lly])ortro]diy  of  the  avrirlcs  always  occurs  with  dilatation.  It  is  more 
common  in  the  left  chamber,  which  hypertrophies  in  mitral  sti'nosis  and 
iiicompet(Micy,  and  naturally  assists  in  restoring;-  the  balance  of  the  circu- 
lation. There  are  no  distinctive  physical  siirns.  and  we  nsiially  can  infm- 
its  jiresence  only  by  the  existence  of  mitral  stenosis  and  a  presystolic  miii'- 
mur.  Increased  diilncss  may  be  detennineil  to  the  left  of  the  sternum,  and 
lliere  may  be  a  ))rcsystolic  wave  in  the  second  left  interspace. 

ITypertrophy  and  dilatation  of  the  ri,!;ht  auricle  are  met  Mitli  (associ- 
ated with  a  similar  condition  in  the  right  ventricle  and  incompetency  of 


140 


DISKASKS  OP  THE  CIllCULATORY  SYSTKM. 


/ 


tilt'  li'iciisiiid)  ill  ('iii|iliys('iiia,  cirrhosis  of  the  liiii;;,  clinniic  broiicliitis,  and 
mitral  disease.  In  coMiparison  with  I  lie  left  auricle  llic  jircater  dovcloit- 
int'iit  and  liypcrtropliy  (d'  the  apjiendix  and  its  iniiseidi  pcctinati  is  very 
striking'.  The  latter  may  he  distrihuted  over  the  anterior  wall  ol'  the  sinus 
to  a  "reati'r  extent  than  in  health.  There  are  inerease<l  didness  in  the 
third  and  i'onrth  interspaces,  pulsation  sometimes  presystolic  in  rhythm, 
fijins  of  venous  cii^fori^ement,  jii<,ailar  jmlsation,  and  (ttlier  evidences  of 
dilatation  ol'  tin    ri^ht  heart. 

Diagnosis. — Amon^^  conditions  to  he  distingnished  are: 

(1)  .Neurotic  palpitation,  i"rom  whatever  cause,  even  when  very  fnrcihle, 
luis  not  the  heaving  impulse  of  genuine  hypertrophy.  Enlargement  of  the 
organ  nujy,  however,  follow  ])rolonged  overaction,  as  in  the  snu)ker's  heart, 
the  irrilahle  heart  of  lu'urasthenics,  and  in  cxo])hthalniic  goitre,  hut  it  is 
iisually  slight. 

(2)  The  increased  area  of  didness  may  he  due  to  a  variety  of  causes, 
j:ome  of  which  may  ch)sely  simulate  hypertrophy,  such  as  ])ericardial  elfu- 
sion,  aneurism,  mediastinal  growths,  or  displacement  of  the  heart  from 
pressure,  or  the  existence  of  malformation  of  the  chest.  "With  the  exer- 
cise of  o.dinary  care,  however,  the  diagnosis  can  usually  he  made.  There 
are  two  opposite  conditions  which  frequently  give  trouhle.  With  the  left 
lung  contracted  from  i)leurisy,  jihthisis,  or  cirrhosis,  a  large  surface  of  the 
heart  is  exposed;  the  ])ulsation  nuiy  he  extensive  and  forcihle,  and  may  ai 
first  sight  suggest  hypertr()|)hy.  In  this  condition  there  is  dislocation 
iijiward  and  to  the  left.  The  existence  of  ])ulmonary  or  pleuriti'^  disease 
and  the  fixation  of  the  lung  on  deep  inspiration  will  sulTice  to  ])revent 
mistakes.  A  less  extensive  exposure  of  the  heart  may  occur  without  any 
disease  in  very  narrow-chested  ])ers()ns  with  ill-develojied  lungs;  here, 
tliongii  the  area  of  dulness  may  he  much  increased,  the  normal  ])ositiou 
of  the  apex,  the  ahsence  of  forcihle,  heaving  impulse,  and  of  any  ohvious 
cause  of  hypertrophy  will  afford  satisfactory  criteria  for  a  diagnosis.  Tlu' 
reverse  condition  exist:;  in  some  cases  in  Avhich  em])hysema  masks  moderate 
cardiac  hypertrophy.  The  area  of  didness  may  l)e  normal,  or  even  dimin- 
ished, and  the  ])ulse  and  character  of  the  sounds  will  help  in  the  diagnosis; 
hut  it  is  sometimes  a  difficnlt  matter. 

Prognosis. — The  course  of  any  case  of  cardiac  hypertrophy  may  1)C 
divided  into  three  stages: 

(a)  Tne  period  of  development,  Avhich  varies  with  the  nature  of  the 
]irimary  lesion.  For  example,  in  rupture  of  an  aortic  valve,  during  a  sud- 
den exertion,  it  may  require  months  l)eforc  the  hyjiertropliy  hecomes  fully 
develo]ied;  or,  indeed,  it  may  never  do  so,  and  death  may  follow  irom  an 
imcompensated  dilatation.  On  the  other  hand,  in  sclerotic  alfections  of  the 
valves,  with  stenosis  or  incompetency,  the  hypertrophy  develops  step  hy 
step  with  the  lesion,  and  may  continue  to  counterhalance  the  progressive 
and  increasing  impairment  of  the  valve. 

(h)  The  period  of  full  com])ensation — the  latent  stage — during  whicli 
the  heart's  vigor  meets  the  re(iuirements  of  the  circulation.  This  period 
may  last  an  indefinite  time,  and  a  patient  may  never  he  made  aware  hy 
any  symptoms  that  he  has  a  valvular  lesion. 


lU'liitis,  and 
cr  (I('V('l(i|t- 
luiti  is  very 
)!'  llio  sinus 
ni'ss  in  tlio 
in  rliyllini, 
vidi'nct's  ol' 


'ry  forrihlc, 
ncnt  of  the 
iki-r's  heart, 
•0,  but  it  is 

,'  of  causes, 

ardial  elfu- 

lit'iirt   from 

li  tiie  exer- 

ide.     Tiu're 

ith  the  left 

•face  of  the 

ind  may  ai 

dislocation 

iti''  disease; 

to  ])rovent 

ilhout  any 

n^s;    here, 

d  ])osition 

ny  olnious 

losis.     The 

moderate 

■en  dimin- 

diagnosis; 

ly  may  be 

re  of  tlie 
n<,''  a  sud- 
Jiues  fully 
from  an 
ons  of  the 
IS  step  hy 
rogressive 

11  g  which 
lis  period 
aware  hy 


JIYIT.UTUOPIIY  AND   DILATATION. 


741 


(r)  The  period  of  l)roi\cn  compensation,  which  may  come  on  suddenly 
(hiring  very  severe  I'Xcition.  Pealli  may  resuh  from  acute  dilatation;  l)Ut 
more  commonly  it  takes  place  slowly  and  results  from  degeneration  and 
weakening  of  the  heart-muscle. 

The  breaking  or  rupture  of  cardiac  I'ompciisiition  may  lie  imluced  hy 
many  causes,  among  which  the  most  important  are:  (1)  Failure  of  the 
general  nutrition.  In  nuiny  instances  of  heart -disease,  exposuic,  poor  food, 
and  alcohol  combine  to  bring  about  distuibance  of  a  well-balanced  heart 
lesion,  .\ciite  illne.**ses,  jiarti'-ularly  the  fevers,  may  induce  general  debility 
;iud  with  it  weakening  of  the  heart-muselc.  (2)  Disturbance  of  the  local 
nutrition  of  the  heart,  owing  to  gradual  sclerosis  of  the  conmary  arteries, 
is  a  common  cause.  (iJ)  N'ery  severe  muscular  exertion,  which  may  disturb 
a  compensation,  ])erfect  for  years,  and  induce  death  in  a  few  days  (Traube). 
(4)  ^lental  emotions.  Severe  grief  or  fright  may  bring  on  hiilurt,"  of  com- 
pensation. 

The  prognosis  is  largely,  as  already  stated,  a  matter  of  maintained  com- 
pensation. Once  established,  the  hypertrophy  rarely,  if  evt-r,  disa|>pears, 
inasmuch  as  the  cause  usually  persists.  Occasionally,  jierhaps,  the  hyper- 
trophy a.ssoeiated  with  neurotic  pal[)itation  from  tobacco,  or  other  causes, 
or  the  hypertrophy  following  muscular  overe.\ertion,  may  di.<appear. 

DiLATATlOJf    OF    TIIK    JIkAUT. 

Two  varieties  arc  recognized,  dilatation  with  thickening  and  dilatation 
with  thinning.  The  former  is  the  more  common,  and  corresponds  to  the 
dilated  or  eccentric  hypcrtro])Iiy. 

Etiology. — Two  im])()rtant  ca  ses  comi)ine  to  ])roduce  dilatation — 
increased  pressure  within  the  cavities  and  impaired  resistance,  due  to  weak- 
ening of  the  muscular  wall — whi(4i  may  act  sing!;.,  hut  are  often  combined. 
A  weakened  wall  may  yield  to  a  normal  distending  force,  or  a  normal  wall 
may  yield  under  a  heightened  blood-pressure. 

(1)  Hrnghtened  endocardiac  ])ressure  results  either  from  an  increased 
(plant ity  of  blood  to  he  moved  or  an  obstacle  to  ho  overcome,  and  is  the 
more  frecpient  cause.  It  does  not  necessarily  bring  about  dilatation;  simple 
hy])ertroj)hy  may  follow,  as  in  the  early  jieriod  of  aortic  stenosis,  and  in  the 
hyjiertrophy  of  th.^  left  ventricle  in  Wright's  disease. 

A  majority  of  the  imjiortant  causes  of  increased  endocardiac  pressure 
have  already  been  discussed  under  hypertroi)hy.  One  or  t'  may  he  con- 
sidered more  in  detail. 

The  size  of  the  cardiac  chanihers  varies  in  healtli.  A\  ith  slow  action 
of  the  heart  the  dilatation  is  complete  and  fuller  than  it  is  with  rapid 
action.  Physiologically,  the  limits  of  dilatation  are  reached  when  the 
chamber  does  not  enijity  itself  during  the  systole.  This  may  occur  as  an 
acute,  transient  condition  in  severe  exertion — during,  for  example,  the 
ascent  of  a  mountain.  There  may  he  great  dilat-ation  of  the  right  heart, 
as  shown  hy  the  increased  epigastric  pulsation,  and  even  increase  in  the 
cardiac  dulness.  The  safety-valve  action  of  the  tricus])id  valves  may  here 
come  into  play,  relieving  the  lungs  hy  permitting  regurgitation  into  the 


/ 


742 


DISKASKS  OF  TIIK  CIllClliAIOUV   SVSTKM. 


iMiiiclc.  Willi  I'csl  till'  coiidil  ion  is  n'liioNcd,  Imt  if  it  jpis  lit'cii  cxticiiii'. 
llir  lifiii'l  iiiiiv  Miller  a  stniiii  I'rnm  uhicli  ii  in.iy  rccitvcr  slowly,  or,  iii(li'0(|, 
tlic  iii(li\i<liliil  liiiiy  never  he  iilile  il;^iiiii  In  iiiiderliike  severe  cxerlioli.  Ill 
llie  [irocL'.-s  ol'  Iriiiiiiii;:,  (lie  ^cttiii;,'  wind,  iis  it  is  called,  is  Inruely  a  ;,M'adiial 
ineicasc  in  the  eti|iahility  of  (he  heart,  |iiirticiilarly  of  the  ri;;hl  (dianihers. 
A  define  of  e\erl  ion  can  he  safely  niaiiitaiiied  in  lull  training  which  would 
he  (|nlte  inipossihle  under  other  circiiinslanees,  hccaiise,  hy  a  jiradiial  proct'tisi 
of  what  \\t'  may  cidl  physical  eihieatioii,  the  heart  has  stren;^!  Iieiu'(|  its 
reserve  f(n'ce--\\  idened  enormously  its  limits  of  |)hysioh><iieal  wink.  V.n- 
dinaiice  in  in'ohni-zcd  contests  is  measured  hy  (lu!  caimhilities  of  the  heart, 
and  its  essence  consists  ill  heiiifi  aide  to  meet  the  conlinnons  tciiduicy  to 
()verste|)  (he  limits  of  dilatation. 

We  have  no  positive  kiiowlcdji-e  (d'  the  nalnii'  of  the  changes  in  the 
Ileal!  which  occur  in  this  process,  hut  it  must  he  in  the  direclioii  of  in- 
creased miiMiihr  and  nervous  energy.  The  lar;^!'  heart  of  athlcies  may  he 
due  to  the  prolon<;('d  use  of  their  inus(dcs,  hut  no  man  hecoines  u  jfreat 
runner  or  oarsman  who  has  not  naturally  a  capahle  if  not  a  lar<;(!  heart. 
.Ma>ter  .Mcdralh,  the  celehratecl  '•.reyhouml,  and  I'lclipse,  the  race-liorse, 
hotli  famous  for  endurance  rather  than  s^peed,  had  very  lar^c   hearts. 

Iv\c<'ssive  dilalatioii  durin^j'  severe  muscular  eH'ort  results  in  heart- 
strain.  A  iiiaii,  perhaps  in  poor  condition,  calls  upon  his  heart  for  extra 
work  dniiii;,''  the  ascent  of  a  hi^h  iiiountain,  and  is  at  once  seized  with 
pain  ahoiit  the  licai'l  and  a  sense  of  distress  in  the  epifiast riiim.  lie 
lircathcs  rapidly  for  some  time,  is  "  ]»ull'cd,"  as  we  say,  hiil  the  symptoms 
pass  oil'  after  a  iiijiht's  (piiet.  An  attempt  to  repeat  tho  exercisu  is  followed 
hy  anollier  attack,  or,  indeed,  an  attack  oJ'  cardiac  dyspnd-a  may  come  on 
w  Idle  he  is  at  rest.  For  months  such  a  man  imiy  he  nnlittcd  for  severe  exer- 
tion, or  he  may  he  permanently  incapacitated.  In  some  way  he  has  over- 
sliaiiied  his  liemt  and  liecoiiie  "  hroken-winded."  Exactly  what  lias  taken 
placi'  in  these  hearts  w"  cannot  Si'y,  l)ut  their  reserve  force  is  lost,  and  with 
it  the  powi'r  of  meetin;;  the  demands  exacted  in  maintainin^jj  the  circula- 
tion during'  sovoro  exertion.  'J'lie  '"heart-shock""  of  Jiatham  includes  cases 
of  this  natiiH' — sudden  cardiac  breakdown  diirinji'  exertion,  iu)t  due  to  rup- 
ture of  a  vaLve.  It  seems  j)robal)le  that  sudden  death  in  men  during  long- 
continued  eirorts,  as  in  a  race,  is  sometimes  due  to  overdisti'iition  and  [laraly- 
sis  of  the  lieart. 

Exam])k's  of  dilatation  occur  in  all  forms  of  valve  lesions.  In  aortic 
incompetency  blood  enters  the  left  ventricle  during  diastole  from  the  un- 
guarded aorta  and  from  tlie  left  auri(de,  and  the  tpiantity  of  blood  at  the 
termination  of  diastole  subjects  the  walls  to  an  extreme  degree  of  pressure, 
under  Avliicb  they  inevitably  yield.  In  time  they  augment  in  tliiekness, 
and  ])resent  tlie  ty]>ical  eccentric  liy])ertro|)liy  of  this  condition. 

In  mitral  insulliciency  hlood  wliicli  sbould  have  been  driven  into  the 
aorta  is  forced  into  and  dilates  tlie  auricle  from  wliicli  it  came,  and  tlien 
in  the  diastole  of  the  ventricle  a  large  ainount  is  returned  from  the  auri- 
cle, and  with  increased  force.  In  mitral  stenosis  the  left  auricle  is  the 
peat  of  greatly  increased  tension  during  diastole,  and  dilates  as  well  as 
hypertrophies;  the  distention,  too,  may  be  enormous.     Dilatation  of  the 


ill 


IIVI'KUTUOIMIY   AM)   DILATATION. 


r4:5 


II  cxIrciiH', 
1)1',  iiiilccd, 
riioii.  Ill 
a  ;,'i;i(liiiil 
cliiiiiiltcis. 
licli  wiiiild 
liil  process 
IIk'IrmI  itrt 
(nk.  I'lii- 
tlu'  heart, 
iukii('3'  (() 

,''cs  ill  the 
ion  of  i li- 
es may  Ijo 
L'S  tt  t,n'eat. 
rgc  heart, 
•aet'-liorso, 

I'tS. 

in    heai't- 

I'nv  extra 

i/cd    with 

iuiii.      lie 

syiiiptoiiis 

h  i'ollowed 

eoiiie  on 

\ere  exer- 

has  ovcr- 

as  taken 

iiid  wiih 

eiiciila- 

d«'S  eases 

e  to  i'U]i- 

iiLi,'  lon^- 

[.araly- 

n  aortic 

the  un- 

4  at  the 

»ressiire, 

licknoss, 

into  tlie 
nd  tlieii 
iie  aiiri- 
■  is  tlie 
well  as 
of  the 


ri^i'lit  veiitriele  is  imMliieed  hy  a  luimher  of  eonditions,  whieli  were  con- 
sidered ninh'T  liypertro|thy.  All  eireiiiiislaiiees,  such  as  iiiilral  stenosis, 
eiiiphyseiiia,  etc,,  whieli  pei maiu'iil ly  iiieicase  the  tension  of  the  blood  in 
the  pulmonary  vesstds,  cause  its  dilatation. 

(«)  Impaii'rd  niilritioii  of  tlie  licai't-walls  may  lead  to  a  diiiiiniil  ion  (d' 
tiie  resisting,'  power  so  that  dilatation  readily  occurs. 

The  loss  of  tone  due  to  [larciichyiiiatous  (le<;eiicratioii  or  myocarditis 
in  fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recog- 
nized cause  of  death   in  scarlatinal  dropsy  ((J limit),  and   may  occur  in 

rheumatic  i'evt'r,  typhus,  typhoid,  erysipelas,  etc.  The  cliaiij;-cs  in  the 
heart-muscle  which  accompany  acute  endocarditis  or  pericarditis  may  lead 
to  dilatation,  especially  in  the  latler  disease.  In  ameiiiia,  leiika'inia,  and 
chlorosis  the  dilatalion  may  he  coiisiderahlc.  In  sclerosis  of  the  walls,  the 
yit'lding  is  always  where  this  process  is  most  advanced,  as  at  the  left  a|iex. 
I'nder  any  of  these  circiiinslancts  the  w  ills  may  yield  willi  iiurm;il  hlood- 
pressure. 

IV'ricar<lial  adhesions  are  a  cause  of  dilalalioii,  and  ue  ^(■nerally  liiid 
in  cases  with  e.\teiisi\e  and  ririn  union  coiisideTahle  hypertrophy  and  dila- 
tation. There  is  usually  here  some  impairment  as  well  id'  the  siiperlieial 
layers  of  muscle. 

Morbid  Anatomy. — The  condition  nsually  exists  with  .ypertrophy 
III  two  or  more  chamhers.  Il  is  more  commoii  on  (he  I'i^ht  ihan  on  ihe 
left  side.  The  most  extreme  ililalatioii  is  in  cases  n\'  aortic  iiicoinpeleiicy, 
ill  which  all  the  cavities  may  he  enormously  distendei'.  In  mitral  stenosis 
the  left  auricle  is  often  trelded  in  capacity,  and  the  ri;;,lit  chamhers  also  art; 
Aery  capacious,  ^riie  auricles  may  contain  from  IS  to  '^0  ounces  of  hlood. 
1,1  chronic  lesions  of  the  Iiiiilis  the  riulit  chamhers  are  eliielly  involved. 
In  >;Teat  distention  (d'  one  ventricle  the  .^eptum  may  Iml^  ■  toward  the  other 
side.  The  nnriculo-vent ricular  ring's  are  often  dilateil,  and  there  may  he 
an  increase  in  the  circiimference  of  1,]  or  even  2  incli(>s.  'i'lius.  the  tricus- 
pid orifice,  the  circiinifereiice  id'  which  is  alioiii  1.1  inches,  may  freely  admit 
a  <i'ra(luati'<l  heart-cone  .>f  ahove  (i  inches;  and  the  mitral  oriliee,  which 
normally  is  ahout  'A.^  inches,  may  admit  the  ■one  to  r)i  inches  or  even 
more.  (Jreat  dilatation  is  always  accom])anic(l  hy  relative  iiicoinpeteiicy 
()\'  the  valves,  so  that  free  re<,nir<iitation  into  the  auricles  is  permitted. 
The  orifices  of  the  veme  cava'  and  of  the  pulmonary  veins  may  he  ereatly 
dilated. 

The  endocardium  is  often  opaipie,  ])art ieiilarly  that  of  the  auricles. 
The  muscle  sidistance  varies  accordin;;  to  the  ])resence  or  alisenco  of  de- 
generations. '^Plie  microscope  may  show  marked  fatty  or  parenchymatous 
chanfTc,  hut  in  some  instances  no  special  alteration  may  Ik;  noticeahle. 
There  is  much  truth  in  Xiemeyer's  assertion  "that  it  is  not  possihie  hy 
means  of  the  niicroscojie  to  n'eojriiize  all  the  alterations  of  the  mnsciiLir 
fil)rill;e  which  diminish  the  functional  ])ower  of  the  heart."  Of  the  clian.ires 
in  the  fjanpi'lia  of  the  heart  we  know  very  little.  7\s  centres  of  control 
they  ])rohal)ly  have  more  to  do  with  cardiac  atony  and  hreakdown  than  we 
ponernlly  admit.  Degeneration  of  them  has  hcen  noted  hy  Putjakin,  Ott, 
and  others. 


7U 


DISEASES  t)F  THE  CIIICULATOUY  SYSTEM. 


/ 


Symptoms  and  Physical  Signs. — Dilatation  causes  weakness  of 
tho  eartliac  wails,  diminishes  the  vigor  of  their  contractions,  and  is  there- 
fore the  reverse  of  hyi)ertroi)hy.  So  long  as  coin[)ensation  is  maintained 
the  enlargement  of  a  cavity  may  be  considerable.  The  limit  is  reached 
when  the  liy[)ertroj)liied  walls  in  the  systole  can  no  longer  expel  all  the 
contents,  part  of  which  remain,  so  that  at  each  diastole  the  chamber  is 
al)normally  full.  Thus,  in  aortic  incompetency  blood  enters  the  left  ven- 
tricle from  the  aorta  as  well  as  the  auricle;  dilatation  ensues,  and  also 
hypertrojjhy  as  a  direct  ell'ect  of  the  increased  pressure  and  increased 
iimount  of  blood  to  be  moved.  lUit  if  from  any  cause  the  hyj)ertrophy 
Aveakens  and  the  ventricle  during  systole  fails  to  em[)ty  itself  completely, 
a  still  larger  amount  is  in  it  at  the  end  of  each  diastole,  and  the  dilatation 
becomes  greater.  Tl.c  amount  remaining  after  systole  prevents  the  blood 
from  entering  freely  from  the  auricle.  Incompetency  of  the  auricnlo- 
vontricular  valves  follows,  Avitli  dilatation  of  the  auricle  and  impeded 
Llood-flow  in  the  pulmonary  veins.  Dilatation  and  hypertroi)hy  of  the 
right  heart  may  comjjensate  for  a  time,  bnt  when  this  fails  the  venous 
system  becomes  engorged  and  dropsy  may  result.  The  consideration  of 
the  symptoms  of  chronic  valvular  lesions  is  largely  that  of  dilatation  and 
its  effects.  Acute  dilatation,  such  as  mc  see  in  fevers  or  in  sudden  failure 
of  a  hypertrophied  heart,  is  accompanied  by  three  chief  symptoms — weak, 
usually  rapid,  impulse,  dyspna>a,  and  signs  of  obstructed  venous  circula- 
tion.   Cardiac  pain  may  be  ])rescnt,  but  is  often  absent. 

The  phi/sical  signs  of  dilatation  are  those  of  a  weak  and  enlarged 
organ.  The  impulse  is  diffuse,  often  undulatory,  and  is  felt  over  a  wide 
area,  and  an  a])ex  beat  or  a  point  of  maximum  intensity  nuiy  not  be  found. 
When  it  does  exist,  it  may  be  visible  and  yet  cannot  be  felt — a  valuable 
observation  made  by  AValshe.  An  extensive  area  of  impulse  with  a  quick, 
weak  maximum  apex  beat  may  be  present.  When  the  right  heart  is  chiefly 
<lilated  the  left  may  be  pushed  over  so  as  to  occui)y  a  much  less  extensive 
area  in  front  of  the  heart,  and  the  true  apex  beat  cannot  be  felt;  but  the 
•chief  impulse  is  just  below,  or  to  the  right  of,  the  xiphoid  cartilage,  and 
there  is  a  wavy  pulsation  in  the  fourth,  fifth,  and  sixth  inters])aces  to  the 
left  of  the  sternum.  In  extreme  dilatation  of  the  right  auricle  a  pulsation 
may  sometimes  be  seen  in  the  third  right  interspace  close  to  the  sternum, 
^nd  with  free  tricus[)id  regurgitation  this  may  be  systolic  in  character. 
Whether  the  pulsation  frequently  seen  in  the  second  left  interspace  is  ever 
■due  to  a  dilated  left  auricle  has  not  been  determined.  I  have  sometimes 
thought  it  was  presystolic  in  rhythm,  though  it  may  be  distinctly  systolic. 
Post  mortem,  it  is  rare  in  the  most  extreme  distention  to  see  the  auricular 
ap})endix  so  far  forward  as  to  warrant  the  belief  that  it  could  beat  against 
the  second  interspace.  The  area  of  dulness  is  increased,  but  an  emphysema- 
tous lung  or  the  fuily  distended  organ  in  a  state  of  brown  induration  may 
cover  over  the  heart  and  greatly  limit  the  extent.  The  directions  of  increase 
were  considered  in  connection  with  hypertrophy. 

The  first  soimd  is  shorter,  sharper,  more  valvular  in  character,  and 
more  like  the  second.  As  the  dilatation  becomes  excessive  it  gets  weaker. 
Eeduplication  is  not  common,  but  occasionally  differences  may  be  heard 


IlYPEHTUorilY  AND  DILATATION. 


745 


it'iikness  of 
id  is  tlieri'- 
niaiutained 
is  ix'iiclic'd 
])c'l  all  the 
L'liamber  is 
e  left  veu- 
',  and  also 
increased 
y])er(roi)hy 
•onipletely, 
dilatation 
the  blood 
;  auriculo- 
1  impeded 
•hy  of  the 
he  venous 
eration  of 
tation  and 
len  failure 
ms — weak, 
IS  cireula- 

[  enlarijed 
•er  a  wide 
be  found. 
I  valuable 
1  a  quick, 

is  chiefly 

extensive 

t;  but  the 

ilage,  and 

*es  to  the 

])ulsation 

sternum, 

laracter. 
ee  is  ever 
ometimes 

systolic, 
auricular 
t  against 
physema- 
tion  may 

increase 

•ter,  and 
!  weaker, 
je  heard 


in  the  first  sound  over  the  right  and  left  hearts.  The  sounds  are  frequently 
obscured  by  niurniurs,  wiiich  are  itroduced  by  i'lcoinpeteney  of  the  valves 
due  t(/  the  great  dilatation,  or  are  associated  with  tlie  chroiuc  valve  dis- 
.■ase  on  whicli  the  condition  de})eiuls.  The  aortic  second  sound  is  replaced 
by  a  murmur  in  aortic  regurgitation.  The  })ulmonary  sound  is  accentuated 
in  mitral  I'egurgitation  and  j)idm()nary  congestion,  but  with  extreme  dilata- 
tion it  may  l)e  nuieii  weakened.  The  heart's  action  is  irregular  and  inter- 
mittent, and  the  ])ulse  is  small,  weak,  and  quick. 

On  auscultation  both  the  sounds  may  be  free  from  murmur.  There 
is  the  coiulition  known  as  embryocardia  or  fcetal  heart-rhythm,  in  which 
the  lirst  and  second  sounds  are  very  alike,  a  id  the  long  ])ause  is  shortened. 
In  other  instances  there  is  the  typical  and  characteristic  gallop  rhythm, 
rarely  found  apart  from  c  )nditions  of  dilatation.  With  the  various  valvu- 
lar lesions  the  corresponding  murmurs  may  be  heard,  niurniurs,  however, 
which  have  been  })resent  may  disappear,  as  in  the  case  of  mitral  stenosis. 
In  other  instances  a  loud  systolic  murmur  may  be  heard  at  the  apex,  and 
when  the  case  first  comes  under  observation  it  nuiy  be  iinj)ossible  to  say 
whether  this  is  due  to  organic  mitral  lesion.  The  murmur  may  be  con- 
fined to  the  ai)ex  region,  or  ])ropagated  well  to  the  back.  It  is  extremely 
common  in  the  dilatation  which  follows  the  hy})ertro})hy  of  the  left  ventri- 
cle in  arterio-sclerosis.  Under  treatment,  with  the  gradual  disa[)pearance 
of  the  dilatation,  a  murmur  of  this  kind,  even  though  most  intense,  may 
•completely  disappear,  showing  that  it  has  been  due  to  a  relative  insuthciency, 
not  to  a  valvular  lesion.  All  varieties  of  arrhythmia  may  occur  in  dilata- 
tion of  the  heart.  The  pulse,  as  a  rule,  is  small,  weak,  quick,  and  often 
irregular. 

Dilation  and  Hypertrophy  due  to  Overexertion  and  Alcohol. — There 
is  a  group  of  cases  of  dilatation  and  hypertrophy  dependent  upon  pro- 
longed overexertion,  which  rarely  comes  under  observation  until  compen- 
sation has  failed,  and  which  then  may  be  very  dillicult  to  distinguish  from 
the  similar  conditions  produced  by  valvular  disease.  The  patients  are 
able-bodied  men  at  the  middle  period  of  life,  and  com])lain  first  of  pal- 
l)itation  or  irregularity  of  the  action  of  the  heart  and  shortness  of  breath; 
subsequently  the  usual  synii)toms  of  cardiac  insufiiciency  develop.  On  in- 
quiring into  the  history  of  these  patients  none  of  the  usual  etiological 
factors  causing  valve-disease  are  present,  but  they  have  always  been  en- 
gaged in  laborious  occupations  and  have  usually  been  in  the  habit  of  taking 
stimulants  freely.  This  is  the  alfection  which  has  been  specially  .studied 
by  j\IcLean,  Clifford  Albutt,  Seitz,  and  others,  and  in  its  earlier  condition 
by  Ua  Costa,  in  what  he  termed  the  irritable  heart.  It  is  met  with  very 
frequently  in  soldiers.  These  cases  may  return  to  hospital  three  or  four 
times  with  cardiac  insufilciency,  sometimes  with  slight  anasarca,  luemop- 
tysis,  and  signs  of  pulmonary  engorgement.  The  condition  is  by  no  means 
infrequent.  Bollinger  has  called  attention  to  the  common  occurrence  of 
dilatation  and  hypertro])hy  in  beer-drinkers,  ])articularly  in  the  workers 
in  the  German  breweries,  who  drink  20  or  more  litres  in  the  day.  Striim- 
jiell,  at  his  Erlangen  clinic,  told  me  that  this  condition  was  very  common 
in  the  draymen  and  workers  in  the  breweries  of  that  town,  very  few  of 


740 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


wlioiii  piuss  tlio  forty-fil'th  year  witliout  indicatioius  of  liypcrtroph}  and 
dilatation  of  the  lit'art.  On  i>o.st-niorteni  examination  the  valves  may  Ijo 
(jiiile  iu'alliiy,  tlic  aoi'ta  smooth,  and  extensive  arterio-sck'rosis  or  renal  dis- 
ease absent.  The  heart  wei^dis  i'rom  JS  to  2~)  onnees;  the  ehamhers  are 
dilated.  The  eondition  has  heen  met  with  also  in  animals,  and  Ilon<;liton 
states  that  the  heart  of  the  celebrated  ffreyhoiind  blaster  MctJrath  wei'-hed 
D.T)?  onnees,  just  threefold  in  excess  of  the  normal  jjrojjortion  of  heart- 
Aveij,dit  to  body-\vei<rht. 

Idiopathic  Dilatation. — And,  lastly,  there  are  other  cases  in  which  dila- 
tation of  the  heart  occurs  without  discoverable  cause.  In  some  instances 
there  has  been  a  history  of  sudden  exercise  or  of  mental  emotion,  but  in 
other  cases  the  condition  seems  to  have  come  on  spontaneously.  In  some 
it  is  acute  and  the  jjatient  has  dyspna'a,  sli<iht  cyanosis,  cough,  and  great 
cardiac  distress.  Death  may  occnr  in  a  few  days,  or  drojjsy  may  supervene 
and  the  case  may  Ijecome  chronic.  Delafield  has  reported  an  interesting 
series  of  cases  of  this  uroup. 

Treatment. — The  treatment  of  hypertrophy  and  dilatation  has  al- 
ready heen  considered  nnder  the  section  on  val\  ular  lesions.  1  would 
only  '.  re  emphasize  the  ^act  that  with  sij.,Mis  of  dilatation,  as  indicated  by 
gallop  rhythm,  nrgent  dyspntea,  and  slight  lividity,  venesection  is  in  many 
cases  the  only  means  hy  which  the  life  of  the  ]»aticnt  may  he  saved,  and 
from  2o  to  30  ounces  of  blood  should  be  abstracted  without  delay.  Subse- 
quently stimulants,  such  as  ammonia  and  digitalis,  may  he  administered, 
hut  tlu'y  are  accessories  only  to  the  bleeding  in  the  critical  condition  of 
acute  dilatation,  whit'h  is  so  frequently  met  with  in  cardiac  lesions. 


IV.    AFFECTIONS    OF    THE    MYOCARDIUM. 

1.  Lesions  due  to  Disease  of  the  Coronary  Arteries. — A  knowledge  of  the 
changes  produced  in  the  myocardium  by  disease  of  the  coronary  vessels 
gives  a  key  to  the  understanding  of  many  i)roblems  in  cardiac  pathology. 
The  terminal  branches  of  the  coronary  vessels  are  end-arteries;  that  is,  the 
communication  Ijctween  neighboring  branches  is  through  ca])illaries  only. 
F.  n.  Pratt*  has  lately  shown  that  the  vessels  of  Tiiel)esius,  which  o])e  i 
froiu  the  ventricles  and  auricles  into  a  system  of  line  branches  and  thus 
communicate  with  the  cardiac  cai)illarie3  and  coronary  veins,  may  bo  ca- 
])able  of  feeding  the  inyocardium  snihciently  to  keep  it  alive  even  when  the 
coronary  arteries  are  occluded.  The  blocking  of  one  of  these  vessels  by  a 
thrombus  or  an  end)olus  leads  nsiudly  to  a  condition  which  is  known  as — 

(d)  AiHi'Dilc  nrrrosis,  or  white  infarct.  When  this  does  not  occur  the 
reason  may  be  sought  in  (1)  the  existence  of  abnormal  anastomoses,  which 
by  their  })resence  take  the  coronary  system  out  of  the  group  of  end-arteries; 
or  (2)  the  vicarions  flow  through  ,.ie  vessels  of  Thebesins  and  the  coronary 
veins.  The  condition  is  most  commonly  seen  in  the  left  ventricle  and  in  the 
se])tTmi,  in  the  territory  of  distribntion  of  the  anterior  coronary  artery.    The 


*  The  American  Journal  of  Physiology,  vol.  i,  1898. 


AFFECTIUNS  OP  THE  MYOCARDIUM. 


747 


iifTcott'd  area  lias  a  yt'llowish-wluto  color,  sonic'tiiiics  a  turbid,  i)arboik'<l 
iispcct,  at  other  tinics  a  jiniyisii-rcd  tint.  It  may  l)i'  soiiu'wliat  wcd^^e-sliafXMl, 
iiioi'u  ot'li'ii  it  is  irregular  in  eoiilour  and  [irojeet.s  al)ove  tiie  siirl'aee.  Aliero- 
se()})ically  the  ehaiiges  aiv  vi'ry  eharacteriritic.  The  nuclei  either  disapi)oar 
from  the  niuselo  lihre.s  or  tiiey  undergo  fragmentation.  Leucocytes  wander 
in  from  tlie  surrounding  tissue,  and  tiiese  may  sull'er  disintegration.  At  a 
hiter  stage  a  new  growth  of  lihrous  tissue  is  found  in  the  peripliery  of  the  in- 
farct which  idtinuitely  nuiy  entirely  rejdace  tiie  dead  liljres.  The  iiln'cs  pre- 
sent a  homogeneous,  hyaline  api)earunce.  Jn  some  instances  there  is  eom- 
plete  ti'ansforjnation,and  even  to  the  naketl  eye  a  iirm  white  patch  of  liyaline 
degeneration  may  a|)[)ear  in  tiie  centre  of  tlie  area.  Sudden  deatii  not  in- 
liiMiuently  follows  the  blocking  of  one  of  the  branches  of  the  coronary  ar- 
tery and  the  i)roduction  of  this  anannic  necrosis.  In  medicu-leyal  cases  it 
is  a  puinl  of  priinuri/  inipoiiance  to  renwinbcr  (lud  this  is  one  of  the  common 
nnisrs  of  sudden  death.  This  condition  should  be  carefully  sought  for,  in- 
^'smuch  as  it  may  be  the  sole  lesion,  except  a  g.'Ueral,  sometim-.'s  slight 
arterio-sclerosis.  JJupture  of  the  heart  may  be  associated  with  aniL'inic 
necrosis. 

[ti)  The  seco'  '  imi)()rtant  efl'ect  of  coronary-artery  disease  u[)on  the 
myocardium  is  seen  in  the  production  of  fHnvus  myocarditis.  'J'his  may 
result  from  the  gi'adiud  transfornuitiou  of  areas  of  amenuc  necrosis.  .More 
connnonly  it  is  caused  by  the  narrowing  of  a  coronary  branch  in  a  process 
of  obliterative  endarteritis.  Where  the  process  is  gradual  evidences  of  gran- 
ulation tissue  are  often  wanting,  aiul  any  distinction  between  the  necrotic 
uuiscle  iibres  and  the  new  scar  tissue  is  dillicult  to  establish.  J.  J>.  ^lac- 
C'allum  has  shown  that  the  muscle  iibres  undergo  a  change  the  reverse  of 
that  of  their  nornuil  development  and  lose  their  fibril  binidles  preliminary 
to  their  com])lete  rei)lacenient  by  connective  tissue.  The  sclerosis  is  most 
frc(iuently  seen  at  the  ajiex  of  the  left  ventricle  and  in  the  sej)tnm,  but  it 
may  occur  in  any  portion.  In  the  se[)tum  and  walls  there  are  often  streaks 
and  patches  which  are  only  seen  in  carefully  nu)de  systematic  sections. 
Hypertrophy  of  the  heart  is  commonly  associated  with  this  degeneration, 
it  is  the  invariable  precursor  of  aneurism  of  the  heart. 

C'om])lete  ol)literation  of  one  coronary  artery,  if  ])roduccd  suddenly,  is 
usually  fatal.  When  induced  slowly,  cither  by  arterio-sclero  is  at  the  ori- 
fice of  the  artery  at  the  root  of  the  aorta  or  by  an  obliterating  endarteritis 
in  the  course  of  the  vessel,  the  circulation  may  be  carried  on  through  the 
other  vessel.  Sudden  deatli  is  not  uncommon,  owing  to  thrombosis  of  a 
vessel  which  has  become  narrowed  by  sclerosis.  In  the  most  extreme  grade 
one  coronary  artery  may  be  entirely  blocked,  with  the  production  of  ex- 
tensive fibroid  disease,  and  a  uuiin  branch  of  the  dlher  also  may  be  occluded. 
A  large,  powerfully  built  ind)ecilc,  aged  thirty-five,  at  the  Elwyn  Institu- 
tion, Pennsylvania,  who  had  for  years  enjoyed  doing  the  heavy  work  about 
the  place,  died  suddenly,  without  any  preliminary  symptoms.  The  heart, 
which  is  in  my  collection,  weighed  over  20  ounces;  the  anterior  coronary 
artery  was  practically  occluded  by  obliterating  endarteritis,  and  of  the 
itosterior  artery  one  main  branch  was  l)locked. 

(r)  Septic  Infarcts. — In  pyaemia  the  smaller  branches  of  the  coronary 


us 


DISEASES  OF  THE  CIIICULATOIIV  SYSTEM. 


/ 


iirtcric'S  may  he  hlocUcd  with  cniholi  wliich  ^ivc  rise  to  in  feet  ions  or  soplio 
iiil'ari-ts  in  the  niyocanlinm  in  the  I'orni  of  aljsccssos,  varyin^f  in  size  from 
n  pea  to  a  ))in's  head.  Tlicsi'  may  not  caiiso  any  disturltancc.  hut  wlini 
hw'fH'  tiicy  may  pi'rfoi'ato  into  the  vuntric-le  or  into  the  itcricardium,  fonn- 
in<x  what  lias  hccn  calh'd  acute  idccr  of  the  hoact. 

Si.  Acute  Interstitial  Myocarditis. —  In  some  infections  diseases  and  in 
acute  pericarditis  the  interniuscuhir  connective  tissue  may  l)e  swoih-n  and 
inlilt lilted  witii  small  round  cells  and  leucocytes,  the  l)l()od-vessels  dilated, 
and  the  mnsci(>  (ihres  the  seat  of  «iranular,  fatty,  and  hyaline  dej^eneration. 
Occasionally,  in  i)yii'mia  the  infiltration  with  pus-cells  has  heen  ditfuse  and 
conlined  chietly  to  the  interstitial  tissue.  Councilman  has  described  this 
condition  of  the  heart  wall  in  uonorrluea,  and  succeeded  in  demonstratinLi' 
the  tronococcus  in  the  diseased  areas.  'JMie  commonest  examples  are  found 
in  di])htheria,  iy])hoi(l  fever,  and  acute  endocarditis,  as  shown  by  the  sludies 
of  Jioml)er<,'.  The  foci  may  bo  the  starting-i)oints  of  i)atclies  of  fibrous 
luyocnrditis. 

15.  Fragmentation  and  Segmentation. — This  condition  was  described  by 
IJenaut  and  Landouzy  in  ISTT,  and  has  been  carefully  studied  by  dill'ereut 
pathologists.*  Two  forms  are  met  with:  1.  Segnieiitation.  The  muscle 
lil)res  have  separated  at  the  cement  line.  2.  I'^ragmentation.  ^IMie  fracture 
has  been  across  the  fibre  itself,  and  i)erha})S  at  the  level  of  the  nucleus. 
Longitudinal  division  is  uiuisnal.  Although  the  condition  doubtless  arises 
in  some  instances  during  the  death  agony,  as  in  cases  of  sudden  death  by 
violence,  in  others  it  would  seem  to  have  clinical  and  pathological  signili- 
cance.  It  is  found  associated  with  other  lesions,  librous  myocarditis,  infarc- 
tion, and  fatty  degeneration.  J.  15.  MacCallnm  distinguishes  a  simide  from- 
a  degenerative  f'  igmentation.  The  first  takes  ])lace  in  the  normal  fibre, 
which,  however,  hows  irregular  extensions  and  contractions.  The  second 
succeeds  dcgcnerai  n  in  the  fibre.  Hearts  the  seat  of  marked  fragmenta- 
tion are  lax,  easily  lorn,  the  muscle  fibres  widely  separated,  and  often  pale 
and  chnidy. 

4.  Parenchymatous  Degeneration. — This  is  usually  met  with  in  fevers, 
or  in  connection  with  endocarditis  or  pc  >rditis,  and  in  infections  and  in- 
toxications generally.  It  is  characterized  by  a  })ale,  turbid  state  of  the  car- 
diac muscle,  which  is  general,  not  localized.  Turbidity  and  softness  are  the 
special  features.  It  is  the  softened  heart  of  Laennec  and  Louis.  Stokes 
speaks  of  an  inst-mce  in  which  "  so  great  was  the  softening  of  the  organ 
that  when  the  he..i  i  was  grasped  by  the  grc.it  vessels  and  held  with  the  apex 
pointing  upward,  it  fell  down  over  the  hand,  covering  it  like  a  cap  of  a 
large  mushroom.'' 

Histologically,  there  is  a  degeneration  of  the  muscle  fibres,  which  are 
infiltrated  to  a  various  extent  with  granules  which  resist  the  action  of  ether, 
but  are  dissolved  in  acetic  acid.  Sometimes  this  granular  change  in  the 
fibres  is  extreme,  and  no  trace  of  the  strisi?  can  be  detected.  It  is  probably 
the  effect  of  a  toxic  agent,  and  is  seen  in  its  most  ex(iuisitc  form  in  the 
hunbar  muscles  in  cases  of  toxic  "v'moiilobinuria  in  the  horse.     It  is  met 


*  Ilektoen,  American  Journal  of  the  IMeilical  Sciences,  1897. 


AFKKCTIOXS   OF   TilK   ^lYOCAUDll'M, 


740 


or  septic 
si/c  I'riiin 
;)Ul   when 


m, 


lonii- 


's  and  in 
olU'ii  and 
is  dilated. 
I'ueration. 
ilViise  and 
ril)ed  tlii> 
jiistratinLi' 
are  found 
he  stndies 
of  lil)roii.>-- 

jcvibed  In 
y  ditTcrent 
ho  nuis(  le 
10  fraeture 
e  nncdeus. 
Ik'ss  arises 
1  death  hy 
cal  signitl- 
tis,  in  farc- 
in plo  from- 
nial  fibre, 
10  second 
ajiinonta- 
fton  pale 

in  fevers, 
IS  and  in- 
)f  the  car- 
ess are  the 
Stokes 
e  orfiaii 
li  the  ajiox 
cap  of  a 

which  are 
1  of  ether, 
igo  in  the 
^  probal)ly 
rin  in  the 
It  is  met 


with  in  cases  of  typlioid,  typhus,  pmall-pox,  nnd  other  infectious  diseases, 
|iMrti(ularly  when  the  course  is  protraeteil.  'I'liere  is  no  delinite  relation 
lietween  it  and  the  hi^li  temperature. 

5.  Fatty  Heart. — I'lidor  this  term  are  embraeed  fatty  doj^eneration  and 
fatty  overgrowth. 

{(i)  Fall  11  tlri/nicniliiiii  is  a  very  common  condition,  and  mild  <rr;ides  are 
met  with  in  manv  diseasi's.  It  is  found  in  the  failing  nutrition  of  old  a-'o, 
of  wastin;;'  diseases,  and  of  cachectic  states;  in  prolonj;i'd  infection-;  fevers, 
in  which  it  may  follow  or  accompany  the  parenchymatous  ehan;,'i';  associ- 
ated with  acute  and  chronic  aiueniias.  Certain  poisons,  such  as  j)hosplioru9, 
|irodiico  an  intense  fntty  de;,feneration.  Local  causes:  Pericarditis  is  .;su- 
ally  associated  with  fatty  or  paronchymalons  chan<,n'S  in  the  superlicial 
liiyers  of  the  myocardium.  Disease  of  the  coronary  arteries  is  a  common 
and  important  cause,  and  it  is  associated  with  fat  emholism.  Lastly,  in 
llie  hypertrophied  ventricular  wall  in  chronic  lieart-disease  fatty  chaiijfo  is 
hy  no  means  infrecpieiit.  'I'his  degeneration  may  he  limited  to  the  heart  or 
it  may  l)e  more  or  less  general  in  the  solid  viscera.  The  diaphragm  may 
idso  he  involved,  even  when  the  v-ther  muscles  show  no  special  changes. 
'I'liere  ai)pears  to  be  a  special  proneness  to  fatty  degeneration  in  the  heart- 
muscle,  which  may  perhajjs  ho  connected  with  its  incessant  activity.  So 
great  is  its  need  of  an  abundant  oxygon  supply  that  it  feels  at  once  any  do- 
ticioncy,  and  is  in  consequence  the  first  muscle  to  show  nutritional  changes. 

Anatomically  the  condition  may  be  local  or  general.  The  left  ventricle 
is  most  freciuently  afl'octod.  If  the  process  is  advanced  and  general,  the 
heart  looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish-brown 
tint,  or,  as  it  is  called,  a  faded-leaf  color.  Its  consistence  is  reduced  and 
the  substance  tears  easily.  In  the  left  ventricle  the  pai)i'.iary  columns  and! 
the  muscle  beneath  the  endocardium  show  a  streaked  or  patchy  ajipoarance. 
Microsc()])ically,  the  fibres  are  seen  to  be  occujiied  by  minute  globules  dis- 
ti'ilnited  in  rows  along  the  line  of  the  i)rimitivc  fibres  (Welch).  \n  ad- 
vanced grades  the  fibres  seem  completely  occupied  by  the  minute  globules. 

(h)  Follji  Overtjnnrlh. — This  is  usually  a  simple  excess  of  the  normal 
subjiericardial  fat,  to  which  the  term  cm-  adiposum  was  given  by  the  older 
writers.  In  ])ronounced  instances  the  fat  infiltrates  between  the  muscular 
sidistance  and,  separating  the  strands,  may  reach  even  to  the  endocardium, 
ill  corpulent  persons  there  is  always  much  pericardial  fat.  It  forms  part 
of  the  general  obesity,  and  occasionally  leads  to  dangerous  or  even  fata! 
iin]iairniciit  of  the  contractile  power  of  the  heart.  Of  IS'i  cases  analyzed 
hy  Forchhoimer  there  were  88  males  and  3-t  females.  Over  80  per  cent 
occurred  between  the  fortieth  and  seventieth  years. 

The  entire  heart  may  be  envelojied  in  a  thick  sheeting  of  fat  through 
which  not  a  trace  of  nni>'cle  substance  can  be  seen.  On  section,  the  fat 
infiltrates  the  muscle,  separating  the  fibres,  and  in  extreme  cases — particu- 
larly in  the  right  ventricle — reaches  the  endocardium.  In  some  places  there 
may  be  even  complete  substitution  of  fat  for  the  muscle  substance.  In 
rare  instances  the  fat  may  be  in  the  papillary  muscles.  The  heart  is  usually 
imich  relaxed  and  the  chambers  are  dilated.  ^Microscopically  the  muscle 
fibre    .  lay  show,  in  addition  to  the  atrophy,  marked  fatty  degeneration. 


I-Tf 


iiiO 


DISRASES  OP  THE  CIRCULATORY  SYSTEM. 


/ 


(5.  Other  Degenerations  of  the  Myocardium,  (n)  I : mini  Mrojiln/. — 
TIiLs  is  ii  (oiiiiiion  chiiii^ic  in  tlic  liciirt-imisclc,  [liirt  iciiliuiy  in  chronic  viil- 
viilar  !<'si()ii,s  ami  in  nc  senile  lieait.  Wlicii  iulvaiurd,  tlio  color  ol'  tlie 
muscles  is  a  dariv  red-brown,  and  tlie  ((insistence  is  usually  increased,  '['lie 
liliics  |(r(sent  an  accumulation  ol'  vellow-lirow  n  |M;;inent  cliielly  about  the 
nuclei.  'I'be  cenu'iit  sul)stniice  is  ol'len  u  'usually  distinct,  but  seems  moic 
l'ni<iile  than  in  healthy  imiscle. 

(h)  .\myloid  dej^'ciuTal  ion  (d'  the  lu'art  is  occasionally  seen.  Tt  occurs 
in  the  inteiiuuscidai'  connective  tissue  and  in  the  blood-vessels,  not  in  the; 
libres. 

(r)  '['he  hyaline  I  lanslorniation  of  Zenker  in  somotinu's  met  willi  in  i)ro- 
lon^-ed  fevers.  Tbe  airectcd  iibi'es  arc  swollen,  liomo;^eneou>,  translucent, 
and  the  stria'  arc  very  I'aint  or  entirely  absent. 

((/)  Calcareous  defi'eneration  may  occur  in  the  myocardium,  and  tho 
muscle  libres  nuiy  he  inliltratcd  and  yet  I'ctain  their  apitearance  as  ilgurcd 
and  descril)ed  by  t'oats  in  his  Texl-hook  of  i'atholo<iy. 

Symptoms  of  Myocardial  Disease. — These  are  notoriously  un- 
certain. A  man  with  atlvanced  libroid  myocarditis  may  drop  dead  sud- 
denly, while  doing  heavy  work,  witiiout  having  complained  of  cardiac  dis- 
tress. On  the  other  hand,  a  patient  may  present  enfeebled,  irregular  action 
and  signs  of  dilatation;  he  may  have  shoi'tness  of  breath,  (rdema,  and  the 
general  symptoms  believed  to  lie  characteristic  of  cases  of  fibroid  and  fatty 
heai't,  and  the  })ost  moilem  show  little  or  no  ch..nge  in  the  myocai'dium. 

Cardio-sclerosis  or  libroid  heart  is  in  some  cases  characterized  by  a 
feeble,  irregular,  slow  pulse,  with  dysinuea  on  exertion  and  occasional  at- 
tacks of  angina,  irregularity  is  jiresent  in  many,  but  not  in  all  cases. 
'JMie  pulse  may  be  very  slow,  even  ;5U  or  -lU  jier  nnnute.  Ultimately  the 
cases  come  ^  .ider  observation  with  the  symptoms  of  cardiac  insulliciency. 
'fhe  arrhythniia,  which  nuiy  have  been  present,  becomes  aggravated  and, 
according  to  i>Megel,  may  not  only  precede,  but  also  })ersist  after  the  car- 
diac insulliciency  has  passed  away. 

Fatty  degenei'ation  of  the  heart  presents  the  same  dilhculties.  Jvvtreme 
fatty  changes,  as  in  pernicious  ana-mia,  may  be  consistent  with  a  full,  regular 
pulse  and  a  regularly  acting  heart.  In  some  of  these  cases  the  fat  does  not 
a[)pear  to  interfere  seriously  with  the  function  of  the  organ.  The  truth 
is,  it  may  exist  in  an  extreme  grade  without  producing  symptoms,  so  long  as 
great  dilatation  of  the  clnunbers  does  not  occur.  The  cardiac  irregularity, 
the  dyspno'a.  ])alpitation,  and  small  ])idse  are  in  reality  not  symptoms  of 
the  fatty  degeneration,  but  of  dilatation  which  lias  supervened.  The  fatly 
amis  sciiilis  is  of  no  moment  in  the  diagnosis  of  fatty  In^art.  The  heart- 
sounds  may  be  weak  and  the  action  iri'cgular.  When  dilatation  occurs, 
there  is  often  the  gallo])  rhythm,  shortening  of  tlie  long  pause,  and  a  sys- 
tolic ninrmur  at  the  a})ex.  Shortness  of  breath  on  (Exertion  is  an  early 
feature  in  many  cases,  and  anginal  attacks  may  occur.  There  is  some- 
times a  tendency  to  syncope,  and  in  both  filiroid  and  fatty  heart  there  arc 
attacks  in  which  the  patient  feels  '^'^'hl  and  depressed  and  the  pulse  sinks 
to  40  or  .'^lO,  or  even,  as  in  one  case  which  T  saw,  to  2(k  The  patient  may 
Avake  from  sleep  in  the  early  morning  with  an  attack  of  severe  cardiac 


Irnj)lni. — 
onic  vnl- 
»r  (iT  llic 

v^\.  The 
ilxjiil  Ihc 
.'ins  iiKirc 

It  occurs 
III  ill  tlic 

li  ill  jiro- 
uislucciit, 

and   till' 
i.s  jigurcd 

ously  iin- 
Icad  siid- 
rdiac  dis- 
lar  action 
I,  and  the 
and  i'attv 
iirdinni. 
izcd  1)y  a 
sional  at- 
all  cases, 
lately  the 
Inlliciency. 
ated  and, 
•  ihu  car- 

Iv\treine 
,  n'gidar 
docs  not 
lie  truth 
()  lontj"  as 
\t;ularity, 
tonis  of 
1ie  fatty 
le  heart- 
1   occurs, 
nd  a  sys- 
an  early 
is  some- 
there  are 
ilse  sinks 
ient  may 
e  cardiac 


11 


AFFKCTIONS  OF  THK   MYOCAUDIUM. 


m 


nstluna.  These  "  s]>ells  "  may  he  associated  with  nausea  and  may  alter- 
nate with  others  in  which  there  are  an>.Mnal  syni|>toins.  These  are  the 
cases,  too,  in  which  for  weeks  there  may  lie  mental  sym|)t()ms.  'j'he  pa- 
tient has  delusions  and  may  even  liecome  maniacal.  Toward  the  close, 
the  tyjte  of  hri'athini,'  known  as  (Jheyne-Stokes  may  occur.  It  was  descrihed 
ill  the  followinjf  terms  hy  John  Clicyne,  speakin;;;  of  a  case  of  fatty  heart 
(Duhliii  Hospital  J{eports,  vol.  ii,  )).  'i'l\,  IHIS):  "For  several  days  his 
hreathin^'  was  irretjular;  it  would  entirely  cease  for  a  (piarter  of  a  minute, 
then  it  would  hecome  jiereeptihle,  thouj^ii  very  low,  then  hy  degrees  it  be- 
came lieavin,ir  and  (piick,  and  then  it  would  ;iradually  cease  again:  this 
revolu'iion  in  tlii'  sta'e  of  his  breathing  lasted  about  a  minute,  during  which 
there  were  ai)out  thirty  acts  of  respiration."  It  is  seen  much  more  fre- 
([uently  in  arterio-sclerusis  and  uiuMuic  states  than  in  fatly  heart. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very 
iibi'se  persons.  It  produces  no  symptoms  iintil  the  muscular  fibre  is  so 
weakened  that  dilatation  occurs.  IMiese  patients  may  for  years  ])resent  a 
I'eeble  but  regular  pulse;  the  heart-sounds  are  weak  and  mullled,  and  a 
murmur  may  be  heard  at  the  apex.  Attacks  of  cardiac  asthma  are  not 
uiictiiiimon,  and  the  ])alient  may  suH'er  from  bronchitis.  Dizziness  and 
]iseii(io-ap()|)lectic  .seizures  may  occur.  Su(hlen  death  may  result  from  syn- 
cope or  from  ruj)ture  of  the  heart.  The  physical  examination  is  often  dilTi- 
cult  because  of  tho  great  increase  in  the  fat,  and  it  may  be  impossible  to 
define  the  area  of  dulncss. 

For  jiractical  imrjioscs  we  may  group  the  cases  of  myocardial  disease 
as  follows: 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous  indi- 
cations of  heart-trouble.  Sclerosis  of  the  coronary  arteries  exists — in  some 
instances  with  recent  thrombus  and  white  iiifarcts;  in  others,  extensive 
libroid  disease;  in  others  again,  fatty  degeneration,  ^lany  ])atients  never 
complain  of  cardiac  distress,  but,  as  in  the  case  of  Chalmers,  the  celebrated 
Scottish  divin-^-,  enjoy  unusual  vigor  of  mind  and  body. 

i'i)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  fif  breath  on 
exertion,  attacks  of  cardiac  asthma,  sometimes  anginal  attacks,  collapse 
sviii|)tonis  with  sweats  and  extremely  slow  pulse,  and  occasionally  marked 
mental  symptoms.  Tliese  are  the  cases  in  which  the  condition  may  be 
strongly  susjiected  and,  in  some  instances,  diagnosed.  It  is  rarely  possible 
to  make  a  distinction  between  the  fatty  and  fibroid  heart. 

(;5)  Cases  in  which  there  are  cardiac  insufliciency  and  symptoms  of  dila- 
tation of  the  heart.  Dropsy  is  often  present,  and  with  a  loud  murmur  at 
Hie  apex  it  may  be  difficult,  unless  the  case  has  been  seen  from  the  outset, 
to  deteTmin(>  whether  or  not  a  valvular  lesion  is  jiresent. 

Prognosis. — The  outlook  in  afTections  of  tho  myocardium  is  extreme- 
ly grave.  I'atients  recover,  however,  in  a  surprising  way  from  the  most 
serious  attacks,  ])articularly  those  of  the  second  grou]i. 

Treatment. — ^fany  cases  never  come  under  treatment;  the  first  arc 
the  final  symyitoms. 

Cases  with  signs  of  a>  ell-marked  cardiac  insufficiency,  as  manifested  by 
dyspnoea,  weak,  irregular,  rapid  heart,  and  oedema ,    nay  be  treated  on  the 
47 


752 


DlSKASEr  OF  THE  CIRCULATORY  SYSTEM, 


/ 


plan  laid  down  for  the  treatment  of  broken  compensation  in  valvnlar  dis- 
ease. i)i<iilalis  may  be  given  even  if  fatty  degeneration  is  suspected,  and 
is  often  very  Ijenelicial. 

^liuh  more  ditlieult  is  the  management  of  those  cases  in  whicli  there 
is  marked  cardiac;  arrliythmia,  witii  a  feebU',  irreguhir,  very  slow  pulse,  and 
pyncope  or  angina.  Dropsy  is  not,  as  a  ruk",  present;  the  heart-sounds  niiiy 
be  perfectly  clear,  and  there  a-e  no  signs  of  (Hlatation.  Digitalis,  under 
these  circumstances,  is  not  advisable,  particularly  when  the  pulse  is  infre- 
quent. Complete  rest  in  bed,  a  carefully  regulated  diet,  and  the  use  of  the 
aronuitic  spirits  of  ammonia,  sulphuric  ether,  and  stimulants  are  indicated. 
For  the  rcstlessiu'ss  and  distressing  feelings  of  anxiety  mor[)hia  is  invalu- 
able, l-'rom  an  eightieth  to  a  si.xtieth  of  a  grain  of  strychnia  may  be  given 
three  times  a  day.  If,  as  is  sometimes  the  case,  the  i)ulse  is  hard  and  lirnu 
nitroglycerin  may  be  cautiously  administered,  beginning  with  1  minim  of 
the  1-per-cent  solution  three  times  a  day  and  increased  gradually. 

In  certain  cases  of  weak  heart,  ])articular]y  when  it  is  due  to  fatty  over- 
growth, the  plans  recommended  by  Uertel  and  by  Schott  are  advantageous. 
They  are  invalual)le  methods  in  those  forms  of  heart-weakness  due  to  in- 
temperance in  eating  and  drinking  and  defective  bodily  exercise.  The 
Oertel  jdan  consists  of  three  parts:  First,  the  reduction  in  the  amount  of 
li([uid.  This  is  an  important  factor  in  reducing  the  fat  in  these  patients. 
It  also  slightly  increases  the  density  of  the  blood.  Oertel  allows  daily  about 
.'}(j  ounces  of  liquid,  which  includes  the  amount  taken  with  the  solid  fooiL 
Free  perspiration  is  promoted  by  bathing  (if  advisable,  the  Turkish  bath), 
or  even  by  the  use  of  pilocarpine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  should 
consist  largely  of  proteids. 

MorniiKj. — Cup  of  coffee  or  tea,  with  a  little  milk,  about  G  ounces  alto- 
gether.    Bread,  3  ounces. 

Noon. — Three  to  4  ounces  of  soup,  7  to  8  ounces  of  roast  beef,  veal, 
game,  or  poultry,  salad  or  a  light  vegetable,  a  little  fish;  1  ounce  of  bread 
or  farinaceous  pudding;  3  to  G  ounces  of  fruit  for  dessert.  No  liquids  at 
this  meal,  as  a  rule,  but  in  hot  weather  G  ounces  of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  of  coffee  or  tea,  with  as  much  water.  As  an 
indulgence  an  ounce  of  bread. 

Evening. — One  or  2  soft-boiled  eggs,  an  ounce  of  bread,  perhaps  a  small 
slice  of  cheese,  salad,  and  fruit;  G  to  8  ounces  of  wine  with  4  or  5  ounces  of 
water  (Yeo). 

The  most  im]iortant  element  of  all  is  graduated  exercise,  not  on  the 
level,  but  up  hills  of  various  grades.  The  distance  walked  each  day  is 
niarked  off  and  is  gradually  lengthened.  In  this  way  the  heart  is  systemat- 
ically exercised  and  strengthened. 

The  Schott  Treatment. — This  consists  in  a  combination  of  baths  with 
exercises  at  Nanheim.  The  water  has  a  temperature  of  from  82°-9r)°  F., 
and  is  very  richly  charged  with  COo.  The  good  effects  of  the  bath  are 
claimed  by  Schott  to  come  from  a  ciita neons  excitation,  induced  by  the 
mineral  and  gaseous  constituents  of  the  bath,  and  a  stimulation  of  the 
sensory  nerves.    There  is  no  question  that  the  bath,  in  suitable  cases,  will 


AFFIXATIONS  OF  TIIK   MYUCAUDIUM. 


753 


and 


niter  tlic  ])osition  of  tlif  apex  heat,  and  tliat  it  lessens  the  nrea  of  (anliao 
(lulness;  this  means  that  it  diniinisiies  the  dilatation  of  the  heart.  Artificial 
haths  nro  used,  consisting'  of  forty  gallons  of  water,  with  various  strengths 
of  sodium  chloride  and  calcium  chloride.  The  uxercises,  resistance  gym- 
nastics, consist  in  slow  movenuMits  executed  by  the  patient  and  resisted 
hy  the  opi'rator.  Any  one  wishing  to  carry  out  in  private  the  S(  Iiott  treat- 
ment should  consult  the  work  of  llesley  'I'horne.  Camac's  articles  (J.  11, 
Ji.  Uulletin,  vol.  viii,  and  .lour,  of  the  Am.  !Med.  Assoc,  18U7,  ii)  givo  a 
brief  account  of  our  ex})erience  with  it. 


on  the 

day  is 

•stemat- 

is  with 
-95°  F., 
atli  are 
by  the 
of  the 
ies,  will 


.^N'KUIUSM    OF    TIIK    JIkAUT. 

(a)  Aneurism  of  a  valve  results  from  r'-ute  endocarditis,  which  pro- 
duces softening  or  erosion  and  nuiy  lead  either  to  perforation  of  the  seg- 
ment or  to  gradual  dilatation  of  a  limited  area  under  the  iidluence  of  the 
blood-pressure.  The  aneurisms  are  usually  si)heroidal  and  project  from 
the  ventricular  face  of  a  sigmoid  valve.  They  are  much  less  common  on 
the  mitral  segments.  They  freiiuently  rupture  and  produce  extensive  de- 
struction and  incom[)eteney  of  the  valves. 

(h)  Aneurism  of  the  walls  results  from  the  weakening  iiuluced  by 
chronic  myocarditis,  or  occasionally  it  follows  acute  mural  endocarditis, 
which  more  commonly,  however,  leads  to  i)erforation.  Jt  has  followed  a 
stab-wound,  a  gumma  of  the  ventricle,  and,  according  to  some  authors,  peri- 
cardial adhesions.  The  left  ventricle  near  the  ai)ex  is  usually  the  seat,  this 
being  the  situation  in  which  fibrous  degeneration  is  nuist  common.  Fifty- 
nine  of  the  ()0  cases  collected  by  J.egg  were  situated  here.  In  the 
early  stages  the  anterior  wall  of  the  ventricle,  near  the  se[)tum,  sometimes 
even  the  septum  itself,  is  slightly  dilated,  the  endocardium  onacjue,  and 
the  niuseular  tissue  sclerotic.  In  a  more  advanced  stage  the  dilatation  is 
pronounced  and  layers  of  thrombi  occupy  T  sac.  Ultimately  a  large 
rounded  tumor  may  ])roject  from  the  ventricle  and  may  attain  a  size  eiptal 
to  that  of  the  heart.  Occasionally  the  aneurism  is  sacculated  and  com- 
municates with  the  ventricle  through  a  very  small  orifice.  The  sae  may  be 
double,  as  in  the  cases  of  Janeway  and  Sailer.  In  the  museum  of  Guy's 
Il()S])ital  there  is  a  s'pecimen  showing  the  wall  of  the  ventricle  covered  with 
aneurismal  bulgings.     Ilupture  occurred  in  7  of  the  i)U  cases  collected  by 

The  si/mptoms  produced  hy  aneurism  of  the  heart  are  indefinite.  Occa- 
sionally there  is  marked  bulging  in  the  apex  region  and  the  tunu)r  may  per- 
forate the  chest  wall.  In  mitral  stenosis  the  right  ventricle  may  bulge  and 
produce  a  visible  pulsating  tumor  below  the  left  costal  border,  which  I  have 
known  to  he  mistaken  for  cardiac  aneurism.  When  the  sac  is  large  and 
jiroduces  pressure  upon  the  heart  itself,  there  may  he  a  marked  disproportion 
between  the  strong  cardiac  impulse  and  the  feeble  pulsation  in  the  periph- 
eral arteries. 

EUPTURE    OF    THE    IIeART. 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  degenera- 
tion of  the  heart-muscles.     In  some  instances,  acute  softening  in  conse- 


754 


DISKASKS  OF  TIIH  CIIKULATORY  HYSTKM. 


/ 


(jucnco  of  ('nil)()lisiii  of  u  Ijiiiiuli  of  tlic  coronary  iirttTV,  suppurativo  myo- 
(MirditiH,  or  a  ^Miirmiatoiis  jfrowtli  has  lu'eii  tlit'  ruu.-^o.  01'  lOU  casus  col- 
li'clcd  l)y  (^iiaiii,  fatty  (Icjrciicratiou  was  noted  in  TT.  'I'wo  thirds  of  tlu; 
patients  wvw  over  sixty  years  of  a;,'e. 

The  rent  may  oeeur  in  any  of  the  eharnhers,  hnt  is  fonnd  most  fre- 
(piently  in  the  left  ventrieh'  on  the  anterior  wall,  not  far  fioni  the  septum. 
Tlu'  aeeident  nsnally  lakes  place  dnrin^f  exertion.  There  may  lie  no  pre- 
liminary synipt(tms,  hnt,  without  any  warninj,'  tlie  patient  may  fall  and  die 
in  a  few  moments.  Sudden  death  occurred  in  71  percent  of  (^uain's  ca.ses. 
In  othei'  instance^  there  may  he  in  the  caidiac  re;iion  a  sense  of  anguish  and 
sun'ocalion,  and  life  may  he  prolon^'e(l  for  several  liours.  In  a  Montreal 
case,  whicli  I  examined,  the  patient  walked  up  a  steep  hill  after  the  onset  of 
the  symptoms,  and  lived  for  thirteen  hours.  A  case  is  on  record  in  which 
the  patient  lived  for  eleven  days. 

Nl';W    ({UOWTIIS    AND    r.VHASITKS. 

Tubercle  and  svphilis  have  alreadv  been  considered.  Prinuirv  cancer 
or  sarcoma  is  extremely  rare.  Secondary  tumors  may  he  single  or  mul- 
tii)le,  ami  are  usually  unattended  with  symptoms,  even  when  the  disease 
is  most  extensive.  In  one  case  1  found  in  the  wall  of  the  ri^ht  ventricle 
a  mass  which  involved  the  anterior  se<,Mnent  of  the  tricuspid  valve  and 
partly  blocked  the  orifice.  Tlie  surface  was  eroded  and  there  weic  nunu'r- 
ous  cancerous  end)oli  in  the  ])ulmonary  artery.  In  anotlier  instance  the 
heart  was  <rreatly  enlarged,  owiuff  to  the  ])resence  of  innumerable  masses  of 
colloid  cancer  the  size  of  cherries.  The  mediastinal  sarcoma  nuiy  penetrate 
the  heart,  tliongh  it  is  iiMuarkable  bow  extensive  tlie  disease  of  the  medias- 
tinal filands  may  he  without  involvement  of  the  heart  or  vessels. 

Cysts  in  the  heart  are  rare.  They  are  found  in  difl'erent  ])arts,  and 
are  filled  either  with  a  brownish  or  a  clear  fluid.  IMond-cysts  occasionally 
■occur. 

The  parasites  have  lieen  discu.s,sed  under  the  appropriate  section,  but  it 
may  be  mentioned  here  that  both  the  ri/stirerus  cclluloscc  and  the  echino- 
cocous  cysts  occnr  occasionally  in  the  heart. 


Wounds  and  Fokkign  Bodies. 

Wounds  of  the  heart  are  usually  fatal,  althnnn:h  there  are  many  in- 
stances in  which  recovery  has  taken  place.  lUdlcts  have  been  found  en- 
cysted inside  the  ventricle.  A  majority  of  the  cases  of  gunshot  wounds. 
however,  are  necessarily  fatal.  Pnncture  of  the  heart  by  a  sharp-pointed 
])ody,  such  as  a  needle  or  a  stiletto,  does  not  always  prove  fatal.  Peabody 
has  rep(M'ted  a  case  in  which  a  pin  was  found  embedded  in  the  left  ven- 
tricle. Suicide  has  been  attempted  by  passini^  a  needle  or  ])in  into  the 
lieart.  This  is  not,  however,  necessarily  fatal.  ]\roxon  mentioned  a  case,  at 
the  Clinical  Society  of  London,  in  which  a  medical  student,  while  on  a 
spree,  passed  i.  pin  into  his  heart.  The  pericardium  was  opened,  and  the 
head  of  the  pin  was  found  outside  of  the  riglit  ventricle.     It  was  grasped 


NKUROSKS  OP  Till']  JIKAllT. 


765 


ivo  myo- 
•asL's  col- 
Id  oi  llu! 

nost  frc- 

'    SC|ltlllll. 

'  IK)  prt'- 
1  and  (lio 
m's  cases. 
:iiisli  and 
Montreal 
'  onset  of 
in  which 


•V  can  cor 
or  inul- 
e  disease 
ventricle 
alve  and 
e  iiunier- 
ance  the 
inasscs  of 
)enetrate 
niedias- 

rts,  and 
isionally 

n,  l)ut  it 
eeliino- 


lany  in- 
und  en- 
woimds, 
-])ointed 
'eal)()(ly 
eft  ven- 
nto  tho 
ease,  at 
1(>  on  a 
and  the 
grasped 


and  nn  »tlem|»t  inadi!  to  remove  it,  Tint  H  \va«  withdrawn  into  the  heart 
and,  it  is  said,  caused  the  patient  no  t'urtli t  Iroidile.  Hysterical  udrls  soine- 
linies  swallow  pins  and  needles,  which,  passing'  throii;:h  tlu!  (esopliaj,'iis  and 
stomach,  are  I'mind  in  various  parts  of  tlu!  hody.  A  remarkai)lc  eaHu  is 
reported  by  Alk'U  J.  Smith  of  u  girl  from  whom  aevcrul  dozen  needles  und 
pins  were  removed,  chielly  from  snlicutaiieous  ahseesses.  Several  years 
later  she  developed  symptoms  ot  I'hronic  heart-disease.  At  the  pitst  nior- 
li'iii  needles  were  found  in  llu!  tissues  of  the  adherent  pericardium,  and  he- 
Iween  thirty  and  forty  were  emhcdded  in  the  lhie]\ened  pleural  nuMuhranoa 
of  the  left  side. 

Puncture  of  the  heart  has  been  I'ecomnicndcd  as  a  therapeutic  procedure 
to  stimulate  it  to  action,  as  in  chlorofonn  narcosis,  and  experimental  evi- 
dence has  been  brought  forward  by  !>.  A.  Watson  in  fasur  of  the  operation. 
Ho  advises  abstraction  of  blood  in  cond)ination  with  the  pum-lure — ear- 
diocentesis.  'I'lie  i)r()ceeding  is  not  without  risk,  lia'morrhage  may  take 
l)lace  from  the  puncture,  though  it  is  not  often  extensive.  Sloane  has  re- 
cently urged  its  use  in  all  cases  of  as[)hyxia  and  in  sulfocation  by  drowning 
and  from  coal-gas.  The  successful  ease  which  he  reports  illustrates  forcibly 
its  stimulating  action. 


V.    NEUROSES    OF    THE    HEART. 

I'aIJ'I  lATlOX. 

In  health  we  are  unconscious  of  the  action  of  the  heart.  In  some  people 
one  of  the  lirst  indications  of  debility  or  overwork  is  the  consciousiu'ss  of 
the  cardiac  pulsations,  which  may,  hi)wevi'r,  be  i)erfectly  regidar  aiul  or- 
derly. This  is  not  palpitation.  The  term  is  properly  limited  to  irregular 
or  forcil)le  action  of  the  heart  perci'ptiljle  to  the  individual. 

Etiology. — The  expression  "  ])erce])tible  to  the  individual"  covers 
the  essential  element  in  pal])itation  of  the  heart.  The  most  extreme  dis- 
turbance of  rhythm,  a  condition  even  of  what  is  ternu'd  di'liriuin  curd  is, 
may  be  luiattended  with  subjective  sensations  of  distress,  aiul  there  may 
be  no  coiisciousness  of  disturbed  action.  On  the  other  hand,  there  ai-e 
cases  in  which  complaint  is  made  of  the  most  distressing  palpitation  and 
sensations  of  throbbing,  in  which  the  physical  examination  reveals  a  regu- 
larly acting  heart,  the  sensations  being  entirely  subjective.  We  meet  with 
this  symptom  in  a  large  grouj)  of  cases  in  which  there  is  increased  excita- 
bility of  the  nervous  system.  ral[)itation  may  be  a  marked  feature  at  the 
time  of  })uberty,  at  the  climacteric,  and  occasionally  during  menstruation, 
it  is  a  very  common  symptom  in  hysteria  and  neurasthenia,  particularly  in 
the  form  of  the  latter  which  is  associated  with  dyspe]isia.  iMuotions,  such 
as  fright,  are  connnon  causes  of  palpitation.  It  may  occur  as  a  sequence  of 
the  acute  fevers.     Females  are  more  liable  to  the  all'ection  than  males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the 
heart  of  certain  substances,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And, 
lastly,  palpitation  may  he  associated  with  organic  disease  of  the  heart, 
either  of  the  myocardium  or  of  the  valves.     As  a  rule,  however,  it  is  a 


750 


DISKASKS  OF  T!IR  ClHCULATOllY  SYSTKM. 


/ 


jiurily  nt'i'voufl  plu'iioiiu'iion — Hi'ldoin  UHrtociatcd  with  or^'iuiic  (linonsc — in 
which  the  niorit  violent  uction  ami  the  moHt  cxtrt'ini'  inc^ailarity  may  exint 
willmut  that  nuhji'i'tivf  I'lcmciit  (if  coiirtciouHiicrtH  of  liie  (liHturhancc  wliiiiU 
coiistitutt'H  the  cssciilial  feature  («f  pnlpitatinii. 

The  iriilal)le  heart  deseriheil  hy  l>a  ('(inta,  which  wan  ho  coiiiiiKtii  amoii}^ 
the  young  yoldieirf  during  the  civil  war,  is  a  neuroHirt  of  this  kind.  Tho 
chief  Hymploms  were  palpitation  with  great  frecjuency  of  the  pulse  on  ex- 
ertion, a  variable  amount  of  cardiac  pain,  and  dyspmea.  'J'he  faet(»rri  at 
work  in  proihicing  tiiis  condition  appeared  to  he  the  mental  cxeitenu'id, 
the  unwonted  muscular  exertion  associated  with  tho  drill,  and  diarrluua. 
The  condition  is  not  infre([uent  in  civil  life  among  young  men,  and  it  lead^ 
in  some  cases  to  hypertrophy  of  the  heart. 

Symptoms. —  In  tiie  mildest  form,  such  as  occurs  during  a  dyspeptic 
attack,  there  is  slight  iluttering  of  the  heart  and  a  sense  of  what  jiatients 
sometimes  call  "  goneness."  In  more  severe  attack?  the  heart  heats  vio- 
lently, its  |)ulsations  against  the  chest  wall  are  visible,  the  rapiility  of  tho 
action  is  much  increased,  the  arteries  throb  forcil»ly,  and  there  is  a  sense 
of  great  distress.  In  some  instances  the  heart's  action  is  not  at  all  (pnek- 
ened.  The  most  striking  cases  are  in  neurasthenic  women,  in  whom  tho 
mere  entrance  of  a  ])ers()n  into  the  room  may  cause  the  most  violent  action 
of  the  heart  and  throl)])ing  of  the  ])eripheral  arteries.  The  ulse  may  bo 
rapidly  increased  until  it  reachi's  l.')!!  or  l(i().  A  diirusc  flushing  of  tho 
skin  may  appear  at  tiie  same  time.  After  such  attacks,  there  may  be  tho 
passage  of  a  large  quantity  of  ])ale  iirine.  In  many  cases  of  palpitation, 
])articularly  in  young  nu-n,  tho  condition  is  at  once  relieved  by  exertion. 
A  patient  with  extreme  irn-gularity  of  tho  heart  nuiy,  after  walking  (puckly 
100  yards  or  running  Uj  tairs,  return  with  tho  jiulse  perfectly  regular. 
This  is  not  infreciuently  seeu,  too,  in  the  irregular  actioi)  of  the  heart  in 
mitral  valve  disease. 

Tiu!  ]>hysical  examination  of  tlie  heart  in  usually  negative.  The  sounds, 
the  shock  of  which  nuiy  bo  very  ])alpable,  are  on  auscultation  clear,  ringing, 
and  metallic.  ])ut  not  associated  with  murmurs.  The  second  sound  at  tho 
base  may  be  greatly  accentuated.  A  murmur  may  somotimos  bo  heard 
over  tho  pulmonary  ariery  or  even  at  tho  apex  in  cases  of  rapid  action  in 
neurasthenia  or  in  severe  aua'uiia.  The  attacks  may  bo  transient,  lasting 
only  for  a  few  minutes,  or  may  persist  for  an  hour  or  more.  In  some  in- 
stances any  attempt  at  exertion  renews  tho  attack. 

The  prng)}flsifi  is  usually  good,  though  it  may  be  extremely  difficult  to 
remove  tho  conditions  underlying  the  palpitation. 


AmiTIYTlTMIA. 

An  intermission  occurs  when  one  or  more  boats  of  the  heart  are  dropped. 

Irregularity  is  tho  condition  when  tlie  boats  are  unequal  in  volume  and 

force,  or  follow  each  other  at  unccpial  distances.     Allorrhythmia  is  a  term 

which  is  also  used  to  express  deviations  from  tho  normal  heart  rhythm. 

Tho  following  varieties  of  arrhythmical  action  may  be  recognized: 

(1)  Tho  paradoxical  pulse  of  Kussmaul,  in  which  the  beats  during  in- 


I  sense — m 
limy  exist 
ICO  wliirli 

:)n  ninoi)^ 
ii.l.     Tin; 

■it!    Oil    C'X- 

I'at'torH  at 
X'iti'iiu'iil, 
(liarrlui'ii. 
(I  it   IciliU 

c1ysi)t'[)tic 
t  patioiitH 
x'ata  vio- 
ty  of  till) 
is  a  scnso 
ill  qiiick- 
riiom  tlio 
■lit  action 
L'  may  bo 

Ig    of    tilt' 

ly  1)(3  tilt' 
Ipitatioii, 
exertion. 
y  (luickly 

re^Milar. 

lieart  in 

L'  sounds, 
I'injriii^r, 
(1  at  the 
)e  lieanl 
let  ion  in 
lasting 
-onie  in- 

ficult  to 


ro])])cd. 
1110  and 
a  term 
lim. 
d: 
ring  in- 


NKUROSKS  OF  THK  IIKAUT, 


75T 


'•liirntinn  nro  mnro  fro(|Uent  Init  less  full  than  during  rxpirntion.  This  il 
liiiiiKJ  in  weak  heart,  in  chronic  pericaMlitis,  and  when  llludiis  hands  on- 
( irele  the  root  of  the  aorta;  hut  it  may  also  occur  in  rmally  from  the  inllii- 
enee  of  the  respirationH  ij|M)n  the  heart.  It  irt  sonietinieH  tu  ho  felt  in  Hleeiiing 
1  liildren. 

('.')  Inlerniittenee,  in  which  there  Ih  simply  an  intermission  or  dropping 
of  a  cardiac  heat.  'J'he  term  (Ir/icii'iice  is  niori'  correctly  applied  to  thoso 
iiistaiices  in  which  the  ahseneo  of  the  heart-sound  provi'S  that  the  systolo 
is  really  omitted.  The  syHtolo  may  he  ho  weak  an  not  to  produce  a  pulsa- 
tion, and  yet  at  the  same  time  u  feehle  first  sound  may  ho  heard. 

(;i)  The  alternate  heart-heat,  in  which  strong  and  weak  contractions} 
alternate  regularly  and  which  is  exi)ressod  in  tho  peri|iheral  arteries  by 
alternate  full  and  feohlo  pulso-hoats. 

(I)  Tho  higemiual  and  trigeminal  pulsations  occur  when  two  or  threo 
heats  follow  each  other  in  rapid  succession,  each  gr-nip  lu-iiig  se[>aratL.' 
from  the  following  hy  a  longer  interval.  This  is  not  very  uncommon  in 
mitral  disea-so  and  as  an  elfeet  of  digitalis.  In  tho  Ijigeminal  imlse  tho 
tirst  heat  of  tho  ]»air  is  usually  tho  stronger.  Indeed,  in  tho  condition 
known  as  heart  higcniinism  the  second  systole  is  so  feohlo  that  tho  pulso 
wave  does  not  reach  the  peripheral  arteries  and  tho  two  systoles  aro  repro- 
f-ciited  hy  only  a  single  pulse-heat  at  the  wrist. 

(5)  Delirium  cordis,  in  which  these  various  factors  arc  combined  and 
tho  heart's  action  is  wholly  irregular. 

((i)  Fo'lal  heart  rhythm — enihryoeardia — described  liy  Stok(>s,  is  a  very 
common  condition  in  which  the  long  jiause  is  shortened  and  tho  charac- 
ters of  the  sounds  arc  "almost  com])letely  identical."  The  rcsomblaneo 
to  the  fcetal  heart-heat  is  very  striking.  In  the  later  stages  of  fevers 
;'iid  in  extreme  dilatation  this  form  of  heart  rhythm  is  very  frecpiontly 
heard. 

(T)  (hillop  rhythm,  in  which  the  sounds  resemble  tho  footfill  of  a  horso 
at  canter,  usually  results  from  tho  reduplication  of  tho  sounds  in  a  rapidly 
acting  heart.  It  is  expressed  by  the  words  "  rnt-ta-tat."  Sometimes  it 
seems  as  if  the  Hrst  sound  was  split;  more  commonly  it  is  the  second. 
It  is  most  frecpiently  heard  in  tho  failing  heart  of  interstitial  nephritis  and 
arterio-sclerosis.  Its  mode  of  origin  hi.s  been  much  discussed,  and  it  is 
doubtful  whether  a  satisfactory  cxjilanation  has  yet  been  given.  As  (Jraliam 
Steell  states,  its  presence  indicates  muscle  weakness.  It  is  interesting  among 
disturbances  of  rhythm  as  the  only  one  which  we  can  see  and  feel  as  well 
as  hear. 

The  canses  of  these  various  disturbances  of  rhythm  are  thus  classified 
by  0.  r>aumgarten:  * 

(1)  Those  duo  to  contra! — cerebral  -cansos,  either  organic  disease,  as 
in  hiTpinorrhage,  or  concussion;  more  commonly  ]tsycliical  influences. 

(?)  Reflex  influences,  .such  as  produce  the  cardiac  irregularity  in  dys- 
pepsia and  diseases  of  the  liver,  lungs,  and  kidneys. 

(3)  Toxic  influences.     Tobacco,  coffee,  and  tea  are  common  canses  of 


Transactions  of  the  Association  of  American  Physicians,  vol.  iii. 


758 


DISEASES  OP  TUE  CIRCULATORY  SYSTEM. 


/ 


arrliytlnnia.  Narioiis  drugs,  siu-li  us  tligitalis,  bolladonim,  and  aconite, 
may  also  iiiduco  it. 

(I)  ("lianf^c's  in  the  heart  itself,  (a)  In  the  cardiac  ganj,dia.  Fatty, 
]>iji^ni('ii(ary,  and  yclerotic  ciiaii<;('!!  liavo  heen  dcscrihed  iji  cases  of  this 
sort  and  may  have  an  important  iiilhiciice  in  j)rodiK'in«;-  (listurl)anees  in  tlie 
rhytinn;  hut  as  yet  we  do  not  Icnow  tlieir  exact  signilicanee.  They  may 
be  present  in  cases  which  Juive  not  presented  arrliythmia.  (/>)  ^Mural  changes 
are  common  in  conditions  of  this  Icind.  Simple  dilatation,  hitty  degenera- 
tion, and  sclerosis  are  most  cojumoidy  ])rcsent,  the  two  latter  usually  asso- 
ciated with  sclerosis  of  the  coronary  arteries. 

The  signifif  auce  of  arrhythmia  is  not  always  easy  to  determine.  Simple 
irregular  action  of  the  heart  may  ])ersist  for  years.  The  late  ('hancellor 
Fcrrier,  of  ^McCiill  .  iiiversity,  a  man  of  unusual  bodily  and. mental  vigor, 
who  died  at  the  age  of  eighty-seven,  had  an  extremely  irregular  pulse  for 
almost  fifty  years  of  his  life.  One  or  two  other  instances  have  come  under 
my  notice  of  jjcrsons  in  good  health,  without  arterial  or  cardiac  disease,  in 
whom  the  heart's  action  was  ])crsistently  irregular.  The  bigeminal  and 
trigeminal  ])ulsations  arc  found  more  frequently  in  mitral  than  in  other 
conditions.  The  delirium  cordis  is  met  with  in  the  dilatation  associated 
with  valvular  lesions,  particularly  toward  the  latter  stages.  Fa'tal  heart 
rhythm  is  rarely  found  apart  from  dilatation. 


]{A1'I1)    11  HAKT TACTIYCAltniA. 

The  rapid  action  may  l)e  perfectly  natural.  There  are  indi^-iduals 
whose  nornuil  heart  action  is  at  100  or  even  more  per  minute.  It  may 
be  caused  by  tiie  various  conditions  which  induce  i)al])itation;  but  the 
two  are  not  necessarily  associated.  Emotional  causes,  violent  exercise,  and 
fevers  all  produce  great  increase  in  the  ra])idity  of  the  heart'd  action.  The 
extremely  rapid  action  which  follows  fright  may  ])ersist  for  days,  or  even 
weeks.  Trauhe  reports  an  instance  in  which,  after  violent  exercise,  the 
rai)idity  of  the  heart  continued.  Cases  are  not  uncommon  at  the  meno- 
pause. 

There  are  cases  again  in  which  the  condition  can  hardly  be  termed  a 
neurosis,  since  it  dejjends  u])on  definite  changes  in  the  ])neumogastrics 
or  in  the  medulla.  Cases  have  been  reported  in  which  tumor  or  clot  in 
or  about  the  medulla  or  pressure  U])on  the  vagi  has  been  associated  with 
hc°a't  hurry.  Some  of  the  cases  of  frequent  action  of  the  heart  in  women 
have  been  thought  to  l)e  due  to  retlex  irritation  from  ovarian  or  uterine 
disease. 

rdni.ri/siiut]  tarlii/rardia  is  a  remarkable  affection,  characterized  hy  spells 
of  heart  hurry,  during  which  the  action  is  greatly  increased,  the  ])ulse 
reaching  200  and  over,  '^riie  cases  are  not  common.  The  condition  has 
been  thoroughly  studied  by  Xothnagel.  The  attack  mny  be  quite  short 
and  ])ersist  only  for  an  hour  or  so.  A  ])atient  at  the  Philadeli)hia  Infirmary 
for  Nervous  Diseases  was  attacked  every  week  or  two;  the  pidse  would  rise 
to  220  or  230,  and  there  were  sr  ^h  feelings  of  distress  and  uneasiness  that 
the  patient  always  had  to  lie  down.    There  may  be,  however,  no  subjective 


NEUROSES  OP  THE  HEART. 


750 


I   acoiuto, 

I.  Fatly, 
'S  oi'  this 
L'os  in  tliu 
L'licy  may 
il  clian^'os 
ik'^c'iiura- 
ally  asso- 

.  Simple 
'hanci'lloi' 
tal  vigor, 

])u]se  Tor 
1110  uiulor 
lisL'aso,  ill 
liiial  and 

in  other 
associated 
;tal  heart 


idi^'idiials 

It  may 

but  tlie 

cise,  and 

on.    The 

or  even 

cise,  the 

e  meno- 

termed  a 
logastries 
r  clot  in 
ted  with 
1  women 
V  uterine 

hy  sjiells 
lie  ])ulse 
ion  lias 
itc  sliort 
ndrmary 
ouhl  ris(! 
nes.s  that 
Libjectivo 


(lisiurhancc,  and  in  another  case  the  patient  was  al»le  to  walk  about  during 
the  paroxysm  and  liad  no  dysj)na'a.  One  of  tlie  most  reniarlvahle  cases  is 
i('|)orted  by  II.  C  Wood.  A  pliysician  in  his  eighty-seventh  year  had  had 
attacks  at  intervals  since  his  thirty-seventh  year.  Tlie  onset  was  abrupt  and 
tlie  |)ulse  would  rapitlly  rise  to  2W  a  minute.  For  more  than  twenty  yeais 
the  taking  of  ice-water  or  strong  colfee  would  arrest  t'"  •  attacks,  i'xniveri't 
has  analyzed  a  number  oi  cases  of  this  essential  or  idiopathic  form;  ho 
liuds  that  a  permanent  cure  is  rare,  and  that  the  jiaiients  sull'er  for  ten 
or  more  years.  Four  instances  terminated  fatally  from  heart-failure.  i\Iar- 
lius  looks  upon  it  as  a  symptom  of  an  acute  dilatation  of  the  heart,  appt'ar- 
ing  paroxysmally.  Wood  suggi'sts  that  these  cardiac  paroxysms  are  caused 
hy  discharging  lesions  alfecting  the  centres  of  the  accelerator  nerves. 
Francois  Franck  has  shown  that  the  acceleration  of  the  heart's  action  is 
i\\w.  to  the  shortening  of  the  diastole,  and  during  the  .>^ystole  so  little  blood 
is  ex|)elled  from  the  heart  that  the  average  amount  in  the  minute  is  not 
increased.  JMoreover,  the  accelerators  appear  to  have  no  troiihic  relation 
'o  the  heart,  and  stimulation  of  them  is  not  accompanied  either  by  in- 
creased arterial  pressure  or  by  augmentation  of  the  work  done  by  tlie  heart. 

Slow  Heart — TiuACiiYCAiuiiA  {llradycanlia). 

SloAV  action  of  the  heart  is  sometimes  normal  and  may  be  a  family  pecul- 
iarity.   Napoleon  is  stated  to  have  had  a  luilse  of  only  40  per  minute. 

In  any  case  of  slow  pulse  it  is  imj)ortant  first  to  make  sure  that  the 
number  of  heart  and  arterial  beats  corresj)ond.  In  many  instances  this  is 
not  the  case,  and  with  a  radial  pulse  at  40  the  cardiac  jiulsations  may  be 
80,  half  the  beats  not  reaching  the  wrist.  The  heart  contractions,  not  the 
l)iilse  wave,  should  be  taken  into  account.  A  most  exhaustive  study  of 
this  condition  has  been  made  by  Kiegel,  whose  division  is  here  followed: 

{(i)  Physiological  brachycardia.  ]n  the  puerperal  state  the  jiulse  may 
beat  from  44  to  GO  per  minute,  or  may  even  be  as  low  as  34.  It  is  seen  in 
])reniature  labor  as  well  as  at  term.  The  exjilanation  of  its  occurrence  at 
this  ])eriod  is  not  clear.  Slowness  of  the  pulse  is  associated  with  hunger. 
Uracliycardia  depending  on  individual  peculiarity  is  extremely  rare. 

(h)  Tathological  brachycardia,  which  is  met  with  under  the  following 
conditions:  (1)  In  convalescence  from  acute  fevers.  This  is  extn  inoly 
common,  particularly  after  pneunionia,  ty])hoid  fever,  acute  rheumatis'n, 
and  diphtheria.  It  is  most  fretpieiitly  seen  in  young  persons  •,v^^\  in  cases 
Mliich  have  run  a  normal  course.  Traube's  explanation  that  it  is  due  to 
exhaustion  is  ])robably  the  correct  one.  (2)  In  diseases  of  the  digestive 
system,  such  as  chronic  dys])e])sia,  nicer  or  cancer  of  the  stomach,  and 
jaundice.  The  largest  numlier  of  IJiegel's  cases  were  of  this  group.  (3) 
In  diseases  of  the  res])iratory  system.  Here  it  is  l)y  no  means  so  common, 
but  is  seen  not  infre(|U('ntly  in  emi)hyseina.  (I)  In  diseases  of  the  circu- 
latory system.  Excluding  all  cases  of  irregularity  of  the  heart,  brachy- 
cardia is  not  common  in  diseases  of  the  valves.  It  is  most  frequently  seen 
ill  fatty  and  fibroid  changes  in  the  heart,  but  is  not  constant  in  them,  (r)) 
In  diseases  of  the  urinary  organs.     It  occurs  occasionally  in  nephritis  and 


760 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


.  \ 
/ 


may  bo  a  feature  of  uiwinia.  (0)  From  the  action  of  toxic  agents.  It  occurss 
in  urtrniia,  ])oisoning  by  lead,  alcohol,  and  follows  the  use  of  tobacco, 
colfec,  and  digitalis.  (7)  In  constitutional  disorders,  such  as  anaemia, 
chlorosis,  and  dial)etes.  (S)  In  diseases  of  the  nervous  system.  Apoplexy, 
ei)ilei)sy,  the  cerebral  tumors,  affections  of  the  medulla,  and  diseases  and 
injuries  of  the  cervical  cord  may  be  associated  with  very  slow  pulse.  In 
general  i)aresis,  mania,  and  melancholia  it  is  not  infrequent.  (9)  It  occurs 
occasionally  in  alfeetions  of  tlie  skin  and  sexual  organs,  and  in  sunstroke, 
or  in  ])rolongcd  exhaustion  from  any  cause. 

The  Stokes-Adams  Syndrome. — Sluw  Pulse  with  Syncopal  AUacls. — 
Ko])crt  Adams  and  Stokes  described  a  remarkable  condition  in  which  the 
])idse  was  permanently  slow  in  association  with  attacks  of  syncojjc.  The 
])atients  are  usually  advanced  in  years  and  show  an  extreme  grade  of  arterio- 
sclerosis. The  ])ulse-rate  may  be  30  or  'ZO  to  the  minute,  or,  as  in  Prentice's 
case,  as  low  as  12,  or  even  10  or  5.  The  cerebral  symptoms  are  very  re- 
markable, and  Stokes  suggested  for  them  the  name  of  false  or  pseudo- 
ai)oplexy.  Attacks  of  vertigo,  which  may  recur  several  times  in  the  day, 
attacks  of  syncojjc,  in  which  the  patient  is  insensible  for  four  or  five  min- 
utes, or  epileptiform  attacks,  as  in  Ogle's  cases,  are  the  most  pronounced 
cerebral  symptoms.  Huchard  regards  the  condition  as  the  result  of  changes 
in  the  pneumogastric  centres  due  to  disease  of  the  arteries  of  the  medulla. 
{See  Tiecture  IV  in  my  monograph  on  Angina  Pectoris  and  Allied  States.) 

Treatment  of  Palpitation  and  Arrhythmia. — An  important 
element  in  many  cases  is  to  get  the  patient's  mind  quieted,  and  he  can  be 
assured  that  there  is  no  actual  danger.  The  mental  element  is  oftentimes 
very  strong.  In  palpitation,  before  using  medicines,  it  is  well  to  try  the 
effect  of  hygienic  measures.  As  a  rule,  moderate  exercise  may  be  taken 
with  advantage.  Regular  hours  should  be  kept,  and  at  least  ten  hours 
out  of  the  twenty-four  should  be  spent  in  the  recumbent  posture.  A  tepid 
bath  may  be  taken  in  the  morning,  or,  if  the  patient  is  weakly  and  nerv- 
ous, in  the  evening,  followed  by  a  thorough  rubbing.  Hot  baths  and  the 
Turkish  bath  should  be  avoided.  The  dietetic  management  is  most  im- 
portant. It  is  best  to  prohibit  absolutely  alcohol,  tea,  and  coffee.  The 
<liet  should  be  light  and  the  patient  should  avoid  taking  large  meals.  Arti- 
cles of  food  known  to  cause  flatulency  should  not  be  used.  If  a  smoker, 
the  patient  should  give  up  tobacco.  Sexual  excitement  is  particularly 
pernicious,  and  the  patient  should  be  warned  specially  on  this  point.  For 
the  distressing  attacks  of  palpitation  which  occur  with  neurasthenia,  par- 
ticularly in  Avomcn,  a  rigid  Weir  Mitchell  course  is  the  most  satisfactory. 
It  is  in  these  cases  that  we  find  the  most  distressing  throbbing  in  the  abdo- 
men, which  is  apt  to  come  on  after  meals,  and  is  very  much  aggravated 
by  flatulency.  The  cases  of  palpitation  due  to  excesses  or  to  errors  in  diet 
tind  dyspepsia  are  readily  remedied  by  hygienic  measures. 

A  course  of  iron  is  often  useful.  Strychnia  is  particiilarly  valuable, 
and  is  perhaps  best  administered  as  the  tincture  of  nux  vomica  in  large 
doses.  Very  little  good  is  obtained  from  the  smaller  quantities.  It  should 
be  given  freely,  20  minims  three  times  a  day. 

If  there  is  great  rapidity  of  action,  aconite  may  be  tried  or  veratrum 


It  occur? 
)f  tobacco, 
IS   nnajiuiti, 

Apoplexy, 
isoases  and 

l)ulse.  In 
)  li  occurs 

sunstroke, 

At  I  a  els. — 

Avliich  tlio 

:opo.     The 

of  arterio- 

i  Prentice's 

re  very  re- 

or  pscudo- 

n  the  day, 

r  five  min- 

)ronounced 

of  changes 

le  meduUa. 

led  States.) 

important 

he  can  be 

oftentimes 

to  try  the 

be  taken 

:en  hours 

:\.  tepid 

and  nerv- 

is  and  the 

most  ini- 

ee.     The 

s.    Arti- 

a  smoker, 

irticuLarly 

)int.     For 

enia,  par- 

isfactory. 

the  abdo- 

ggravatcd 

•rs  in  diet 

valuable, 
in  large 
It  should 

veratrum 


ik 


NEUROSES  OP  THE  HEART. 


761 


viride.  There  are  cases  associated  with  slee})lessness  and  restlessness  which 
are  greatly  benefited  by  bromide  of  jjotassiuni.  Digitalis  is  very  rarely 
indicated,  but  in  obstinate  cases  it  may  be  tried  with  the  nux  vomica. 

Cases  of  heart  hurry  arc  often  extremely  obstiiuite,  as  may  be  judged 
from  the  case  of  the  physician  reported  by  II.  C.  Wood,  in  whom  the  con- 
dition persisted  in  spite  of  all  measures  for  fifty  years.  The  bromides  are 
sometimes  useful;  the  general  condition  of  neurasthenia  should  be  treated, 
and  during  tlie  paroxysm  an  ice-bag  may  be  placed  upon  the  heart,  or 
Jiciter's  coil,  through  which  ice-water  may  be  i)assed.  Electricity,  in  the 
form  of  galvanism,  is  sometimes  serviceable,  and  for  its  mental  elfect  the 
Franklinic  current.  For  the  condition  of  slow  jjulse  but  little  can  be  done. 
A  great  majority  of  the  eases  are  not  dangerous. 

Angina  rECToius. 

Stenocardia,  or  the  breast-pang,  described  by  Ileberden,  is  not  an  inde- 
pendent affection,  but  a  symptom  associated  with  a  number  of  morbid 
conditions  of  the  heart  and  vessels,  more  particularly  with  sclerosis  of 
the  root  of  the  aorta  and  changes  in  the  coronary  arteries.  True  angina, 
hicli  is  a  rare  disease,  is  characterized  by  paroxysms  of  agonizing  pain 
n  the  region  of  the  heart,  extending  into  the  arms  and  neck.  In  violent 
attacks  there  is  a  sensation  of  impending  death. 

Etiology. — It  is  a  disease  of  adult  life  and  occurs  almost  exclusively 
in  men.  In  Iluchard's  statistics  of  237  cases  only  42  were  in  women.  In  my 
series  of  40  cases  there  was  only  one  woman.  It  may  occur  through  several 
generations,  as  in  the  Arnold  family.  Gout,  diabetes,  and  syphilis  are  im- 
l)ortant  factors.  A  number  of  cases  of  angina  pectoris  have  followed  influ- 
enza. Attacks  are  not  infrequent  in  certain  forms  of  heart-disease,  par- 
ticularly aortic  insufficiency  and  adherent  pericardium.  It  is  much  less 
common  in  disease  of  the  mitral  valve.  Almost  without  exception  the  sub- 
jects of  true  angina  have  arterio-sclerosis,  either  general  or  localized,  at  the 
root  of  the  aorta,  with  changes  in  the  coronary  arteries  and  in  the  myo- 
cardium. 

Phenomena  of  the  Attack. — The  exciting  cause  is  in  a  majority  of  all 
cases  well  defined.  In  only  rare  instances  do  the  patients  have  attacks 
when  quiet.  They  come  on  during  exertion  most  frequently,  as  in  walking 
u]i  hill  or  something  entailing  sudden  muscular  effort;  occasionally  even  the 
effort  of  dressing  or  of  stooping  to  lace  the  shoes  may  bring  on  a  paroxysm, 
^rental  emotion  is  a  second  very  potent  cause.  John  Hunter  appreciated 
this  when  he  said  that  "  his  life  was  in  the  hands  of  any  rascal  who  chose 
to  annoy  and  tease  him."  In  his  case  a  fatal  attack  occurred  during  a  fit 
of  anger.  A  third,  and  in  many  instances  the  most  important,  factor  i.:; 
Ihitulent  distention  of  the  stomach.  Another  common  exciting  .ause  is 
cold;  even  the  chill  of  getting  out  of  bed  in  the  morning  or  on  bathing 
may  bring  on  a  paroxysm. 

Usually  during  exertion  or  intense  mental  emotion  the  patient  is  seized 
Avlth  an  agonizing  pain  in  the  region  of  the  heart  and  a  sense  of  constric- 
tion, as  if  the  heart  had  been  seized  in  a  vice.     The  pains  radiate  up  the 


762 


DISEASES  OF  THE  CIRCULATOIIY  SYSTEM. 


/ 


iiuck  and  down  the  iirni,  and  thcro  may  be  nuniI)no.s.s  of  tlio  fingers  or  in 
tlic  cardiac  rc^non.  'I'lic  I'ace  is  uyiialiy  i)allid  and  Jiuiy  assuiuc  an  ashy- 
gray  tint,  and  not  inircquciitly  a  protusc  sweat  hrcaivs  out  over  tlic  surface. 
Tlie  paroxysm  lasts  from  several  seconds  to  a  minute  or  two,  during  which, 
in  severe  attacks,  the  patient  feels  as  if  death  were  imminent.  As  jjointed 
out  by  Latham,  there  are  two  elements  in  tlie  paroxysm,  the  i)ain — dolDr 
pectoris — and  the  indescribable  feeling  of  anguish  and  sense  of  imminent 
dissolution — aiujor  uiiiiiii.  There  are  great  restlessness  and  anxiety,  and 
the  patient  may  dro})  dead  at  the  height  of  the  attack  or  faint  and  pass  away 
in  syncope.  'J'he  condition  of  the  heart  during  the  attack  is  variable;  the 
l)ulsations  may  be  uniform  and  regular.  The  pulse  tension,  however,  is 
usually  increased,  but  it  is  surprising,  even  in  cases  of  extreme  severity, 
how  slightly  the  character  of  the  jjuIsc  may  be  altered.  After  the  attack 
there  may  be  eructations,  or  the  passage  of  a  large  quantity  of  clear  urine. 
The  paticjit  usually  feels  exhausted,  and  for  a  day  or  two  may  be  badly 
shaken;  in  other  instances  in  an  hour  or  two  the  ])atient  feels  himself 
again.  While  dyspiura  is  not  a  constant  feature,  the  ])aroxysm  is  not  infre- 
quently associated  with  a  form  of  asthnm;  there  is  wheezing  in  the  bron- 
chial tubes,  which  may  come  on  very  rapidly,  and  the  patient  gets  short  of 
breath.  j\rany  patients  the  subject  of  angina  die  suddenly  without  warn- 
ing and  not  in  a  ])aroxysm.  In  other  instances  death  follows  in  the  first 
well-marked  i)aroxysm,  as  in  the  case  of  Thomas  Arnold.  In  a  third  group 
there  are  recurring  attacks  over  long  periods  of  years,  as  in  John  Hunter's 
ease;  while  in  a  fourth  group  of  cases  there  are  rapidly  recurring  attacks 
for  several  days  in  succession,  with  progressive  and  increasing  weakness 
of  the  heart. 

With  reference  to  the  radiation  of  pain  in  angina,  the  studies  of  Mac- 
kenzie and  of  Head  are  of  great  interest.  Head  concludes  that  (1)  in  dis- 
eases of  the  heart,  and  more  ])articularly  in  aortic  disease,  the  pain  is  re- 
ferred along  the  first,  second,  third,  and  fourth  dorsal  areas;  (2)  in  angina 
jjcctoris  the  pain  may  be  referred  in  addition  along  the  fifth,  sixth,  and 
seventh,  and  even  the  eighth  and  ninth  dorsal  areas,  and  is  always  accom- 
panied by  pain  in  certain  cervical  areas. 

Theories  of  Angina  Pectoris. — (1)  That  it  is  a  neuralgia  of  the  cardiac 
nerves.  In  the  true  form  the  agonizing  cramp-like  character  of  the  pain, 
the  suddenness  of  the  onset,  and  the  associated  features,  are  unlike  any 
neuralgic  affection.  Tlie  pain,  however,  is  undoubtedly  in  the  cardiac 
plexus  and  radiates  to  adjacent  nerves.  It  is  interesting  to  note,  in  con- 
nection with  the  almost  constant  sclerosis  of  the  coronary  arteries  in  an- 
gina, that  Thoma  has  found  marked  sclerosis  of  the  temporal  artery  in 
migraine  and  Dana  has  met  with  local  thickening  of  the  arteries  in  some 
cases  of  neuralgia.  (2)  Ileberden  believes  tiiat  it  was  a  cramp  of  the  heart- 
muscle  itself.  Cramp  of  certain  muscular  territories  woidd  better  ex- 
])lain  the  attack.  (3)  That  it  is  due  to  the  extreme  tension  of  the  ven- 
tricular walls,  in  conseiiuence  of  an  acute  dilatation  associated,  in  the  ma- 
jority of  cases,  with  affection  of  tlie  coronary  arteries.  Traube,  who  sup- 
])orted  this  view,  held  that  the  agonizing  pain  resulted  from  the  great 
stretching  and  tension  of  the  nerves  in  the  muscular  substance.    A  modi- 


ngcrs  or  in 
ic  an  a.sliv- 
111'  surraco. 
■ing  wliicli. 
As  pointed 
lain — dolor 

imminent 
ixioty,  and 
1  jiass  awiiy 
rialiie;  tlu' 
lowcvcr,  is 
le  severity, 
the  attaclc 
:lear  nrine. 
)'  be  badly 
ils  himself 
1  not  infre- 

the  bron- 
ts  short  oi" 
lout  warn- 
n  the  first 
hird  group 
1  Hunter's 
ng  attacks 

weakness 

s  of  jNIac- 
(1)  in  dis- 
ain  is  re- 
in angina 
ixth,  and 
ys  acconi- 

e  cardiac 
the  pain, 
nlike  any 
e  cardiac 
2,  in  con- 
es in  an- 
artcry  in 
F  in  some 
le  heart- 
etter   ex- 
the  ven- 
tlie  ma- 
who  su Ji- 
ll e  great 
A  modi- 


NEUROSES  OP  THE  HEART. 


iC3 


(led  form  of  this  view  is  that  there  is  u  spasm  of  the  coronary  arteries  with 
great  increase  of  the  intracardiac  pressure. 

(-1)  The  theory  of  Allan  lUirns,  revived  I)y  I'otaiii  and  others,  that  the 
condition  is  one  of  transient  iscluemia  of  the  heart-muscle  in  consequence 
of  disease,  or  spasm,  of  the  coronary  arteries.  'J'lie  condition  known  as 
intermittent  claudication  illustrates  what  may  take  place.  In  man  (and 
ill  the  horse),  in  consequence  of  thrombosis  of  the  abdominal  aorta  or 
iliacs,  transient  parajilegia  and  s}iasm  may  follow  exertion.  The  collateral 
circulation,  ami»le  when  the  limbs  are  at  rest,  is  insuilicient  after  the  mus- 
cles are  actively  used,  and  a  state  of  relative  ischa.'mia  is  induced  with  1(jss 
of  power,  which  disajipcars  in  a  short  time.  This  "intermittent  claudica- 
tion" theory  has  been  ajiplied  to  explain  the  angina  paroxysm.  A  heart 
the  coronary  arteries  of  which  are  sclerotic  or  calcilied,  is  in  an  analogous 
state,  and  any  extra  exertion  is  likely  t.  be  followed  by  a  relative  iscluemia 
and  spasm,  Jn  Allan  JUirns's  work  on  The  Heart  (ISOD)  the  theory  is  dis- 
cussed at  length,  but  he  does  not  think  that  spasm  is  a  necessary  acconi- 
jiaiiiment  of  the  ischa^'mia. 

Jn  fatal  cases  of  angina  the  coronary  arteries  are  almost  invariably  dis- 
eased either  in  their  main  divisions,  or  there  is  chronic  endarteritis  with 
great  narrowing  of  the  orifices  at  the  root  of  the  aorta.  Experimentally, 
occlusion  of  the  coronary  arteries  produces  slowing  of  the  heart's  action, 
gradual  dilatation,  and  death  within  a  very  few  minutes.  Cohnhcim  has 
shown  that  in  the  dog  ligation  of  one  of  the  large  coronary  branches  pro- 
duces within  a  minute  a  condition  of  arrhythmia,  and  within  two  minutes 
the  heart  ceases  in  diastole.  These  experiments,  however,  do  not  throw 
much  light  upon  the  etiology  of  angina  pectoris.  Extreme  sclerosis  of  the 
coronary  arteries  is  common,  and  a  large  majority  of  the  cases  present  no 
symptoms  of  angimi.  Even  in  the  cases  of  sudden  death  due  to  blocking 
of  an  artery,  jiarticularly  the  anterior  branch  of  the  coronary  artery,  there 
is  usually  no  great  ]iain  either  before  or  during  the  attack. 

Diagnosis. — There  are  many  grades  of  true  angina.  A  man  may  have 
slight  jinccordial  pain,  a  sense  of  distress  and  uneasiness,  and  radiation  of 
the  pains  to  the  arm  and  neck.  Such  attacks  following  slight  exertion,  an 
indiscretion  in  diet,  or  a  disturbing  emotion,  may  alternate  with  attacks 
of  much  greater  severity,  or  they  may  occur  in  connection  with  a  pulse  of 
increased  tension  and  signs  of  general  arterio-sclerosis.  Tn  the  milder 
grades  tlie  diagnosis  cannot  rest  upon  the  symptoms  of  the  attack  itself, 
since  they  may  be  simulated  liy  the  jiseudo-angina;  but  the  diagnosis  should 
be  based  upon  the  examination  of  the  heart  and  arteries  and  a  careful  con- 
sideration of  the  mode  of  onset  and  symptoms.  The  cases  of  pseudo-angina 
])ectoris  in  women  are,  after  all,  the  ones  which  call  for  the  greatest  care 
in  the  diagnosis,  and  attention  to  the  jioints  given  in  the  table  of  Huchard 
will  be  of  the  greatest  aid. 

Pseudo-Angina  Pectoris. — False  angina  may  be  divided  into  two  main 
groups,  the  neurotic  and  the  toxic.  The  former  embraces  tlie  hysterical 
and  neurasthenic  cases,  which  are  very  common  in  women.  ITuchard  has 
given  an  excellent  differential  table  between  the  true  and  the  spurious  at- 
tacks. 


ro4 


DISEASES  OF  THE  CIRCULATORY  SYSTEA^ 


I 


TBUE   ANGINA. 

Most  common  between  the  ngcs 
of  forty  and  fifty  years. 

Most  common  in  men.  AttacivS 
l)rou<^lit  on  by  exertion. 

AttacivS  rarely  periodical  or  noc- 
turnal. 

Not  associated  with  other  symp- 
toms. 

A'aso-motor  form  rare.  Agoniz- 
ing pain  and  sensation  of  compres- 
sion by  a  vice. 

Pain  of  short  duration.  Atti- 
tude: silence,  immobility. 

Lesions  :  sclerosis  of  coronary 
artery. 

Prognosis  grave,  often  fatal. 

Arterial  medication. 


PSEUDO-AXOINA. 

At  every  age,  even  six  years. 

Most  common  in  women.  At- 
tacks spontaneous. 

Often  })eriodical  and  nocturnal. 

Associated  with  nervous  symp- 
toms. 

Yaso-motor  form  common.  Pain 
less  severe;  sensation  of  distention. 

Pain  lasts  one  or  two  hours.  Agi- 
tation and  activity. 

Neuralgia  of  nerves  and  cardio- 
l)lexus. 

Never  fatal. 

Antineuralgic  medication. 


A  form  which  Nothnagel  has  described  as  vaso-moior  angina  is  not  infre- 
quent. The  symptoms  set  in  with  coldness  and  numljness  in  the  extremi- 
ties, followed  by  great  ])ra^cordial  pain  and  feelings  of  faintness.  Some 
have  recognized  also  a  reilex  variety. 

Toxic  Angina. — This  embraces  cases  due  to  the  abuse  of  tea,  coffee,  and 
tobacco.  There  are  three  groups  of  cases  of  so-called  tobacco  heart:  First, 
the  irritable  heart  of  smokers,  seen  ])articularly  in  young  lads,  in  which 
the  symptoms  arc  pa]])itation,  irregularity,  and  rapid  action;  secondly, 
heart  pain  of  a  sharp,  shooting  character,  which  may  l)e  very  severe;  and, 
thirdly,  attacks  of  such  severity  that  they  deserve  the  name  of  angina. 
Huchard  remarks  that  they  are  usually  of  the  vaso-motor  type,  accom- 
])anied  with  chilling  of  tlic  extremities,  feeble  pulse,  and  a  tendency  to  syn- 
cope. This  author  distinguishes  between  functional  tobacco  angina,  due, 
he  thinks,  to  spasmodic  contraction  of  the  coronary  arteries,  and  an  organic 
tol)acco  angina  due  to  a  nicotine  arterio-sclerosis  of  these  vessels. 

Prognosis. — Cardiac  pain  without  evidence  of  arterio-sclerosis  or 
valve-disease  is  not  of  much  moment.  True  angina  is  almost  invariably 
associated  with  marked  cardio-vascular  lesions,  in  which  the  prognosis  is 
always  grave.  "With  judicious  treatment  the  attacks,  however,  may  be 
long  deferred,  and  a  few  instances  recover  completely.  The  prognosis  is 
naturally  more  serious  with  aortic  insufficiency  and  advanced  arterio-scle- 
rosis. Patients  who  have  had  well-marked  attacks  may  live  for  many  years,, 
but  much  depends  upon  the  care  with  which  they  regulate  their  daily  life. 

Treatment. — Patients  subject  to  this  affection  should  live  a  quiet 
life,  avoiding  particularly  excitement  and  sudden  muscular  exertion.  Dur- 
ing the  attack  nitrite  of  amyl  should  be  inhaled,  as  advised  by  Lauder 
Brunton.  From  2  to  5  drops  may  be  placed  ujion  cotton-wool  in  a 
tumbler  or  upon  the  handkerchief.  This  is  frequently  of  great  service  in 
the  attack,  relieving  the  agonizing  pain  and  distress.    Subjects  of  the  dis- 


w 
\i\ 

ol 
()> 
ot 


CONGENITAL  AFFECTIONS  OF  THE   IIKAUT. 


705 


years. 

men.     At- 

locturnal. 

ous   symp- 

iion.    Pain 
istontion. 


5urs.    Agi- 


nd  cardio- 


on. 

not  infrc- 
e  extremi- 
ss.     Some 

?offee,  and 
art:  First, 
in  whieli 
secondly, 
ere;  and, 
angina, 
accom- 
y  to  syn- 
ina,  due, 
n  organic 

crosis  or 
ivariably 
gnosis  is 

may  be 

gnosis  is 

erio-sclo- 

ly  years,. 

lily  life. 

a  quiet 
1.    Dur- 

Lauder 
ol  in  a 
rvice  in 
the  dis- 


ease should  carry  the  pcrlcs  of  the  nitrite  of  amyl  with  them,  and  use  them 
(in  tlie  lirst  indication  of  an  attack.  In  some  instances  tlie  nitrite  oi  amyl 
is  quite  powerless,  though  given  freely.  If  within  a  minute  or  two  relief  is 
not  obtained  in  this  way,  chloroform  should  at  once  be  given.  A  few  in- 
halations act  promi)tly  and  give  great  relief.  Should  the  pains  continue, 
a  hyi)odermic  of  morphia  nuiy  be  a(hninistercd.  In  severe  and  repeated 
paroxysms  a  patient  may  display  remarkable  resistance  to  the  action  of 
this  drug. 

In  the  intervals,  nitroglycerin  may  be  given  in  full  doses,  as  recom- 
jiiended  by  jMurrell,  or  the  nitrite  of  sodium  (^hitthew  Hay).  The  nitro- 
glycerin should  be  used  for  a  long  time  and  in  increasing  doses,  beginning 
with  1  minim  three  times  a  day  of  the  1-per-cent  solution,  and  increas- 
ing the  dose  1  minim  every  five  or  six  days  until  the  patient  complains 
of  ihishing  or  headache.  The  fluid  extract  of  English  hawthorn — crategus 
oxyacantha — has  been  strongly  recommended  by  Jennings,  Clements,  and 
others. 

Iluchard  recommends  the  iodides,  believing  that  their  prolonged  use 
influences  the  arterio-sclerosis.  Twenty  grains  three  times  a  day  may  be 
given  for  several  years,  omitting  the  medicine  for  about  ten  days  in  each 
month.  In  some  instances  this  treatment  is  certainly  beneficial.  Two 
men,  both  with  arterio-sclerosis,  ringing,  accentuated  aortic  sound,  and 
attacks  of  true  angina,  have  under  its  use  remained  jiractically  free  from 
attacks — one  case  for  nearly  three,  and  the  other  for  fully  eight  years. 
This  treatment  is,  however,  not  always  satisfactory,  and  I  have  had  several 
cases  in  which  the  condition  has  not  been  at  all  relieved  by  it. 

For  the  pseudo-angina,  the  treatment  must  be  directed  to  the  general 
nervous  condition.  Electricity  is  sometimes  very  beneficial,  i)arlicularly 
the  Franklinic  xorm. 


VI.    CONGENITAL   AFFECTIONS    OF   THE    HEART. 

These  have  only  a  limited  clinical  interest,  as  in  a  large  proportion  of 
the  cases  the  anomaly  is  not  compatible  with  life,  and  in  others  nothing 
can  be  done  to  remedy  the  defect  or  even  to  relieve  the  symptoms. 

The  congenital  affections  result  from  interru])tion  of  the  normal  course 
of  development  or  from  inflammatory  processes — endocarditis;  sometimes 
from  a  combination  of  both. 

(a)  Of  (jeneral  anomalies  of  development  the  following  conditions  may 
be  mentioned:  Acardia,  absence  of  the  heart,  which  has  been  met  with 
in  the  monstrosity  known  by  the  same  name;  dnnhle  heart,  which  has  occa- 
sionally boon  found  in  extreme  grades  of  fictal  deformity;  dextrocardia, 
in  which  the  heart  is  on  the  right  side,  cither  alone  or  as  part  of  a  general 
transposition  of  the  viscera;  ectopia  cordite,  a  condition  associated  with 
fission  of  the  chest  wall  and  of  the  abdomen.  The  heart  may  bo  situated 
in  the  cervical,  pectoral,  or  abdominal  regions.  Except  in  the  abdominal 
varietv  the  condition  is  very  rarely  compatible  with  -extra-uterine  life. 
Occasionally,  as  in  a  case  reported  by  ITolt,  the  child  lives  for  some  months,. 


706 


DISEASKS  OF  THE  CIRCULATORY  SYSTEM. 


/ 


nnd  lli(>  lioirl  nuiy  l)o  seen  and  folt  bcatiiij;  Lcnont])  ilic  skin  In  tlic  cpi- 
^fjistric  r»';^ioii.     'I'liis  infiiiit  was  (ivc!  luoiitlis  old  at  the  dale  of  cxamiiia 
lion. 

(/>)  Anomalies  of  the  Cardiac  Septa. — The  septa  of  holh  auricles  and 
ventricles  may  ho  dofcctive,  in  which  case  the  heart  consists  of  but  two 
ciianihers,  the  cor  hildnihirc  or  reptilian  heart.  In  the  septnni  of  the  auri- 
cles there  is  a  very  common  detect,  ()\vin<;  to  the  fact  that  the  mcMuhrane 
closiu},'  the  loramcn  ovale  has  failed  at  one  point  to  hecoine  attached  to  the 
rin<j,  and  leavi'S  a  valvular  slit  which  may  he  lar;j;o  enou«,di  to  admit  the 
luindle  oi'  a  scalpel.  Neither  thi.s  nor  the  small  crihriforni  perl'orations  of 
the  nuMuhrane  are  of  any  si<i:ni(icance. 

The  foramen  ovale  may  be  patent  without  a  trace  of  nuMnbranc  closing 
it.  In  some  instances  this  exists  with  other  serious  doi'octs,  such  as  steno- 
sis of  the  ])ulmonary  artery,  or  imperfection  of  the  ventricular  se[)tuni. 
In  others  tlie  i)atent  foramen  ovale  is  the  oidy  anomaly,  and  in  many  in- 
stances it  does  not  appear  to  have  caused  any  eml)arrassment,  as  the  con- 
dition has  been  found  in  i)ersons  who  have  died  of  various  all'ections.  The; 
ventricular  septum  may  be  absent,  the  condition  known  as  trilocular  heart. 
;Muc1i  more  frecpiently  there  is  a  small  defect  in  the  upper  ])ortion  of  the 
se])tuni,  either  in  the  situation  of  the  nuMnbranous  ])ortion  kiu)wn  as  the 
*•  undefended  sj)ace  "  or  in  the  rej^ion  situated  just  anterior  to  this.  Tlu; 
anomaly  is  very  frecpiently  associated  with  narrowin<f  of  the  pidmonary 
orifice  or  of  the  conns  arteriosus  of  the  right  ventricle. 

(r)  Anomalies  and  Lesions  of  the  Valves. — Numerical  anomalies  of  the 
valves  are  not  uncommon.  The  semilunar  segments  at  the  arterial  orifices 
are  not  infrequently  increased  or  diminished  in  number.  Supernumerary 
segments  are  more  frequent  in  the  jmlmonary  artery  than  in  the  aorta. 
Four,  or  sometimes  five,  valves  have  been  found.  The  segments  nuiy  be  of 
e(pml  size,  but,  as  a  rule,  the  su])ernunierary  valve  is  small. 

Instead  of  three  tliere  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  bicuspid  coiulilion.  In  my  experience,  this  is  most  frequent 
in  the  aortic  valve.  Of  21  instances  only  2  occurred  at  the  pulmonary 
orifice.  Two  of  the  valves  have  united,  and  from  ^iie  ventricular  face 
show  either  no  trace  of  division  or  else  a  slight  depression  indicating  wliere 
the  union  had  occurred.  From  the  aortic  side  there  is  usually  to  be  seen 
some  trace  of  division  into  two  sinuses  of  Valsalva.  There  has  been  a  dis- 
cussion as  to  the  origin  of  this  condition,  whether  it  is  really  an  anomaly 
or  whether  it  is  not  due  to  endocarditis,  fecial  or  post-natal.  The  com- 
bined segment  is  usually  thickened,  but  the  fact  that  this  anomaly  is  met 
with  in  the  foetus  without  a  trace  of  sclerosis  or  endocarditis  shows  that  it 
may,  in  some  cases  at  least,  result  from  a  develo]imental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the 
liability  of  the  combined  valve  to  sclerotic  changes.  Except  two  foetal 
specimens  all  of  my  cases  showed  thickening  and  deformity,  and  in  15 
of  those  which  I  have  reported  death  resulted  directly  or  indirectly  from 
the  lesion. 

The  little  fenestrations  at  the  margins  of  the  sigmoid  valves  have  no 
significance;  they  occur  in  a  considerable  proportion  of  all  bodies. 


n  llic  cpi- 
t'  e.xamina- 

iriclcs  and 
)!'  Itiit  two 
r  the  auri- 
mombrano 
lu'd  to  the 
admit  till' 
jnitiuas  oL' 

me  closiiif^ 
1  as  stcno- 
ir  st'i)tiim. 
I  many  in- 
is  the  con- 
ions.  Tli(" 
ular  licart. 
ion  of  tiie 
)\\n  as  tlio 

tills.       Th(! 

l)ulnu)nary 

lies  of  the 
ial  orifices 
rmiiiiorary 
the  aorta, 
may  bo  of 

,  as  it  is 

frequent 

)idinonary 

uhir   face 

n<j;  wliere 

o  be  seen 

een  a  dis- 

ariomaly 

'ho  com- 

ly  is  met 

ivs  that  it 

,(,'•  to  tlie 
wo  foot  a  1 
nd  in  15 
?tly  from 


have  no 


}S. 


CONGKXITAL  AFPiM'TIONS  OP  TIIK   IIKAKT. 


ro7 


Anomalies  of  tlie  aui'ieuio-ventricnhir  \al\i's  are  not  often  nut  with. 

FoBtal  endocarditis  niiiy  occur  either  nt  the  mtciial  or  aurienlo-ven- 
trieidar  orilict's.  it  is  nearly  always  of  the  chronic  or  sclerotic  variety. 
\'ery  rarely  indeed  is  it  of  the  warty  or  veriucose  form.  There  are  liltlo 
no(hdar  bodies,  souK.'times  six  or  ei^dit  in  nnnd)er,  on  (he  mitral  and  tri- 
(  iispid  se^Muents — the  no(hdes  of  Albini — which  represent  the  remains  of 
lietal  structures,  and  must  not  he  mistaken  I'oi'  cndoeanHal  <ud|^rowths. 
The  little  rounded,  beatl-like  hii'nu)rrhages  (d'  a  deep  purple  color,  which 
are  very  common  on  the  heart  valves  (d'  children,  ai'e  also  not  to  he  mis- 
lidxcn  for  the  products  of  endocarditis.  In  fietal  endocarditis  (he  se<,Mnent9 
iire  usually  thickened  at  (he  ed<i,('s,  shrunken,  and  smooth,  in  the  mitral 
;ind  tricuspid  valves  (he  cusps  are  found  united  and  the  chord:e  (endinea' 
;iiv  (hickened  ami  shor(ened.  in  (he  semilunar  valves  all  trace  of  (he 
se^xments  has  disappeared,  lcavin«(  a  stilf  nu'nd)ranous  diaphrajiui  per- 
forated by  an  oval  or  I'ounded  orilice.  I(  is  sonu'tinies  very  diilicult  (o  say 
whether  this  condition  has  resuUed  fr(un  fietal  endocarditis  or  whether  it 
is  an  error  in  developnu'id.  In  very  many  instances  (he  jjrocesses  are 
(•(unbined;  an  anomalous  valve  becomes  (he  seat  of  chronic  sclerotic 
clian^cs,  and,  according  to  Kauchfuss,  emloearilitis  is  more  comnu)n  on 
the  ri<iht  side  of  the  heart  oidy  because  the  valves  are  hero  nujst  often  the 
seat  of  devclopnu'ntal  errois. 

Lesions  at  the  Pulmonary  Orifice. — Slcnasis  of  this  oriiiee  is  one  of  the 

connnonest  and  most  imi)or(an(  of  congenital  heart  aU'ections.  A  slow 
endocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the 
orifice  to  such  a  degree  that  it  oidy  admits  the  snudlest-sized  ])robe.  In 
sonu."  of  the  cases  the  snu)otli  mendiranous  condition  of  the  combined  seg- 
ments is  such  that  it  would  ajija'ar  to  be  the  resuH  of  faulty  development. 
In  some  instances  vegetations  develo[).  The  condition  is  compatihle  with 
life  for  many  years,  and  in  a  considerable  proi)ortion  of  the  cases  of  heart- 
disease  above  the  tenth  year  this  lesion  is  present.  With  it  there  may  l)e 
defect  of  the  ventricular  septum.  Pulmonary  tuberculosis  is  a  very  common 
cause  of  death.  Oblitei'ation  or  alresia  of  the  puhnonary  orifice  is  less  fre- 
(|Ueut  but  a  more  serious  condition  than  stenosis,  it  is  associated  with  de- 
fect of  the  ventricular  septum  or  i)ntency  of  the  foramen  ovale  and  per- 
sistence of  the  ductus  arteriosus  with  hypertrophy  of  the  right  heart.  Sle- 
Hosis  of  ilw  cDinis  (irlcridsiis  of  the  right  ventricle  exists  in  a  consideral)le 
|)ro])ortion  of  the  cases  of  obstruction  at  the  ])ulmonary  orifice.  At  the  ont- 
set  a  dovelojnnental  error,  it  may  be  combined  with  sclerotic  changes.  The 
ventricular  septum  is  lm])erfect,  (he  foramen  ovale  Is  usually  open,  and  (he 
ductus  arteriosus  jiatent.  Those  three  lesions  at  the  pulmonary  orifice 
constitute  the  most  important  group  of  all  congenital  cardiac  alfections. 
Of  181  inslanies  of  various  congenital  anomalies  collected  by  Peacock  110 
cases  came  under  this  category,  aiul,  according  to  this  author,  in  81!  per 
cent  of  the  patients  living  beyond  the  twelfth  year  the  lesion  is  at  this 
orifice. 

Con(]enUal  lesions  of  lite  aorlic  ori/irc  are  not  very  frequent.     ]?auchfus3 
has  collected  24  eases  of  stenosis  and  atresia;  stenosis  of  the  loft  conus 
arteriosus  may  also  occnr,  a  condition  which  is  not  incompatible  with  pro- 
48 


708 


DISKASMS   OF   TIIK   CIRCrLATOllY   SYSTKM. 


/ 


lnii;j:('(l  life.     'IVn  of  till'  1(1  C'i'si's  tiil)iiliit('<l  hy  Dilj^  were  over  thirty  years 
ol"  ii;,a'. 

Troiisposillon  of  llir  lun/r  (trlrrial  Iriiiils  is  n  not  unconininn  nnnmjilv. 
'J'iicrc  niiiy  l»i'  licit licr  liyitci'tropliy,  cyiiiiosis,  nor  In-art  iiiiiniiur. 

Symptoms  of  Congenital  Heart-disease. — Cyanosis  occurs  in 
over  !M)  per  cent  of  tlic  cases,  and  forms  so  distinctive'  a  feature  that  tlic 
terms  "  hhie  disease"  and  "  niorlms  ca-rulcus  "  are  practically  syiioiiyiiH 
for  eon;,'enital  lieart-disease.  'I'lie  lividity  in  a  majority  of  cases  appears 
early,  within  the  first  week  of  life,  and  may  he  general  or  condncd  to  the 
lips,  nose,  and  oars,  and  to  the  linj^ers  and  toes.  In  sonic  instances  there 
is  in  addition  a  jrenernl  dusky  sull'usion,  and  in  the  most  cxtromo  grades 
the  skin  is  alniosl  purple.  Jt  may  vary  a  good  deal  and  may  only  he  in- 
tense on  exertion.  'J'lie  external  teiiiperature  is  low.  J)ys[)nu'a  on  exertion 
and  cough  are  common  symptoms.  A  great  increase  in  the  numhor  of  the 
red  cori)Uscles  has  been  noted  hy  (Jihson  and  hy  A'aiiuez.  Jn  a  case  of  (Jih- 
son's  there  uere  above  eight  millions  of  red  blood-cor|)Uscles  to  the  cubic 
millimetre.  The  children  rarely  thrive,  and  often  display  a  lethargy  of  both 
mind  and  body.  The  lingers  and  toes  are  clubbed  to  a  degree  rarely  nu't 
with  in  any  other  aU'ection.  The  cause  of  the  cyanosis  has  been  much  dis- 
cussed. !^lorgagni  referred  it  to  the  general  congestion  of  the  venous  sys- 
tem due  t(j  obstruction,  and  this  view  was  supported  in  a  ])aper,  one  of  thr 
ablest  that  has  been  written  on  the  sul)ject,  by  Moreton  Stille.  Morrison's 
recent  aiuUysis  of  75  cases  of  congenital  heart-disease  shows  that  closure 
of  the  pulmonary  orifice  and  patency  of  the  foramen  ovale  and  the  ven- 
tricular se])tum  are  the  lesions  most  fre(piently  associated  with  cyanosis, 
and  he  concludes  that  the  deficient  aeration  of  the  blood  owing  to  dimin- 
ished lung  function  is  the  nu)st  important  factor.  Another  view,  advo- 
cated by  William  Hunter,  was  that  the  discoloration  Avas  due  to  the  ad- 
mixture in  the  heart  of  venous  and  arterial  blood;  but  lesions  may  exist 
which  permit  of  very  free  mixture  without  producing  cyanosis.  The  ques- 
tion of  the  cause  of  cyanosis  really  cannot  be  considered  as  settled.  A'ariol 
has  recently  made  the  suggestion  that  the  cause  is  not  entirely  cardiac,  but 
is  associated  with  disturbance  throughout  the  whole  circulatory  system,  and 
particularly  a  vaso-motor  paresis  and  malaeration  of  the  red  blood-cor- 
puscles. 

Diagnosis. — Tn  the  case  of  children,  cyanosis,  with  or  without  en- 
largement of  the  heart,  and  the  existence  of  a  murmur  are  sulficient,  as  a 
rule,  to  determine  the  presence  of  a  congenital  heart-lesion.  The  cyanosis 
gives  us  no  clew  to  the  precise  nature  of  the  trouble,  as  it  is  a  symptom 
common  to  many  lesions  and  it  may  be  absent  in  certain  conditions.  The 
murmur  is  usually  systolic  in  character.  It  is.  however,  not  always  pres- 
ent, and  there  are  instances  on  record  of  complicated  congenital  lesions  in 
which  the  examination  showed  normal  heart-sounds.  In  two  or  three  in- 
stances fu>tal  eiulocarditis  has  been  diagnosed  in  gravida  by  the  presence 
of  a  rough  systolic  murmur,  and  the  condition  has  been  corroborated  sub- 
sequent to  the  birth  of  the  child.  Hypertrophy  is  present  in  a  majority  of 
the  cases  of  congenital  defect.  The  fatal  event  may  be  caused  by  abscess 
of  the  brain.     It  is  impossible  in  a  work  of  this  sort  to  enter  upon  elabo- 


CONUKNITAL  AFFKCTlUNb  OF  TlIK   IlKAUT. 


709 


hirty  yonv< 

w  iinoiiinlv. 

occurs    ill 
I't'  that  tlic 
synonviii-i 
3C8  appears 
iiu'd  to  tilt' 
mccs  there 
I'lnc  <^ni(l('> 
only  ho  iii- 
on  exertion 
iilior  of  the 
■ase  oi'  (lih- 
3  the  cul)ic 
rgy  of  botii 
rarely  met 
1  much  dis- 
venous  sys- 
,  one  of  the 
Morrison's 
hat  chwun; 
id  the  ven- 
h  cyanosis 
;  to  dimin- 
iew,  advo- 
to  the  ad- 
may  exist 
The  ques- 
'd.     A'aridt 
■ardiac,  but 
v<tem,  and 
hlood-cor- 

ithout  en- 
icient,  as  a 
le  cyanosis 
I  symptom 
ions.  The 
ways  pros- 
lesions  in 
three  in- 
0  presence 
)rated  suh- 
najority  of 
by  abscess 
pon  elabo- 


rate di'tails  in  dilTerential  dia|,Mi(»sis  l)et\voen  the  various  c()ii<i;onital  heart- 
lesions.      1  here  iilistract  the  coiieliisions  of  !Ioelisinj,M'r: 

"(1)  In  childiiodd.  loud,  roii^ih.  iiiiisical  hearl-nmrniurs,  with  normal 
or  oidy  rtli^dit  increase  in  (he  heart -diihicss,  occur  only  in  congenital  hcart- 
diseuse.  The  accpiirod  endocardial  defects  with  loud  heart-murmurs  in 
young  children  are  almost  always  associated  with  great  increase  in  the 
lieart-dulness.  In  the  transposition  of  the  large  arterial  triinl<s  tliere  niuy 
ho  no  cyanosis,  no  heart-murmur,  and  an  al)sence  of  hypertruphy. 

"  {'i)  In  young  children  heurt-nuirmurs  with  great  increase  in  the  car- 
diac dulnoss  and  feeble  apex  beat  suggest  congi'iiital  ciianges.  The  in- 
creased diilness  is  chielly  of  the  right  heart,  whereas  the  left  is  only  slightly 
altered.  Un  the  other  hand,  in  the  actpiired  I'lidocarditis  in  children,  the 
left  heart  is  chielly  aU'ected  and  the  a|)ex  heat  is  visible;  the  dilatation  of 
the  right  heart  comes  late  and  does  not  materially  change  the  increased 
strength  of  the  apex  heat. 

'•  (."!)  Tlu'  entire  absence  of  miirniurs  at  the  apex,  with  their  evident 
presence  in  the  region  of  the  auricles  and  over  the  i)ulinonary  orillco,  is  al- 
ways an  important  element  in  diHerential  diagnosis,  and  points  rather  to 
t<e])tum  defect  or  })\ilmonary  stenosis  than  to  endocarditis. 

"  (1)  An  abnormally  weak  second  pulmonic  sound  associa(e(l  with  a 
distinct  systolic  murmur  is  a  symi)tom  which  in  early  childhood  is  only  to 
he  explained  by  the  assumption  of  a  congenital  pulmonary  stenosis,  and 
|)ossesses  therefore  an  importance  from  a  point  of  diU'erential  diagnosis 
which  is  not  to  be  underestimated. 

"  (.j)  Absence  of  a  i)alpable  thrill,  despite  loud  murmurs  which  are 
hoard  over  the  whole  priecordial  region,  is  rare  except  with  congenital  de- 
•"octs  in  the  septum,  and  it  speaks  therefore  against  an  accjuired  cardiac 
aH'oction. 

"  ((!)  Loud,  especially  vibratory,  systolic  murmurs,  with  the  point  of 
maximum  intensity  over  the  upper  third  of  the  sternum,  associated  with 
a  lack  of  marked  symptoms  of  hypertrophy  of  the  left  ventricle,  are  very 
inij)ortant  for  the  diagnosis  of  a  persistence  of  the  ductus  liotalli,  and  can- 
not be  ex})lained  by  the  assumption  of  an  endiK'arditis  of  the  aortic  valve." 

Treatment. — The  child  should  be  warmly  clad  and  guarded  from  all 
circumstances  liable  to  excite  bronchitis.  In  the  attacks  of  urgent  dysj)- 
iKoa  with  lividity  blood  should  be  freely  let.  Saline  cathartics  are  also 
useful.  Digitalis  must  be  used  with  care;  it  is  sometimes  beneficial  in  the 
later  stages.  When  the  compensation  fails,  the  indications  for  treatment 
are  those  of  valvular  disease  in  adults. 


770 


DISKASMS  OF  TIIK  rrRCrriAToRY  SYSTEM. 


III.    JJISEASKS   OV  TIIK  AKTEKIKS. 
I.    DEGENERATIONS. 

Falli/  dcijciwrntion  of  (lie  intiiiia  is  cxtrcincly  <niiim(iii,  niid  \a  seen  in 
llic  form  of  vi'llowish-wliitc  spots  in  the  aorta  and  Inr^^'cr  vessels.  Calri/ini- 
iiiiii  of  tlie  nrli'iiiil  wall  follows  I'littv  dej^'enenitioii  mid  sclerosis,  and  is  asso- 
ciated will)  nthei'oniatons  clian<:cs.  It  occurs  in  the  intiina  and  the  media. 
In  the  latter  it  produces  what  is  sometimes  known  as  annular  caleilieation, 
which  occurs  particularly  in  the  middle  coat  of  medium-sized  vessels  and 
may  convert  them  into  lirm  tuhes. 

Ili/dlliii'  ilriinirniliiin  may  attack  either  the  lar^rer  or  the  smaller  vessels. 
In  the  former  the  intima  is  converted  into  a  smooth,  homo<feneous  suh- 
HtaiU'c;  this  is  commonly  an  initial  sta^c  of  arterio-sclerosis;  licro  it  is  a 
transformation  of  the  endothelial  lining'.  Of  the  smaller  arteries  and  capil- 
laries hyaline  metamorphosis  is  oftenest  seen  in  the  f^lomendi  of  the  kidneys. 
It  is  not  to  he  coulounded  with  the  amyloid  chauii'c  which  is  prt.ne  to 
occur  in  the  same  situation.  Tlu'  condition  is  variously  re<,^arded  as  (\\H' 
to  coa^ndation  of  i.n  nlhuminous  lluid  and  hyaline  metamorphosis 
of  leucocytes  or  of  lihrin.  This  substance  reaets  liki'  the  last  with  Weij^ort's 
fihriii  slain. 


II.    ARTERIO-SCLEROSIS   (Arferio-capillary  Fibroaia). 

The  conception  of  arterio-sclerosis  as  an  in(le,iendent  aTection — u  gen- 
eral disease  of  the  vascular  system — is  due  to  (lull  and  Sutton. 

Definition.- — .\  condition  of  thickening,  dilfuse  or  circumscribed,  be- 
ginning in  the  intima,  consequent  upon  primary  changes  in  the  media  and 
advent  it  ia,  but  which  later  involves  the  other  coats.  The  ])rocess  leads,  in 
the  larger  arteries,  to  what  is  known  as  atheroma  and  to  endarteritis  de- 
formans. 

Etiology.— (1)  As  an  involution  process  arterio-sclerosis  is  an  accom- 
))animent  of  old  i\yf(\  and  is  the  expression  of  the  natui'al  wear  and  tear  to 
which  the  tubes  are  subjected.  Longevity  is  a  vascular  (pu'stion,  which  has 
been  well  expressed  in  the  axiom  that  "a  man  is  only  as  old  as  his  arte- 
ries." To  a  majority  of  men  death  conies  primarily  or  secondarily  through 
this  i)ortal.  The  onset  of  what  may  be  called  physiological  nrterio-sclerosis 
dejiends,  in  the  first  ]dace,  upon  the  (piality  of  ai'terial  tissm^  (vital  rub- 
ber) which  the  individual  has  inherited,  and  secondly  u|)on  the  amount  of 
wear  and  tear  to  which  he  has  subjected  it.  That  the  former  ])lays  the 
most  im]iortant  roh  is  shown  in  the  cases  in  which  arterio-sclerosis  sets  in 
early  in  life  in  individuals  in  whom  none  of  the  recognized  etiological  fac- 
tors can  be  found.  Thus,  for  instance,  a  man  of  twenty-eight  or  twenty- 
nine  may  have  the  arteries  of  a  man  of  sixty,  and  a  man  of  forty  may  pre- 
sent vessels  as  much  degenerated  as  they  should  be  at  eighty.  Entire  fami- 
lies sometimes  show  this  tendency  to  early  arterio-sclerosis — a  tendency 


i«  scon  in 
( 'nlri/ird- 

11(1  i.-i  iisso- 

tllC   IlKMlill. 

Iciliciitioti, 
csscls  und 

Icr  vessels. 
K'OUH    Slllt- 

•re  it  is  u 
iiiid  ciipil- 
ic  kidneys. 

|»r(.iie  to 
ed  as  due 
inorphosis 

Weigert's 


AUTJ:III()  SCLKROSIS. 


77  L 


n — a  gen- 

rilx'd,  !)(•- 

ie(liii  and 

leads,  in 

erilis  de- 

n  aeeoni- 
(I  tear  to 
vliieli  lias 
lis  arte- 
ilirouf^h 
)-scler()sis 
ital  rul)- 
inoiint  of 
lays  tlic! 
is  sots  in 
ical  fae- 
twonty- 
niay  pre- 
irp  f ami- 
tendency 


which  cannot  lie  cxphiined  in  any  other  way  than  that  in  the  tnake-np  of  thu 
iiiacliine  liad  luateiial  was  used  for  tho  tnhin^;. 

Mori!  conunonly  the  arterio-scU'rostia  results  from  tin,'  bud  uso  of  good 
ressels,  and  among  the  eircumstancoH  which  tend  to  produce  this  condi- 
tion are  the  folhiwing: 

(•.')  Clinmii:  I niDjications. — ...... hoi,  lead,  gout,  and   sy[ihilis   |>lay  an 

inijtortant  rola  in  the  causation  of  arterio-Hclerosis,  although  the  precisu 
mode  of  thoir  action  is  not  yet  very  clear.  Tliey  may  act,  as  'I'rauhe  sug- 
Lzcstrt.  hy  increasing  the  peripheral  resistance'  in  the  smaller  vessels  and  in 
this  way  raisin  <■  the  hlood  tension,  or  ]>ossihly.  as  Bright  taught,  they  alter 
I  he  (piality  of  hi;  hlood  and  render  more  dillicult  its  passage  through  tho 
lapillaricri. 

The  |»oison  of  sy[)hilis  and  of  gout  may  act  directly  on  the  arteries,  pro- 
(hicing  degenerative  changes  in  the  media  and  adventitia. 

(i!)  Orrrfdiiiii/. — .Many  authors  attrihute  an  important  part  of  tlu;  etiol- 
ogy of  arterio-sclerofiis  to  the  overlilling  of  the  hlood-vessels  which  occurs 
when  unnecessarily  large  quantities  of  food  aiul  drinU  are  taken.  I'articu- 
larly  is  this  tlu'  case  in  stout  persons  who  take  very  little  exercise. 

(1)  Orcnrark  of  the  mitscirs,  which  acts  hy  increasing  the  peri[)hcral  re- 
sistance and  hy  raising  the  hlood-prcssure. 

(."))  Jieiial  Disease. — The  relation  hetwcen  the  arterial  and  k  -^y  lesions 
has  heen  much  discussed,  some  regarding  the  arterial  dcgcni'ration  as  sec- 
ondary, others  as  primary.  There  are  certainly  two  groups  of  cases,  one  in 
which  the  artei'io-sclerosis  is  the  (ii'st  change,  and  the  other  in  which  it 
iippears  to  he  secondary  to  a  primary  aU'ection  of  the  kidneys.  The  foritier 
occurs,  I  lielieve,  with  much  greater  freipiency  tliatj  has  heen  supposed. 

Morbid  Anatomy. — Thoma  divides  the  cases  into  ftriiiutni  arterio- 
sclerosis, in  which  there  are  local  changes  in  the  arteries  leading  to  dilata- 
iioii  and  a  com[)ensatc'"'  increase  of  the  connective  tissue  of  the  intima; 
scroiiddri/  arterio-sclerosis,  dxw  to  changes  in  the  arteries  which  follow  in- 
creased resistance  to  the  ])lood-ilow  in  the  ])eripheral  vessels.  This  in- 
creased tension  leads  to  dilatation  aiul  to  slowing  of  the  hlood-stream  and  a 
secondary  com})ensatory  dcvi'lopnuMit  of  tlu;  intima. 

In  a  study  of  41  autoj)sies  upon  artcrio-sclerotic  cases  fi-om  my  wards, 
Councilman  follows  the  useful  division  into  nodular,  senile,  and  dilTuso 
forms. 

(d)  Xodiddf  Form. — In  the  circumscribed  or  nodular  variety  the  ma- 
croscopic changes  are  very  characteristic.  The  aorta  presents,  in  the  early 
stages,  from  the  ring  to  bifurcation,  numerous  flat  projections,  yellowish 
or  yellowish-white  in  color,  hemispherical  in  outline,  and  situated  particu- 
larly aliout  the  orifices  of  the  liranches.  In  the  early  stage  these  patches 
are  scattered  and  do  iu)t  involve  the  entire  intima.  In  more  advanced 
grades  +he  patches  undergo  atheromatous  changes.  The  material  constitut- 
ing the  button  undergoes  softening  and  breaks  np  into  granular  material, 
consisting  of  molecular  debris — the  so-called  atheromatous  abscess. 

In  the  circumscribed  or  nodular  arterio-sclerosis  the  primary  alteration 
consists  in  a  degeneration  or  a  local  infiltration  in  the  media  and  adven- 
titia, chiefly  about  the  vasa  vasorum.     The  affection  is  really  a  mesarteritis 


772 


DISKASKS  OK  THK  (.'IIICIJLATOKY   SYSTI;M. 


/ 


mill  fi  pcriartcrili-^.  '^riicsc  clifmjrci^  lend  In  Hhi  \vc(il<('iiiii<,'  of  the  \v;ill  in 
the  iilTcr-tcfl  iircii,  )it  uliicli  spot  the  prolifcriit ivc  cliiirij^fcs  (•(•iiiiiiciic*'  in  ili<; 
intiiiiii,  pjirticiiliirly  in  tlic  .-nljcndot  licliiil  sliiict  mits,  with  •.TJidnnl  tliick 
ciiin;,'  iiinl  llic  fortnation  ol'  an  at  licroniatoiis  Imttun  or  a  patcli  of  nodular 
arti  rio-sclcrosis.  'I'lic  rcscarclics  of  'I'lionia  have  shown  that  this  is  really 
ii  conipcnsalory  jiroccss,  and  that  licforc  its  dc/^Miicration  the  nodnlar  hiil- 
ton,  which  post  niorlctn  projects  heyond  the  lumen,  dnrinj,'  life  fills  uj)  and 
ohiitcrates  what  wonid  otherwise  he  a  depression  of  the  wall  in  consefpienet! 
of  the  weakenin;^^  of  the  media.  A  similar  process  goes  on  in  the  smaller 
vessels,  and  in  any  one  of  the  smaller  hranehes  it  can  be  readily  seen  on  see- 
lion  that  each  paleli  of  endarteritis  corresponds  to  a  riefeet  in  the  media 
and  often  to  chaii^^es  in  the  adventitia.  The  eonditior.  is  one  which  may 
lead  to  rapid  dilalatif.n  or  to  the  production  of  an  aneurism,  ])articularly  in 
llie  early  sta^^e,  hefore  the  weakened  spot  is  thickened  and  strengthened  hy 
the  intimal  changes. 

(h)  Senile  Aiicrio-srlerosis. — TIk!  larger  arteries  are  dilated  and  tortu- 
ous, the  walls  thin  hut  stiff,  and  often  converted  into  rigid  tuhes.  The 
suhcTidothelial  tissue;  undergoes  degeneration  and  in  spots  l)real<s  down, 
forming  the  so-called  atheromatous  ahscess,  the  contents  of  which  con- 
sist of  a  niolecidar  dfhris.  'I'hey  may  open  into  tin;  lun-.en.  when  they  are 
known  as  atheromatous  ulcers,  'I'he  greater  portion  of  the  intiniii  may 
J)C  occu])ied  by  rough  caIcar<!Ous  plates,  with  here  and  there  fissures  and 
losses  of  substance,  upon  which  not  infreipicntly  white  thrond)i  are  de- 
j)osited.  ]\Iicroscopically  there  is  extreme  degeneration  of  the  coats,  [)ar- 
ticularly  of  the  media.  S(,'nile  atrophy  of  the  liver  and  kidneys  usually  ac- 
companies these  changes.  Senile  changes  are  common  in  other  organs. 
The  heart  may  be  small  and  is  not  necessarily  hypertroj)hied.  In  7  of  II 
oiHcs  of  Councilman's  series  there  was  no  enlargement.  J»rown  atro]ihy  is 
common. 

{(■)  Diffvfie  Arlrrin-srln-fisls. — 'I'Ik-  i)roc(,'ss  is  widespread  throughout  the 
aorta  and  its  branches,  in  the  former  usually,  but  not  necessarily,  associated 
with  th(!  nodular  form.  The  sultjects  of  this  variety  are  usually  middle- 
aged  men,  but  it  may  occur  early.  Of  the  27  in  Councilman's  series  b(!- 
longing  to  this  group  the  majority  were  between  the  ages  of  forty  and  fifty- 
five.  Tlu!  youngest  was  a  negro  of  twenlv-three  and  the  oMest  a  man  of 
sixty.  The  alfectioM  is  very  prevalent  among  negroes;  less  than  50  per  cent 
were  in  whites,  whereas  the  ratio  of  colorecl  to  white  patients  in  the  wards 
is  one  to  seven.  '^Fhe  affection  is  met  with  in  strongly  built,  muscular  men 
ami,  as  CouncilmaTi  remarks,  they  rarely  pre.itiit  on  the  antopsy  table  sign.s 
of  general  anasarca  or,  if  (edema  exists,  it  has  conu;  on  during  the  last  few 
days  of  life.  1'he  aorta  and  its  branches  arc;  more  or  less  dilated,  the 
branches  sometimes  more  than  the  Irtink.  The  intinui  may  be  smooth  and 
show  very  slight  cbang(!S  to  the  naked  eye;  more  commonly  there  are  scat- 
tered elevated  areas  of  an  oparpie  white  color,  some  of  which  may  have  un- 
dergone atheromatous  changes  as  in  the  seriih.'  form. 

Microscopically  in  the  several  forms  thr'  tiirilid  shows  ncjcrolic  and  hya- 
line chnnges,  ii^volving  in  the  larger  arteries  both  muscular  and  elastic;  ele- 
ments, and  the  inlinia  presents  a  great  increase  in  the  subendothelial  con- 


ic  Willi    ill 

ic*'   ill    tll(' 

ii-il  tliick- 
>1'  nodiiiiir 
■t  is  rciilly 
liiliir  hul- 
ls ii|)  iind 

I1SC(|I1CIIC(! 

It;  .siiuillcr 
en  on  hva:- 
lic  iiicdiii 
liicli  (ii;iy 
•iihirly  in 
lii'iicd  liy 


Ml]   tnrtii- 

)fS.      'I'Ik; 

ks  down, 

lidi   coii- 

llicy  nvv. 

iina  niiiy 

^iircs  find 

i   are  dc- 

)at.s,  par- 

iiially  ac- 

•  oi'iraiis. 

7  of  J  1 

I'opliy  is 

lOIlt  tlio 
ssocialcd 

Miiddlc- 
■rics  ])(;- 
lid  fifty- 

iiiaii  of 

)cr  cont 
IC  wards 

ir  moil 
lie  si^^ns 
last  fdw 

(•<!,  thf 
ol  li  and 
re  srat- 
iive  mi- 
ld liya- 
■\\c  f'lo- 

il  fon- 


AUTHIlIO-SL'LKItOSFS. 


H-,, 


iicclivf!  tissue,  wliicli  is  part  iciiiiiily  marked  opposite  areas  of  advanced 
ile;fcnei'ation  in  the  media.  The  Miiall  arteries — tliost,'  in  the  kidneys,  for 
(  xanipic — show  ''  a  tliickenini:  of  the  wall,  due  to  the  formation  of  a  homo- 
geneous hyaline  tissin;  within  the  niii>ciilar  coat.  'J'liis  tissue  eoiilaiiiH  hut 
lew  cells,  is  faintly  striated,  and  stains  a  li^'lit  hrown  in  the  osmic  acid  uscid 
III  tin.'  liardcnin^'  solntion.  In  many  of  the  smallest  vessels  notliin<f  can  ho 
(•(II  of  tli(!  clastic  lamina,  in  oth(.'rs  only  fra;:;nientrt  can  he  made  out,  in 
nlhers  it  is  presorvcd.  .  .  .  The  muscular  (il)rcs  of  the  mediu  show  marked 
jitrophic;  ehan^M'S.  I'atty  de^'oneration  of  the  C(;I1h  fan  ho  made  out  hoth  in 
Iresli  sections  and  after  liardeiiiiiff  in  Flemmin^^'s  solution.  'J'ho  niK.-lei  are 
lliiii  and  atrophic  and  vacuoles  arc  sonietimes  seen  in  them.  In  souk;  ar- 
teries the  nius(;io-flhrcs  have  almost  disapiioarcd  and  the  media  is  clian<,'ed 
into  a  homoffcneous  tissue,  similar  to  that  in  the  thitikonod  intima"  ((.'oun- 
(ilman).  The  (le<reneration  of  the  media  is  most  marked  in  the  smaller 
jirterics.  The  capillaric^s  art;  thickened,  jiarticularly  those  of  the  f.domeruli 
(if  the  kidneys,  which  are  often  ohiitorated  and  involved  in  extensive  hya- 
line de^fonoration. 

It  is  in  this  j^roup  of  cases  that  the  heart  sliows  the  most  important 
I  liaii<res.  The  averaf:<;  wei^dit  in  the  cases  referred  to  was  over  \')i)  ^franinies, 
;iii(|  there  wer(!  two  eases  in  which  without  valvular  dis(;aso  the  wei;.diL  was 
over  SOO  frra mines.  Fihrous  myocarditis  is  often  pn.'sont,  yiarticnlarly  when 
the  coronary  arteries  are  iiivolve(l.  The  semilunar  valv<'S  are  sometimes 
iipaquo  and  sclerotic,  and  may  ho  incompetent.  The  kidmys  may  show 
extensive  sclerosis,  hut  in  many  cases  the  chan<fes  are  so  slight  that  ma(;ro- 
.-(■opically  they  miLdit  he  overlooked.  Tliiy  may  Ijo  in(;rcas(;(l  in  size;.  The 
(iipsule  is  usually  adherent,  tin;  surface  a  little  7'oui.d),  and  \cvy  ofleii  prc;- 
sentH  atropine  areas  at  a  lower  level,  of  a  deep-red  color.  Incr<!ased  consist- 
( lice  is  always  present. 

Sclerosis  <if  the  ]nihii(iu(irii  (irlrrif  is  met  with  in  all  conditions  vvhieli 
fur  a  lon^  time  increase  the  tension  in  the  lesser  circulation,  particularly 
ill  mitral  valve  disease  and  in  emphysema.  Sometimes  the  sclerosis  roachefl 
ii  liiLdi  i.n'ade  and  is  ace(jiii|)anied  with  aneiirisnial  dilatation  of  the  primary 
iiiid  secondary  hranches,  mor(!  rarely  with  insudieieiuy  of  the  pulmonary 
viilve.  In  a  remaikfihlo  case  of  a  yoiirif^  man  of  twenty-ffuir,  r<'|»orted  hy 
h'(iiiil)er;j;  from  Curschmanirs  clinic,  the  piilmoiiiiry  arteries  were  involved 
III  most  extensive  artorio-sch^rosis;  the  main  hranches  were  dilated,  and  the 
-iiuiller  hranclies  wen;  the  seat  of  the  most  extreme  sclerotic  chan<.''es.  On 
the  other  hand,  the  aorta  and  its  l)ranches  were  normal.  The  heart  was 
LH'eatly  hyy)ertrc)pliied,  and  the  clinical  symptoms  were  those  of  a  con<.feni- 
liil  heart  affection.  In  many  cases  of  arterio-sch'rosis  tli"  condition  is  not 
confined  to  the  arteries,  hiit  extends  not  only  to  the  capillaries  hut  also  to 
I  he  veins,  and  may  jiroperly  lie  termed  an  aiif/io-srlrrosis. 

Sclerosis  of  the  veins — phlrhn-sclrrdsis — is  not  at  all  an  uncommon  ac- 
eoiiipaniment  of  arterio-selerosis,  and  is  a  condition  to  which  of  late  a  <rood 
dc;il  of  attention  has  heen  paid.  It  is  seen  in  conditions  of  hei<:htened 
hlooil-pressiire,  as  in  the  portal  system  in  cirrhosis  of  the  liver  and  in  the 
pulmonary  veins  in  mitral  stenosis.  The  affected  vessels  are  usually  dilated, 
and  the  intima  shows,  as  in  the  arteries,  a  compensatory  thickening,  which 


774 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


/ 


is  particularly  marked  in  those  re<i;i()ns  in  which  the  media  is  thinned. 
Tiie  new-fonncd  tissue  in  the  end()i)hi('l)itis  ninv  under<,'o  hyaline  (h'f^'cnera- 
tion,  and  is  sonietimes  extensively  ealeilied.  In  a  case  oi'  libroid  ubliteni- 
tion  of  the  portal  vein  of  long  standing,  1  found  the  intima  of  the  greatly 
dilated  gastric,  splenic,  and  mesenteric  veins  extensively  calcified.  Without 
existing  arterio-sclerosis  the  ])eriph(>ral  veins  may  be  sclerotic,  usually  in 
conditions  of  debility,  but  occasionally  in  young  persons. 

Symptoms. — hirrcascd  Tension. — The  })ressiire  with  which  the  blood 
flows  in  the  arteries  de|)ends  upon  the  degree  of  peripheral  resistance  and 
the  force  of  the  ventricular  contraction.  A  high-tension  pidse  may  exist 
with  very  little  arterio-sclerosis;  l)ut,  as  a  rule,  when  the  condition  has  been 
persistent,  the  sclerosis  and  high  tension  are  found  together.  The  pulse 
wave  is  slow  in  its  ascent,  enduring,  subsides  slowly,  and  in  the  intervals 
hetween  the  heats  the  vessel  remains  full  and  firm.  Jt  may  be  very  difTiculi 
to  obliterate  the  ])ulse,  and  the  finnest  ])ressure  on  the  radial  or  the  teni- 
])oral  artery  jnay  iu)t  be  sntlieient  to  annihilate  the  })idse  wave  beyond  the 
point  of  ])ressure.  This  is  not  always  a  sign  of  high  tension.  The  anas- 
tomotic or  recurrent  ])ulse  may  be  felt  even  when  the  tension  is  low,  as  in 
the  early  stage  of  ty])hoid  fever.  Pressure  on  the  ulnar  artery  at  once  ob- 
literates it.*  The  sphygmograi)hic  tracing  shows  a  slo])ing,  short  U])-strok(', 
no  i)ercussion  wave,  and  a  slow,  gradual  descent,  in  which  the  dicrotic  wave 
is  very  slightly  marked.  It  may  be  dillicult  to  estimate  how  much  of  the 
hardness  and  firmness  is  due  to  the  tension  of  the  blood  within  the  vessel, 
aiul  how  much  to  the  thickening  of  the  wall.  IVut  if,  for  example,  Avhen 
the  radial  is  compressed  with  the  index-finger  the  artery  can  be  felt  beyond 
the  point  of  comjjression,  its  walls  are  sclerosed. 

llyperirophij  of  the  Heart. — In  consequence  of  the  peripheral  resistance 
and  increased  work  the  left  ventricle  increases  in  size,  and  some  of  the 
purest  cxani])les  of  sim])le  hypertrophy  occur  in  this  condition.  The  cham- 
ber may  be  little,  if  at  all,  dilated.  The  apex  beat  is  dislocated  in  advanced 
cases  an  inch  or  more  beyond  the  nip])le  line.  The  imj^ulse  is  heaving  and 
forcible.     The  aortic  second  sound  is  clear,  ringing,  and  accentuated. 

The  combination  of  increased  arterial  tension,  a  palpable  thickening 
of  the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the 
aortic  second  sound  are  signs  pathognomonic  of  arterio-sclerosis.  From 
this  period  of  establishment  the  course  of  the  disease  may  be  very  varied. 
For  years  the  patient  may  haA'e  good  health,  and  be  in  a  condition  analo- 
gous to  that  of  a  ])erson  with  a  well-compensated  valvidar  lesion.  There 
may  be  no  renal  symj)toms,  or  there  may  be  the  passage  of  a  larger  anu)unt 
of  urine  than  normal,  with  transient  all)uminuria,  and  now  and  then 
hyaline  tube-casts.  The  subsequent  history  is  extraordinarily  diverse,  de- 
pending upon  the  vascular  territory  in  which  the  sclerosis  is  most  advanced, 
or  u])on  the  accidents  which  are  so  liable  to  ha])pen,  and  the  sym])tonis  may 
be  cardiac,  cerebral,  renal,  etc. 

(1)  Cardiac. — The  involvement  of  the  coronary  arteries  may  lead  to 
the  various  symptoms  already  referred  to  under  that  section — thrombosis 


*  The  student  is  referred  to  Ewart  On  the  Pulse,  and  to  his  larger  Heart  Studies. 


ARTERIO-SCLEROSIS. 


775 


tliinnod. 
dt'jfciK'ra- 

(jhliliTM- 
ic  ;jrn'iitly 

A\'illi()iit 
sually  ill 

the  blood 
aiice  and 
nay  exist 
has  been 
'he  pulse 
intervals 
•  dilliculi 
the  teni- 
yond  the 
'he  anas- 
nv,  as  in 
onee  ob- 
p-stroke, 
)tie  wave 
h  of  the 
le  vessel, 
le,  when 
I  beyond 

sistanee 
of  the 
le  chain- 
Ivanced 
in^  and 
ed. 

ekeninj,'' 

of  the 

From 

varied. 

1  analo- 

There 

imonnt 

d    then 

rse,  de- 

vanced, 

ns  may 

lead   to 
)nibosis 

lies. 


with  sudden  death,  fibroid  degeneration  of  tlie  heart,  aneurism  of  the  heart, 
rii|)tnre,  and  anjiina  jieetoris.  Angina  peetoris  is  not  uneoinmon,  and  in 
ilie  true  variety  is  almost  always  associated  with  arterio-selerosis.  A  see- 
oiid  important  groiij)  of  cardiac  sympioms  results  from  tlie  dilatation  which 
ultimately  may  follow  the  hypertrophy.  The  patient  tlien  i)resenls  all  the 
symptoms  of  cardiac  insulliciency — dysj)n(ea,  scanty  urine,  and  very  often 
serous  cifusions.  If  the  ease  has  come  under  ol)servation  for  the  first  time 
the  clinical  picture  is  that  of  chronic  valvular  disease,  and  the  existence  of 
a  loud  blowing  murmur  at  the  apex  may  throw  the  iiractitioner  oif  his 
guard.     Many  cases  terminate  in  this  way. 

(2)  The  cerebral  symptoms  of  arterio-sclerosis  are  varied  and  important, 
and  embrace  those  of  many  degeiu'rative  processes,  acute  and  chronic 
(which  follow  sclerosis  of  the  smaller  branches),  and  cerebral  h:\'morrhage. 

Transient  hemiplegia,  monoplegia,  or  ajihasia  may  occur  in  advanced 
arterio-sclerosis.  llecovery  may  be  })erfect.  It  is  ditlicult  to  say  upon 
what  these  attacks  depend.  Sj)asm  of  the  arteries  has  been  suggested,  but 
tiie  condition  of  the  smallest  arteries  is  not  very  favorable  to  this  view. 
I'eabody  has  recently  called  attention  to  these  cases,  which  are  more  com- 
mon than  is  indicated  in  the  literature.  \'ertig()  occurs  frequently,  and  may 
he  either  simjile,  or  is  associated  with  slow  jiulse  and  syncopal  or  eiiilepti- 
form  attacks  (Grasset,  Church). 

(;?)  licnaJ  symptoms  supervene  in  a  large  number  of  the  cases.  A  sclero- 
sis, patchy  or  diffuse,  is  present  in  a  majority  of  the  cases  at  the  time  of 
autoj)sy,  and  the  condition  is  practically  that  of  contracted  kidney.  It  is 
seen  in  a  ty[)ical  manner  in  the  s(;nile  form,  and  not  infre(pieiitly  develo|)s 
early  in  life  as  a  direct  sequence  of  the  dilfuse  variety.  It  is  often  dillicult 
to  decide  clinically  (and  the  (piestion  is  one  ujion  whicdi  good  observers 
might  not  agree  in  a  given  case)  whether  the  arterial  or  the  renal  disease 
has  been  primary. 

(4)  Among  other  events  in  arterio-sclerosis  may  be  mentioned  gangrene 
of  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dislodgment 
of  thrombi.  IJespiratory  symptoms  are  not  uncommon,  particularly  bron- 
chitis and  the  symptoms  associated  with  enq)hysema. 

Treatment. — In  the  late  stages  the  conditions  must  be  treated  as  they 
arise  in  connection  with  the  various  viscera.  In  the  early  stages,  before 
any  local  symptoms  are  manifest,  the  patient  should  be  enjoined  to  live  a 
quiet,  well-regulated  life,  avoiding  excesses  in  food  and  drink.  It  is  usu- 
ally best  to  ex])lain  frankly  the  condition  of  alTairs,  and  so  gain  bis  intelli- 
gent co-operation.  Special  attention  should  be  paid  to  the  state  of  the 
bowels  and  nrine,  and  the  secretion  of  the  skin  should  be  kept  active  by 
daily  baths.  Alcohol  in  all  forms  should  be  prohibited,  and  the  food  should 
be  restricted  to  plain,  wholesome  articles.  The  use  of  mineral  waters  or  a 
residence  every  year  at  one  of  the  mineral  springs  is  usually  serviceable. 
If  there  has  been  a  syphilitic  history  an  occasional  course  of  iodide  of  po- 
tassium is  indicated,  and  whenever  the  pulse  tension  is  high  nitroglycerin 
may  be  used. 

In  c.n.ses  which  come  under  observation  for  the  first  time  with  dyspnoea, 
slight  lividity,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated. 


i  I 


c 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


In  sonic  instances,  with  very  liifxh  tension,  striking  relief  is  afCorcleJ  by  tiio 
abstraction  of  20  ounces  of  blood. 


/ 


III.    ANEURISM. 

Tlie  following  forms  of  aneurism  are  usually  recognized: 

(«)  The  true,  in  which  the  sac  is  formed  of  one  or  more  of  the  arterial 
coats.  This  may  be  fusiform,  cylindrical,  or  cirsoid  (in  which  the  dilatation 
is  in  an  artery  and  its  branches),  or  it  nuiy  be  circumscribed  or  sacculated. 
Aneurisms  are  nsually  fusiform,  resulting  from  uniform  dilatation  of  tlie 
vessel,  or  saccular. 

(h)  The  false  aneurism,  in  which  there  is  ruj)ture  of  all  the  coats,  and 
the  blood  is  free  (or  circumscribed)  in  the  tissues. 

(f)  The  cUxseciiiifi  aneurism,  which  results  f'  in  injury  or  laceration  of 
the  internal  coat.  The  blood  dissects  betwen  the  layers;  hence  the  name, 
dissecting  aneurism.     This  occurs  usually  in  the  aorta,  persisting  for  years. 

{(1)  Arterio-venous  aneurism  results  when  a  communication  is  established 
between  an  artery  and  a  vein.  A  sac  may  intervene,  in  which  case  we  have 
what  is  called  a  varicose  aneurism;  but  in  numy  cases  the  communication  is 
direct  and  the  chief  change  is  in  the  vein,  which  is  dilated,  tortuous,  and 
pulsating,  the  condition  being  termed  an  aneurismal  varix. 

Etiology  and  Pathology. — Aneurisms  arise:  (a)  By  the  gradual 
diffuse  distention  of  the  arterial  coats,  which  have  been  weakened  by  arterio- 
sclerosis, particularly  in  its  early  stages,  before  comi)ensatory  endarteritis 
devcloi)s.  The  arch  of  the  aorta  is  often  dilated  in  this  way  so  as  to  form 
an  irregular  aneurism. 

(h)  In  consequence  of  circumscribed  loss  of  resisting  power  in  the  media 
and  advcntitia,  and  often  frcnn  a  lacer.tion  of  the  media.  This  is  the 
most  common  cause  of  sr.cculated  aneurism.  The  laceration  is  frequently 
found  in  the  ascending  portion  of  the  arch  and  occurs  early  in  the  process 
of  arterio-sclerosis,  before  the  compensatory  thickening  has  taken  place. 
Occasionally  one  meets  with  remarkable  specimens  illustrating  the  impor- 
tant part  played  by  this  process.  The  intima  may  also  be  torn.  In  a  case 
of  Daland's  there  was  just  above  the  aortic  valves  an  old  transverse  tear 
of  the  intima,  extending  almost  the  entire  circumference  of  the  vessel. 
Sclerosis  of  the  media  and  advcntitia  had  taken  place  and  the  process  was 
evidently  of  some  standing.  An  inch  or  more  above  it  was  a  fresh  trans- 
verse rent  which  had  ])roduced  a  dissecting  aneurism.  These  artcio-scle- 
rotic  aneurisms,  as  they  are  called,  are  found  also  in  the  smaller  vessels. 

{(■)  Embolic  Aneurism. — When  an  embolus  has  lodged  in  a  vessel  and 
permanently  plugged  it,  aneurismal  dilatation  may  follow  on  the  proximal 
side.  The  embolus  itself  may.  if  a  calcified  fragment  from  a  valve,  lacer- 
ate the  wall,  or  if  infected  may  produce  inflammation  and  softening. 

{(I)  Mijcoiic  Aneurism. — The  importance  of  this  form  has  been  specially 
considered  by  Eppinger  in  his  exhaustive  monograph.  The  occurrence  of 
multiple  aneurisms  in  malignant  endocarditis  has  been  observed  by  several 
writers.     Probably  the  first  case  in  which  the  mycotic  nature  was  recog- 


L'd  by  tlio 


c  artcriiil 
lilatatioii 
icculatfd. 
)n  of  the 

oats,  and 

ration  of 
he  name, 
for  years. 
tal)lishe(l 
we  have 
ication  is 
loiis,  and 

gradual 
V  arterio- 
larteritis 

to  form 

10  media 
s  is  the 
equcntly 

process 
n  jjlace. 

impor- 
n  a  case 
rso  tear 

vessel. 
:'css  was 
1  trans- 
'"io-scle- 
sels. 
sel  and 
ro.ximal 
5,  laccr- 

pecially 
cnce  of 
several 


recog- 


ANEURISM. 


777 


iiized  was  one  which  oc(  red  at  the  Montreal  (leneral  Jlos[)ital  and  is  re- 
ported in  full  in  my  lectures  on  malignant  endocarditis.  In  addition  to  the 
ulceration  of  tlie  valves  there  were  four  aneurisms  of  the  arch,  of  which 
one  was  large  and  saccular,  and  three  were  not  bigger  than  cherries.  An  ex- 
tensive growth  of  nucrococci  was  present. 

A  form  of  parasitic  aneurism  which  occurs  with  great  fretjucncy  in  thi; 
iiusenteric  arteries  of  the  horse  is  due  to  the  development  of  the  slrumjijUttt 
itnnalus. 

Thoma  has  described  a  "traction"  aneurism  of  the  concavity  of  tlie 
arch  at  the  i)oint  of  insertion  of  ihe  remnant  of  the  ductus  iJotalii  (Vir- 
chow's  Archiv,  IM.  Vl'i). 

And,  lastly,  there  are  cases  in  which  without  any  definite  cause  there 
is  a  tendency  to  the  develoi)mcnt  of  aneurisms  in  various  ])arts  of  the 
body.  A  remarkable  instance  of  it  in  our  ])rofession  was  all'ordcd  1)y  the 
brilliant  Thomas  King  Clunnbers,  who  first  had  an  aneurism  in  the  left 
])o|)liteal  artery,  eleven  years  subsequently  an  aneurism  in  the  right 
leg  which  was  cured  by  i)ressure,  and  finally  aneurism  of  both  carotid 
arteries. 

Incidence  of  Aneurism. — At  St.  Bartholomew's  Hospital  during  thirty 
years  there  were  G31  cases  of  aneurism.  In  408  the  disease  alTected  the 
aorta,  in  80  the  popliteal,  in  21  the  femoral,  in  14  the  subclavian,  in  8  the 
carotid,  in  G  the  external  iliac  artery  (Oswald  A.  ]]rownc). 

AxEURiSM  OF  Tiri']  TiiouAcic  Aorta. 

The  canses  which  favor  the  development  of  arterio-sclerosis  prevail  in 
aortic  aneurism,  particularly  alcohol,  syphilis,  and  overwork.  The  great- 
est danger  probably  is  in  strong  muscular  men  witli  commencing  degen- 
erative ])rocesses  in  the  arteries  (a  consequence  of  syphilis  or  alcohol  or  a 
icsult  of  hereditary  weakness  of  the  arterial  tissues),  who  during  a  sudden 
muscular  exertion  are  liable  to  lacerate  the  media,  the  intima  not  yet  being 
strengthened  by  compensatory  thickening  over  a  spot  of  mesarteritis.  Aneu- 
lisnis  of  the  thoracic  aorta  vary  greatly  in  size  and  shape.  A  majority  of 
them  are  saccular.  They  may  be  small  and  situated  just  above  the  aortic 
ring.  Others  form  large  tumors  which  project  externally  and  occnpy  a 
large  portion  of  the  upper  thorax.  Small  sacs  from  the  descending  por- 
tion of  the  arch  may  compress  the  trachea  or  the  bronchi.  In  the  tho- 
racic portion  the  sac  may  erode  the  vertebrte  or  grow  into  the  pleural  cavity 
and  compress  the  lung.  In  some  instances  it  grows  through  the  ribs  and 
appears  in  the  back. 

Symptoms. — The  chief  influence  of  an  aneurism  is  manifested  in 
wliat  are  known  as  pressure  cfTects.  In  the  absence  of  these  the  aneurisms 
aitain  a  large  size  without  producing  symptoms  or  seriously  interfering 
with  the  circulation.  Indeed,  a  useful  clinical  subdivision  as  given  by 
I'ramwell  is  into  three  groups — aneurisms  which  are  entirely  latent  and 
give  no  physical  signs;  aneurisms  which  present  signs  of  intrathoracic 
pressure,  although  it  is  difficult  or  impossible  to  determine  the  nature  of  the 
lesion  producing  the  pressure;  and,  lastl}',  aneurisms  which  produce  dis- 


778 


DISEASES   OP   THE  CIRCULATORY  SYSTEM. 


tinct  tuiiioi'rt  Avitli  wt'll-niarked  pressure  symptoms  and  external  signs. 
Mroadhont  nuikcs  anotlier  useful  division  into  nnourisni  ol'  symptoms  and 
iincurisni  ol'  pliysical  si^ns.  it  is  pcrliajjs  best  to  eonsider  iineurisms  of  the 
uortii  aceording  to  the  situation  ol  tiie  tumor. 

(a)  Ani'iirisiiis  of  llie  Af<ccii(llii(/  I'orliun  of  flic  Arch. — Wlien  just  abovt; 
the  sinuses  of  A'alsalva  they  are  often  small  and  latent.  Tlie  first  symp- 
tom nuiy  be  ru])ture,  wiiieii  usually  lakes  ])la('o  into  the  jjericardium  and 
causes  instant  death.  AI)ove  tlie  siniisi's,  along  the  convex  border  of  the 
ascending  part,  aneurism  fretpu'iitly  develops,  and  may  grow  to  a  large 
size,  either  ])assing  out  iido  the  right  ])leura  or  forward,  pointing  at  the 
second  or  third  interspace,  eroding  the  ribs  aiul  sternum,  and  producing 
large  external  tumors.  Jn  this  situation  the  sac  is  liable,  indeed,  to  coui- 
])ress  the  suj)erior  vena  cava,  causing  engorgenu'nt  of  the  vessels  of  the 
head  and  arm,  sometimes  comi)ressing  only  the  subclavian  vein,  and  caus- 
ing cnlargenu'iit  and  (edema  of  the  right  arm.  I'erforation  may  take  })lace 
into  the  superior  vena  cava,  of  which  accident  I'epper  and  ({rillith  have 
collected  ^i)  cases.  Jn  rare  instances,  Mhen  the  aneurism  springs  from  the 
concave  side  of  the  vessels,  the  tunu)r  may  apjjcar  to  the  left  of  the  sternum. 
T^arge  aneurisms  in  this  situation  may  cause  much  dislocation  of  tlu; 
heart,  pushing  it  down  and  to  the  left,  and  sometimes  compressing  the 
inferior  vena  cava,  and  causing  swelling  of  the  I'eet  and  ascites.  The  right 
recurrent  laryngeal  nerve  is  often  })ressed  u|)on  by  these  tunu)rs.  The  in- 
nominate artery  is  rarely  involved.  Death  comnu)nly  follows  from  ru])ture 
into  the  ])ericar(lium,  the  i)leura,  or  into  tlie  su[)eri()r  cava;  less  commoidy 
from  rupture  externally,  sometimes  from  syncoj)e. 

(h)  Aiiciirisvis  of  lite  J'nnisrrrse  Airli. — The  direction  of  their  growtli  is 
most  commoidy  backward,  but  they  uuiy  grow  forward,  erode  the  sternum, 
and  ])r()(lu('e  large  tumors.  The  tunu)r  })reseids  in  the  nuddle  line  and  to 
the  right  of  the  sternum  much  more  often  than  to  the  left,  which  occurred 
in  only  4  of  155  aiunirisms  in  this  situation  (0.  A.  Browne).  Kven  when 
small  and  ])ro(lucing  no  extermd  tumor  they  may  cause  marked  pressure 
signs  in  their  growth  l)ackward  toward  the  spine,  involving  the  trachea 
and  the  reso])hagus,  and  giving  rise  to  cough,  which  is  oi'ten  of  a  jjarox- 
ysmal  cluiracter,  and  (lys])hagia.  '^Phe  left  recurrent  laryngeal  is  often  in- 
volved in  its  course  round  the  arch.  A  snuill  aneurism  from  the  lower  or 
posterior  wall  of  the  arch  may  conijjress  a  bronchus,  iiulucing  bronchor- 
rha'a,  gradual  bronchiectasy,  and  snp])uration  in  the  lung — a  ])rocess  which 
by  no  means  infrecpiently  causes  death  in  aneurism,  and  a  condition  which 
at  the  ^lontreal  General  Hospital  we  were  in  tlie  habit  of  terming  aneu- 
risnial  ])hthisis.  Occasionally  enormous  aneurisms  develop  in  this  situa- 
tion, and  grow  into  both  ]deuiw,  extending  between  the  manubrium  and  tlie 
vertebra\;  they  may  persist  for  years.  The  sac  may  be  evident  at  the  sternal 
notch.  The  innominate  artery,  less  commonly  the  left  carotid  and  sub- 
clavian, may  be  involved  in  the  sac,  and  the  radial  or  carotid  ])ulse  may  be 
absent  or  retarded.  Pressure  on  the  sympathetic  may  at  first  cause  dilata- 
tion and  subsequently  contraction  of  the  pujiil.  Sometimes  the  thoracic 
duct  is  compressed. 

The  ascending  and  transverse  portions  of  the  arch  arc  not  infrequently 


ANEUIIISM. 


Y79 


lal  sirjn?!. 
tonis  iiiid 
Ills  ol'  the 

list  above 
rst  syiiip- 
liiiiii  and 
IT  ol'  tho 
[)  a  largu 
ig  at  the 
)i'o(lucing 

,  to  COIll- 
Is  of  the 
II  nd  caiis- 
ake  jiluee 
litli  have 
from  the 
stoi'uuiii. 
n  oi'  the 
ssiiig  th(! 
rhe  right 
The  iii- 
11  nipturc 
'oniiiioiily 

growtli  is 
sterninn, 
le  and  to 
occnrred 
■en  when 
])ressiire 
trachea 
h  ])ar()X- 
oi'ten  in- 
h)\ver  or 
•roiichor- 
ss  wliic'h 
)n  whieh 
ig  ancii- 
is  sitiia- 
aiid  tlie 
e  stern;',! 
nd  sub- 
may  he 
e  dihita- 
tlioracie 

:>qucntly 


involved  togotlior,  iiPunlly  Avithout  the  l)ranclios;  tlio  tumor  grows  upward, 
(ir  upward  and  to  the  right. 

{(■)  Aneurisms  uf  the  OcsrriKliiKj  I'oriiitn  of  (he  Arch. — Tlie  sac  jirojeets 
to  tlie  left  and  backward,  and  ol'ten  erodes  the  vertehra)  from  the  third  to 
the  sixtli  oorsal,  causing  great  pain  and  sometimes  coni[)ression  of  the  spinal 
(onh  Dyspliagia  is  coiiunon.  Pressure  on  the  bronciii  may  induce  bron- 
(liiectasy,  witii  retention  of  secretions,  and  fever.  A  tumor  may  apiiear 
externally  in  the  region  of  the  scai)ula,  and  here  attain  an  enormous  size. 
Death  not  infrequently  occurs  from  rui)ture  into  the  ])leura. 

{(I)  Aneiirlsins  of  the  Descending  Thoracic  Aurta. — The  larger  nundjer 
(icciir  close  to  the  diaphragm,  the  sac  lying  upon  or  to  th(>  left  of  the  bodies 
oi'  the  lower  dorsal  vertebra;,  which  are  often  eroded.  The  sac  may  reach 
a  largo  size  and  form  a  very  large  tumor  in  the  back. 

Diagnosis  and  Physical  Signs. — Inspecliun. — A  good  ligld  is  es- 
sential; cases  are  often  overlooked  owing  to  a  hasty  inspection.  In  many 
instances  it  is  negative.  On  I'ither  side  of  the  sternum  there  may  be  abnor- 
mal })ulsation,  due  to  dislocation  of  tin;  heart,  to  deformity  of  the  thorax, 
or  to  retraction  of  the  lung.  The  ancurismal  pulsation  is  usually  above 
the  level  of  the  third  rib  and  most  commoidy  to  the  right  of  the  sternum, 
either  in  the  lirst  or  second  inters])ace.  It  may  be  only  a  dilfuse  heaving 
impulse  without  any  external  tumor.  Often  the  impulse  is  noticetl  only 
wlien  the  chest  is  looked  at  oblicjiiely  in  a  favorable  light.  When  the  in- 
nominate is  involved  the  throbbing  may  ])ass  into  the  neck  or  be  ajiparent 
at  the  sternal  notch.  Posteriorly,  wlu'n  pulsation  occurs,  it  is  most  com- 
monly found  to  the  left  of  the  s])ine.  An  external  tumor  is  ])resent  in 
many  cases,  ])rojecting  either  through  the  upper  ])art  of  the  sternum  or  to 
the  right,  sometimes  involving  the  sternum  and  costal  cartilages  on  both 
sides,  forming  a  swelling  the  size  of  a  cocoa-nut  or  even  larger.  The  skin 
is  thin,  often  blood-stained,  or  it  may  liave  ru])tured,  exposing  tlie  laminae 
of  the  sac.  The  apex  beat  may  be  much  dislocated,  particularly  when  the 
sac  is  large.  ]t  is  more  commonly  a  dislocation  from  pressure  than  from 
enlargement  of  the  heart  itself. 

Palpal  Ion. — The  area  and  degree  of  pulsation  are  best  deternuned  by 
])alpation.  When  the  aneurism  is  deep-seated  and  not  ap])arent  externally, 
the  bimanual  method  slioidd  be  used,  one  hand  ujjon  the  s])ine  and  the 
other  on  the  sternum.  When  the  sac  has  perforated  the  cliest  wall  the 
impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and  ex])ansile.  The  resistance 
may  be  very  great  if  there  are  thick  laniiiuv  beneath  the  skin;  more  rarely 
tlie  sac  is  soft  and  fluctuating.  The  hand  u])on  the  sac,  or  on  the  region 
in  which  it  is  in  contact  with  the  chest  wall,  feels  in  many  cases  a  diastolic 
shock,  often  of  great  intensity,  which  forms  one  of  the  valuable  physical 
signs  of  aneurism.  A  systolic  thrill  is  sometimes  ])resent,  not  so  often  in 
saccular  aneurisms  as  in  the  dilatation  of  the  arch.  The  pulsation  may 
sometimes  be  felt  in  the  suprasternal  notch. 

Percussion. — The  small  and  deep-seated  aneurisms  are  in  this  respect 
negative.  In  the  larger  tumors,  as  soon  as  the  sac  reaches  the  chest  wall, 
there  is  produced  an  area  of  abnormal  dulness,  the  position  of  which  de- 
pends u})on  the  part  of  the  aorta  affected.     Aneurisms  of  the  ascending 


780 


DISKASKS  OF   THH   ClUCULATOliV   SYSTEM. 


/ 


nrcli  fjrow  forward  and  to  the  ri^^lit,  iirodiioing  didncss  on  one  side  of  tli(> 
manubrium;  those  from  the  transverse  arch  produee  didne.ss  in  the  middh 
line,  extending  toward  tiie  h'ft  of  tlio  sternum,  wliilc;  aneurisms  of  the 
descending  portion  most  eommonly  produee  dulness  in  liie  hd't  inter- 
scapular and  seapnhir  regions.  Tlie  percussion  note  is  tiat  and  gives  a 
feeling  of  increased  resistance. 

AitKculUfliim. — Adventitious  sounds  are  not  always  to  l)e  heard.  Even 
in  a  large  sac  there  may  he  no  murmur.  ]\lueh  (le[)ends  upon  the  thick- 
ness of  the  lamiuie  of  iibrin.  An  important  sign,  ])articularly  if  heard 
over  a  dull  region,  is  a  ringing,  accentuated  second  sound,  a  phenomenon 
rarely  missed  in  large  aneurisms  of  the  aortic  arch.  A  systolic  murmur 
nuiy  l)e  i)resent;  sometimes  a  double  murmur,  in  which  ease  the  diastolic 
bruit  is  usually  due  to  associated  aortic  insullieieney.  The  systolic  mur- 
mur alone  is  of  little  moment  in  the  diagnosis  of  an  aneurismal  sac.  With 
the  single  stethoscope  the  shock  of  the  impulse  with  the  first  sound  is 
sometimes  very  nuirked. 

Among  other  })hysical  signs  of  importance  are  slowing  of  the  pulse  in 
the  arteries  heyond  the  aneurism,  or  in  those  involved  in  the  sac.  There 
may,  for  instance,  be  a  marked  difference  between  the  right  and  left  radial, 
both  in  volume  and  time.  A  physical  sign  of  large  thoracic  aneurism. 
Mhich  I  have  not  seen  referred  to,  is  obliteration  of  the  pulse  in  the  ab- 
dominal aorta  and  its  branches.  i\Iy  attention  was  called  to  this  in  a 
patient  who  was  stated  to  have  aortic  insufficiency.  There  was  a  well- 
marked  diastolic  murmur,  but  in  the  femorals  and  in  the  aorta  I  was 
suri)rised  to  find  no  trace  of  pulsation,  and  not  the  slightest  throbbing  in 
the  abdominal  aorta  or  in  the  i)eri])heral  arteries  of  the  leg.  The  circula- 
tion was,  however,  unimi)aired  in  them  and  there  was  no  dilatation  of  the 
veins.  Attracted  by  this,  I  then  made  a  careful  examination  of  the  ])a- 
tient's  back,  when  the  circumstance  was  discovered,  which  neither  the 
patient  himself  nor  any  of  his  physicians  had  noticed,  that  he  had  a  very 
large  area  of  pulsation  in  the  left  scapular  region.  The  sac  probably  was 
large  enough  to  act  as  a  reservoir  annihilating  the  ventricular  systole,  and 
converting  the  intermittent  into  a  continuoiis  stream. 

The  tracheal  tufjginf/,  a  valuable  sign  in  deep-seated  aneurisms,  was 
described  by  Surgeon-Major  Oliver,  and  was  s])ecially  stiulied  by  my  col- 
leagues Ross  and  MacDonnell  *  at  the  ]\rontreal  General  Hospital.  Oliver 
gives  the  following  directions:  "  Place  the  patient  in  tbe  erect  position, 
and  direct  him  to  close  his  mouth  and  elevate  his  chin  to  almost  the  full 
extent;  then  grasp  the  cricoid  cartilage  between  the  finger  and  thumb, 
and  use  steady  and  gentle  upward  pressure  on  it,  when,  if  dilatation  or 
Aneurism  exists,  the  pulsation  of  the  aorta  will  be  distinctly  felt  trans- 
mitted through  the  trachea  to  the  hand."  On  several  occasions  I  have 
known  this  to  be  a  sign  of  great  value  in  the  diagnosis  of  deep-seated  aneu- 
risms. I  have  never  felt  it  in  tumors,  or  in  the  extreme  dynamic  dilatation 
of  aortic  insufficiency.     It  may  be  visible  in  the  thyroid  cartilage. 

Occasionally  a  systolic  murmur  nuiy  be  heard  in  the  trachea,  as  pointed 


*  London  Lancet,  1891. 


ANEUKISM. 


781 


;i(lo  of  tlio 
:lic'  iiiiddli 

MIS    ui'    tllf 

k'l't  iiitcr- 
ul  gives  a 

ml.  Even 
tlio  tliifk- 
)'  il'  lu'urd 

OIlOlIlOllOll 

c  murniiir 
0  diaatolic 
tolic  miir- 
3ac.  "With 
;  sound  is 

e  pulse  ill 

ic.     Tlieiv 

leit  radial, 

aneurism. 

in  the  al)- 

tliis  in  a 

as  a  well- 

rta  I  was 

ebbing  in 

eirculii- 

on  of  the 

the  ])a- 

her   the 

d  a  very 

)ably  was 

;ole,  and 

sms,  was 

niv  eol- 

Oliver 

)osition. 

tlie  full 

tliunib, 

ation  or 
t  trans- 
I  have 

3d  aneu- 

ilatation 

pointed 


nut  by  David  Dniniinond,  or  even  at  the  jmlient's  mouth,  when  opened. 
This  is  eitlier  tlie  sound  conveyefj  from  the  sac,  or  is  [trodueed  by  tiie  air 
as  it  is  driven  out  of  tlie  wind-pipe  during  tlie  .systole. 

An  important  but  variable  feature  in  thoracic  aneurism  is  ixiin,  which 
is  ])articuhirly  nuirked  in  deep-seated  tumors.  It  is  usually  paro.xysmal, 
sharp,  and  lancinating,  often  very  severe  when  tlie  tumor  is  eroding  the 
vertebra",  or  perforating  the  chest  wall.  In  tiie  latter  case,  atler  [lerl'ora- 
ti(jn  the  i)ain  may  cease.  Anginal  attacks  are  not  uncommon,  particularly 
in  aneurisms  at  the  root  of  the  aorta.  Frecpiently  the  ])ain  radiates  (h)wn 
the  left  arm  or  up  the  lU'ck,  soiuetimes  along  the  upper  intercostal  nerves. 
CiiiK/h  results  cither  from  the  direct  pressure  on  tlie  wind-pipe,  or  is  as- 
!-(»ciated  with  bronchitis.  'J'lie  expectoration  in  these  instances  is  al)un(lant, 
thin,  and  watery;  subsequently  it  becomes  thick  and  turbid.  Paro.xysmal 
cough  of  a  peculiar  brazen,  ringing  character  is  a  characteristic  symptom 
in  some  cases,  jiarticularly  when  there  is  ])ressure  on  the  recurrent  laryn- 
geal nerves,  or  the  cough  may  have  a  jieculiar  wheezy  cpiality — the  "  goose 
cough." 

Dyspnoea,  which  is  common  in  cases  of  aneurism  of  the  transverse  por- 
tion, is  not  necessarily  associated  with  pressure  on  the  recurrent  laryn- 
geal nerves,  but  may  be  due  directly  to  compression  of  the  trachea  or  the 
left  bronchus.  It  may  occur  ^ith  marked  stridor.  Loss  of  voice  and 
hoarseness  are  consequences  of  pressure  on  the  recurrent  laryngeal,  usually 
the  left,  inducing  either  a  spasm  in  the  muscles  of  the  left  vocal  cord  or 
paralysis. 

Paralysis  of  an  abductor  on  one  side  may  be  present  without  any  symp- 
toms. It  is  more  jiarticularly,  as  Semon  states,  when  the  paralytic  con- 
tractures supervene  that  the  attention  is  called  to  laryngeal  symi)toms. 

Ha'tnorrhaf/e  in  thoracic  aneurism  may  come  from  (a)  the  soft  granula- 
tions in  the  trachea  at  the  point  of  compression,  in  which  case  the  sputa  are 
blood-tinged,  but  large  quantities  of  blood  are  not  lost;  (h)  from  rujiture 
of  the  sac  into  the  trachea  or  bronchi;  (c)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rajiidly  prov- 
ing fatal,  and  is  a  common  cause  of  death.  It  may  persist  for  weeks  or 
months,  in  which  case  it  is  simply  hamiorrhagic  weeping  through  the  sac, 
Mhich  is  exposed  in  the  trachea.  In  some  instances,  even  after  a  very- 
profuse  ha?morrhage,  the  patient  recovers  and  may  live  for  years,  A  man 
with  well-marked  thoracic  aneurism,  whom  I  showed  to  my  class  at  the 
I'nivcrsity  of  Pennsylvania  and  who  had  had  several  brisk  liaMnorrhages, 
died  four  years  after,  having  in  the  meantime  enjoyed  average  health. 
Death  from  hamiorrhage  is  relatively  more  common  in  aneurism  of  the 
third  portion  of  the  arch  and  of  the  descending  aorta. 

Diflficulty  of  swallowing  is  a  com])aratively  rare  synijitom,  and  may  be 
due  either  to  spasm  or  to  direct  compression.  The  sound  should  nev(;r 
be  passed  in  these  cases,  as  the  resoiihagus  may  be  almost  eroded  and  a  per- 
foration may  be  made. 

Heart  Symptoms. — Pain  has  been  referred  to;  it  is  often  anginal  in 
character,  and  is  most  common  when  the  root  of  the  aorta  is  involved.  The 
heart  is  hypertrophied  in  less  than  one  half  the  cases.     The  aortic  valves. 


7.S2 


DISEASES  OV  THE  CIRCULATOllY  SYSTEM. 


/ 


nrc  BoiiU'tiiiH'H  incomix'tciil,  litluT  from  discnsc  dl'  tlic;  Hc^^inciitH  or  frnni 
hi  retch  iiif,'  of  llu'  aortic  riii^'. 

Aiiioii^'  otiuir  si^'iiri  and  sviiiptoms,  venous  coinprcssion,  wliUli  lui-, 
already  lieen  in(;nti<>ni'(|,  niay  involve  one  subclavian  or  tlic  HU|K'rior  vena 
cava.  A  curious  j)lienouicnon  in  iutratlioracic  ancui'isni  is  tlio  cluhhin;; 
of  the  liii^'crs  and  incurving'  of  tin;  Jiails  of  one  hand,  of  which  two  ex- 
amples have  hecn  under  my  care,  in  hotli  witluHit  any  special  distention 
or  si^jus  of  venous  en'^orycment.  Tumors  of  the  iirch  mav  involve  the 
pulmonary  artery,  producing  compression,  or  in  some  instances  adhesinu 
of  the  pulmonary  segments  and  insulliciency  (d'  the  valve;  or  the  sac  may 
jiiplurc  into  the  artery,  an  accident  which  happened  in  two  of  my  caso, 
jtrodiicing  instanlancous  death. 

Pressure  on  the  sympathetic  is  |)articularly  lial)le  to  occur  in  growtii> 
fi'om  the  ascending  portion  of  the  arch.  Millier  the  upper  dorsal  or  the 
lower  cci'vical  ganglion  is  involvetl.  The  symptoms  are  variahle.  If  the 
Jierve  is  sim|)ly  irritated,  there  is  stimulation  of  the  vaso-dihitor  lihres  and 
dilatation  of  the  ]iupil.  With  this  may  he  associated  jjallor  of  the  same 
side  of  the  face.  On  the  other  hand,  (h'sl  ruction  of  the  cilio-spinal  branches 
causes  paralysis  ol'  the  dilator  fibres,  in  conseiiuence  of  which  the  iris  con- 
tracts, the  vessels  on  the  side  of  the  head  dilate,  causing  congestion,  and 
iji  some  instances  unilati'ral  sweating.  It  is  nuu-h  more  common  to  sec 
the  pnpill;,.y  sym|)toms  alone  than  iu  conibiiuition  either  with  i)all(>r,  red- 
ness, or  sweating. 

The  clinical  |»icture  of  anenrism  of  the  aorta  is  extremely  varied.  ^lany 
cases  ])resent  characteristic  symptoms  and  no  ])hysical  signs,  while  otheis 
have  well-marked  physical  signs  and  no  syin|)toms.  As  JJroadbent  re- 
marks, the  aneurism  of  plu/sical  niyiis  springs  from  the  ascending  portion 
of  the  aorta;  the  aneurism  of  symptoms  grows  from  the  transverse  arch. 

Aneurism  of  the  aorta  may  he  confounded  with:  (a)  The  violent  throb- 
bing impulse  of  the  arch  in  aortic  insudicicney.  I  have  already  referred 
to  a  case  of  this  kind  in  which  the  diagnosis  of  anenrism  was  made  bv  sev- 
cral  good  observers. 

(h)  Simple  Di/naniic  Puhalion. — Xo  instance  of  this,  which  is  common 
in  the  abdominal  aorta,  has  ever  come  under  my  iiotice.  One  which  came 
under  the  care  of  William  ^Inrray  and  JiramwcU  presented,  without  any 
pain  or  pressnre  sym])toms,  ])ulsation  and  dulness  over  the  aorta.  The  con- 
dition gradnally  disai)i)eared  and  was  thought  to  be  nenrotic. 

(r)  Dislocation  of  the  heai't  in  curvature  of  the  spine  may  cause  great 
displacement  of  the  aorta,  so  that  it  has  been  known  to  jmlsate  forcibly 
to  the  right  of  the  sternum. 

{d)  Solid  Tumors. — When  the  tnmor  ])rojects  externally  and  ])ulsates 
the  diflicidty  may  be  considerable.  In  tumor  the  heaving,  expansile  ])nlsa- 
tion  is  absent,  and  there  is  not  that  sense  of  force  and  power  which  is  so 
striking  in  the  throbbing  of  a  ]ierforating  aneurism.  There  is  not  to  be 
felt  as  in  aortic  anenrism  the  shock  of  the  heart-sounds,  particularly  the 
diastolic  shock.  Auscultatory  sounds  are  less  definite,  as  large  aneurisms 
may  occur  without  murmur;  and,  on  the  other  hand,  murmurs  may  be 
heard  over  tumors.     The  greatest  difTiculty  is  in  the  deep-seated  thoracic 


■^  or  fpim 

kliiili    lull 
•rioi"  vena 

cllll)l)ili;; 
li    (wo   l'\- 

(listciilioii 
volvc  the 
udlu'sinii 
'  sac  iiiiiy 
my  cutit's, 

1  growths 
-111  or  tlic 

■.       If    the 

lil)rcs  iiiiil 

tllO    SilllKJ 

bmiK'lics 
'  iris  con- 
{'\(>n,  ami 
on  to  SCO 
illor,  ri'd- 

(l.    ]\laiiy 
lie  otJicrs 
Ibciit   re- 
port ion 
arcli. 
t  throl)- 
reJ'crrcd 
Ijy  scv- 

COllllllOll 

I'll  came 
loiit  any 
he  con- 

ise  frrcat 
forcibly 

])iilsates 
'('  ])ulsa- 
cli  is  so 
t  to  l)e 
iirly  the 
eiirisms 
may  l)e 
;horacic 


AXEUniSM. 


i83 


Mimors,  anil  liorc  tlic  cliagnoHij»  Jiiay  be  im|)ossibk'.  1  have  alre.uly  re- 
lerri'(l  to  the  cnso  which  was  rcgariU'd  by  Skoda  n.x  niiciirism  niid  by  ()p- 
polzcr  as  timior.  'J'lie  physicul  signs  may  be  indefinite.  The  ringing 
aortic  i^econd  sound  is  ot'  great  importance  and  is  rarely,  if  ever,  heard 
(i\er  Uimor.  Tracheal  lugging  is  here  a  valuable  sign,  i'ressnre  i)he- 
nonicnu  are  less  common  in  tumor,  whereas  pain  is  nioro  frequent.  Tho 
;.eneral  a|tpearance  of  the  patient  in  aneurism  is  much  better  than  in 
lumor,  in  which  there  may  be  cachexia  and  enlargement  of  the  glands  in 
ilic  axilla  or  in  the  neck.  Healthy,  strong  males  who  have  worked  hanl 
a. id  have  had  syphilis  are  the  most  common  subjects  of  aneurism.  Occa- 
sionally cancer  of  the  a^sophagus  may  simulate  aneurism,  producing  ))rcssuro 
on  the  left  bronchus,  and  in  one  instance  at  the  I'hiladelphiii  llos[)ilal,  with 
;■.  husky,  brazen  cough,  the  symptoms  were  very  suggestive. 

{(')  I'lilmtinij  riviirisj/. — In  cases  of  ciiipi/rmd  iiccassilalis,  if  the  pro- 
jecting tumor  is  in  the  neighborhood  of  the  heail  and  pulsates,  the  condi- 
tion may  readily  be  mistaken  for  aneurism.  The  absence  of  the  heaving, 
liiiu  distention  and  of  the  diastolic;  shock  would,  togi'lher  with  tho  his- 
tory and  the  existence  of  pleural  ell'usion,  determine  the  nature  of  the  case. 
if  necessary,  puncture  may  be  made  with  a  line  hypodermic  nec(lle.  In  a 
majority  of  the  cases  of  ])ulsating  jileurisy  the  throbbing  is  dilfuse  and 
wi(les])read,  moving  the  whole  side. 

Prognosis. — The  outhxdc  in  thoracic  aneurism  is  always  grave.  Life 
may  be  prolonged  for  some  years,  but  the  ])atients  are  in  constant  jeopardy. 
Spontaneous  cure  is  not  very  infrtHpient  in  the  small  sacculated  tninors  of 
the  ascending  and  thoracic  portions.  Tho  cavity  becomes  filled  with  1am- 
inte  of  firm  fibrin,  which  become  mere  and  more  dense  and  hard,  the  sac 
shrinks  consideral)ly,  and  ilnally  lime  salts  are  deposited  in  the  old  fibrin. 
The  lamina'  of  fibrin  may  lie  on  a  level  with  the  lumen  of  the  vessel,  caus- 
ing complete  obliteration  of  the  sac.  The  cases  which  ru])tnre  externally, 
as  a  ride  run  a  ra])id  course,  although  to  this  there  are  exceptions;  the 
sac  may  contract,  become  firm  and  hard,  and  the  patient  may  live  for  five, 
or  even,  as  in  a  case  mentioned  by  JJalfour,  for  ten  yi'ars.  The  cases  which 
have  lasted  longest  in  my  ex])ericnec  have  been  those  in  which  a  sa?cular 
aneurism  has  ])rojectcd  from  the  ascending  arch.  (Jne  patient  in  .Mont- 
real had  been  known  to  have  aneurism  for  eleven  years.  The  aneurism 
may  be  enormous,  occu])ying  a  large  area  of  the  chest,  and  yet  life  be  pro- 
longed for  many  years,  as  in  the  case  mentioned  as  under  tiic  care  of 
Skoda  and  Oppolzer.  One  of  the  most  remarkable  instances  is  the  case  oi! 
dissecting  aneurism  reported  by  Graham.  The  patient  was  invalided  after 
the  Crimean  War  with  aneurism  of  the  aorta,  and  for  years  was  under  the 
o))servation  of  J.  H.  l^ichardson,  of  Toronto,  under  whose  care  he  died 
in  1885.  The  autopsy  showed  a  healed  aneurism  of  the  arch,  with  a  dis- 
secting aneurism  extending  the  whole  length  of  the  aorta,  which  formed  a 
double  tube. 

Treatment. — In  a  large  projiortion  of  the  cases  this  can  only  be  pal- 
liative.    Still  in  every  instance  measures  should  be  taken  which  are  known 
to  promote  clotting  and  consolidation  within  the  sac.    In  any  large  series 
of  cured  aneun.'ms  a  considerable  majority  of  the  patients  have  not  been 
4» 


7b4 


DISHASKS  OF  THK  CIHCrLATOllV  SYSTKM. 


/ 


know  II  to  lio  HultjcciH  of  tiic  (lisciiHO,  l)ut  lilt'  oMitcrii UmI  hiic  Ims  liccn  fouinl 
ucL'idciiliilly  at  the  post  iiiortfiii. 

The  iiioHt  Kiilisl'iulory  plnii  in  early  caHos,  wlicii  it  (•.•m  he  carried  out 
tlioroiiKlily.  •><  tl"it  ailvined  hy  the  late  Mr.  'riiliiell,  ol'  Duhliii,  the  essen- 
tials of  which  are  rest  and  u  restricted  diet.  Hcst  is  essential  and  shoulil. 
as  far  as  |tossil)le,  he  ahsolutc.  The  reduction  of  the  daily  nunihcr  oi' 
heart-heats,  when  a  patient  is  recinnhcnt  and  makes  no  exertion  whatever, 
aniounts  to  many  thousands,  and  is  one  of  the  prinei|)al  advanta;,a'8  of 
this  plan.  Mental  (piiet  nhould  also  he  enjoined,  'i'he  diet  advised  by 
Tufnell  is  extremely  rigid — for  breakfast,  2  ounces  of  bread  and  butter 
and  )i  ounces  of  milk;  for  dinner,  2  or  3  ouiu'cs  of  meat  and  ;{  or  I  ounces 
of  milk  or  claret;  for  supper,  2  tunees  of  bread  aiul  2  ounces  of  milk. 
This  low  diet  diminishes  the  blood-volumo  and  is  thought  also  to  render 
tho  blood  more  (ihriimus.  It  reduces  greatly  the  blood-pressure  within 
the  sac,  in  this  maniu'r  favoring  coagulation.  This  treatment  should  be 
])ursue(l  for  several  months,  but,  except  in  persons  of  a  good  deal  of  mental 
stamina,  it  is  impossible  to  carry  it  out  for  more  than  a  few  weeks  at  a 
time.  It  is  a  form  of  treatnuMit  adapted  only  for  the  saccular  form  of 
aneurism,  aiul  in  cases  of  large  sacs  communicating  with  the  aorta  by  a 
comparatively  small  orilice  the  chaiu'cs  of  con.s(»lidation  are  fairly  good, 
rnipiestionably  rest  and  the  restriction  of  the  li([uids  are  the  important 
])arts  of  tho  treatment,  and  a  greater  variety  and  quantity  of  food  may 
be  allowed  with  advantage.  If  this  ])lan  cannot  be  thoroughly  carried  out, 
the  patient  should  at  any  rate  be  advised  to  live  u  very  (piiet  life,  moving 
about  with  deliberation  and  avoiding  all  sudden  mental  or  bodily  excite- 
ment. The  bowels  should  bo  kept  regular,  and  consti])ation  and  strain- 
ing should  be  carefully  avoided.  Of  medicines,  iodide  of  ])otassium,  as 
advised  by  IJalfour,  is  of  great  value.  U  may  be  given  in  doses  of  from 
10  to  15  or  20  grains  three  times  a  day.  Larger  doses  are  not  necessary.  The 
mode  of  action  is  not  well  understood.  It  may  act  by  increasing  the  secre- 
tions and  so  insi)issating  the  blood,  by  lowering  the  blood-pressure,  or, 
as  l?alfour  thinks,  by  causing  thickening  and  contraction  of  the  sac.  The 
most  striking  elTect  of  the  iodide  in  my  experience  has  been  the  relief  of 
the  ])ain.  The  evidence  is  not  conclusive  that  the  syphilitic  cases  are  more 
benefited  by  it  than  tho  non-sy])hilitic.  All  these  measnres  have  little  value 
nnlcss  tho  sac  is  of  a  snitable  form  and  size.  The  largo  tumors  with  wide 
mouths  communicating  with  the  ascending  portion  of  the  aorta  may  be 
'  "•  fited  on  the  nuist  ap])roved  plans  for  months  witho\it  the  slightest  intlu- 
other  than  reduction  in  the  intensity  of  the  throbbing.  A  ])atient 
lIi  a  tumor  projecting  into  the  right  jdoura  remained  on  tho  most  rigid 
Tufnell  treatment  for  more  than  one  Inmdrcd  days,  during  which  time  ho 
also  took  iodide  of  potassium  faithfully.  The  pulsations  were  greatly  re- 
duced and  tho  area  of  dulness  diminished,  and  we  congratulated  ourselves 
that  tho  sac  was  probably  consolidating.  Sudden  death  followed  ru]iture 
into  the  pleura,  and  the  sac  contained  only  fluid  blood,  not  a  shred  of 
fahrin.  In  cases  in  which  the  tumor  is  large,  or  in  which  there  seems  to  be 
very  little  prospect  of  consolidation,  it  is  perhaps  better  to  advise  a  man 
to  go  on  quietly  with  his  occu2)ation,  avoiding  excitement  and  worry.    Our 


ANKUULSM. 


•85 


ec'ii  found 

iirricd  uiil 
till'  rsHi'ii- 
11(1  sliouM, 
lUllllllT    o|' 

wliati'viT. 

iiitii;,a's  of 

id  vised    hy 

iiid    hiittiT 

r  1  ounces 

s  of   niilL 

to  render 

iri!  within 

slionld  he 

of  mental 

veeks  at  u 

r  form  of 

lortii  hy  11 

lirly  good. 

important 

I'ood  may 

irriud  out. 

:'o,  moving' 

ily  excite- 

nd  strain- 

ssiuin,  as 

s  of  from 

sary.  The 

the  secre- 

ssure,  or, 

sae.     Tlie 

relief  of 

are  more 

ttlo  value 

ivith  wide 

1   may  he 

est  influ- 

V  ])atient 

lost  ri;iid 

1  time  he 

I'eatly  re- 

oursclves 

rujiture 

shred  of 

ms  to  he 

e  a  man 

rv.    Our 


profession  lins  nlTcrcd  nuiny  examples  of  j;ood  work  'horonj^hly  and  cou- 
MJentiously  carried  out.  hy  men  with  aneurism  of  the  aorta,  who  wisely, 
1  thiidv,  preferred,  as  did  the  late  Jlilton  l''a<r;ie,  to  die  in  harness. 

Siiri/iral  Mntsitrcs. — In  n  few  niHeH  consolidation  may  he  promoted  in 
the  nac  hy  tiio  iii'roductiou  of  a  foreign  Ixidy,  such  an  wire,  horse-hair,  or 
hy  the  conitdnation  (d'  wiring  ami  (dectrolysis.  Moore,  in  lS(i|,  first  wired 
a  sac,  putting  in  :;'S  feet  (tf  line  wire.  Death  occurreil  on  the  fifth  day.  Cor- 
radi  proposed  the  comhined  method  of  wiring  with  electrolysis,  which  was 
lirst  used  hy  Hurreni  in  1ST!).  His  patient  lived  for  three  and  a  half  months, 
llorse-hair,  watch-spring  wire,  catgut,  and  Florence  Hilk  have  heeii  used, 
llunner  has  collected  for  mi;  the  statistics  of  Moore's  method  (wiring), 
(if  which  there  were  IM  cases,  8  of  thoracic  aneurism,  all  fatal;  5  aneurisms 
(if  the  ahdoininal  aorta,  '2  of  which  were  successful.  Of  10  ca.se8  treated 
hy  wiring  and  electrolysis  (Corradi's  method),  all  were  thoracic;  of  these, 
the  cases  of  Kerr,  I{osenstirn,  1).  1).  Stewart,  and  Ilershey,  all  American 
cases,  were  successful,  'i'he  most  favorahle  cases  are  those  ii.  which  the 
luieiirism  is  sacculated,  hut  this  is  a  point  not  easily  deteriniiu'd,  and  ofti'H 
from  a  sac  particularly  favorahle  for  wiring  there  may  he  secondary  i)ro- 
jtctions  of  great  thinness.  In  a  case  of  ahdominal  aneurism  recently 
(i|ierated  U|)on  hy  Ilalsted  all  the  conditions  were  very  favorahle,  and  tlu^ 
man  seemed  doing  very  well  when  sudden  death  occurred  on  the  third 
(lay  from  ru])ture  of  a  small  i)rojection  of  the  sac  thro  gh  the  diaphragm 
into  the  ])Ieura. 

Oilier  Si/inplnnis  roquh'huj  Tirdhiirnl. — Pressure  on  veins  causing  en- 
gorgement, particularly  of  the  head  and  arms,  is  sometimes  proni|,tly  re- 
lieved hy  free  venesection,  and  at  any  time  during  the  course  of  a  thoracic 
iiiieiirisni,  if  attacks  of  dysjuKca  with  lividity  supervene,  l)leeding  may  be 
resorted  to  with  great  henelit.  It  has  the  advantage  also  of  ])romptly 
checking  the  ])ain,  for  which  symptom,  as  already  mentioned,  the  iodide 
of  potassium  often  gives  relief.  Jn  the  final  stages  morphia  is,  as  a  rule, 
necessary.  l)ysi)n(x'a,  if  associated  with  cyanosis,  is  best  relieved  by  bleed- 
ing. Chloroform  inhalations  may  be  necessary.  The  question  sometimes 
conies  up  with  reference  to  tracheotomy  in  these  cases  of  urgent  dys|)no'a. 
If  it  can  he  shown  by  laryngoscoi)ic  examination  that  it  is  due  to  bilateral 
idiductor  paralysis  the  trachea  may  be  opened,  but  this  is  extremely  rare, 
iind  in  nearly  every  instance  the  urgent  dyspnoea  is  caiised  by  j)rcssure 
about  the  bifurcation.  "When  the  sac  appears  etxernally  and  grows  large, 
iin  ice-cap  may  be  ai)])lied  u])on  it,  or  a  belladonna  ])laster  to  allay  the 
pain.  In  some  instances  an  elastic  siqiport  may  be  used  with  advantage. 
Mild  T  saw  a  physician  with  an  enormous  external  aneurism  in  the  right 
mammary  region  who  for  many  months  had  obtained  great  relief  by  the 
clastic  support,  passing  over  the  shoulder  and  under  the  arm  of  the  oppo- 
site side. 

Digitalis,  ergot,  aconite,  and  veratrum  viride  are  rarely,  if  ever,  of  serv- 
ice in  thoracic  aneurism. 


78G 


/ 


DISEASES  OF  THE  ClRCULATUltY  SYSTEM. 


Aneurism  of  tut.  Aduomixal  Aohta. 


The  sac  is  most  coiuiiioii  just  below  the  diiiphragiu  in  the  neighborhood 
of  the  eo'liac  axis.  Tliis  variety  is  rare  in  coinparison  witli  thoracic  luieii- 
risiii.  Of  the  408  cases  of  aortic  aneurism  at  St.  Bartholomew's  Hospital,  ::.':i 
involved  the  abdominal  aorta.  The  tumor  may  be  fusiform  or  sacculated, 
and  it  is  sfunetiuu'S  multii)le.  J'rojecting  backward,  it  erodes  the  vertebra' 
and  may  cause  nundjness  ami  tingling  in  the  legs  and  linally  paraplegia,  or 
it  may  i)ass  into  the  thorax  and  burst  into  the  ])leura.  ^lore  commonly  the 
sac  is  on  the  anterior  wall  and  projects  forward  as  a  definite  tumor,  which 
jnay  Ite  either  in  the  middle  line  or  a  little  to  the  left.  The  tumor  nuiy 
])roject  in  the  epigastric  region  (which  is  most  common),  in  the  left  hypo- 
chondrium,  in  the  left  flank,  or  in  the  lumbar  region.  When  high  u|i 
beneath  the  pillar  of  the  diaphragm  it  may  attain  considerable  size  without; 
being  very  a])parent  on  ])al|)ation. 

The  symi)toms  are  chiefly  ])ain,  very  often  of  a  cardialgic  nature,  pass- 
ing round  to  the  sides  or  localized  in  the  back,  and  gastric  symi)toms,  i)ar- 
ticularly  vomiting.  Retardation  of  the  pulse  in  the  femoral  is  a  very  com- 
mon symptom. 

Diagnosis  and  Physical  Signs. — Insi)cction  may  show  markeil 
])ulsation  in  the  epigastric  region,  sometimes  a  definite  tumor.  A  thrill 
is  not  uncommon.  The  ])ulsation  is  forcible,  exi)ansile,  and  sometimes 
double  when  the  sac  is  large  and  in  contact  with  the  pericardium.  On  ])al- 
])ation  a  (Icfiiiitc  tumor  can  he  fell.  If  large,  there  is  some  degree  of  dul- 
ness  on  ])ercussion  which  usually  merges  with  that  of  the  left  lobe  of  the 
liver.  On  auscultation,  a  systolic  murmur  is,  as  a  rule,  audible,  and  is 
sometimes  best  heard  at  the  back.  A  diastolic  murnnir  is  occasionally 
present,  usually  very  soft  in  quality.  One  of  the  commonest  of  clinical 
errors  is  to  mistake  a  throbbing  aorta  for  an  aneurism.  It  is  to  be  remem- 
bered that  no  ])idsation,  however  forcible,  (U'  the  ])resence  of  a  thrill  or  a 
systolic  murmur  justifies  the  diagnosis  of  abdominal  aneurism  unless  there 
is  a  definite  tumor  triiich  can  be  grasped  and  which  has  an  expansile  pulsa- 
tion. Attention  to  this  rule  will  save  many  errors.  The  throbbing  aorta 
— the  "  ])reternatural  pulsation  in  the  epigastrium,"  as  Allan  Burns  calls 
it — is  met  with  in  all  neurasthenic  conditions,  particularly  in  women.  In 
auipmia,  particularly  in  some  instances  of  traumatic  anaemia,  the  throblnng 
may  be  very  great.  In  the  case  of  a  large,  stout  man  with  severe  hfcmor- 
Thages  from  a  duodenal  \dcer  the  throbbing  of  the  abdominal  aorta  not 
only  shook  violently  the  whole  abdomen,  but  communicated  a  pulsation 
to  the  bed,  the  shock  of  which  was  distinctly  jjcrceptible  to  any  one  sitting 
upon  it.  Very  frequently  a  tumor  of  the  pylorus,  of  the  pancreas,  or  of 
the  left  lobe  of  the  liver  is  lifted  with  each  impulse  of  the  aorta  and  may 
be  confounded  with  aneurism.  The  absence  of  tlie  forcible  expansile  im- 
j)ulse  and  the  examination  in  the  knee-elbow  position,  in  which  the  tumor, 
as  a  rule,  falls  forward,  and  the  pulsation  is  not  then  communicated,  suf- 
fice for  differentiation.  The  tumor  of  abdominal  aneurism,  though  usually 
fixed,  may  be  very  freely  movable. 

The  outlook  in  abdominal  aneurism  is  bad.     A  few  cases  heal  spon- 


L'ighborliood 
Dracic  ant'ii- 
llof^pital,  i':'> 
•  fiaet'ulatLMl, 
lie  vertebra' 
iraplejiia,  oi' 
iiiiiionly  the 
iiiiur,  which 
tumor  may 
e  lei't  hyi>o- 
eii  hi^li  up 
iize  without 

atiire,  pai?:<- 
ptoms,  par- 
II  very  com- 

ow   marked 

'.     A  thrill 

sometimes 

n.     On  ])al- 

^ree  of  dul- 

lohe  of  the 

ble,  and  is 

)eeasionally 

of  cHnical 

be  remem- 

thrill  or  a 

niess  tliere 

He  pidfiii- 

l)ing  aorta 

Uirns  calls 

omen.     In 

throbbinLT 

re  ha?mor- 

aorta  not 

pulsation 

:)ne  sitting 

•eas,  or  oF 

and  may 

msile  im- 

he  tumor, 

a  ted,  suf- 

jfb  usually 

leal  spon- 


ANEURISM, 


<04 


IS 


tancously.  Death  may  result  from  {a)  eompleto  obliteration  of  the  lumen 
hy  elots;  (/>)  com[)ression  paraplegia;  {c)  rupture  (wliieh  is  almost  the 
rule)  either  into  the  pleura,  retroperitoneal  tissues,  jjoritona^'um  or  the  in- 
testines, very  commonly  the  duodenum;  (</)  by  embolism  of  the  superior 
nu'senteric  artery,  producing  infarction  of  the  intestines. 

The  Irealiiienl  is  such  as  already  advised  in  thoracic  aneurism.  When 
the  aneurism  is  low  down  pressure  has  been  successfully  applied  in  a  case 
hy  ^Murray,  of  Newcastle.  Jt  must  be  kept  up  for  many  hours  under  chloro- 
lorm.  The  ])lan  is  not  without  risk,  as  patients  have  died  from  bruising 
and  iitjury  of  the  sac. 

A.VKL'niSM    OF    TUV:    r>RAXCHE.S    OF   THE    ABDOMINAL    AoRTA. 

The  ni'liuc  aris  is  itself  not  infrequently  involved  in  aneurism  of  the 
iiist  i)ortion  of  the  abdominal  aorta.  Of  its  Ijranches,  the  splenic  aiiery  is 
occasionally  the  seat  of  aneurism.  This  rarely  causes  a  tumor  large  emnigh 
to  he  felt;  sometimes,  liowever,  the  tumor  is  of  large  size.  I  have  re[)(n'ted 
a  case  in  a  man,  aged  thirty,  who  had  an  illness  of  several  mont'i:;'  dura, 
tion,  severe  ei)igastric  pain  and  vomiting,  which  led  his  physicians  in  Xew 
York  to  diagnose  gastric  ulcer.  There  was  a  deep-seated  tumor  in  the  left 
liyi)ochondriac  region,  the  dulncss  of  which  merged  with  that  of  the  spleen. 
There  was  no  ])ulsation,  but  it  was  thought  on  one  occasion  that  a  bruit 
was  heard.  The  chief  sym[)toms  while  tinder  ol)servation  were  vomiting, 
severe  epigastric  jiain,  occasional  ha-niatemesis,  and  finally  seveie  hivmor- 
rhage  from  the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a 
c;)coa-nut  was  situated  between  the  stomach  above  and  the  transverse  colon 
helow,  and  extended  to  the  left  as  far  as  the  level  of  the  navel.  The  sac 
contained  densely  laminated  fibrin.  It  had  perforated  the  colon.  I  have 
twice  seen  small  aneurisms  on  the  splenic  artery.  Of  39  instances  of  aneu- 
rism on  the  branches  of  the  a])dominal  aorta  collected  by  Lebert,  10  were 
of  the  s])lenic  artery. 

Aneurism  of  the  hepatic  artery  is  very  rare,  and  there  are  only  10  or  12 
cases  on  record.  The  sym])toms  are  extremely  indelinite;  the  condition 
could  rarely  be  diagnosed.  In  the  case  reported  by  Ross  and  myself,  a  man 
aged  twenty-one  had  the  sym])toms  of  pyannia.  The  liver  was  greatly 
enlarged,  M'eighed  nearly  5,000  grammes,  and  presented  innumerable  small 
abscesses.  An  oval  aneurism,  half  the  size  of  a  small  lennni,  involved  the 
right  and  part  of  the  left  branches.  In  J.  B.  S.  Jackson's  *  case  the  aneu- 
rism perforated  the  hepatic  duct. 

A  few  cases  of  aneurism  of  the  superior  mesenteric  artery  are  on  record, 
'{'he  diagnosis  is  scarcely  ])ossible.  riugging  of  the  branches  or  of  the  main 
stem  may  cause  the  sym})toms  of  infarction  of  the  l)owels  which  have  al- 
ready been  considered. 

Small  aneurisms  of  the  renal  artery  are  not  very  uncommon.  Large 
tumors  are  rare.  The  sac  may  rupture  and  give  rise  to  extensive  retro- 
iieritnncal  luvmorrliage. 


*  Metliciil  ^Fagazine,  1834,  iii. 


788 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


/ 


Arterio-venous  Aneurism. 

In  tliis  form  tliore  is  abnormal  communication  l)etwccn  an  artery  and 
a  vein.  When  a  tumor  lies  between  the  two  it  is  known  as  varicose  aneu- 
rism; when  there  is  a  direct  communication  without  tumor  the  vein  is 
chiefly  distended  and  the  condition  is  known  as  aneurismal  varix. 

An  aneurism  of  the  ascending  portion  of  the  arch  may  o))e]i  directly 
into  the  vena  cava.  Twenty-nine  cases  of  this  lesion  have  been  analyzed 
by  Pei)per  and  (jirilfith.  Cyanosis,  tedema,  and  great  distention  of  the 
veins  of  the  u])per  part  of  the  body  are  the  most  frequent  symptoms,  and 
develop,  as  a  rule,  with  suddenness.  Of  the  i)hysical  signs  a  thrill  is  pres- 
ent in  some  cases.  A  continuous  murmur  with  systolic  intensification  is 
of  great  diagnostic  value.  Jn  a  recent  case,  after  the  existence  for  some 
time  of  ])ressure  symptoms,  intense  cyanosis  developed  with  engorgement 
of  the  veins  of  the  head  and  arms.  Over  the  aortic  region  there  was  a 
loud  continuous  murmur  with  systolic  intensification. 

A  majority  of  the  cases  of  arterio-venous  aneurism  and  of  aneurismal 
varix  result  from  the  accidental  opening  of  an  artery  and  vein  as  in  vene- 
section, and  are  met  with  at  the  bend  of  the  elbow  or  sometimes  in  the 
tem])oral  region.  The  condition  may  ])ersist  for  years  without  causing 
any  trou1)le.  Pulsation,  a  loud  thrill,  and  a  continuous  humming  murmur 
are  usually  present. 

Congenital  Aneurism. 

In  consequence  of  failure  of  proper  development  of  the  elastic  coat  in 
many  ])laces  in  the  arterial  system,  multiple  aneurisms  may  develop.  Ju 
the  well-known  case  described  by  Kussmaul  and  Maier,  upon  many  of  the 
mediinn-sized  arteries  there  were  nodular  prominences,  which  consisted  of 
thickening  of  the  intima  and  infiltration  of  the  adventitia  and  of  the 
media,  with  a  nuclear  growth  M-hicli  in  juaces  looked  quite  sarcomatous. 
They  called  it  a  case  of  nrriarieritis  nodosa,  and  Ep])inger  holds  that  it 
belongs  to  the  category  which  he  makes  of  congenital  aneurism.  As 
many  as  63  aneurismal  tumors  have  been  found  in  one  case.  In  the 
smaller  branches,  such  as  the  coronary  and  the  mesenteric  arteries  or  in 
the  ])ulmonary  arteries,  there  may  be  numerous  elongated  or  saccular 
aneurisms  varying  in  size  from  a  cherry  to  a  hazel-nut.  These  are  true 
aneurismal  dilatations,  and,  according  to  Eppinger's  careful  study,  the  wall 
consists  of  the  intima  and  the  adventitia,  the  elastic  lamina  having  disap- 
])eared.  The  condition  has  been  met  with  in  children.  Some  of  tlie  cases, 
however,  have  been  in  adults;  but  the  term  as  applied  by  Ep])inger  ex- 
presses, and  probably  correctly,  the  deep-seated  fundamental  error  in  de- 
A'elopment  which  must  lie  at  the  basis  of  this  condition.  A  favorite  situation 
is  in  the  coronary  arteries;  a  case  has  been  reported  by  Gee  in  a  boy  of 
seven. 


artery  and 
ricose  antni- 
tlio  vein  is 
rix. 

)eii  directly 
en  analyzed 
tion  of  the 
iptoms,  and 
irill  is  pres- 
sifieation  is 
:'e  for  some 
tigorgement 
;liere  Mas  a 


aneurismal 
as  in  vene- 
mes  in  the 
)iit  causing 
iig  murmur 


•tic  coat  in 
!velop.     In 
jiny  of  the 
onsisted  of 
nd  of  the 
rcomatous. 
Is  that  it 
ism.      As 
In   tlie 
ries  or  in 
r  saccular 
3  are  true 
,  the  wall 
11  g  disap- 
the  cases, 
)inger  ex- 
'or  in  de- 
situation 
a  boy  of 


SECTION   VIII. 

DISEASES  OF  THE  BLOOD  A:XD  DUCTLESS 

GLA]^IDS. 


I.    AN>EMIA. 

Ax.TiMiA  may  he  defined  as  a  reduction  in  the  amount  of  the  blood  as 
a  whole  or  of  its  corpuscles,  or  of  certain  of  its  more  important  constitu- 
ents, such  as  albumin  and  Inemoglobin.  The  condition  may  be  general 
or  local.  The  former  alone  we  are  here  considering.  It  is  interesting  to 
note,  however,  that  the  ])allor,  particularly  of  the  face,  which  is  one  of  the 
most  striking  symptoms  of  iuuvmia,  is  just  as  characteristic  of  local  ana'mia 
due  to  fright  or  to  nausea.  There  are  persons  i)ersistently  pale  without 
actual  anaemia  in  whom  the  condition  may  be  due  to  inherited  jjeculiarities. 

Our  knowledge  is  not  yet  sufficiently  advanced  to  classify  satisfactorily 
the  various  forms  of  anannia.  The  following  ])rovisional  grouping  may 
be  made:  (1)  Secondary  or  symptomatic  amemia;  {2)  primary,  essential, 
or  cytogenic  anamiia. 

Secondary  Ax.emia. 

Tender  this  division  comes  a  large  proportion  of  all  cases.  The  follow- 
ing are  the  most  important  groups,  based  on  the  etiology: 

(1)  Ana'mia  from  liannorrharje,  either  traumatic  or  spontaneous.  The 
loss  of  blood  may  be  rapid,  as  in  lesions  of  large  vessels,  in  injury  or  in 
rupture  of  aneurisms,  in  cases  of  ulcer  of  the  stomach  or  duoch'nuni,  or 
in  post-partum  haemorrhage.  If  the  loss  is  excessive,  death  results  from 
lowering  of  the  arterial  ])ressure.  In  sudden  profuse  ha-morrhage  the 
loss  of  3  or  4  pounds  of  blood  may  prove  fatal.  In  the  rupture  of 
an  aneurism  into  the  pleura  the  loss  of  blood  may  amount  to  74^  ]iounds, 
the  largest  quantity  T  have  known  to  be  shed  into  one  cavity.  In 
a  case  of  hamiatemesis  the  patient  lost  over  10  pounds  by  measurement 
in  one  week  and  yet  recovered  from  the  inmiediate  effects.  Even  after  very 
severe  haemorrhage  the  number  of  red  blood-corpuscles  is  not  reduced  so 
greatly  as  in  forms  of  idiopathic  ana-mia.  Thus  in  one  case  just  mentioned, 
at  the  termination  of  the  week  of  bleeding  there  were  nearly  1,390.000  red 
blood-corpuscles  to  the  cubic  millimetre.  The  i)rocoss  of  regeneration  goes 
on  with  great  rapidity,  and  in  some  "  bleeders  "  a  week  or  ten  days  suffice 

789 


790 


DISPLVSES   OF   TilE   BLOOD   AND    DUCTLESS   GLANDS. 


to  re-ostiiljlish  the  normal  amount.  Tlic  watery  and  saline  constituents  of 
the  blood  are  readily  restored  by  absorption  from  the  gastro-intestinal 
tract.  The  albuminous  elements  also  are  quickly  renewed,  but  it  may 
take  weeks  or  months  for  the  corijuscles  to  reach  the  normal  standard.    The 


APRIL.       1                              • 

rIAV.                                                JUNE. 

JULY. 

1    0«  M    ..    *l    W1   K 

110^ 

lOOK 

r),(K)o,(xx) 

^ 

90^ 

"-'- 



80^ 

4,000,000 

_.___ 

70^ 

t  .^J 

--"'"      1 

60* 

3,000,000         V                /       ~~^ 

\      1 

\    j 

50^ 

\   f 

_ 

iOi 

2,000,000 

30^ 

-*— A — A—  v^- - :- -  »-  - *-  --h  -  •;. 

--it-  -:  r-  -  *-  -k  -  :•: 

«,- -(r  - 

■ft-  -   ■). 

--  •; 

14,0OO 

12,000           |s     ,^ 

10,000          /     '       ^ 

8,000        /                \ 

0,000                          *■  —  " 

"■""■"■-[- -^^ 

4,000 

'^^^ 

2,000 

'~                                     *■> 

BLACK,  J1ED  CORPUSCLES, 


RED,  HAEMAQLOBIN. 


MEAN  NORM. 
NUMBER  OF 

WHITE 
CORPUSCLEt 


BLUE.  COLORLESS  CORPUSCtES. 


Chart  XVIL — Illustrates  the  rapidity  with  which  anaemia  is  produced  in  purpura 
haeinorrhagica  and  the  gradual  recovery.* 

haemoglobin  is  restored  more  slowly  than  the  corpuscles.  The  accompany- 
ing chart  illustrates  the  rapid  fall  and  gradual  restitution  in  a  case  of  severe 
purpura  hasmorrhagica. 

The  microscopical  characters  of  the  blood  after  severe  haemorrhage  may 
not  i)e  greatly  changed.  The  red  corpuscles  show,  usually,  rather  more 
marked  differences  in  size  than  normally,  while  the  average  size  may  be  a 
trifle  reduced;  there  may  be  a  moderate  poikilocytosis.  The  corpuscles 
are  paler  than  normally.  Nucleated  red  corpuscles  appear,  almost  always, 
soon  after  the  hemorrhage;  they  are,  however,  not  numerous.  These  are 
small  bodies  of  about  the  same  size  as  a  normal  red  corpuscle  with  a  small. 


♦On  September  27th  the  patient  roturnol  from  the  country,  where  she  had  spent 
the  summer.  The  blood -count  was  tlion  :  Red  corpuscles,  5,350,000;  white  corpuscles, 
5,500;  hnemoglobin,  94  per  cent. 


ANEMIA. 


791 


round,  (k'oi)ly  tstaining  nuclcufi.  Fruu  nuclei  may  ho  found.  The  color- 
K'?;.s  corpui^ck's  ixvc,  at  first,  iiicrcast'd  in  nunihcr.  Tlifre  is  a  modorato 
h'uc'ocytosis,  tlie  diU'erc'iit ial  count  sliowing  an  increase  in  tiie  niultinuidear 
ncutrcjpliilcri  with  a  diminution  in  the  small  mononuclear  elements.  Dur- 
ing recovery  the  leiicocytosis  diminishes. 

The  reduction  in  luvmoglobin  is  always  proi)ortionatcly  greater  than 
that  in  the  corpnscles. 

In  some  instances  a  rajjidly  fatal  ana'uiia  may  follow  a  single  severe 
JKcmorrhage,  or  repeated  small  luvmorrliages  as  in  j)nrpura.  Here  the 
appearances  of  the  red  corpuscles  are  much  the  same,  except  in  the  total 
absence  of  nucleated  red  cori)Uscles. 

The  leucocytes  in  these  case  are  usually  reduced  in  number;  the  i)oly- 
nuclear  elements  are  present  in  a  relatively  diminished  proportion,  while 
the  snuill  mononuclear  forms  are  numerous.  The  autopsy,  in  these  cases, 
reveals  iisually  a  total  absence  of  any  regenerative  activity  on  the  part  of 
the  bone-marrow. 

(2)  Ana,'mia  is  frequently  produced  by  long-continued  drain  on  the 
albuminous  materials  of  the  blood,  as  in  chronic  suppuration  and  Jiright's 
disease.  Prolonged  lactation  acts  in  the  same  way.  Ka[)idly  growing 
tumors  may  cause  a  j)rofound  ana'ui.a,  as  in  gastric  cancer.  The  charac- 
ters of  the  blood  here  may  be  much  the  same  as  in  the  acute  cases.  Usu- 
ally, though,  the  poikilocytosis  is  much  more  marked;  in  severe  cases  it 
may  be  excessive.  The  presence,  hoAvever,  of  the  very  large  corpuscles, 
such  as  one  sees  in  pernicious  ana'mia,  is  not  noted,  the  average  size  ap- 
l)oaring  to  be  rather  smaller  than  normal. 

Nucleated  red  corjjuscles  are  usually  scanty.  In  long-continued  chronic 
secondary  ana'mias  occasional  larger  nucleated  red  cor])uscles  may  be  seen, 
i)odies  with  larger  palely  staining  nuclei;  in  some  of  these  cells  karyo- 
kinetic  figures  occur.  Nucleated  red  corpuscles  with  fragmentary  nuclei 
may  also  be  seen. 

The  leucocytes  may  be  increased  in  number,  though  in  some  severe 
chronic  cases  there  may  be  a  diminution. 

(3)  Anccmia  from  Inanition. — This  may  be  brought  about  by  defective 
food  supply,  or  by  conditions  which  interfere  with  the  proper  reception 
and  preparation  of  the  food,  as  in  cancer  of  the  oesophagus  and  chronic 
dysjiepsia.  T'le  reduction  of  the  blood  mass  may  be  extreme,  but  the 
]ilasma  suffers  proportionately  more  than  the  corpuscles,  which,  even  in  the 
wasting  of  cancer  of  the  tr'so])hagus,  may  not  be  reduced  more  than  one 
half  or  three  fourths.  In  some  instances  the  reduction  in  the  plasma  may 
be  so  great  that  the  corpuscles  show  an  apparent  increase. 

(4)  Toxic  anccmia,  induced  by  the  action  of  certain  poisons  on  the 
blood,  such  as  lead,  mercury,  and  arsenic,  among  inorganic  substances, 
and  the  virus  of  syiihilis  and  malaria  among  organic  poisons.  They  act 
t'ither  by  directly  destroying  the  red  blood-corpuscles,  as  in  malaria,  or  by 
increasing  the  rate  of  ordinary  consumiition.  The  an.Tmia  of  pyrexia 
may  in  part  be  duo  to  a  toxic  action,  but  is  also  caused  in  part  by  the  dis- 
turbance of  digestion  and  interference  with  the  function  of  the  blood- 
making  organs. 


702 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


/ 


ritlMAKY    OU    ESSEXTIAL   Ax^EMIA. 

1.  Chlorosis. 

Definition. — An  una'uiia  of  unknown  cause,  occurring  in  young  girls, 
characterized  by  a  nuirlvcd  relative  diminution  of  the  hiunioglolnu. 

Etiology. — It  is  a  disease  of  girls,  more  often  of  blondes  than  of 
brunettes.  It  is  dou1)tful  if  males  are  ever  alTeeted.  I  have  never  seen  true 
chlorosis  in  a  boy.  TJie  age  of  onset  is  between  the  fourtt'i'iitli  and  seven- 
teentli  years;  under  the  age  of  twelve  cases  are  rare.  Kecurrenees,  which 
are  common,  may  extend  into  the  third  decade.  Of  the  essential  cause  of 
the  disease  we  know  notliing.  There  exists  a  lowered  energy  in  the  blood- 
making  organs,  associated  in  some  obscure  way  with  the  evolution  of  the 
sexual  a])paratus  in  women.  Hereditary  iniluences,  particularly  chlorosis 
and  tuberculosis,  jday  a  part  in  some  cases.  Sometimes,  as  Virchow  pointed 
out,  the  condition  exists  wit'  a  defective  development  (hypoplasia)  of  the 
circulatory  and  generative  organs. 

The  disease  is  most  common  among  the  ill-fed,  overworked  girls  of 
large  towns,  who  are  confined  all  day  in  close,  badly  lighted  rooms,  or 
have  to  do  much  stair-climbing.  Cases  are  frequent,  however,  under  the 
most  favorable  conditions  of  life.  Lack  of  proper  exercise  and  of  fresh  air, 
and  the  use  of  iin])ro])er  food  are  important  factors.  Emotional  and  nerv- 
ous disturbances  may  be  prominent — so  prominent  that  certain  writers  have 
regarded  the  disease  as  a  neurosis.  l)e  Sauvages  speaks  of  a  chloruse  par 
amour.  Newly  arrived  Irish  girls  wave  very  prone  to  the  disease  in  Mont- 
real. The  "  corset  and  chlorosis  "  expresses  0.  Eosenbach's  opinion.  Men- 
strual disturbances  are  not  xmcommon,  but  are  probably  a  sequence,  not  a 
cause,  of  chlorosis.  Sir  Andrew  Clark  believed  that  constipation  plays  an 
im])ortant  roJc,  and  that  the  condition  is  in  reality  a  cuprceinia  due  to  the 
absorption  of  poisons — leucomaines  and  ptomaines — from  the  large  bowel, 
a  view  which  always  appeared  to  me  baseless,  considering  the  great  fre- 
quency of  the  condition  in  women. 

Symptoms. — (a)  General. — The  symptoms  of  chlorosis  are  those  of 
ana'mia.  The  subcutaneous  fat  is  well  retained  or  even  increased  in 
amount.  The  comjdexion  is  peculiar;  neither  the  1 'inched  aspect  of  ha?m- 
orrhage  nor  the  muddy  pallor  of  grave  anaMuia,  but  a  curious  yellow-green 
tinge,  which  has  given  to  the  disease  its  name,  and  its  popular  designation, 
the  green  sickness.  Occasionally  the  skin  shows  areas  of  ])igmentation, 
particularly  about  the  joints.  In  cases  of  moderate  grade  the  color  may 
be  deceptive,  as  the  cheeks  have  a  reddish  tint,  ]iarticularly  on  exertion 
(chlorosis  rubra).  The  subjects  com])lain  of  breathlessness  and  palpita- 
tion, and  there  may  be  a  tendency  to  fainting — sym])toms  which  often 
lead  to  the  suspicion  of  heart  or  lung  disease,  ruffmess  of  the  face  and 
swelling  of  the  ankles  may  suggest  ne])hritis.  The  disposition  often 
changes,  and  the  girl  becomes  low-s])irited  and  irritable.  The  eyes  have 
a  peculiar  brilliancy  and  the  sclerotic?  are  of  a  bluish  color. 

(b)  Special  Features. — Bhod. — The  drop  as  expressed  looks  pale. 
Johann  Duncan,  in  ISCT,  first  called  attention  to  the  fact  that  the  essen- 


mg  girls, 
u. 

tlian  of 
sc'C'U  tnu' 
id  sevcn- 
is,  which 

cause  of 
lie  bhjod- 
)n  of  the 
chlorosis 
v  pointed 
a)  of  the 

.  girls  of 

•ooius,  or 

mder  the 

fresh  air, 

md  nerv- 

iters  have 

'oruse  par 

in  Mont- 

n.    Men- 

ce,  not  a 

})lay3  an 

le  to  the 

le  bowel, 

reat  fre- 

those  of 
eased  in 
of  ha?m- 
Dw-green 
ignation, 
.'ntation, 
)lor  may 
exertion 

palpita- 
•h  often 

ace  and 
n    often 

es  have 


,.s 


pale. 


e  essen- 


AN^MIA. 


T93 


tial  feature  was  not  a  great  reduction  in  the  miniher  of  the  corpuscles,  but 
a  quantitative  change  in  the  lueniogioliin.  Tiie  corpuscles  tlieuiselves  look 
pale.  In  ()3  consecutive  cases  e.vaniined  at  my  clinic  by  Thayer,  the  average 
uuud)er  jter  cubic  millimetre  of  the  red  blood-corpuscles  was  4,0!)G,514, 
or  over  80  per  cent,  whereas  the  percentage  of  luemoglobin  for  the  total 
nund)er  was  42.3  per  cent.  Tlie  aec()mi)anying  chart  illustrates  well  these 
striking  dill'erences.  There  may,  however,  be  well-nuirked  actual  anaemia. 
The  lowest  blood-count  in  the  series  of  cases  referred  to  above  was  l,i)32,()U0. 
There  may  be  all  the  physical  characteristics  and  symptoms  of  a  profound 
anaemia  with  the  number  of  the  blood-corpuscles  nearly  at  the  normal 


120^ 
110^ 
100* 
90* 
80* 
70* 
CO* 
50* 
40* 

ao* 

20* 


JANUARV.                                       FEB 

RUARY.                                           MARCH. 

1 

0,000,000 

'\  ■■..  ■■;:;;::^ 

1 

.V  ^ 

5,ooo.oon                                           / 

\/ 

/ 

/ 

4,000,000                                         y  ^ 

"■"--,./'' 

3,000,000 

2,000,000 

1,000,000 

ft  _.^ ^—  .}  -  „j._  -i:  -  V ..^-  - .;.-  -A  -  .J-  - 

-  •;  -  — .!:-  -• !.-  -  V!   -  *-  -  •}: '-  -••:      •}  - 

14.000 

12,000 

10,000                                      /^    "">, 

8,000                       ^---^                ^.^^ 

r T 

r,,ooo 

4,000 

7 

2,000 

T 

BLACK,  RED  CORPUSCLES. 


RED,  HAEMAQLOBIN. 

Chart  XVIII. — Chlorosis. 


MEAN  NORM. 

NUMBER  or 

WHITE 

CORPUSCLES 


BLUE,  COLORLESS  CORPUSCLES. 


standard.  Thus  in  one  instance  the  globular  richness  was  over  85  per 
cent,  with  the  ha}moglol)in  about  35.  Xo  other  form  of  anaemia  presents 
this  feature,  at  least  with  the  same  constancy  and  in  the  same  degree.  The 
importance  of  the  reduction  in  the  hemoglobin  depends  upon  the  fact  that 


I 


794 


DISEASES  OF  THE  IJLOOD  AND  DUCTLESS  GLANDS. 


/ 


it  is  the  iron-containing  ck'nients  of  the  l)lo()(l  with  which  in  ivspirntion 
the  oxygen  enters  into  (■(tnihiniition.  'i'his  niarivcd  (liniiniition  in  tlic  iron 
liiis  also  hecn  (leterniined  by  chemical  analysis  of  the  lilood.  The  niiiTo- 
Bcopical  characteristics  of  the  lilood  are  as  follows:  In  severe  eases  the 
corpnseles  may  he  extremely  irregular  in  size  and  shape — poikiloeytosis, 
which  may  occasionally  he  as  marked  as  in  some  cases  of  pernicious  aiuemia. 
The  large  forms  of  red  hlood-eells  are  not  as  common,  and  the  average 
size  is  stated  to  he  helow  mti'inal.  The  color  of  the  cor[)Uscles  is  noticeably 
pale  and  the  deliciency  may  he  seen  either  in  individual  corpuscles  or  in 
the  blood  mixture  prepared  i'or  counting.  Nucleated  red  corpuscles  (normo- 
blasts) are  not  very  uncommon,  ami  may  vary  greatly  in  nund)ers  in  the 
same  case  at  diU'erent  periods.  The  leucocytes  may  show  a  sligiit  increase; 
the  average  in  the  (ui  cases  above  referred  to  was  8,4G7  per  cubic  millimetre. 

{c)  Gastro-intestinal  Symptoms. — The  api)etite  is  capricious,  and  |)a- 
tients  often  have  a  longing  i'or  unusual  articles,  particularly  acids.  In 
some  instances  they  eat  all  sorts  of  indigestible  things,  such  as  chalk  or 
even  earth.  Superacidity  of  the  gastric  juice  is  commonly  associated  with 
chlorosis.  In  19  out  of  1^1  cases  in  Kiegel's  clinic  this  condition  was  found 
to  exist.  In  the  other  two  instances  the  acidity  was  normal  or  a  trille  in- 
creased. Distress  after  eating  and  even  cardialgic  attacks  may  be  associ- 
ated with  it.  Constipation  is  a  common  symptom,  and,  as  already  men- 
tioned, has  heen  regarded  as  an  imi)ortant  element  in  causing  the  disease. 
A  majority  of  chlorotic  girls  who  wear  corsets  have  gastro])tosis,  and  on 
inflation  the  stomach  will  be  found  vertically  placed;  sometimes  the  organ 
is  very  much  dilated.  The  motor  power  is  nsnally  well  retained.  Enter- 
optosis  with  ])alpahle  right  kidney  is  not  uncommon. 

{(I)  Circulatory  Symptoms. —  i'alpitation  of  the  heart  occnrs  on  exer- 
tion, and  may  he  the  most  distressing  symptom  of  which  the  patient  com- 
plains. Percussion  may  show  slight  increase  in  the  transverse  dulness.  A 
systolic  mnrmnr  is  heard  at  the  apex  or  at  the  hase;  more  commoidy  at 
the  latter,  hnt  in  extreme  eases  at  both.  A  diastolic  murmur  is  rarely 
heard.  The  systolic  mnrmnr  is  nsually  loudest  in  the  second  left  inter- 
costal space,  where  there  is  sometimes  a  distinct  ])ulsation.  The  exact 
mode  of  production  is  still  in  dis])ute.  Balfour  holds  that  it  is  in-oduced 
at  the  mitral  orifice  by  relative  insufficiency  of  the  valves  in  the  dilated 
condition  of  the  ventricle.  On  the  right  side  of  the  neck  over  the  jugular 
vein  a  continuous  murmur  is  heard,  the  bruit  de  Jinhlc,  or  humming-top 
murmur. 

The  pulse  is  usually  full  and  soft.  Pulsation  in  the  peripheral  veins  is 
sometimes  seen.  There  is  a  tendency  to  thrombosis  in  the  veins;  most 
commonly  in  the  femoral,  but  in  other  instances  in  the  longitudinal  sinus; 
or  the  thrombosis  may  be  multiple.  Exce])t  in  the  sinuses,  the  condition 
is  rarely  serious.  Tnckwell  has  reported  an  instance  in  wdiich  there  was 
embolism  of  the  right  axillary  artery  with  the  loss  of  a  thumb  and  part 
of  the  fingers.  P)rayton  P)all  has  recently  called  attention  to  the  impor- 
tance of  this  feature  of  chlorosis. 

As  in  all  forms  of  essential  anaemia,  fever  is  not  uncommon.  Especial 
attention  has  of  late  been  directed  to  this  by  French  writers.     Chlorotic 


ANyDMIA. 


795 


pntionts  pufTur  fnMjiK'ntly  from  hciidiu-lu;  mikI  luiinil^ria,  which  may  be 
|iiir()\ysmiil.  The  hands  and  li'ct  are  olu-n  cohl.  J)t'i'matt)grai»liia  id  com- 
mon. Jlystt-rictal  manilVstation.s  aro  not  inlreqiiont.  .Menstrual  disturb- 
ancL's  art'  vury  common — amcnorrhd'a  or  dysmonorrliam.  With  the  im- 
provcMU'nt  in  th((  Idood  condition  tliis  function  is  usually  restored. 

Diagnosis. — Tlie  ^'reen  sickness,  as  it  is  sometimes  called,  is  in  many 
instances  reco^Miized  at  a  <;lance.  The  well-nourished  condition  oi'  the 
;iirl,  the  peculiar  complexion,  whicli  is  most  marked  in  brunettes,  and  the 
white  or  bluish  sclerotics  are  very  characteristic.  A  special  danger  exists 
ill  nustakin<,'  the  apparent  auivmia  oi"  the  early  stage  of  pulmonary  tuber- 
culosis i'or  chlorosis.  .Mistakes  of  this  sort  may  often  be  avoided  by  tiie  very 
simple  test  fnrnisiied  by  allowing  a  dro^)  of  blood  to  fall  on  a  white  towel 
or  a  piece  of  blotting  paper — a  deliciency  in  luemogloljin  is  readily  appre- 
ciated. 'J'lie  palpitation  of  the  heart  and  shortness  of  breath  freipiently 
suggest  heart-disease,  and  the  (edenui  of  the  feet  and  geni'ral  pallor  cause 
tile  cases  to  be  mistaken  for  Hright's  disease.  Jn  the  great  jnajority  of 
cases  the  characters  of  the  blood  readily  separate  chlorosis  from  other 
forms  of  ana'mia. 


Enter- 

•n  exer- 
it  com- 
ss.  A 
Illy  at 
rarely 
inter- 
exact 
oduced 
lilatcd 
iigular 
ng-top 


2.  Idiopathic  or  Progressive  Pernicious  Anaemia. 

The  disease  was  first  clearly  described  by  Addison,  who  called  it  idio- 
pathic ansemia.  C'hanning  and  (.insserow  described  the  cases  occurring 
post  partum,  but  to  Jjiermer  we  owe  a  revival  of  interest  in  the  subject. 

Etiology. — The  existence  of  a  separate  disease  worthy  of  the  term  pro- 
gressive pernicious  anaemia  has  been  doubted,  but  there  are  unciuestionably 
cases  in  which,  as  Addison  says,  there  exist  none  of  the  usual  causes  or 
concomitants  of  auiTcmia.  Clinically  there  are  several  dill'erent  groups 
which  present  the  characters  of  a  ])rogressive  and  jiernicious  aniemia  and 
are  etiologically  ditferent.  Thus,  a  fatal  an:emia  may  be  due  to  the  pres- 
ence of  parasites,  or  may  follow  hemorrhage,  or  be  associated  with  chronic 
atrophy  of  the  stomach;  but  when  we  have  excluded  all  these  causes  there 
remains  a  grou])  which,  in  the  words  of  Addison,  is  characterized  by  a 
"general  anwmia  occurring  without  any  discoverable  cause  whatever,  cases 
in  which  there  had  been  no  previous  loss  of  blood,  no  exhausting  diarrhoea, 
no  chlorosis,  no  purpura,  no  renal,  splenic,  miasmatic,  glandular,  strumous, 
or  malignant  disease." 

Tdio])athic  ana-mia  is  widely  ^distributed.  It  is  of  frequent  occurrence 
in  the  Swiss  cantons,  and  it  is  not  uncommon  in  this  country.  It  affects 
middle-aged  persons,  but  instances  in  children  have  been  described.  Grifllth 
mentions  about  10  cases  occurring  under  twelve  years  of  ag.}.  The  youngest 
jiatient  I  have  seen  was  a  girl  of  twenty.  ^lales  are  more  frequently  af- 
fected than  females.  Of  my  37  eases,  10  were  females  and  17  were  males. 
Of  110  cases  collected  by  Coupland,  56  were  in  men  and  54  in  women. 
Sinkler  and  Eshner  give  3  cases  in  one  family,  the  father  and  two  girls;  the 
father  had  symptoms  of  posterior  sclerosis. 

With  the  following  conditions  may  bo  associated  a  profound  anfcmia 
not  to  be  distinguished  clinically  from  Addison's  idiopathic  form: 


roo 


DISKASKS   OK  TlIK   lU.OOl)   AND   DUCTLESS  (HiANDS. 


(ii)  I'iri/ndiirif  and  I'ldiurilioii. — Tlu"  sviii|tl(>iiis  may  dcvcloi)  (liirlnj:^ 
]tr(<,niiiii('y,  m  in  1!>  of  *-i!>  ciiscs  nf  this  ;i:rnii|)  in  I'licliliorst's  taliU'.  Mori; 
coiiinioiily,  in  my  ('.\|»('ri''nc(',  the  comlitinii  lins  hct-n  [lost  piirtiim;  thus, 
ol  my  'vT  ciiscs,  .')  [((Howcd  (h-livcry. 

{h)  Almiiln/  of  the  J^hniifirli. — Tiiis  conditinii,  mrly  rccojiiiizcd  hy  I'iint 
iind  Fonwick,  may  certainly  canse  a  pro^'rensivo  pt'rnicions  ana-miii.  Ily 
iiKxh'rn  mi'tii(»ds  it  may  now  ix'  possihlc  to  cxclndc  this  extreme  ^^astrie 
atrophy. 

(r)  I'dnislh's. — 'I'he  mowt  severe  form  may  l)e  (ln(>  to  the  |)resenee  of 
])arasites,  and  the  aeeonnts  of  cases  depending'  npon  the  anchylostoma  and 
the  l)othrioeepiialiis  deserihe  a  pro;i:ressive  and  (dten  pernicious  ana-mia. 

Al'ter  the  exclnsion  of  tiiese  forms  there  remains  a  iar;,'e  jjroportion, 
nundx'i'in^'  IS  cases  in  my  series,  which  correspond  to  AcMison's  descrip- 
tion. 'I'iie  etiolofjy  of  these  eases  is  still  dark.  The  re.>*earehes  of  Quincke 
and  his  student  I'eters  showed  that  there  was  an  enormous  increase  in  the 
iron  in  the  liver,  and  they  su^f<reste(l  that  the  aU'ection  was  prol)al)ly  (\uv  to 
increased  lueniolysis.  This  has  heen  str()n«;ly  supported  hy  the  extensive 
()l)servations  of  lIuiHer,  who  has  also  shown  that  the  \irine  excreted  is 
darker  in  color  and  contains  ])atholoj.ncal  urohilin.  The  lemon  tint  ol'  the 
skin  or  the  actual  jaundice  is  attrihuted,  on  this  view,  to  an  overproduction. 
To  e\]>lain  the  luemolysis,  it  has  heen  thon<j;ht  that  in  the  condition  of 
faulty  pistro-intestinal  diji'estion,  which  is  so  commonly  associated  with 
these  cases,  poisonous  materials  are  develo[)ed,  which  when  ahsorbed  cause 
destruction  of  the  eor[)Uscles.  Certainly  the  evidence  for  lueniolysis  is 
very  stronj:,  l)nt  we  are  still  far  away  from  a  full  knowledi^e  of  the  condi- 
tions under  which  it  is  |)r()duce(l. 

Stocknuin  su<r<fests  that  repeated  small  ca))illary  luviuorrhages — chiefly 
internal — i)lay  an  ini])ortant  role  in  the  causation  of  the  disease,  which 
also  explains,  he  holds,  the  existence  of  a  j^reat  excess  of  iron  in  the  liver. 

On  the  other  luuul,  F.  1'.  Henry,  Stephen  ^lackenzie,  Rindlleisch,  and 
other  authorities  incline  to  the  helief  that  the  essence  of  the  disease  is  in 
defective  ha'mogcnesis,  in  consequence  of  which  the  red  hlood-corpuseles 
are  abnormally  vulnerable.  A  ])oint  noted  by  Copeman,  that  the  lueuu)- 
globin  crystallizes  from  the  blood-corpuscles  with  jj;reat  readiness,  can 
scarcely  be  re^'^arded  as  favorin<;  the  view  of  im]»erfeet  luvmoj-enesis,  since 
this  is  a  feature  specially  characteristic  of  the  blood  of  the  younir. 

Morbid  Anatomy. — Tlu'  body  is  rarely  emaciated.  A  lemon  tint 
of  the  skin  is  ])resent  in  a  majority  of  the  cases.  The  muscles  often  are 
intensely  red  in  color,  like  horse-tlesh,  while  the  fat  is  lifrht  yellow.  Ifauu- 
orrhajics  are  common  on  the  skin  and  serous  surfaces.  The  heart  is  usu- 
ally lar<re,  fiabljy,  and  empty.  Tn  one  instance  I  obtained  only  2  drachms 
of  blood  from  the  ritrht  heart,  and  between  3  and  4  from  the  left.  The 
nniscle  substance  of  the  heart  is  intensely  fatty,  and  of  a  pale,  li^dit-yellow 
color,  fn  no  affection  do  we  see  nK)re  extreme  fatty  dc<jeneration.  The 
lun<rs  show  no  special  chan<;es.  The  stomach  in  many  instances  is  normal, 
but  in  pome  cases  of  fatal  ann?mia  the  mucosa  has  been  extensively  atrn- 
l>hicd.  In  the  case  described  by  Henry  and  myself  the  mucous  membrane 
had  a  smooth,  cuticular  appearance,  and  there  was  comideto  atrophy  of 


M.'.      Mnvv 

tiiiii;  tlui.i, 

fl  by  Flint 
I'liiiii.  Iiv 
1110  /g^Lstric; 

rosenc'o  of 

SIOIIUI    1111(1 

iiiui'iiiiii. 
»f(t|K)rti()ii, 
"s  (Icscrip- 
il"  (^iiincko 
Jisc  in  the 
bly  due  to 
oxtonsive 
xcrotc'd  is 
iiit  ol'  tlio 
nidiiction. 
idition  of 
atod  with 
iic'd  causi' 
iiiolysis  is 
liu  condi- 

i — chiefly 
■e,  which 
\\v  liver, 
isch,  and 
use  is  in 
)ri)iiscle8 
e  luenio- 
less,  can 
■^is,  since 

lion  tint 
It  en  are 
ILeiii- 
is  usn- 
ilrachnis 
't.  The 
t-vellow 
1."  The 
normal, 
ly  ntro- 
ni  bra  lie 
)phy  of 


A  N.K.MIA. 


m 


the  secreting'  tidmles.  I'hc  liver  niiiy  be  enlar^^'cd  and  fatty.  In  most  of 
my  aiitt»|isies  it  was  normal  in  size,  bnl  usually  fatty.  The  iron  is 
ill  excess,  a  striking;  ctuiliast  to  the  condition  in  I'ases  of  secondary  aiuemia. 
It  is  deposited  in  the  outer  and  middle  zono.s  of  the  lobules,  and  in  two 
specimens,  which  1  examined,  seemed  to  have  kucIi  a  distribution  that  the 
bile  capillaries  were  distinctly  oulliiied.  This,  Hunter  states,  is  a  special 
and  characteristic  lesion,  possibly  peculiar  to  pernicious  anu'iida.  A.  J. 
Scott  examined  for  me  the  livers  in  1.*)  eonseeutive  autopsies  without  finding 
(except  in  pernicious  ana'mia)  this  special  distribution  of  pijiinent. 

The  spleen  shows  no  important  clianj,'es.  in  one  of  Palmer  Howard's 
<Mses  the  or/^nin  wei^died  only  1  ounce  and  5  drachms.  The  iron  |)i;,nnent 
is  usually  in  excess.  Tlu'  lymph-;,dan(ls  may  be  of  a  deep  red  color.  The 
amount  uf  iron  pif;nient  is  increased  in  the  kidneys,  ehielly  in  tin;  convo- 
luted tubules.  The  hone  nuirrow,  as  jjointed  out  by  II.  ('.  Wood,  is  usually 
red,  lymphoid  in  character,  showing;  ^M'eat  numbers  (»f  nucleated  red  cor- 
puscles,especially  the  lar;;er  forms  called  by  Mhrlich  >,d<;antoblasts.  Changes 
in  the  gangliiMi  cells  of  tlu;  sympathetic;  have  been  ri'ported  on  several  oc- 
casions, iiiehtheim  has  found  sclerosis  in  the  posterior  columns  of  the 
cord.  IWirr  described  a  series  of  cases.  The  subject  is  referred  to  again 
undc'-  diseases  of  the  spinal  cord  (rniversity  Med.  Magazine,  ]H!),')). 

Symptoms. — The  patient  may  have  been  in  previous  good  lu-alth, 
but  in  many  casus  there  is  a  history  of  gastro-intestinal  disturbance,  mental 
.'^hoek.  or  worry.  The  description  given  by  Addison  presents  the  chief 
features  of  the  disease  in  a  masterly  way.  "  It  makes  its  approach  in  so 
slow  and  insidious  a  manner  that  the  patient  can  hardly  lix  a  date  to  the 
earliest  feeling  of  that  languor  which  is  shortly  to  become  so  extreme. 
The  countenance  gets  ])ale,  the  whites  of  the  eyes  become  ])early,  the  gen- 
eral frame  flabby  rather  than  wasted,  the  ])ulse  ))erhaps  large,  but  remark- 
al)ly  soft  and  compressible,  and  occasionally  with  a  slight  jerk,  especially 
under  the  slightest  excitement.  There  is  an  increasing  indisposition  to 
exertion,  with  an  uncomfortable  feeling  of  faintness  or  breath lessness  in 
nttempting  it;  the  heart  is  readily  nuide  to  ])alpitate;  the  whole  surface 
of  the  body  ])resents  a  blanched,  smooth,  and  waxy  appearance;  the  li])s, 
gums,  and  tongue  seem  bloodless,  the  llabbiness  of  the  solids  increases,  the 
ai)|)etite  fails,  extreme  languor  and  faintness  sn])ervene,  breathlessness 
and  ])alpitations  arc  ])roduced  by  the  most  trifling  exertion  or  emotion; 
some  slight  o'dema  is  probably  perceived  about  the  ankles;  the  debility 
becomes  extreme — the  ])atient  can  no  longer  rise  from  bed;  the  mind  oc- 
casionally wanders;  he  falls  into  a  prostrate  and  half-tor])id  state,  and  at 
length  exjnrcs;  nevertheless,  to  the  very  last,  and  after  a  sickness  of  several 
months'  duration,  the  bulkiness  of  the  general  frame  and  the  amount  of 
obesity  often  present  a  most  striking  contrast  to  the  failure  and  exhaustion 
observable  in  every  other  respect." 

The  Blood. — The  corpuscles  may  fall  to  one  fifth  or  less  of  the  normal 
number.  They  may  sink  to  500,000  ])cr  cubic  millimetre,  and  in  a  case 
of  Quincke's  the  number  was  reduced  to  14.3,000  per  cubic  millimetre. 
The  ha'moglobin  is  relatively  increased,  so  that  the  individual  globular 
richness  is  plus,  a  condition  exactly  the  opposite  to  that  which  occurs  in 


798 


DISKASKH  ()P  TIIK   BLOOD   AND   DUf'TIiKSS  OLANDS. 


chloroHiH  iind  the  sccniidary  iiniMiiin,  in  wliicli  tlu?  corpUHcular  licluu'KS  in 
coloring  iimtttT  in  niimiH.  'I'iic  itliilivc  iiu-ri'iiHt'  in  tho  huMHoglohin  is 
piolmldy  iihsociatt'd  with  the  avi'nij,'(i  incrniM'  in  the  Hizo  of  iho  retl  hlood- 
C'or|tiiscl('s.  'I'ht'  iiccoinpiiiiyin^f  chart  ilhistratcs  these  points.  Microscop- 
ically the  red  hlood-corpusclcs  present  a  j,'reat  variation  in  size,  and  there 
can  he  aeon  hirge  giant  forms,  niegahjcytes,  which  are  often  ovoid  in  form. 


/ 


rii. 

MAR,                     <PH. 

• 

MAY                  JUN 

■ 

JUL* 

1 

« 

«ua. 

tlfT.               OCT.        II 

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- 

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8,000,000 

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501 
101 

801 
201 
101 


MEAN  NORM, 
NUMBER  OF 

WHITE 
COKPUSCLCt 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 

Chart  XIX. — Pernicious  antvraia. 


BLUE,  COLORLESS  CORPUSCLES, 


measuring  8,  11,  or  oven  15  ft  in  diameter — a  circumstance  which  ITenry 
regards  as  indicating  a  reversion  to  a  lower  type.  Laache  thinks  these 
pathognomonic,  and  they  certainly  form  a  constant  feature.  There  are 
also  small  round  cells,  microcytos,  from  2  to  G  /*  in  diameter,  and  of  a 
deep  red  color.  The  corpuscles  show  a  remarkable  irregularity  in  form; 
they  are  elongated  and  rodlike  or  pyriform;  one  end  of  a  corpuscle  may 


['linosB  in 

I'd   1)|()0(|- 

1  i('r()S('n|i- 

md  then! 

in  form. 


"S 


'r-f-./ 


'k 


llO.t 
1001 
00» 
80^ 
70< 
00% 
50< 
iO;< 
80% 
20% 
10^ 


MEAN  NORM, 
NUMBER  OF 

WHITe 
C0HPU9CLES 


S8  CORPUSCLES. 


1  TTcnry 

ks  thof-e 
lore  are 
nd  of  a 
n  form; 
ele  may 


ANJ-^MIA. 


799 


rotain  Its  slinix'  while  tlio  other  in  nnrrow  and  o.\teii(h'd.    To  this  ponditioii 
of  irre^idaril  y  (^iiiinke  ^'ave  tiic  name  iMiikilucytosis. 

Nucleated  ltd  l»i(»()d-('oi'|Misfics  ari'  aliimst  always  |)resent,  as  |i(»iiite(l 
(lilt  \>\  Mhrlic'li.  JW'sides  the  ordinary  form,  which  is  of  the  same  size  as  tho 
common  corpuscle  and  which  has  a  small,  deeply  stained  nucleus  (iiormo- 
hliists),  tliere  are  vi-ry  lar^*'  foi'ius  with  palely  staining'  nuclei  (;;i^aiito- 
l»la.>-ts),  which  reseinide  somewhat  the  lar^'er  inej^alocytes.  Mhrlich  re- 
^^irds  the  presence  of  these  as  almost  distinctive  of  progressive  pernicious 
aniemia.  'i'hoiijfh  these  lar^je  forms  are  most  ehurueteristie,  oceasionally 
forms  (dosely  similar  to  them  may  he  found  in  the  jfraver  secondary  an- 
M'lnias — e.  j;.,  hothrificeplialiis  aiuemia,  anchylostomiasis— and  in  leiikiemia. 
Karyokinelic  li;fiircs  may  Ik;  seen  in  these  hodics.  [{ed  corpuscles  with 
fra^'mentinj;  nuclei  are  common  in  pernicious  aiuemia.  The  leucocytes 
are  gi'iierally  normal  or  diminished  in  numher;  and  in  the  j,'raver  eases 
II  marked  relative  increase  in  the  small  inonoiuiclear  forms,  with  a  diminu- 
tion in  the  polynuclear  h'ucocytes,  is  often  noted.  The  hlood-|tlatcs  are 
either  ahseiit  or  very  scanty. 

'J'he  cardio-vascular  symptoms  are  i'.iiportant  and  are  noted  in  the  de- 
scription ^iven  ahove.  liaMiiie  murmurs  are  constantly  present.  The 
liirjjer  arteries  pulsate  visihiy  and  the  tlirohhinj,'  in  them  may  he  distress- 
ing,' to  the  patient.  The  ]>ulse  is  I'ull  and  frei|uenlly  su<,'<,'ests  the  water- 
'lamnier  heat  of  aortie  insuHiciency.  The  cajiillary  pulse  is  freijuently  to 
he  seen.  The  superficial  veins  are  often  prominent,  and  in  '^  eases  1  have 
seen  well-marked  pulsation  in  them.  Ila-niorrha^'os  may  occur,  either  in 
the  skin  or  from  the  mucous  surfaces.  Ketinal  luemorrhaffes  are  eonr..on. 
'{'here  ar(!  rarely  symptoms  in  the  respiratory  or;;ans. 

(histro-intestinal  sym])toms,  such  as  dyspepsia,  nausea,  and  vomit in;^, 
may  he  ])resent  throu<rhout  the  disease.  Diarrluea  is  not  infretjuent.  The 
urine  is  usually  of  a  low  specific  gravity  and  sometimes  ]>ale.  hut  in  other 
instances  it  is  of  a  deep  sherry  color,  shown  hy  Hunter  and  .Mott  to  he 
due  to  |i;reat  excess  of  urohilin.  Fever  is  a  variahle  symptom.  For  weeks 
at  a  time  the  temjieratnre  nuiy  he  normal,  and  then  irregular  pyrexia  may 
develoj).  Xervous  sym|)loms  may  occur,  niimhness  and  tin;^lin<r,  and"  oc- 
casionally symptoms  reseml)lin<^  those  of  tahes.  JA'pine  reports  a  case  of 
extensive  ])aralysis. 

Diagnosis. — From  chlorosis  the  dii«easc  is  readily  distintjuishod.  I 
have  not  seen  a  case  in  which  the  two  diseases  could  have  heen  confounded. 
Several  points  in  tho  hlood  examination  are  of  especial  imjiortanre.  namely, 
the  relative  increase  in  the  ha'mo<^''lohin  and  the  ])resence  of  me.nalocytes 
imd  of  the  lirfje  forms  of  nncloated  red  hl()od-cor]>uscles,  the  ^M<fantol)lasts 
of  Khrlich.  Poikilocytosis  may  occur  in  any  severe  amemia.  The  soi)ara- 
lion  of  tho  diU'erent  clinical  forms  ahove  referred  to  can  usually  ho  made. 
The  ])rofonnd  secondary  ana-mia  of  cancer  of  tho  stomach  may  sometimes 
he  puzzlinfj,  hut  the  skin  is  rarely,  if  ever,  lemon-tinted,  and  the  hlood  has 
the  characteristics  of  a  secondary,  not  a  primary,  anaemia. 

Prognosis. — Tn  the  true  Addisonian  eases  the  outlook  is  had,  thoiifrh 
of  late  years  on  the  arsenic  treatment  tho  proportion  of  recovery  has  in- 
creased.   My  personal  experience  of  progressive  pernicious  anauiiia  to  Janu- 


800 


DISEASES  OF  T]IE  BLOOD  AXD  DUCTLESS  GLANDS. 


/ 


ary,  18!)5,  was  as  follows:  Of  2T  casos,  4  were  tlu'n  under  observation,  2 
o!  these  having'  recovered  with  arsenic.  01'  the  reniainin^^f  '^li,  -i  of  the  5 
})ost-})artiini  cases  recovered,  and  when  J  left  Montreal  3  of  these  cases  had 
remained  in  good  health  for  several  years.  Of  the  remaining  18  cases  '2 
were  lost  sight  of;  1  had  improved  very  much.  The  remaining  10  were 
dead.  Six  of  these  fatal  cases  recovered  from  tlie  lirst  attack;  one  had  an 
interval  of  nearly  three  years,  and  another  nearly  two  years,  before  the 
return.  One  j)atient  in  hosjjital  in  18!)0  recovered  completely,  and  died  in 
lS!»(i  of  cancer  of  the  stomach.  In  rye-Smith's  article  in  tiie  Ouy's  llos- 
]»ital  J{ej)orts,  he  mentions  :^0  cases  of  recovery.  Jlale  White,  in  a  recent 
article,  states  that  one  of  these  cases,  treated  with  arsenic  in  ISSO,  remained 
alive  anil  well  January,  18!)1.  One  oi'  my  i)atients  made  an  ajjparently  com- 
plete recovery  and  resumed  active  business  and  political  duties.  So  char- 
acteristic are  recurrences  in  this  alfection  that  Stephen  ^lackenzie,  in  his 
lectures,  considered  them  under  a  se])arate  heading  of  rehipsing  j)ernicious 
anivmia.  The  examination  of  the  blood  nuiy  give  us  some  help.  The  pres- 
ence of  numerous  normoblasts  api)ears  in  some  instances  to  be  indicative 
of  an  active  regeneration  in  the  marrow.  Cases  in  which  a  majority  of  the 
nucleated  red  corpuscles  are  gigantoblasts  are  generally  more  malignant. 
A  marked  relative  increase  in  the  small  mononuclear  leucocytes  appears  to 
be  also  an  unfavorable  sign. 

Treatment  of  Ansemia. — Svcondanj  Aiicemia. — The  traumatic 
cases  do  best,  and  with  plenty  of  good  food  and  fresh  air  the  blood  is 
readily  restored.  The  extraordinary  rapidity  with  which  the  normal  per- 
centage of  red  blood-corpuscles  is  reached  without  any  medication  what- 
ever is  an  imi)ortant  lesson.  The  cause  of  the  hiemorrliage  should  be 
sought  and  the  necessary  indications  met.  The  large  group  depending 
on  the  drain  on  the  albuminous  nuiterials  of  the  blood,  as  in  Bright's  dis- 
ease, sn-ppiiration,  and  fever,  is  difficult  to  treat  successfully,  and  so  long 
as  the  cause  keeps  up  it  is  impossible  to  restore  the  normal  blood  condition. 
The  anaemia  of  inanition  requires  plenty  of  nourishing  food.  When  de- 
})endent  on  organic  changes  in  the  gastro-intestinal  mucosa  not  much 
can  be  exi)ected  from  either  food  or  medicine.  In  the  toxic  cases  due  to 
mercury  and  lead,  the  ]ioison  must  be  eliminated  and  a  nutritious  diet 
given  with  full  doses  of  iron.  In  a  great  majority  of  these  cases  there  is 
deficient  blood  formation,  and  the  indications  are  briefly  three:  plenty  of 
food,  an  open-air  life,  and  iron.  As  a  rule  it  makes  but  little  ditference 
what  form  of  the  drug  is  administered. 

The  treatment  of  chlorosis  alfords  one  of  the  most  brilliant  instances — 
of  which  we  have  but  three  or  four — of  the  specific  action  of  a  remedy. 
A])art  from  the  action  of  quinine  in  malarial  fever,  and  of  mercury  and 
iodide  of  potassium  in  syphilis,  there  is  no  other  drug  the  beneficial  effects 
of  which  we  can  trace  with  tlie  accuracy  of  a  scientific  experiment.  It 
is  a  minor  matter  hoir  the  iron  cures  chlorosis.  In  a  week  we  give  to  a 
case  as  much  iron  as  is  contained  in  the  entire  blood,  as  even  in  the  worst 
case  of  chlorosis  there  is  rarely  more  than  a  deficit  of  2  grammes  of  this 
metal.  Iron  is  present  in  the  fa'ccs  of  chlorotic  ])atients  before  they  are 
])laeed  u])on  any  treatment,  so  that  tlie  disease  does  not  result  from  any 


ANAEMIA. 


801 


rvation,  2 
:  of  the  ') 
L'a.sos  liad 
.8  ca&L'S  2 
;  Hi  were 
le  had  a  a 
lel'ore  the 
il  (iit'il  ill 
iiy'.s  Jlos- 
i  a  recent 
remained 
ntly  coni- 
So  char- 
ie,  in  his 
)ernioiou3 
riie  pres- 
ndicative 
ity  or  tiu" 
lalif^'nant. 
ppears  to 

ra  lunatic 

blood  is 

•nial  per- 

m  what- 

lould  l)e 

.'pending 

dit's  disi- 

so  long 

)ndition. 

'hen  de- 

)t   much 

5  due  to 

ons  diet 

there  is 

lenty  of 

ll'erence 

ances — 

remedy. 

iry  and 

1  effects 

nt.     It 

ve  to  a 

e  worst 

of  this 

ley  are 

rm  anv 


(leiicicncy  of  availahle  iron  in  liie  food.  JJungc  bclicA'cs  that  it  is  the  sul- 
phur whieii  interferes  with  the  digestion  and  as;  jlation  of  this  natural 
iron.  The  sulpliides  are  jirodueed  in  tiie  process  of  fermentation  and 
decomposition  in  the  i;eces,  and  interfere  with  the  assimilation  of  the 
normal  iron  coiitaiiie(l  in  the  food,  liy  the  administration  of  an  inorganic 
]ircparatioii  of  iron,  with  wliich  these  siil[)iiides  unite,  the  natural  organic 
cond)inatioiis  in  the  food  are  sjiarcd.  Jii  studying  a  niimhcr  of  charts  of 
chlorosis,  it  is  seen  that  there  is  an  iiicrt-ase  in  the  red  Idood-corpuscles 
under  the  iniluence  of  the  iron,  and  in  some  instances  the  glolndar  rich- 
ness rises  above  nonnal.  The  increase  in  the  ha'inoglobin  is  slower  and 
I  he  maximum  iicrcciitage  Jiiay  not  be  reached  for  a  long  time.  1  have  for 
years  in  the  treatment  of  chlorosis  used  with  the  greatest  success  Blaud's 
]iiils,  mnde  and  given  according  to  the  formula  in  Xiemeyer's  text-1jook, 
in  wiiicii  each  pill  contains  2  grains  of  the  sulphate  of  iron.  During  the 
first  week  one  pill  is  given  three  times  a  day;  in  the  second  week,  two 
])ills;  in  the  tliird  week,  three  ]»ills,  three  times  a  day.  This  dose  should 
be  continued  for  ur  or  five  weeks  at  least  before  •eduction.  An  imi)or- 
tant  feature  in  the  treatment  of  chlorosis  is  to  ])ersist  in  the  use  of  the 
iron  for  at  least  three  nujnths,  and,  if  necessary,  snl)sequently  to  resume 
it  in  smaller  doses,  as  recurrences  are  so  common.  The  diet  should  con- 
sist of  good,  easily  digested  food.  Special  care  should  oe  directed  to  the 
bowels,  and  if  consti])ation  is  ju'cscnt  a  saline  ]mrge  should  be  given  each 
morning.  Such  stress  does  Sir  Andrew  Clark  lay  on  tiie  importance  of 
constipation  in  chlorosis,  that  he  states  that  if  limited  to  the  choice  of  one 
drug  in  the  treatment  of  the  disease  he  would  choose  a  purgative.  The 
good  influence  of  alkaline  waters  in  association  with  the  treatment  by  iron 
has  been  noted  by  von  Jakscli.  In  many  instances  the  dyspeptic  symptoms 
nuiy  be  relieved  by  alkalies  and  a  treatment  directed  toward  a  moderate 
superacidity.  Dilute  hydrochloric  acid,  manganese,  phosphorus,  and  oxy- 
iren  have  been  recommended. 

Treatment  of  Pernicious  Aiuvmia. — Since  the  introduction  by  Byrom 
Bramwell  of  arsenic  in  this  alTection  a  large  number  of  cases  have  been 
temporarily,  a  few  jiermanently,  cured  by  it.  It  should  be  given  as  Fowler's 
solution  in  increasing  doses.  It  is  usually  well  borne,  and  patients,  as  a 
rule,  take  up  to  20  minims  three  times  a  day  without  any  disturbance. 
I  nsnally  begin  with  3  minims  and  increase  to  5  at  the  end  of  the  first 
week,  to  10  at  the  end  of  the  second  week,  to  15  at  tlie  end  of  the  third 
week,  and,  if  necessary,  go  np  to  20  or  2o.  In  a  case  in  which  the  recovery 
])ersisted  for  nearly  three  years  the  dose  was  gradually  increased  to  30 
minims.  These  ])atients  seem  to  stand  the  arsenic  extremely  well.  It  is 
sometimes  better  borne  as  arsenions  acid  in  pill  form.  Vomiting  and  diar- 
rhcea  are  rare;  occasionally  pnffiness  of  the  face  is  produced,  and  in  some 
cases  pigmentation  of  the  skin. 

Eest  in  bed  and  a  light  bnt  nntritions  diet  (giving  the  food  in  small 
amounts  and  at  fixed  intervals)  are  the  first  indications.  I  always  prefer 
to  begin  the  treatment  of  a  case  of  pernicious  anaemia,  whatcTcr  the  grade 
may  be,  with  rest  in  bed  as  one  of  the  essential  elements.  The  beneficial 
effect  0.      assage  has  been  shown  by  J.  K.  ^Mitchell.     I  have  abandoned 


802 


DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 


the  use  of  rectal  injections  of  tlried  blood.  Iron  rarely  acts  well  in  this 
form,  but  in  a  case  in  which  the  arsenic  disagrees  it  may  be  tried.  Bone 
marrow  has  been  recommended.  It  is  best  given  as  a  glycerin  extract.  1 
have  not  seen  any  benefit  follow  its  administration.  Inhalations  of  oxygen 
may  be  tried. 

II.    LEUKAEMIA. 

Definition. — An  affection  characterized  by  persistent  increase  in  the 
white  blood-corpuscles,  associated  with  changes,  cither  alone  or  together, 
in  the  spleen,  lym})hatic  glands,  or  bone  marrow. 

The  disease  was  described  almost  simultaneously  jjy  Virchow  and  by 
Bennett,  who  gave  to  it  the  name  leucocytha.'mia.  It  is  ordinarily  seen  in 
two  main  types,  tiiough  combinations  and  variations  may  occur: 

(1)  S])]eno-medullary  leuktemia,  in  which  the  changes  are  especially 
localized  in  the  spleen  and  the  bone  marrow,  while  the  blood  shows  a  great 
increase  in  elements  which  are  derived  especially  from  the  latter  tissue, 
a  condition  which  Miiller  has  termed  "  myehemia."  Ehrlich  prefers  to 
call  this  type  of  the  disease  "  myelogenous  leukiemia,"  believing  the  part 
played  1)y  the  s])leen  in  the  process  to  be  purely  passive. 

(2)  Lymphatic  leuktemia,  in  which  the  changes  are  chiefly  localized  in 
the  lymphatic  apparatus,  the  blood  showing  an  especial  increase  in  those 
elements  derived  from  the  lymph-glands. 

Etiology. — We  know  nothing  of  the  conditions  under  which  the  dis- 
ease develo^js.  It  is  not  uncommon  on  this  continent.  Of  2G  cases  of  which 
I  have  notes,  to  January,  18J)5,  11  occurred  in  Montreal,  2  in  Philadelphia, 
and  13  in  hospital  and  private  work  in  Baltimore.  It  does  not  seem  more 
frequent  in  the  southern  parts  of  the  country. 

The  disease  is  most  common  in  the  middle  period  of  life.  The  young- 
est of  my  patients  was  a  child  of  eight  months,  and  cases  are  on  record  of 
the  disease  as  early  as  the  eighth  or  tenth  week.  It  may  occur  as  late  as 
the  seventieth  year.  Males  are  more  prone  to  the  affection  than  females. 
Of  my  cases,  17  were  in  males  and  9  in  females.  Birch-IIirschfeld  states 
that  of  200  cases  collected  from  the  literature,  135  were  males  and  65 
females. 

A  tendency  to  '  ^^norrhage  has  been  noted  in  many  cases,  and  some 
of  the  patients  have  suffered  repeatedly  from  nose-bleeding.  In  women 
the  disease  is  most  common  at  the  climacieric.  There  are  instances  in 
which  it  has  developed  during  pregnancy.  The  case  described  by  J.  Clial- 
mers  Cameron,  of  Montreal,  is  in  this  respect  remarkable,  as  the  patient 
passed  through  three  pregnancies,  bearing  on  each  occasion  non-leukir'mic 
children.  The  case  is  interesting,  too,  as  showing  the  .lereditary  character 
of  the  affection,  as  the  grandmother  and  motlier,  as  well  as  a  brother,  suf- 
fered from  symptoms  strongly  suggestive  of  leukaMuia.  One  of  the  pa- 
tient's children  had  leukannia  before  the  mother  showed  any  signs,  and  a 
second  died  of  the  disease,  At  the  last  report  this  patient  had  gradually 
recovered  from  the  third  confinement,  and  the  red  blood-corpuscles  had 
risen  to  4,000,000  per  cu])ic  millimetre,  and  the  ratio  of  white  to  red  was  1 


Ivi. 


LEUKAEMIA. 


803 


11  in  this 
d.  Boue 
ctract.     1 

)!'  oxygon 


se  in  the 
together, 

I'  and  bv 
y  seen  in 

especially 
's  a  great 
L'r  tissue, 
•refers  to 
the  part 

'alized  in 
in  those 

L  the  dis- 
of  which 
adelphia, 
em  more 

young- 

'ecord  of 

late  as 

'emales. 

d  states 

and  65 

id  some 

women 

mres  in 

Chal- 

patient 

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laracter 

or,  suf- 

he  ])a- 

,  and  a 

adually 

es  had 

1  was  1 


to  200,  Siinger  has  reported  a  case  in  which  a  healthy  mother  bore  a  leii- 
kiemic  child. 

Malaria  is  believed  by  some  to  be  an  etiological  factor.  Of  150  cases 
analyzed  by  Cowers,  there  was  a  history  of  malaria  in  30;  in  my  series 
there  was  a  history  in  at  least  9.  Syphilis  appears  in  some  cases  to  have 
been  closely  associated  with  leukivmia.  The  disease  has  followed  injury  or 
a  blow. 

The  lower  animals  are  subject  to  the  affection,  and  cases  have  been 
descri])ed  in  horses,  dogs,  oxen,  cats,  swine,  and  mice. 

Morbid  Anatomy. — The  wasting  may  be  extreme,  and  dropsy  is 
sometimes  present.  There  is  in  many  cases  a  remarkable  condition  of 
j)olyiemia;  the  heart  and  veins  are  distended  with  large  blood-clots.  In 
Case  XI  of  my  series  the  weight  of  blood  in  the  heart  chambers  alone  was 
020  grammes.  There  may  be  remarkable  distention  of  the  ])ortal,  cerebral, 
l)ulnionary,  and  subcutaneous  veins.  The  blood  is  usually  clotted,  and 
the  enormous  increase  in  the  leucocytes  gives  a  pus-like  apjjearance  to  the 
coagula,  so  that  it  has  happened  more  than  once,  as  in  Yirchow's  memor- 
able case,  that  on  opening  the  right  auricle  the  observer  at  first  thought 
lie  had  cut  into  an  abscess.  The  coagula  have  a  peculiar  greenish  color, 
somewhat  like  the  fat  of  a  turtle.  The  alkalinity  of  the  blood  is  dimin- 
ished. The  fibrin  is  increased.  The  character  of  the  corpuscles  will  l)e 
described  under  the  symptoms.  Charcot's  octohedral  crystals  may  separate 
from  the  blood  after  death.  The  specifio  gravity  of  the  blood  is  some- 
what lowered.     There  may  be  pericardial  ecchymoses. 

In  the  spleno-medullary  form  the  spleen  is  greatly  enlarged.  Strong 
adhesions  may  nnite  it  to  the  abdominal  wall,  the  diaphragm,  or  the  stom- 
ach. The  capsule  may  be  thickened.  The  vessels  at  the  hilus  are  enlarged; 
the  weight  may  range  from  2  to  18  pounds.  The  organ  is  in  a  condition 
of  chronic  hyperplasia.  It  cuts  with  resistance,  has  a  uniformly  reddish- 
l)rown  color,  and  the  j\Ialpighian  bodies  are  invisible.  Grayish-white,  cir- 
cumscribed, lymphoid  tumors  may  occur  throngliont  the  organ,  contrasting- 
strongly  with  the  reddish-l)rown  matrix.  In  the  early  stage  tlie  swollen 
spleen  pnlp  is  softer,  and  it  is  stated  that  rupture  has  occurred  from  the 
intense  hypera^mia. 

In  association  with  these  changes  in  the  spleen,  the  l)one  marrow  Is 
involved,  the  liono-medullary  form  of  the  Germans.  The  essential  change, 
indeed,  in  the  disease  appears  to  ])e  the  extraordinary  hy])erplasia  of  the 
rod  marrow,  and  the  a])pearance  of  an  livjierplastic  cellular  tissue  in  regions 
where  in  the  adults  the  marrow  is  fatty.  Instead  of  a  fatty  tissue,  the 
moduUa  of  tlie  long  bones  may  resemble  the  consistent  matter  which 
forms  the  core  of  an  abscess,  or  it  may  Ijc  dark  brown  in  color.  In  Pon- 
fiok's  case  there  were  liaMnorrhagic  infarctions.  There  may  1)e  much  ex- 
jinnsion  of  the  shell  of  bone,  and  localized  swellings  which  are  tender  and 
may  even  yield  to  firm  ])ressure.  Histologically,  there  are  found  in  the 
niodnlla  large  nnml)ers  of  nucleated  red  corpuscles  in  all  stages  of  develop- 
mont,  nnmerons  cells  with  eosinophilic  granules,  both  small  polynucloar 
forms  and  large  almost  giant  mononuclear  elements.  There  are  also  many 
large  cells  with  single  large  nuclei  and  neutrophilic  granules — the  cellules 


80.t 


DISKASH8  OF  TIJE   BLOOD  AND  DUCTLESS  GLANDS. 


/ 


iiu'dnllaircs  of  Cornil — tlu'  iiii/rJori/hts  wliicli  arc  ioiind  in  tlio  l)l(in(l.  flront 
.iiuiiil)i'i'.s  ol'  polyiiiiflt'ar  Iriu-oc-yti's  aru  also  itR'.st'iit,  as  well  as  a  certain 
miniher  ol'  small  niononucloar  elements. 

In  the  lyiii|)hatic  loniis  of  the  disease  there  is  a  general  lymphatic  en- 
largement, wiiicli  is  usnally  associated  with  a  certain  amount  ol"  enlarge- 
ment of  the  spleen.  Jn  oidy  one  of  my  cases  was  the  splenic  enlargement 
jiotahle.  In  the  cases  of  lymphatic  Icnksemia  the  cervical,  axillary,  mesen- 
teric, and  inguinal  groujjs  may  l)e  mnch  enlarged,  hut  the  glands  are  nsn- 
ally  soft,  isolated,  and  movable.  They  may  vary  considerably  in  size  dur- 
ing the  course  of  the  disease.  The  tonsils  and  the  lymph  follicles  of  the 
tongne,  pharynx,  and  month  may  he  enlarged.  A'umerons  mitoses  may  be 
fumid  in  the  small  cells  of  the  lym])hatic  tissue. 

In  some  instances  there  are  leukiemic  enlargements  in  the  solitary  and 
agminated  glands  of  Peyer.  In  a  case  oJ  Willcocks'  there  were  growths 
on  the  surface  of  tlie  stomach  and  gastro-s])lenic  omentum.  The  thymns 
is  rarely  involved,  though  it  has  been  enlarged  in  some  of  the  cases  of  acnte 
lym])hatic  leukivmia.  The  bone  marrow  hi  these  cases  may  be  replaced  by 
a  lymphoid  tissue.  Xucleated  red  cor])nscles  and  the  normal  granular 
marrow  elements  may  be  greatly  reduced  in  number. 

The  liver  may  be  enlarged,  and  in  a  ca  e  described  by  ^Velcli  it  weighed 
over  13  ])ounds.  The  enlargement  is  usually  due  to  a  diffuse  leukiemic 
infiltration.  The  columns  of  liver  cells  are  widely  separated  by  leucocytes, 
which  are  ])artly  within  and  partly  outside  the  lobular  capillaries.  There 
may  be  delinite  leukiemic  growths. 

There  are  rarely  changes  of  im])ortance  in  the  lungs.  The  kidneys  are 
often  enlarged  and  ])ale,  the  ca])illaries  may  be  distended  with  leucocytes, 
and  leuka'mic  tumors  may  occur.  The  skin  may  be  involved,  as  in  a  case 
described  by  Kajjosi. 

Leiikicmic  tumors  in  the  organs  are  not  common.  They  were  ])resent 
in  only  1  of  the  12  auto])sies  in  my  series.  In  159  cases  collected  by  (lowers 
there  were  only  13  instances  of  leuka'mic  nodules  in  the  liver  and  10  in 
the  kidneys.  These  new  growths  ju'obably  develo])  from  leucocytes  which 
leave  the  ca])illaries.  Bizzozero  has  shown  that  the  cells  ■which  compose 
them  are  in  active  fission. 

Symptoms. — The  onset  is  insidious,  and,  as  a  rule,  the  patient  seeks 
advice  for  progressive  enlargement  of  the  abdomen  and  shortness  of  breath, 
or  for  the  enlarged  glands  or  the  i)allor,  ])alpitation,  and  other  symptoms 
of  ana-mia.  lUceding  at  the  nose  is  common.  Gastro-intestinal  symjjtoms 
may  ])recedc  the  onset.  Occasionally  the  first  synii)toms  are  of  a  very  seri- 
ous nature.  In  one  of  the  cases  of  my  series  the  boy  played  lacrosse  two 
days  l)eforc  the  onset  of  the  final  haMiiatemesis;  and  in  another  case  a 
girl,  who  had,  it  was  su]")])osed,  only  a  slight  chlorosis,  died  of  fatal  haem- 
orrhage from  the  stomach  before  any  susi)icion  had  been  aroused  as  to 
the  true  condition. 

Ana'mia  is  not  a  necessary  accompaniment  of  all  stages  of  the  disease; 
the  subjects  may  look  very  healthy  and  well. 

As  has  been  stated,  the  disease  is  most  commonly  seen  in  two  main 
types,  though  combinations  may  occur. 


1(1.    Grcnt 
11  fort  a  ill 

]»liatic  (Mi- 
r  t'li  large- 
la  r^'eiuejit 
ry,  mesc'ii- 
s  are  usii- 
i  size  diir- 
■les  of  the 
OS  may  ho 

litary  and 
0  growths 
le  tliyimis 
's  of  acute 
'placed  hy 
gramdar 

t  Avoighed 
loiikionnc 

OUCOCVtOH, 

!,s.     There 

dncys  are 

oucocytos, 

in  a  case 

e  present 

)y  (iowers 

nd  10  in 

OS  wliieh 

conijjose 

ent  seeks 
if  hreath, 
ynijjtonis 
ym])tonis 
^'cry  seri- 
■osse  two 
r  case  a 
al  harm- 
ed as  to 

disease; 

vo  main 


LEUKAEMIA. 


SOo 


(1)  Spleno-medullary  LeiikaBmia. 

This  is  iiuicli  the  coiniiuinost  tyjjo  of  the  disease.  Tho  gradual  in- 
crease in  the  voltiiiic  ol'  the  spleen  is  the  most  i)roniinont  symptom  iu  a 
majority  of  the  cases.  J'ain  and  tenderness  are  coiunion,  though  the  pro- 
gressive enlargcntent  may  he  ])aiidess.  A  creaking  fremitus  may  he  felt 
liii  jialpation.  The  enlarged  organ  extends  downward  to  the  right,  and 
may  be  felt  just  at  the  costal  ci.hfio,  or  when  large  it  may  extend  as  far 
nver  as  the  navel.  In  many  cases  it  occupies  fully  one  half  of  the  ahdo- 
men,  reaching  to  the  ])uhes  helow  and  extending  heyond  the  middle  line. 
As  a  rule,  the  edge,  iu  some  the  notch  or  notches,  can  he  felt  distinctly, 
lis  size  varies  greatly  from  time  to  time.  Jt  may  be  i)erce[)tibly  larger 
;ifter  meals.  A  hicmorrhage  or  free  diarrha'u  may  reduce  the  size.  The 
pressure  of  the  eidarged  organ  may  cause  distress  after  eating;  in  one  case 
it  caused  fatal  ol)struction  of  the  bowels.  A  murmur  may  sometimes  he 
heard  over  the  spleen,  and  (ierhardt  has  described  a  i)ulsation  in  it. 

'The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume. 
There  are  rarely  any  cardiac  symptoms.  The  apex  beat  may  be  lifted  an 
interspace  by  the  enlarged  spleen.  Toward  tiie  close,  as  a  conse(pience  of 
tlie  feel)le  circulation,  (cdema  may  occur  in  the  feet  or  tliere  may  be  gen- 
eral anasarca,  irjcmorrhage  is  a  common  sym])toni  and  may  be  either 
late  or  early.  There  may  be  most  extensive  purjjura.  Kpistaxis  is  the  most 
frequent  form.  Haemoptysis  and  hamaturia  are  rare.  Uleeding  from  the 
gums  may  be  present.  Hamatemesis  proved  fatal  in  two  of  ray  cases,  and 
ill  a  third  a  large  cerebral  hamorrhage  ra|)idly  killed.  The  leukamic 
retinitis  is  a  part  of  the  hamorrhagic  manifestations. 

Local  gangrene  may  develop,  with  signs  of  intense  infection  and  high 
fever.  There  are  very  few  pulmonary  symptoms.  The  shortness  of  breath 
is  due,  as  a  rule,  to  the  ananua.  Toward  the  end  there  may  be  (edema  of 
the  lungs,  or  })neumonia  nuiy  carry  oif  the  patient.  The  gastro-intestinal 
symptoms  are  rarely  absent.  Xausea  and  vomiting  are  early  features  in 
some  cases.  Diarrhoea  may  be  very  troublesome,  even  fatal.  Intestinal 
hamiorrhage  is  not  common.  There  may  be  a  dysenteric  process  in  the 
colon.  Jaundice  rarely  occurs,  though  in  one  case  of  my  scries  there 
were  recurrent  attacks.  Ascites  may  be  a  prominent  syra])tom,  probably 
due  to  the  i)resence  of  the  splenic  tumor.  A  leukamic  peritonitis  also  may 
Le  ])resent,  due  to  new  growths  in  the  membranes. 

The  nervous  system  is  not  often  involved.  Headache,  dizziness,  and 
fainting  spells  are  due  to  anamia.  The  patients  are  usually  tramiuil  and 
resigned.     Sudden  coma  may  follow  cerebral  hamiorrhage. 

The  special  senses  are  often  atl'ected.  There  is  a  ])eculiar  retinitis,  duo 
cliietly  to  the  extravasation  of  blood,  but  there  may  be  aggregations  of 
leucocytes,  forming  small  leukamic  growths.  Optic  neuritis  is  rare.  Deaf- 
ness has  frequently  been  observed;  it  may  appear  early  and  possibly  is  due 
to  hauuorrhage. 

The  urine  presents  no  constant  changes.  The  uric  acid  excreted  is 
nlways  in  excess,  and  possibly,  as  Salkowski  suggests,  stands  in  direct  rela- 
tion to  the  splenic  tumor,  or  to  the  abundant  leucocytes. 

Priapism  is  a  curious  symptom  which  has  been  present  in  a  large  num- 
50 


806 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


/ 


bcr  of  c.isos.  It  niny,  as  in  one  nf  ImIos'  cases,  be  the  first  syiiiptom.  Pen- 
1)0(1}'  reports  a  case  in  which  it  [tersistcd  lor  six  weeks.  The  cause  is  jmt 
known. 

Hlight  fever  is  present  in  a  majority  of  cases.  Periods  of  i)yrexia  may 
alternate  with  jjrolon^cd  intervals  of  freedom.  'JMie  temi)erature  may 
ran^'c  from  102°  lo  lO.T. 

JUood. — In  all  forms  of  the  disease  the  diagnosis  must  he  made  by  the 
examination  of  the  blood,  as  it  alone  ojfers  distinctive  features. 

The  most  striking  cJiange  in  the  more  common  form,  the  lieno- 
myelogenic,  is  the  increase  in  the  colorless  cor])Uscles.  The  average  normal 
number  of  white  per  cubic  millimetre  is  estimated  at  about  (i, 000-7, OdO; 
thus  the  proj)ortion  of  white  to  red  is  1  to  500-1,000.  In  leukicmia  the  pro- 
portion may  be  1  to  10,  or  1  to  5,  or  may  even  reach  1  to  1.  There  are  in- 
stances on  record  in  which  the  nundjcr  of  leucocytes  has  exceeded  that  of 
the  red  cori)uscles. 

The  character  of  the  cells  in  splenic  myelogenous  leukivmia  is  as  fol- 
lows: The  small  mononuclear  forms  are  little  if  at  all  increased;  relatively 
they  are  greatly  diminished.  The  eosinophiles  are  present  in  normal  or 
increased  relative  proportion,  so  that  there  is  a  great  total  increase,  and 
their  jtrcsence  is  a  striking  feature  in  the  stained  blood-slide.  The  poly- 
nuclear  neutrophiles  may  be  in  normal  ])roportion;  more  frequently  they 
are  relatively  diminished,  and  in  the  later  stages  they  may  form  but  a 
small  proportion  of  the  colorless  elements.  Marked  dilferences  in  size  be- 
tween individual  polynuclear  leucocytes  may  be  noted;  the  same  is  true 
of  the  eosinophiles.  The  most  characteristic  features  of  tho  blood  in  this 
form  of  leukaemia  is  the  presence  of  cells  which  do  not  occur  in  normal 
blood.  They  a])i)ear  to  be  derived  from  the  marrow,  and  are  called  by 
Ehrlich  vijjelocijtes.  They  are  considerably  larger  than  the  large  mono- 
nuclear leucocytes,  and  are  similar  to  them  in  appearance,  but  differ  from 
them  in  the  fact  that  the  protoplasm  is  filled  with  the  fine  neutrojthilie 
granules.  ]\Ililler  has  recently  found  many  large  mononuclear  elements 
with  karyokinetie  figures  in  leuka-mic  blood  and  in  the  marrow.  These 
]irobal)ly  corresjiond  to  the  myelocytes  of  Ehrlich  as  well  as  to  the  "  cellules 
medullaires  "  of  C'ornil.  Polynuclear  cells  with  coarse  baso])hilic  granulrs. 
"  Mastzellen,"  are  always  present  in  this  form  of  leuka^nia  in  consideralik- 
numbers.  The  granules  do  not  stain  in  Ehrlich's  triacid  mixture,  and 
the  cells  may  be  recognized  as  polynuclear  non-granular  elements.  These 
cells,  which  form  only  about  0.28  ])er  cent  of  the  leucocytes  of  norma! 
blood,  may  be  even  more  numerous  than  the  eosinophiles. 

Nucleated  red  blood-corpuscles  are  present  in  considerable  numbers. 
These  are  usually  "  normoblasts,"  but  cells  with  larger  paler  nuclei,  some 
showing  evidences  of  mitosis,  may  be  seen.  Red  cells  with  fragmented 
nuclei  are  common,  while  true  gigantoblasts  may  be  found.  There  is,  as  a 
rule,  only  a  moderate  reduction  in  the  number  of  red  blood-corpuscles; 
the  number  is  rarely  under  2,000,000  per  cubic  millimetre.  The  ha-mo- 
globin  is  usually  reduced  in  a  somewhat  greater  proportion.  The  accom- 
panying blood  chart  is  from  a  case  of  leukaemia  with  an  enormously  en- 
larged spleen.     Among  other  points  about  leukamiic  blood  may  be  men- 


s. 

itoin.    PcM- 
juiise  is  nm 

)_vr('xia  niny 
raturc   iiiii) 

undo  by  tlio 

the  lieiio- 
Yiv^v  lion  Hill 
i,(»(JO-T,(MMi; 
Ilia  the  i)rii- 
'hcre  arc  in- 
■ded  that  nf 

ia  is  as  fol- 
1;  rolativL'ly 
1  normal  or 
icrease,  and 
The  poly- 
nently  they 
form  but  a 
3  in  size  be- 
anie is  true 
lood  in  this 
r  in  nornKil 
e  called  liy 
arfie  nioiio- 
d liter  from 
eutrophiUc 
iir  elements 
ow.     These 
"  cellules 
c  ,<rraniil('s. 
onsidorable 
xture,  and 
lits.     The>e 
of  norma! 

0  numbers, 
uclei,  sonic 
fragmentLMl 
ere  is,  as  a 
corpuscle-: 
be  liaMiiii- 
^he  acconi- 
mously  en- 
y  be  men- 


le 


LEUKAEMIA. 


8(i7 


tioned  the  feebleness  f)f  the  anwehoid  movement,  as  iioti'(l  by  Cafavy,  whieli 
may  be  accounted  I'or  liy  tlie  hirge  numltcr  of  moiioiuudi'ar  elemeiils  present, 
the  polynuck'ar  alone  possessing,'  this  power.  The  Idood-plates  exist  in  vari- 
able numbers;  they  may  be  remarkal)iy  abundant.  Tiie  tiltrin  network 
iietwecn  the  corpuscles  is  usually  thick  and  dense.     In  blood-sli(h's  which 


tago. 

1891.                                                         1 

SEPT. 

OCT. 

NOV, 

OECi 

JAN. 

FEB. 

MAR. 

APR.              MAV 

^ 

s  s  s 

.  58   t 

-  2  t  S 

-  .   5  S  S 

-    S    S   S 

«  .  : : 

«•    «    o 

«5S«»-5« 

0,000,000 

1 

t 

' 

.Ci.QQQ^QOQ.... 

- 

- 

-^ 

- 

A. 

4,000,flO<'> 

-it   *•• 

- 

y 

*-, 

7 

f 

n,oon,ooo 

,/ 

,/ 

■^> 

^ 

V 

y 

■>. 

•^ 

7 

\ 

/ 

,» 

f 

^s 

/^ 

^, 

f 

/ 

■^ 

•>s 

/ 

",000,000 

/ 

">« 

f 

1,000,000 

500,000 

• 

% 

-- 

-[ 

_2iajOOO 

s 

s 

^ 

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200.000 

'v 

■^1  1 

— ■  - 

'  ' 

1. '-,0,000 

100  000 

00,000 

80,000 

fiOOOO 

.'iO.OOO 

40.000 

; 

I 

t 

^ 

30,000 

, 

1 

1       _ 

T 

T 

20,000 

1- 

+  ►■ 

+  + 

- 

- 

\n 

ri 

■'-+L+  t 

18.000 

- 

'■'i 

K 

:; 

^  1 

II 

^ 

4^ 

il 

s 

Ilt^? 

1C.,000 

r 

t 

*H     ,   \ 

Ft 

i-tooo 

T 

12.000 

1 

10.000 

r 

8,000 

^■ 

-~, 

1 

f       I 

iifiOD 

V 

\ 

/ 

4,000 

\ 

2.000 

V* 

"-». 

/ 

120)t 

110< 

lOOjt 

90;< 

80:< 

0% 

00< 

B0% 

40^ 

30^ 

20j( 

10* 
5X 

2% 


\% 


MEAN  NORM. 
NUM3E1  OF 

WMITI 
CORPUSCLCa 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMOQLOaiN. 


BLUE,  COLORLESS  CORPUSCLES. 


Chart  XX. — Leuka'mia. 


are  kept  for  a  short  time,  Charcot's  octohodral  crystals  separate,  and  in  the 
blood  of  leuka'mia  the  luvmoglobin  shows  a  remarkable  tendency  to  crys- 
tallize. 


808 


DISKASB^S  OF  TIIK   HLOOD  AND  DUCTLESS  GLANDS. 


/ 


2.  Lymphatic  Leukroraia. 

Tliis  loriii  ol'  Iciilvii'iiiia  is  ruri'.  As  iiicntioiicd,  in  hut  I  ol'  my  siM'ics 
of  JiO  cases  wore  the  ghiiids  enlaryvd.  Tlu.'  siipcilicial  gi(»u[)s  are  usually 
most  involved,  and  even  wlicn  all'eeted  it  is  rare  to  see  such  lar^'e  l)unclu's 
as  in  Jio(l<fkiirs  disease.  Ivxtcrnal  lymph  tumors  are  rare.  Lym|thati(.' 
leuka'mia  is  ol'len  more  rapid  and  Fatal  in  its  course,  thoU},di  ehronie  cases 
may  occur.     It  is  more  common  in  young  suhjccts. 

The  histolof^ieal  characters  of  the  blood  in  lymphatic  leukiemia  diU'er 
materially  from  those  in  the  spleno-medullary  form.  The  increase  in  the 
colorless  elemcnls  is  never  so  j^rcat  as  in  the  prcccdinji'  form;  a  proportion 
of  1  to  10  would  he  extreme.  This  increase  takes  place?  solely  in  the  lympho- 
cytes, all  other  forms  of  leucocytes  heing  present  in  greatly  diminished 
relative  ])ro])ortion.  In  one  of  my  eases  over  1)8  per  cent  of  all  the  leuco- 
cytes were  lymphocytes.  In  some  cases,  as  Cahot  has  pointed  out,  this 
increase  takes  place  largely  in  the  smaller  forms,  while  in  others  the  large 
lymphocytes — cells  nearly  as  large  as  })olynuclear  leucocytes — predominate. 
Eosinophiles  and  nucleated  red  corpuscles  are  rare.  Myelocytes  are  not 
present. 

The  ])ure  myelogenous  cases  without  associated  enlargement  of  the 
si)leen  are  rare.  The  most  extreme  hyperplasia  of  the  hone  marrow  may 
exist  without  any  tenderness.  Occasionally  the  sternum,  ribs,  and  flat 
bones  show  great  irregularity  and  deformity,  owing  to  definite  tumor-like 
ex])ansions. 

Coml)ined  forms  of  leukivmia  may  occur,  though  they  are  not  common. 
One  such  instance  occurred  at  the  Johns  llojjkins  Hospital.  Here  the 
spleen,  marrow,  and  lymi)hatic  glands  all  showed  marked  changes.  The 
blood  in  this  instance  showed,  besides  a  large  proportion  of  lymphocytes 
and  myelocytes,  a  considerable  number  of  large  mononuclear  leucocytes. 

Anile  Lcnhiinia. — This  is  usually  of  the  lymjibatic  type,  and  occurs  in 
young  persons.  Fussell  and  Taylor  have  collected  56  cases  from  the  litera- 
ture.   The  fatal  event  occurs  in  two  or  three  months. 

Diagnosis. — The  recognition  of  leukannia  can  be  determined  only 
by  microscoi)ical  examination  of  the  blood.  The  clinical  features  may  be 
identical  with  those  of  ordinary  si)lenic  anannia,  or  of  Hodgkin's  disease. 
An  interesting  question  arises  whether  real  increase  in  the  leucocytes  is 
the  only  criterion  of  the  existence  of  the  disease.  Thus,  for  instance,  in 
the  case  whose  chart  is  given  on  page  807,  tlie  patient  came  under  observa- 
tion in  Se])tember,  18!)0,  with  2,000,000  red  l)lood-cor])uscles  per  cubic 
millimetre,  30  per  cent  of  hannoglobin,  and  500,000  white  blood-corpuscles 
per  cubic  millimetre — a  proportion  of  1  to  4.  As  shown  by  the  chart, 
throughout  Sei)teniber,  October,  November,  and  December,  this  ratio  was 
maintained.  Early  in  January,  under  treatment  with  arsenic,  the  white 
corpiiscles  began  to  decrease,  and  gradually,  as  shown  in  the  chart,  the 
normal  ratio  was  reached.  At  this  time  could  it  be  said  that  the  case  was 
one  of  leuka'mia  without  increase  in  the  number  of  leucocytes?  The 
blood  examination  by  Ehrlich's  method,  as  made  by  Thayer,  showed  that 
nucleated  red  corpuscles  in  large  numbers  as  well  as  the  characteristic 
myelocytes,  elements  which  are  but  rarely  found  in  normal  blood,  were 


IIODGKIN'S  DISEASK. 


8u'J 


still  present  in  mnnl)ers  sunicieiit,  at  iiiiv  rate,  to  sn^jn^est,  if  the  patient 
iiiul  ciinie  under  oltservation  Inr  tiie  lirst  time,  tluit  leiilvieniia  niiylit  occur. 
J»y  I'llirlieh's  method  of  hh)oil  examination  »i  eon(lili<in  of  leueoeylotjis  can 
readily  he  distin^niishcd  from  that  of  ieukiemia,  for  in  all  ordinary  leuco- 
eyt()^^^'S  the  increase  takes  place  solely  in  the  polynuclcar  nentrophilic  cells. 

The  reniarkahle  "  ^M'een  cancer"  or  chloroma  is,  accordini;  to  hock,  "a 
lymphomatous  [irocesti  similar  in  its  clussical  features  to  leukiemiu  und 
jisendo-leuka'Tniu." 

Prognosis. — Ifeoovcry  occn.'*innally  occurs.  A  great  majority  of  the 
cases  prove  fatal  within  two  or  tkree  years.  I'nfavorahle  signs  are  n  tend- 
ency to  ha'inorrhage,  persistent  diarrhaui,  early  dropsy,  and  high  fover. 
Kemarkahle  variations  are  displayed  in  the  course,  and  a  transient  im- 
provement may  take  i)lace  for  weeks  or  even  months.  The  pure  lymphatic 
form  seems  to  ho  of  particular  malignancy,  some  cases  proving  fatal  in 
from  six  to  eight  weeks;  hut  there  are  excejjtions,  and  I  have  recently  seen 
a  case  in  which  the  diagnosis  was  nnide  ten  years  ago  hy  W.  Ji.  Draper. 
The  patient  has  had  enlarged  glands  ever  since,  and,  though  not  amemic, 
the  leucocytes  were  242,W{)  per  cuhic  millimetre,  above  KU  per  cent  of 
tlifin  hi'ing  lymphocytes. 

Treatment. — Fresh  air,  good  diet,  and  abstention  from  mental  worry 
and  care,  are  the  important  general  indications.  The  indiailiu  inorbi  can- 
not be  met.  '^Fhere  are  certain  remedies  which  have  an  inllnence  upon  the 
disease.  Of  these,  arsenic,  given  in  large  doses,  is  the  best.  I  have  re- 
|)eatedly  seen  iin|)rovement  under  its  use.  On  the  other  hand,  there  are 
curious  renussions  in  the  disease  which  render  therapeutical  deductions 
very  fallacious.  I  have  seen  such  marked  imi)rovenient  without  special 
treatment  that  the  ])atient,  from  a  bed-ridden,  wretched  condition,  recov- 
ered strength  enough  to  enable  him  to  attend  to  light  duties. 

Quinine  may  be  given  in  cases  with  a  malarial  history.  Iron  may  be 
of  value  in  some  cases,  as  niay  also  inhalations  of  oxygen. 

Excision  of  the  leuka'mic  spleen  has  been  ])erformed  24  times,  with  1 
recovery — the  case  of  Franzolini.  Fussell  gives  the  statistics  of  105  eases 
of  splenectomy  with  48  deaths.  Of  the  cases  of  simple  hy])ertro]diy,  28 
in  number,  9  recovered.    Of  IG  cases  of  lloating  si)leen,  15  recovered. 


III.    HODGKIN'S    DISEASE. 


Definition. — An  affection  characterized  by  progressive  hyperplasia 
of  the  lymph-glands,  with  ana>mia,  and  occasionally  the  development  of 
secondary  lymphoid  growths  in  the  liver,  s])leen,  and  other  organs.  The  dis- 
ease has  also  the  names  pscviht-lnil-annia,  i/cncral  li/mphadennma,  and  adenie, 

ITodgkin,  the  well-known  morbid  anatonust  of  Guy's  Hospital,  first 
described  cases  in  detail,  and  by  the  labors  of  "Wilks,  Yirchow%  Billroth,, 
and  Cohnhoim  the  disease  attained  definite  recognition. 

Etiology. — A  majority  of  the  cases  are  in  young  ]>ersons.  In  Oowors'^ 
table  of  100  cases,  30  were  under  twenty  years,  34  between  twenty  and 
forty,  and  36  above  forty.    Three  fourths  of  the  cases  are  in  males.    In  a 


RIO 


DISKASKS   OF   'I'lIK    IM,(><>I)   AM)    l>r'("'rLKSS   (iIiANI>S. 


/ 


m^ 


i  !: 


\ 


I 


lew  iiK^tiincrs  hiTcdity  lias  bt'cii  adtliict'd  as  a  [lossildo  caiisf.  and  aiitocodent 
di.H'asi',  Hiii'li  as  nypliilis;  liiit  tlu'su  aiv  donhtlid  liictors.  More  iiii|i(»itaiit 
is  lond  irritation,  iipoii  wlucii  'rroiisscaii  lays  spcciid  stress,  iiiid  ^dvcs  iii- 
staiici's  ill  wliicli  cliidiiic  irritiitinii  id  the  sUii.  clirnnii'  nasal  fatiirrli,  «»r  llio 
irritation  ul'  a  decayed  lootli  ^a\r  rise  in  Inenl  ;;lan/l  swellings,  wlueh  |>re- 
(■ede(|  11  H(.|i(.i';il  (|('\('|()|iinent  nf  tlii'  dix'iist".  In  a  hii'^c  majority  of  the 
jii.«e.-  the  diseii;-e  conies  uii  insidiously,  without  any  reeo;,qiiziilde  canso. 

Morbid  Anatomy. — 'I'lic  Liiniiili-iihnnls. —  In  u  few  casfs  the  en- 
lar;:cd  <:laiids  nic  liard  and  firm,  hnt  in  a  majority  the  ;,M'o\vth  is*  soft  and 
elastic.  Ill  tlie  cjirly  sta<,'e  the  individual  jilaiids  are  isolati'(l,  not  iartjer 
than  almonds  or  walnnts,  and  readily  sepai'atcd  and  iiiovahle.  In  more 
advanced  staiics  tlie  glands  fuse  toijfcther.  and  a  ^^roiip,  us  in  the  neck,  may 
foi'iii  a  larye  tumor,  the  size  of  an  uran;:e  or  uvea  of  a  coeuu-aut.  About 
jiiicii  nia^x's  tile  ca|isiilar  tissues  ai'i'  hard  and  dense,  foriiiin,ii'  a  linn  invest- 
ment. >\  ^xrowtli  may  perforate  the  capsule  and  invade  conti;^uoiis  parts, 
such  as  the  muscles,  skin,  or  the  soliti  or,i:ans.  On  section,  llie  tumor  has  a 
^n'ayish-whiti'  appearance;  it  is  smooth,  and  of  variable  consistence,  either 
firm  and  dry  or  soft  and  juicy.  Suppuration  is  most  frefjiicntly  seen  when 
tlie  ^'■rowth  reaches  the  skin.  In  the  deep  glands  the  formation  of  ]uis  is 
rare.  Caseation  i.s  not  common;  occasionally  there  are  areas  of  necrosis 
very  like  it.  The  superficial  <rlaiids  are  most  often  attackeil,  ])articularly  the 
cervical  <rronps,  and  they  may  be  traced  as  continuous  chains  alon<:  the 
trachea  and  tiie  carotids,  unitin<r  the  axillary  and  mediastinal  <>lands. 

The  axillary  <:roU]t  is  involved  next  in  order  of  frecjuency,  and  the 
masses  may  pass  beneath  the  pectonds  and  beneath  the  scapnbe.  The 
in^niinal  ,irlands  occasionally  form  very  lar,tre  masses.  Of  the  internal 
groii|)s.  those  of  the  thorax  are  most  often  atl'ected,  cither  the  chain  in  the 
jiostcrior  mediastinum  or  the  bronchial  izronp,  or  those  of  the  anterior 
mediastinum.  The  trachea  and  the  aorta  with  its  branches  may  be  com- 
]iletely  surrounded  by  the  <:rowtlis,  and  be  but  little  comjn'essed.  From 
the  anterior  mediastinum  the  masses  may  perforate  the  sternum  and  ap- 
pear as  an  external  tnmor. 

Of  the  abdominal  (,n-onps,  the  retroperitoneal  is  most  frecpiently  in- 
volved and  may  form  a  continuous  chain  froia  the  diaphrajini  to  the  in- 
^niinal  canals,  and  extend  into  the  ]ielvis.  The  <flands  may  compress  the 
ureters,  involve  the  sacral  or  himliar  nerves,  or  impiniie  njion  the  iliac  veins. 
Occasionally  they  adhere  to  the  uterus  and  broad  li<;anient  so  as  to  simu- 
late fibroids.  T  saw,  some  years  a<io,  one  of  the  most  dist  in  finished  ^yna'- 
colorrists  of  Germany  ])erform  laparotomy  in  a  case  of  this  kind,  in  wdiicli 
the  diajrnosis  of  myomatous  tumors  of  the  uterus  had  been  made.  Occa- 
sionally the  mesenteric  or  hepatic  lyn;i)h-^dands  may  form  large  abdominal 
tumors. 

JUKh)h)(jir(ilhi  the  chief  chan,i:e  is  an  increase  in  the  cells.,  with  or  with- 
out thickening  of  the  reticulum.  In  the  early  stage  there  is  sim]de  hy])er- 
plnsia  and  ihe  relations  of  the  lym]ih  ])aths  are  maintained,  but  when  the 
glands  are  greatly  enlarged  the  normal  arranirement  is  disturbed.  The 
reticulum  varies  extremely:  in  the  softer  growths  it  is  expanded  and  can 
scarcelv  be  found:  in  the  harder  structures  the  network  of  fibres  is  verv 


inloofdcnt 

llll|i()l'tlUlt 

I  '/i\'i'H  iii- 

ItIi,  III'  the 

vliicli  pri'- 
itv  of  the 
cm  I  so. 

s     llic    Cll- 

8  soft  and 
not  Iiir^fcr 

Iti  more 
nt'C'k,  nmy 
it.  About 
rni  invcst- 
loiis  parts, 
nior  has  a 
ICC,  cither 
seen  when 
of  jHis  is 
f  necrosis 
'uhirly  the 
nlonif  tlic 
ands. 
,  and  the 
la'.      The 

internal 
lin  in  the 

anterior 

1)C    COIll- 

FroMi 
and  ap- 

'Titly  in- 
tho  in- 
iTcss  the 
iae  veins, 
to  simii- 
d  livna'- 
111  wliich 
Ooca- 
idominal 

or  witli- 
c  liy]icr- 
len  tlio 
d.  The 
and  can 
;  is  very 


llODdKlN'S  DISEASE. 


811 


distinct,  and  there  is  prohaldy  an  incronsed  development  of  the  adenoid 
li^sjiio. 

Siiln'ii. — In  To  per  cent  of  the  cases  collected  hy  ( lowers  this  orj^an  was 
h\  [lertrophicd,  and  in  od  of  these  it  presented  lyniplioid  j,M'o\vth8.  'J'lic  en- 
largement is  rarely  j^rcat,  and  does  not  approximate  to  that  of  the  larj^e 
leuKa-niic  spleen.  The  lymphoid  tumors  form  ^rayi.-h-wlutc  hodies  ranj^- 
in;:  in  size  frinn  a  |)ea  to  a  walnut,  and  may  I'csenilije  lympli-;;lands  in  ap- 
pearance and  consistence.  llistolo<i'ically,  they  C()ii>i>i  dj'  lymph  corpne- 
eles  in  a  (ihrons  reticninm. 

The  marrow  of  the  Ioiil;'  hones  may  he  converted  int(»  a  lich  Ivmphoid 
tissue;  in  a  few  instances  the  pyoid  form,  suili  as  is  more  common  in  leu- 
ka'uda,  has  heen  foumi.  The  tonsils  may  be  involvid  and  the  follicles  at 
the  root  of  the  toii<:ue.  Occasionally  secondary  ;:routlis  aie  seen  in  the 
inlesi  ines. 

The  liver  is  often  enlarged  and  may  present  scattered  lymphoid  tumors. 
The  kidneys  are  occasionally  invol\('(|  and  ari'  the  seat  of  ;,M'o\vtlis  similar 
to  those  in  the  spleen  and  li\i'r.  The  lunjis  are  occasionally  directly  at- 
tacked from  the  brom-hial  ^.dands  at  the  root,  and  secondaiy  noihiles  may 
he  found  throughout  their  sutistance.  JMeural  ell'usions  ai'i'  imt  um'om- 
uiou.  InvolvenK'ut  (d'  the  uei'vous  system  is  rare,  but  paraple;^ia  may  be 
iiiduecd  by  invasion  of  the  spinal  canal.  The  skin  may  be  the  seat  of 
adenoid  {.n'owths.  as  in  a  case  reportcfl   by  (ii'eenlield. 

Symptoms. — I'lidai'ii-cment  (d'  the  glands  of  the  neck,  axilla,  or 
groins  is  usually  the  lii-t  symptom  noticed.  Jn  a  few  cases  the  aTueniia 
and  conslituliomd  sympt(uns  attract  attention  before'  the  j.-laiulular  in- 
V(»lvcnicnt  is  evident.  When  the  trouble  bet^ins  in  the  (h'cpei'  irroups, 
pressure  clTccts  nuiy  be  first  noticed;  thus,  ])aroxysnuil  dyspniea  with  ]»ain 
in  the  chest  may  result  from  enlargement  of  the  bronchial  jilands  before 
any  ]diysical  sijius  can  be  detected.  (I'^denui  of  the  feet  and  shooiin^ 
pains  in  the  nerves  were  the  lirst  synii)tonis  in  one  case  which  I  dissected 
f(n'  lioss.  and  in  another  case  at  the  Montreal  (Jenoral  Hospital  there  was 
paraplejria  from  ])ressure  on  the  cord.  Such  instances,  however,  are  ex- 
ceptional, and  in  the  nuijority  of  cases  the  swellinir  of  the  su])er(icial  ^dands 
is  the  earliest  symptom.  l']])istaxis  has  occasioiuilly  been  noted,  but  not  so 
fre(pu'ntly  as  in  leukaunia.  With  ])ropressive  enlar<iement  of  the  filands 
the  patient  becomes  aua'inic. 

T'sually,  the  cervical  .yroup  is  first  afl'ccted,  and  it  nuiy  he  impossible 
to  decide  whether  the  enlaruenu'nt  is  syphilitic,  tuberculous,  or  lymphad- 
enoniatous.  One  side  is  first  affected  as  a  rule,  and  it  may  be  months  or 
even,  as  in  oiu'  of  my  cases,  three  years  hefore  the  aifection  extends  to 
other  jiToiips.  Ultimately  hujre  tumors  may  develop,  which  obliterate  the 
neck  and  extend  npon  the  shoulders  and  over  the  clavicles  ami  sternuTU. 
The  trachea  is  snrroundi'd.  .i^reat  dyspno-a  is  ju'oduccd.  and  not  inl're- 
(pieutly  tracheotomy  is  necessary.  Tn  the  later  stages,  the  skin  beconios 
involved  and  ulcerates.  '^I'lu'  axillary  i^roup  may  form  larije  tumors,  wliicli 
inmpress  the  brachial  or  axillary  veins  and  cause  swelling;'  of  the  arms. 
The  iuiiuinal  ,<ilands  may  form  larce  or  even  ])cndnlous  tumors. 

In  the  thoracic  glands,  as  mentioned,  the  various  grou[)s  may  he  in- 


S12 


DISKASKS  OK  TIIK    WHXM)  AND   DIXTLKSS  (ihANDS. 


/ 


^! 


Vdlvi'd  mill  |iin(lii('('  prcHHuri'  ii|ii)ii  llic  veins  nr  iiitDii  the  triiclicn.  In  ii 
caso  rt'ci'iitly  under  <»l»si'rviitinn  the  sn|H'ii«»r  cava  was  (•(ini|il('(('ly  nlilitiT- 
atcd  and  a  very  cxtcnsivi'  colljitcral  circMlatinn  was  cstahlislicd  hy  means 
dl'  llie  inaniiuary  and  ('|li^■a^l rie  veins.  The  skin  nvt-r  tlio  sleniuni  was  ii 
mass  ol'  lliietnatin;^'  veins,  some  of  whieli  contained  |ihleliolitlis.  In  tlie 
alfdomen  llie  nu'senteric  ^dands  may  he  enhiij^t'd,  or  more  commonly  the 
retro|icritoneid  ^m'ou|».  When  the  |iatient  is  tiiin  tlicre  may  he  no  dillicnlty 
in  detecting,'  these,  hnl  in  stout  persons  the  dia<,Miosis  may  he  impossihle. 
Ju  connection  with  the  all'i'ctions  of  tlie  ahdoniinal  ^dands  there  may  ho 
bronzing  of  tliu  nkin,  which  was  well  mari^ed  in  Case  IV  of  my  series.  A 
remarkahle  feature  is  the  variations  in  the  rate  of  firowth  and  in  the  size 
of  tile  ^dands.  Tiiey  may  reduce  rajtidly  and  almost  (lisai>|>ear  from  a 
re^don,  and  Ixd'ore  deatii  the  numlx'r  of  tiiose  visihle  may  diminish  very 
muili.  Tiie  s|)leen  may  be  eidar;,'i'd  and  readily  i»al|table.  The  thyroid  also 
may  bo  involved,  and  in  a  few  instances  the  thymus  has  been  all'ected. 
Tliou;,di  present  in  a  majority  of  the  cases,  tlicre  may  be  enormous  eiilarire- 
meiit  of  the  lynii)li-;,dan(ls  without  marked  aiuemia.  Jn  one  of  my  cases  the 
lilood-corpuscdes  did  not  sink  below  l.OlHi.dOO  per  cubic  millimetre,  and  in 
oidy  one  instance  luive  I  counted  the  l)lood  below  2,00(),()()(».  The  red  blood- 
corpuscles  rari'ly  show  extreme  jioikilocytosis.  The  white  corpuscles  may 
be  moderately  increasi'd  an<l  the  lymphocytes  abundant,  though  usually 
there  is  little  that  is  characteristic  in  the  blood.  Occasionally  the  leuco- 
cytes are  greatly  increased  and  the  characters  of  the  blood  become  those 
of  a  lymphatic  leuka'iiiia.  Nucleated  red  blood-corimscles  may  be  present, 
but  not  in  such  numbers  as  in  leuka'uiia. 

Of  cardiac  symptoms,  jialpitation  is  common.  Ibeniie  murmurs  are 
often  beard  over  the  heart.  Shortness  of  breath  may  be  due  to  tlie  nna'mia, 
tf)  ])ressure  upon  the  tracbea,  or,  in  some  instances,  to  ])leuritic  elfusion 
associated  with  mediastinal  growtlis.  I"'ever  is  observed  in  nearly  all  cases; 
even  in  the  early  stages  there  is  slight  elevation.  It  may  be  of  an  irregu- 
lar beetle  tyjte,  or  continuous,  with  evening  exacerliation.  Very  remark- 
able are  the  cases  with  ague-like  ])aroxysms,  wbich  may  persist  for  weeks 
or  montbs.  Tbey  were  jiresent  in  Case  I  of  my  series.  Pel,  of  Amster- 
dam, bas  given  a  thorougb  descrijition  of  these  attacks,  and  l^bstein  bas 
described  a  case  under  the  remarkable  title  of  Chronic  l?ecurrent  Fever,  a 
Xew  Infectious  Disease.  In  bis  case  during  nine  montbs  the  attacks  were 
present  for  periods  of  from  twelve  to  fonrteen  days  and  alternated  with 
an  ajiyrcxia  of  ten  or  eleven  days. 

The  digestive  symi»toms  are  usually  not  marked.  It  is  not  uncommon 
to  find  albumin  in  the  urine.  Ileadnche,  giddiness,  and  noi.ses  in  the  ear 
may  be  associated  with  the  ana-mia.  Delirium  and  coma  may  ensue.  Deaf- 
ness may  be  produced  by  growth  of  the  adenoid  tissue  in  the  pharynx  close 
to  the  Eustachian  tubes.  Ineipiality  of  the  jiupils  may  be  jiresent,  owing 
to  ])ressurc  of  the  glands  on  the  cervical  sympathetic.  The  skin  may  show 
definite  secondary  lym])batic  tumors,  bronzing  may  occur,  and  occasionally 
a  most  intense  and  troublesome  prurigo. 

Diagnosis. — A  tuberculous  adenitis  may  at  first  be  very  difTloult  to 
dilTerentiate.    The  chief  points  of  distinction  are  as  follows:  Tuberculous 


lIOlKiKINS   DISKASK. 


S13 


lii'ii.      In  II 
'ly  olilitiT- 

liy  iiifaiiH 
I II III  was  u 
S.  Ill  tlu> 
inoiily  the 
I)  (lilliciilty 
iiii|)(>ssil)|(>. 
iv  niiiy  1h' 

series.  A 
in  the  size 
tir  from  u 
inisli  very 
lyroid  also 
11  uU'eeted. 
is  enliir^'e- 
y  cases  the 
re,  and  in 
red  blood- 
iscles  may 
;li  usually 
the  leuco- 
oiiie  tiiose 
»e  present, 

imirs  are 
'  aiiii'inia, 
'  eirusion 
all  cases; 
in  irre<;u- 

remark- 
t'or  weeks 

\mster- 
stein  has 

l*\'ver,  a 
icks  -were 
led  with 

leoiiiinon 
1  the  ear 
.  Deaf- 
nx  close 
t,  owinir 
lay  show 
iisionnlly 

Ticult  to 
crculoiis 


.nleiiitis  is  more  common  in  the  yoiiii^f  and  involves  the  siiltmaxillary  ^'roup 
'■I'  ;;laiids  more  tri'i|iiriit ly  than  tlio.-c  o|'  the  anterior  and  posterior  cfrvical 
iiian^des,  wliith  are  usually  atVeefed  first  in  llod^ikin's  disease.  The  cii- 
larp'iiK'nt  may  last  for  years  in  ii  ^Toiip  witliout  extending,'.  The  liunehes 
iire  often,  when  small,  welded  to^ielhcr  aii<l,  most  im|iortaiit  of  all,  tend 
lo  suppurate — a  feature  rari'ly  seen  iu  true  lymiiiiaileiioma,  except  when 
ii  has  attained  very  larjii'  si/e.  Strict  limitation  to  one  side  of  the  neek 
Ml-  lo  the  axilla  is  suggestive  of  tuberculous  diseuse  nither  than  lym[ilui(lo- 


iioina 


There  is  an  acute  tiiherculoiis  adenitis,  which  may  involve  the  lymph- 
ulands  (d"  the  neck,  producing  enormous  enlargement.  A  man,  aged  twenty- 
loiir,  was  admitted  to  the  ticncral  Hospital,  .Montreal,  with  great  swelling 
(d'  the  cervical  glands  on  both  sides,  tonsillitis,  and  sl(»iighing  pharyngitis, 
with  irregular  fever  and  diarrluea.  The  case  was  at  lirst  regarded  as  one 
of  llijdgkin's  disease.  The  occurrence  of  rigors  aiul  intermittent  pyrexia 
is  in  favor  of  lymphadenoma.  There  are  cases  in  which  it  may  for  a  time 
he  impossible  to  miUce  a  diagnosis.  Wiu'ii  the  glands  are  only  moderately 
cidarged  on  one  side  of  the  neck  or  axilla,  they  should  be  removed,  and  the 
diagnosis  can  then  be  thoroughly  cstal)lished. 

Prog^nosis. — Recovery  is  very  rare.  The  coiirso  of  the  disease  is  e.x- 
tremcly  variable.  ]\arly  and  rapid  growth  in  tlu'  mediastinal  grou|)s  may 
produce  pressure  cH'ccts  and  cause  death  before  the  development  is  c.v- 
ireme.  In  some  cases  the  enlargements  spread  rapidly  and  group  after 
grou[)  becomes  involved  in  a  few  months.  These  acute  case  may  run  u 
course  in  three  or  four  months.  Chronic  cases  nuiy  last  for  three  or  four 
years,  I'eriods  of  quiescence  are  not  nnconnnon.  The  tumors  nuiy  not 
only  C'case  to  grow,  but  gradually  diminish  and  even  disappear,  without 
special  treatment.  I'sually  a  cachexia  develops,  the  anscmia  ])rogresses, 
and  there  are  dro])sical  symi)toms.  The  nu)de  of  death  is  usually  by 
asthenia;  less  commonly  by  i)rcssuro  from  a  tumor;  and  occasionally  in 
coma. 

Treatment. — AVhen  small  and  locali/^ed  the  glands  should  be  re- 
moved. Local  applications  are  of  doul)tful  benciit.  I  have  never  seen 
s])ecial  improvement  follow  the  i)ersistent  use  of  iodine  or  the  various 
ointments. 

Arsenic  has  a  positive  value  in  the  disease.  It  should  be  given  in  in- 
creasing doses,  and  stop]ied  when  unpleasant  effects  are  manifested.  The 
results  have  in  many  instances  been  striking.  Due  allowance  must  ho 
math'  for  the  fluctuations  in  the  size  of  the  growths  which  occur  sponta- 
neously. Ill  ofTccts  from  the  administration  of  Fowler's  solution,  even 
for  months  at  a  time,  are  rare,  but  I  have  had  a  case  in  Avhich  neuritis 
followed  the  use  of  5  iv  7)  j  TTlxviij  within  a  period  of  less  than  three  months. 
Uecoveries  have  hecn  rejiorted  under  this  treatment.  Personally,  no  in- 
stance of  recovery  has  come  under  my  notice  in  the  cases  of  which  I  have 
notes.  Phosphorus  is  recommended  by  dowers  and  Broadhent,  and  should 
be  used  if  the  arsenic  is  not  well  borne.  Quinine,  iron,  and  cod-liver  oil 
are  useful  as  tonics.  Every  i)0ssihle  means  must  he  taken  to  support  the 
patient's  strength. 


814 


DISEASES  OF  TUE  BLOOD  AND  DUCTLESS  GLANDS. 


IV.    PURPURA. 


/ 


Strictly  speaking,  purpura  is  a  symptom,  not  a  disease;  but  under  this 
term  are  conveniently  arranged  a  number  of  aflcctions  characterized  by 
I'xtravasiitions  ol'  the  blood  into  the  skin.  In  the  ])resent  state  of  our 
knowledge  a  satisfactory  classification  cannot  l)e  made.  J-lxcluding  symp- 
tonuitic  jairpura,  W.  Koch  groui)S  all  forms,  including  hamiophilia,  under 
tlio  designation  ha'i\wrrha(jic  diatlwsis,  believing  that  intermediate  forms 
link  the  mild  purpura  simplex  and  the  most  hitense  jnirpura  ha'morrhagica; 
while  F.  A.  Jloll'mann  considers  them  all  (excejjt  luvmophilia)  under  the 
heading  morhits  iikicuIusus.  The  purpuric  s])ots  vary  from  1  to  3  or  -i  mm. 
in  diameter.  ^Vhen  snudl  and  i)in-point-like  they  are  called  petechia'; 
when  large,  they  are  known  as  ecchymoses.  At  first  bright  red  in  color, 
they  become  darker,  and  gradually  fade  to  brownish  stains.  They  do  not 
disa])pear  on  pressure. 

In  all  cases  of  ])urpura  the  coagulation  lime  of  the  blood  should  be  esti- 
mated (Wright);  the  coagulometer  is  a  usei^d  clinical  instrument  for  the 
l)ur|)ose.  Normal  blood  clots  in  the  tubes  in  from  three  to  five  minutes.  In 
some  forms  of  pur})ura  the  coagulation  time  is  retarded  to  ten  or  lifteen 
minuti's,  and  in  ha'm(.i)hilia  it  has  been  delayed  to  fifty  jiiinutes. 

The  following  is  a  provisional  grouping  of  the  cases: 

Symptoinatic  Purpura. — (a)  Infectious. — In  ])y;eniia,  septicannia, 
and  maligiunit  endocarditis  (particularly  in  the  last  afl'ection),  ecchymoses 
may  be  very  abundant.  In  typhus  fever  the  rash  is  always  purpuric. 
]\Ieasles,  scarlet  fever,  and  more  particularly  small-pox,  have  each  a  variety 
characterized  by  an  extensive  ])uri)uric  rash. 

(h)  Toxic. — The  virus  of  snakes  ])roduces  with  great  ra])idity  extrava- 
sation of  Idood — a  cor  Mtion  which  has  been  very  carefully  studied  l)y 
Weir  ]\Iitchell.  Certain  medicines,  particularly  co])aiba,  quinine,  bella- 
donna, mercuiy,  ergot,  and  the  iodides  occasionally,  are  followed  by  a 
petechial  rash.  Purpura  may  follow  the  use  of  comi)aratively  small  doses 
of  iodide  of  potassium.  It  is  not  a  very  common  occurrence,  considering 
the  great  fre(piency  Mith  ■which  the  drug  is  emjiloyed.  A  fatal  event  may 
be  caused  by  a  small  amount,  as  in  a  case  reported  by  Stei)hen  ^Mackenzie 
of  a  chdd  which  died  after  a  dose  of  2^  grains.  An  erythema  may  ])rece(le 
the  luvmorrhage.  It  is  not  always  a  simple  ])urpura,  but  may  be  an  acute 
febrile  eruption  of  great  intensity.  In  8ei)tcnd)er.  1S94,  a  man  aged  forty- 
eight  was  admitted  imdcr  my  care  with  arterio-sclerosis  and  dropsy.  The 
latter  yielded  ra]iidly  to  digitalis  and  diuretin.  "When  convalescent  he  was 
ordered  iodide  of  potassium  in  10-grain  doses  three  times  a  day,  and  took 
in  fourteen  days  420  grains.  lie  had  high  fever,  coryza,  swelling  of  the 
throat,  and  the  most  extensive  purpura  over  the  whole  body,  lender  this 
division,  too,  comes  the  purpura  so  often  associated  with  jaundice. 

(r)  Cachectic. — T'^nder  this  heading  are  best  described  the  instances  of 
purpura  which  develop  in  the  constitutional  disturbance  of  cancer,  tuber- 
culosi«,  llodgkin's  disease.  r)right's  disease,  scurvy,  and  in  the  delulity  of 
old  age.     In  these  cases  the  spots  are  usually  confined  to  the  extremities. 


PURPURA. 


815 


under  this 
ilt'j'izL'd  by 
ite  of  our 
lin^  syni])- 
ilia,  iiudcr 
iale  forms 
lorrliagica; 
under  the 

or  -i  mm. 

l)etochi;L'; 
I  in  color, 
cy  do  not 

Id  be  csti- 
it  for  the 
iiut(»s.  In 
or  hftcen 


ptictemia, 

?chymosos 

pnrpurie. 

a  variety 

cxtrava- 
udied  l)y 
le,  bella- 
•ed  ])y  a 
all  doses 
isiderin<: 
■ent  may 
ackenzie 

])rece(le 
an  acute 
xl  fortv- 
y.  The 
^  he  was 
nd  took 
:  of  the 
ih'r  this 

uu-es  of 
.  tidxM'- 
)i]ity  of 
cmities. 


They  may  be  very  abundant  on  the  lower  limbs  and  about  the  wrists 
and  hands.  This  constitutes,  probably,  the  commcmest  variety  of  the 
disease,  and  nuiny  e.\ami>les  of  it  can  be  st-en  in  the  wards  of  any  large 
hosi)ital. 

{(I)  Neurotic, — One  variety  is  met  with  in  cases  of  orjianic  disea5;e.  It 
is  the  so-called  myelopathic  ])ur})ura,  which  is  seen  occasionally  in  loco- 
motor ataxia,  particularly  following;  attacks  of  liie  lightning  pains  and, 
as  a  rule,  involving  the  area  of  the  skin  in  which  the  ])ains  have  been  most 
intense.  Cases  have  been  met  with  also  in  acute  myelitis  and  in  transverse 
myelitis,  and  occasionally  in  severe  neuralgia.  Another  form  is  the  re- 
markable hysterical  condition  in  wliith  stigmata,  or  ideeding  points,  a})pear 
ui)on  the  skin. 

(e)  Mechanical. — This  variety  is  most  fre(pien11y  seen  in  venous  stasis 
of  any  form,  as  in  the  ])aroxysuis  of  whooping-cough  and  in  ei)ilepsy. 

Arthritic. — This  form  is  characterized  by  involvement  of  the  joints. 
It  is  usually  known,  therefore,  as  rheumatic,  though  in  reality  the  evideiu'c 
upon  which  this  view  is  based  is  not  conclusive.  Of  200  cases  of  purpura 
analyzed  by  Stei)hen  ]\lackenzie,  Gl  had  a  history  of  rheuuuitism.  For  the 
[tresent  it  seems  nun'c  satisfactory  to  use  the  designation  arthritic.  Three 
groups  of  cases  may  be  recognized: 

(d).  A  mild  form,  often  known  as  Purpura  simplex,  seen  most  com- 
monly in  children,  in  whom,  with  or  without  articular  ])ain.  a  croii  of 
juirpuric  si)ots  appears  upon  the  legs,  less  commonly  njjon  the  ti'unk  and 
arms.  As  pointed  out  by  Graves,  this  form  is  not  infre(iuently  associated 
with  diarrhu'a.  The  disease  is  sehhmi  severe.  There  may  l)e  loss  of  ap- 
l»etite,  and  slight  ana'mia.  Fever  is  not.  as  a  rule,  i)resent,  and  the  ]ia- 
tients  get  well  in  a  week  or  ten  days.  These  cases  are  usually  regarded 
as  rheumatic,  and  are  certainly  associated,  in  some  instances,  with  un- 
doubted rheumatic  manifestations;  yet  in  a  majority  of  the  ])atients  which 
I  have  seen  the  arthritis  was  slighter  than  in  the  ordinary  rheuuuitism  of 
children,  and  no  other  manifestations  were  i)resent. 

(b)  Purpura  (Peliosis)  rheumatica(^'r/(a/;/c//('«  Disease). — This  remark- 
able alfection  is  characterized  by  multi])le  arthritis,  and  an  eruption 
Avhich  varies  greatly  in  character,  sometimes  purpurir,  more  commonly 
associated  with  urticaria,  ox  with  cryllicma  cxudalinim.  The  disease  is  most 
common  in  males  l)etween  the  ages  of  twenty  and  thirty.  It  not  infre- 
quently sets  in  with  sore  throat,  a  fever  from  101°  to  10.')°,  aiul  articular 
pains.  The  rash,  which  makes  its  ap])earance  first  on  the  legs  or  about  the 
alfected  joints,  nuiy  be  a  simple  ])uri)ui'a  or  may  show  ordinary  urticarial 
wheals.  In  other  instances  th(>re  are  nodular  infiltrations,  not  to  be  distin- 
;,  iished  from  erythema  nodosum.  The  cond)ination  of  wheals  and  ])urpuia, 
the  purpura  vrliraiis.  is  very  distinctive.  ^Fuch  more  rarely  vesication  is 
met  with,  the  so-called  pnirp]ii<iiii(]  piirpinri.  The  amount  of  tedema  is  vari- 
able; occasionally  it  is  excessive.  In  one  case,  which  T  saw  in  ^lontreal 
with  ]\lolson,  the  chin  and  lower  li]  're  enormously  swollen,  tense,  glazed. 
and  dee])ly  ecchynu)tic.     IMie  eyt  \vere   swollen  and   ]»ur]»uric,   while 

scattered  over  the  cheeks  and  about  the  joints  were  numerous  s])ots  of 
purpura  urticans.    These  are  the  ^ases  which  have  been  deserilied  as  fehrilo 


I    I 


810 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


/ 


purpuvir  uilvma.  The  temperature  range,  in  mild  eases,  is  not  higli,  but 
Miay  roaeh  lU;i°  or  1U3°. 

The  urine  is  sometimes  reduced  in  amount  and  may  be  albuminous. 
The  joint  all'ections  are  usually  slight,  though  associated  witii  much  \n\\\\, 
jiarticularly  as  the  rash  comes  out.  Kelapses  may  occur  and  the  disease 
may  return  at  the  same  time  ior  several  years  in  succession. 

The  diagnosis  of  Schonlein's  disease  oilers  no  dilliculty.  The  associa- 
tion (d'  multiple  arthritis  with  purpura  and  urticaria  is  very  characteristic. 
In  a  case  which  I  saw  with  Musser  there  was  endo-])ericarditis,  and  the 
question  at  first  arose  whether  the  patient  had  malignant  endocarditis 
with  extensive  cutaneous  infarcts. 

SchiJidein's  peliosis  is  thought  by  most  writers  to  be  of  rheumatic 
origin,  and  certainly  many  of  t^'.e  cases  have  the  characters  of  ordinary 
rheumatic  fever,  plus  ])urpura.  ]>y  many,  however,  it  is  regarded  as  a 
special  alfection,  of  which  the  arthritis  is  a  numifestation  analogous  to 
tliat  which  occurs  in  ha'moi)hilia  and  in  scurvy.  The  fre(piency  with 
which  sore  throat  ])recedes  the  attack,  and  the  occasional  occurrence  of  en- 
docarditis or  pericarditis,  are  certainly  very  suggestive  of  true  rheumatism. 

The  cases  usually  do  well,  and  a  fatal  event  is  extremely  rare.  The 
throat  symi)toms  may  ])ersist  and  give  trouble.  In  two  instances  I  have 
seen  necrosis  and  sloughing  of  a  portion  of  the  uvula. 

(c)  Henoch's  Purpura. — This  variety,  seen  chieily  in  children,  is  char- 
acterized by  (1)  relajjses  or  recurrences,  often  extending  over  several  years; 
(■-3)  cutaneous  lesions,  which  are  those  of  erythema  multiforme  rather  than 
of  simi)lo  purpura;  (3)  gastro-intestinal  crises — ])ain,  vomiting,  and  diar- 
rhoea; (-i)  Joint  ]iains  or  swelling,  often  trilling;  (5)  hemorrhages  from 
the  mucous  membranes.  When  from  the  kidney,  an  intense  htvmorrhagic 
nephritis  may  su])ervene,  which  proved  fatal,  with  tlie  sym])toms  of  acute 
r>right"s  disease,  in  one  of  my  cases,  and  became  chronic  in  a  case  under 
D.  W.  Prentiss.  Any  one  or  two  of  the  above  symptoms  may  be  absent;  the 
intestinal  crises  with  enlargement  of  the  sjdecn  may  be  present  and  recur 
for  months  before  the  tru  '  nature  of  the  trouble  becomes  manifest.  This 
form  has  an  interesting  connection  with  the  angio-neurotic  oedema,  which 
is  also  characterized  by  severe  gastro-intestinal  crises.  The  prognosis  is,  as 
a  rule,  good;  3  of  the  11  cases  which  I  have  reported  died.* 

Purpura  Heemorrhagica. — Under  this  heading  may  be  consid- 
ered the  cases  of  very  severe  ]nir]nira  with  haemorrhages  from  the  mucous 
membranes.  The  aflFection,  known  as  the  morlnis  mariihsus  of  AVerlhof, 
is  most  commonly  met  with  in  young  and  delicate  individuals,  particu- 
larly in  girls;  ])ut  cases  are  described  in  which  the  disease  has  attacked 
adults  in  full  vigor.  After  a  few  days  of  weakness  and  debility,  purpuric 
spots  appear  on  the  skin  and  rapidly  increase  in  numbers  and  size.  Bleed- 
ing from  the  mucous  surfaces  sets  in,  and  the  epistaxis,  ha^maturia,  and 
ha?moptvsis  may  cause  profound  anfrmia.  Chart  XXI  illustrates  the  rapid- 
ity with  which  anaemia  is  produced  and  the  gradual  recovery.  Death  may 
take  place  from  loss  of  Idood,  or  from  ha^morriiage  into  the  brain.     Slight 

*  Am.  Jour,  of  the  Med.  Sciences,  December,  1895. 


PURPURA. 


817 


liigli,  but 

)uminou.s. 
iicli  pain, 
It'  diftcasc 

e  associa- 

acturistic. 

and  tlio 

locarditis 

houiuatic 

ordinary 

dud  as  a 

OgOUd    to 

;icy  witli 
CO  of  t-n- 
lunatism. 
re.  The 
s  I  liave 

is  char- 
al  years; 
lier  than 
nd  diar- 
es  from 
orrliagic 
of  acute 
e  under 
3nt;  the 
id  recur 
This 
which 

IS  is,  as 

consid- 

mucous 
crlliof, 

)articu- 
tacked 

irpuric 
r.leed- 

a,  and 
rapid- 
1  niav 
SI  i -lit 


fever  usually  accomj)anies  the  disease.  In  favoral)le  cases  tiie  airection 
terminates  in  from  ten  days  to  two  weeks.  There  are  instances  of  i)uri»ura 
luemorrhagica  of  great  malignancy,  which  may  prove  fatal  within  twenty- 
four  hours — purpura  fnlminans.  This  form  is  most  commonly  met  with 
in  children,  and  is  characterized  by  cutaneous  lutmorrhages,  which  develop 
with  great  rapitlity.  Death  may  occur  before  any  bleeding  takes  place 
from  the  mucous  membranes. 

In  the  (linijnosis  of  purpura  ha?morrhagica  it  is  important  to  exclude 
scurvy,  which  may  be  done  by  the  consideration  of  the  previous  health. 


APRIL. 

MAY.                            1                         JUNE.                                1    JULY.      1 

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BLACK,  RED  CORPUSCLES. 


BED,  HAEMAGLOBIN, 


MEAN  NORM. 
NUMBER  or 

WHITE 
CORPUSCLCa 


BLUE,  COLORLESS  CORPUSCLES. 


Chart  XXI. — Illustrates  the  rapidity  with  which  anaemia  is  produced  in  purpura 
haeinorrhagica  and  the  gradual  recovery, 

the  circumstances  under  which  the  disease  develops,  and  by  the  absence 
of  swelling  of  the  gums.  The  malignant  forms  of  the  fevers,  particularly 
small-pox  and  measles,  are  distinguished  by  the  prodromes  and  the  higher 
temperature. 

Treatiaent. — In  symptomatic  purpura  attention  should  be  paid  to 
the  conditions  under  which  it  develo])s,  and  measures  should  be  employed 
to  increase  the  strength  and  to  restore  a  normal  blood  condition.  Tonics, 
good  food,  and  fresh  air  meet  these  indications.    In  the  simple  purpura  of 


818 


DISEASES  OF  THE  BLOOD  AiND   DUCTLESS  GLANDS. 


cliiklrcn,  or  that  associated  with  sligiit  aiticiilni'  ti'oul)k',  arsoiiic  in  full 
(loot's  should  1)0  ^dvc'U.  So  yood  is  oUtaiiU'd  Iroui  ihe  suiall  doses,  hut  the 
Fowler's  solution  should  he  )»ushed  freely  until  physiological  ell'ects  are 
ohtained.  la  [)eliosis  rheuinatica  the  sodium  salicylates  may  he  given,  l)Ut 
with  discretioji.  1  confess  not  to  have  seen  any  special  control  of  the  luem- 
orrluiges  hy  this  remedy. 

Aromatic  sulphuric  acid,  ergot,  turpentine,  acetate  of  lead,  or  tannic 
and  gallic  acids,  may  he  used,  and  in  some  instances  they  seem  to  check 
the  bleeding.  Oil  of  turpentine  is  })erhai)s  the  hest  remedy,  in  lU  or  Lj 
nunims  doses  three  or  four  times  a  day.  Wright,  of  Xetley,  advises  the 
use  of  calcium  chloride  in  !<JU-grain  doses  four  times  a  day  (for  three  or 
four  days)  to  increase  the  coagulahility  of  the  blood.  In  bleeding  from 
the  mouth,  gums,  and  nose,  the  inhalation  of  the  carbon  dioxide  is  some- 
times useful.  The  rinsing  of  the  mouth  with  gelatin  has  been  recom- 
mended. 

IIuEMORRHAGIC  DISEASES  OP  THE  NEW-BORN. 

1.  Syphilis  HsBinorrhaglca  Neonatorum. — The  child  may  be  born 
healthy,  or  there  may  he  signs  of  luvmorrhage  at  birth.  Then  in  a  few 
days  tlicre  are  extensive  cutaneous  extrava.sations  and  bleeding  from  the 
mucous  surfaces  and  from  the  navel.  The  child  may  become  dee])ly  jaun- 
diced. The  ])ost  mortem  shows  numerous  extravasations  in  the  internal 
organs  and  extensive  sy|)hilitic  changes  in  the  liver  and  other  organs. 

2.  Epidemic  HsBmoglobinuria  {WindrVs  Disease). — ira>moglohinuria  in 
the  new-born,  which  occasionally  develojjs  in  epidemic  form  in  lying-in 
institutions,  is  a  very  fatal  affection,  which  sets  in  usimlly  about  the  fourth 
day  of  life.  The  child  becomes  jaundiced,  and  there  are  marked  gastro- 
intestinal symptoms,  with  fever,  jaundice,  ra])id  respiration,  and  sometimes 
cyanosis.  The  urine  contains  albumin  and  blood-coloring  matter — me- 
tha'moglobin.  The  disease  has  to  be  distinguished  from  the  sim])le  icterus 
neonatorum,  with  which  there  may  sometimes  be  blood  or  blood-coloring 
matter  in  the  urine.  The  post  mortem  shows  an  absence  of  any  septic 
condition  of  the  umbilical  vessels,  but  the  spleen  is  swollen,  and  there  are 
punctiform  haemorrhages  in  different  ])arts.  Some  cases  hiwo  shown  in 
a  marked  degree  acute  fatty  degeneration  of  the  internal  organs — the  so- 
called  T>uhl's  disease. 

3.  Morbus  Maculosus  Neonatorum. — Ajiart  from  the  common  visceral 
haemorrhages,  the  result  of  injuries  at  l)irth,  bleeding  from  one  or  more 
of  the  surfaces  is  a  not  uncommon  event  in  the  new-born,  particularly  \n 
hos])ital  practice.  Forty-five  cases  occurred  in  0,700  deliveries  (('.  AY. 
Townsend).  The  bleeding  may  be  from  the  navel  alone,  but  more  com- 
monly it  is  general.  Of  Townsond's  .50  cases,  in  20  the  blood  came  from 
the  bowels  {melevna  ncnnniarum),  in  14  from  the  stomach,  in  14  from  the 
mouth,  in  12  from  the  nose,  in  18  from  the  navel,  in  3  from  the  navel 
alone.  The  bleeding  begins  within  the  first  week,  but  in  rare  instances 
is  delayed  to  the  second  or  third.  Thirty-one  of  the  cases  died  and  19 
recovered.  The  disease  is  usually  of  brief  duration,  death  occurring  in 
from  one  to  seven  days.    The  temperature  is  often  elevated.     The  nature 


III 


IIJIMOPIIILIA. 


819 


lie  in  full 
!s,  but  tlie 
L'U'L'cts  a  IV 
ti'iveii,  hut 
llic  liu-'ni- 

or  tanuie 
to  eht'ck 
10  uf  15 
ilviscs  the 
'  three  or 
lin<''  troni 
,'  i.s  souit'- 
'U  rt'coin- 


he  born 
in  a  ft'w 
from  tho 
ply  jauu- 
'  internal 
ins. 

inuria  in 

lying-ill 

10  fourth 

1  gastro- 

inetiincs 

tor — rno- 

e  icterus 

coloring 

eptic 

lere  are 

lowu   in 

-the  so- 


V 


visceral 
>r  more 
larlv  in 

(('."  AV. 
re  com- 
le  from 
0111  the 
e  navel 
stances 
ami  19 
ring  in 

nature 


(if  the  disease  i.s  unknown.  As  a  rule,  nothing  abnormal  is  foiuul  jxjst 
mortem.  The  general  and  not  local  nature  of  the  all'ection,  its  solf-limiled 
(  haraetor,  the  ijresonce  of  I'ovor,  and  the  greater  prevaleiico  of  the  disease 
in  hospitals,  suggest  an  infectious  origin  ('L'owusend).  The  bleeding  may 
he  associated  with  intense  luematngt'iious  jaundice.  Not  every  case  of 
lileeding  from  the  stomach  or  bowels  belongs  in  tliis  category.  Ulcers  of  the 
(i'soi)lingus,  stomach,  and  duodeiiuni  have  been  found  in  the  now-born  dead 
of  iiichviKi  iicDiKitnriini.  The  child  may  draw  the  blood  from  the  breast 
iHid  subsecpK'utly  vomit  it.  In  the  treatment  the  external  warmth  must  be 
maintained,  and  in  feelile  infants  the  couvcuse  may  bo  used.  Camphor  is 
recommondod  and  orgotin  liypodormically. 


V.     HAEMOPHILIA. 

Definition. — An  hereditary,  constitutional  fault,  cliaractorizod  liy  a 
tendency  to  uncontrollable  bleeding,  either  sjiontanoous  or  from  slight 
wounds,  sometimes  associated  with  a  form  of  arthritis.  The  coagulation 
time  of  the  blood  is  usually  much  retarded. 

I'^arly  in  the  century  several  jihysicians  of  this  country  called  attention 
to  the  occurrence  of  ])rofuso  luvmorrhago  from  slight  causes.  The  fact 
that  fatal  luvmorrhago  might  occur  from  slight,  trifling  wounds  had  been 
known  for  centuries.  The  recognition  of  the  family  nature  of  the  disease 
is  due  to  the  writings  of  lUiel,  Otto,  Hay,  Coates,  and  others  in  this  coun- 
try. The  disease  has  boon  elaborately  treated  in  the  nionogra})hs  of  Lcgg 
and  Grandidior. 

Etiology. — In  a  majority  of  cases  the  dis])osition  is  hereditary.  The 
fault  may  be  acquired,  however,  but  nothing  is  known  of  the  conditions 
under  which  the  disease  may  thus  arise  in  healthy  stock. 

The  hereditary  transmission  in  this  disease  is  remarkable.  In  the 
Applcton-Swain  family,  of  Heading,  ]\Iass.,  there  have  l)Ocn  cases  for  nearly 
two  centuries;  and  F.  F.  Brown,  of  that  town,  tells  me  that  instances  have 
already  occurred  in  the  seventh  generation.  The  usual  mode  of  trans- 
mission is  through  the  mother,  who  is  not  herself  a  bleeder,  but  the  daugh- 
ter of  one.  Atavism  through  the  female  alone  is  almost  the  rule,  and  the 
daughters  of  a  bleeder,  though  healthy  and  free  from  any  tendency,  are 
almost  certain  to  transmit  tlie  dis]iosition  to  the  male  offsjiring.  The 
affection  is  much  more  common  in  males  than  in  females,  the  proportion 
being  estimated  at  11  to  1,  or  even  13  to  1.  The  tendency  usually  ai)pears 
within  the  first  two  years  of  life.  It  is  rare  for  manifestations  to  be  do- 
Inved  until  the  tenth  or  twelfth  year.  Families  in  all  conditions  of  life  are 
nfTected.  The  bleeder  families  are  usually  large.  The  members  are  healthy- 
looking,  and  have  fine,  soft  skins. 

Morbid  Anatomy. — Xo  s]iecial  ]ieculiarities  have  been  described. 
In  some  instances  changes  have  been  found  in  the  smaller  vessels;  but 
in  others  careful  studies  have  been  negative.  An  unusual  thinness  of  the 
vessels  has  been  noted.  TTa-'morrhages  have  lieen  found  in  and  about  the 
capsules  of  the  Joints,  and  in  a  few  instances  inflammation  of  the  synovial 


820 


DISEASKS  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


/ 


m 


surfaces.  The  natiiTo  of  the  cli.seasc  is  uiRletcriiiint'd,  and  wo  do  not  yet 
know  whelhov  it  de[»ends  upon  a  pecidiar  frailty  of  tJio  blood-vessels  or 
some  ])eeuliarity  in  the  constitution  of  the  blood,  which  prevents  the  nor- 
mal thrombus  formation  in  a  wound. 

Symptoms. — I'sualiy  lia'iiio|»hilia  is  not  noted  in  the  child  until  a 
triilinj,''  cut  is  followed  liy  serious  or  nncontroUablc  iueiuorrha<;e,  or  spon- 
taneous bleedin<f  occurs  and  presents  insuperable  tlillicullies  in  its  arrest. 
The  synq)toms  may  be  gronjjed  under  three  divisions:  external  bleedings, 
f-pontaneous  and  trannuitic;  interstitial  bleedings,  ])etechiie  and  ecchy- 
nioses;  and  the  joint  aU'ections.  The  e.\termil  bleedings  may  be  si)on- 
taneous,  l)ut  more  commoidy  they  follow  cuts  and  wounds.  In  331  cases 
(lirandidier)  tlie  chief  bleedings  were  ejtistaxis,  l(!iJ;  fnuu  the  mouth,  -13; 
stomach,  15;  bowels,  3ti;  nrethra,  1(J;  lungs,  IT;  and  in  a  few  instances 
bleeding  from  the  skin  of  the  head,  the  tongue,  iinger-tips,  tear-papilla, 
eyelids,  external  ear,  vulva,  navel,  and  scrotum. 

Traumatic  bleeding  may  result  from  blows,  cuts,  scratches,  etc.,  and 
the  blood  may  be  dilfnsed  iiito  the  tissues  or  discharged  externally.  Trivial 
operations  have  i)roved  fatal,  such  as  the  extraction  of  teeth,  circumcision, 
or  venesection.  It  is  possible  that  there  may  be  local  defects  which  make 
bleeding  from  certain  ])arts  of  the  body  more  dangerous.  J).  Hayes  Agnew 
mentioned  to  me  tiie  case  of  a  l)leeder  who  had  always  Ijled  from  cuts  and 
bruises  above  the  neck,  never  from  those  below.  The  bleeding  is  a  caj)il- 
lary  oozing,  it  may  last  for  hours,  or  even  numy  days.  J"]pistaxis  juay 
])rove  fatal  in  twenty-fo\ir  hours.  In  the  slow  bleeding  from  the  mucous 
surfaces  large  blood  tunu)rs  may  form  and  ])roject  from  the  nose  or  mouth, 
forming  reiiuirkable-looking  structures,  and  showing  that  the  blood  has 
the  ])ower  of  coagulation.  The  interstitial  hiemorrhages  may  be  spon- 
taneous, or  may  result  from  injury.  I'etechiiv  or  large  extravasations — 
ha'inatonuita — may  occur,  tlie  Litter  usually  following  blows. 

The  joint  alfections  of  ha'mo])hilia  are  remarkable.  There  may  simply 
be  pain,  or  attacks  which  come  on  suddenly  Avitli  fcA'er,  and  closely  re.sem- 
l)le  acnte  rhenmatism.  The  larger  joints  are  usually  affected.  Arthritis 
may  nshcr  in  an  attack  of  luemorrhage. 

So  far  as  the  blood  examination  goes  the  only  changes  of  s{)ecial  moment 
which  have  been  noted  are  the  absence  or  scanty  number  of  Ijlood  plates  and 
the  retardation  of  the  coagulation  time,  which  may  be  even  fifty-four  seconds. 

Diagnosis. — In  the  diagnosis  of  the  condition  the  family  tendency 
is  important.  A  single  uncontrollable  liaMUorrliage  in  child  or  adult  is  not 
to  1)0  ranked  as  ha'mo])hilia;  but  it  is  only  when  a  person  shows  a  marked 
tendency  to  multiply  haemorrhages,  spontaneous  or  trarrmatic,  which  tend- 
ency is  not  transitory  but  persists,  and  ])articularly  if  there  have  been  joint 
afl'ections,  that  wq  may  consider  the  condition  hivmo])hilia.  Such  condi- 
tions as  e])istaxis,  recurring  for  years — if  no  other  luvmorrhage  occurs — 
or  recurring  luvmaturia  from  one  kidney,  which  has  been  spoken  of  as 
unilateral  renal  ha[emo]')hilia,  have  no  association  Avith  the  true  disease. 
Peliosis  rhoumatica  is  an  aifectiou  which  touches  haemophilia  very  closely, 
particularly  in  the  rebition  of  the  joint  swellings.     It  may  also  show  itself 


SCURVY. 


821 


lo  not  yet 

-vesac'ls  or 
s  tliu  nor- 

1(1  until  a 
,  or  spoil- 
its  arrest. 
Iileediii^s, 
11(1    eccliy- 
be  spoii- 
334  ciLses 
loutli,  43; 
instances 
iir-papilla, 

etc.,  and 
'.  Trivial 
■uiucision, 
lic'li  niak(.' 
es  Agnow 

cut.s  and 
s  a  capil- 
:a.\is  nv,\\ 
e  mucous 
ir  mouth, 
ilood  lias 
1)0  s])on- 
sations — 

y  sim])ly 
y  rcscm- 
Vrtliritis 


in  .several  members  of  a  family.  The  diagiu'jsis  from  the  various  form.s 
nf  puri)ura  is  usually  easy. 

Prognosis. — The  patients  rarely  die  in  the  (irat  bleeding.  The 
\niiuger  the  individual  tlie  worse  is  tlie  (Uitlook,  though  it  is  rarely  fatal 
111  the  llrst  year,  (irandidier  states  that  of  l.')*^  boy  subjects,  81  died  Ind'ore 
llie  termination  of  the  seventh  year.  The  longer  the  l)leeder  survives  the 
greater  the  elianee  of  liis  outliving  the  tendency;  but  it  may  persist  to 
(ild  age,  as  sliouii  in  the  case  of  Oliver  Apjdeton,  the  lirst  rejiorted  Ameri- 
can bleeder,  who  died  at  an  advanced  age  (jf  luemorrhage  from  a  lied-sore 
and  from  the  urethra.  The  prognosis  is  graver  iji  u  boy  than  in  a  girl. 
Ill  the  latter  menstruation  is  sometimes  early  and  excessive,  but  fortunately, 
III  the  female  members  of  luvmophilic  families,  neither  this  function  nor 
the  act  of  parturition  brings  with  it  special  dangers. 

Treatment. — .Members  of  a  bleeder's  family,  jiarticularly  the  boys, 
>hoiild  be  guarded  from  injury,  and  operations  of  all  sorts  should  be 
avoided.  The  daughters  should  not  marry,  as  it  is  through  them  that  the 
tendency  is  propagated. 

When  an  injury  or  wound  has  occurred,  alisolutc  rest  and  compression 
should  first  be  tried,  and  if  these  fail  the  styptics  may  be  used.  In  epis- 
taxis  ice,  tannic  and  gallic  acid  may  be  tried  before  resorting  to  plug- 
ging. Internally  ergot  seems  to  have  done  good  in  several  cases.  Legg 
advises  the  ])erchloride  of  iron  in  half-drachm  doses  every  two  hours  with 
a  [lurge  of  sul])hate  of  soda.  For  the  epistaxis  of  the  disease  the  inhala- 
tion of  carbon  dioxide  through  the  nostrils,  as  recommended  by  A.  E. 
Wright,  may  be  tried.  lie  also  recommends  a  s(dution  of  fibrin  ferment 
and  chloride  of  calcium  as  a  styjitic.  Uiendwald  has  reported  a  case  of  a 
cliild  in  which  the  a]ii)lication  of  fresh  1)lo()d  to  the  wound  checked  the 
lileeding  after  all  other  means  had  failed.  (Jelatin  in  5-per-cent  .solution  is 
warmly  recommended.  Venesection  has  been  tried  in  several  cases.  Trans- 
fusion has  lieen  employed,  but  without  success.  During  convalescence, 
iron  and  arsenic  should  be  freely  used. 


moment 
ates  and 

seconds. 

ndency 
It  is  not 

marked 

h  i end- 
en  joint 
1  condi- 
lecurs — 
n  of  as 

disease. 

closely, 
w  itself 


VI.     SCURVY  {Scorbutus). 

Definition. — A  constitutional  disease  characterized  hy  great  debility, 
with  aniemia,  a  spongy  condition  of  the  gums,  and  a  tendency  to  hirmor- 
rhages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times,  and 
has  prevailed  particularly  in  armies  in  the  field  and  among  sailors  on  long 
voyages. 

From  the  early  part  of  this  century,  owing  largely  to  the  efforts  of 
Lind  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  de- 
pends, scurvy  has  gradually  disappeared  from  the  naval  service.  In  the 
mercantile  marine,  cases  still  occasionally  occur,  owing  to  the  lack  of  proper 
and  suitable  food. 

The  disease  develops  whenever  individuals  have  subsisted  for  pro- 
longed periods  upon  a  diet  in  which  fresh  vegetables  or  their  substitutes 


822 


DISKASHS  OF   TIIK   UI.OOI)  AND   DUCTLESS  ({LANDS. 


are  Inckinj;.  Ai\  iiisiilTiciciit  diet  appcnrs  tn  ho  nil  essential  clement  in 
the  (hscase,  and  all  (ihservers  are  now  unanimous  that  it  is  the  ahsenee  of 
those  ingredients  in  the  food  which  are  su|i|tncd  liy  iresh  vcgetal)les.  What 
these  constituents  are  has  not  yet  heen  delinitcly  deternuneil.  (Janod  hold,- 
that  tlie  defect  is  in  the  al»sence  of  the  potassic  salts.  Otiiers  hclii've  tliat 
the  essential  factor  is  the  ahsenee  of  the  orgaiuc  salts  present  in  fruits  and 
vegetahies.  ifalfe,  wlio  has  nia(h'  a  very  careful  study  of  the  suhject,  he- 
lieves  that  the  ahscnet'  from  the  food  of  the  malates,  citrates,  and  laetates 
rednces  the  alkalinity  of  the  l)lood,  which  depends  ujton  the  carlionale  di- 
rectly derived  from  these  salts.  This  dinnnisheil  alkalinity,  gradually  pro- 
du(,'ed  in  the  scurvy  ])atients,  is,  he  helicNcs,  identical  with  the  ell'ect  which 
can  he  artificially  produced  in  animals  hy  feeding  them  with  an  excess  of 
acid  salts;  the  nutrition  is  imi»aired,  there  are  ecchynioses,  and  i)rofound 
alterations  in  the  characters  of  the  hlood.  The  acidity  of  the  urine  is 
greatly  reduced  and  the  alkaline  ])hosphatcs  are  diminished  in  amount. 
One  of  the  most  interesting  of  recent  facts  relating  to  scurvy  has  heen  the 
great  frequency  of  it  in  children,  in  connection,  as  a  rule,  witii  impro])er 
diet.    It  will  he  referred  to  more  fully  in  a  suhsection. 

In  o))i)osilion  to  this  chemical  view  it  has  heen  urged  that  the  disease 
really  depends  upon  a  specific  (as  yet  unknown)  micro-organism. 

In  the  United  States  scurvy  lias  hecome  a  very  rare  disease.  To  the 
hosi)itals  in  the  seaport  towns  sailors  are  now  and  then  admitted  with  it. 
In  large  almshouses  outhreaks  occasionally  occur.  A  very  great  increase 
of  foreign  ])0])idati()n  of  a  low  grade  has  in  certain  districts  made  the  dis- 
ease not  at  all  uncommon.  Tn  the  mining  districts  of  Pennsylvania  the 
Hungarian,  l)ohemian,  and  Italian  settlers  are  not  infrequently  attacked. 
j\Icfjirew  has  recently  re])orted  43  cases  in  Chicago,  limited  entirely  to 
Poles.  Ho  ascertained  that  in  a  large  ])ro])ortion  of  the  cases  the  diet  was 
composed  of  hread,  strong  coffee,  and  meat.  Occasionally  one  meets  with 
scurvy  among  quite  well-to-do  ])eo])le.  One  of  the  most  characteristic  cases 
I  have  ever  seen  was  in  a  woman  with  chronic  dyspe])sia,  who  had  lived 
for  many  months  chiefly  on  tea  and  hread.  Some  years  ago  scurvy  was 
not  infrequent  in  the  large  hnnhering  camps  in  the  Ottawa  Valley.  Judg- 
ing hnm  the  Eeport  of  the  American  Ptiediatric  Societ}',  we  must  infer  that 
infantile  scurvy  is  on  the  increase  in  this  country. 

In  parts  of  Kussia  scurvy  is  endemic,  at  certain  seasons  reaching  epi- 
demic ])ro])ortions;  and  the  leading  authorities  u])on  the  disorder,  now  in 
that  country,  are  almost  unanimous,  according  to  Iloirmann,*  in  regard- 
ing it  as  infectious. 

Other  factors  play  an  important  part  in  the  disease,  particularly  phys- 
ical and  moral  influences — overcrowding,  dwelling  in  cold,  damp  quarters, 
and  prolonged  fatigue  under  depressing  influences,  as  during  the  retreat 
of  an  army.  Among  prisoners,  mental  de]iression  |ilays  an  important  role. 
It  is  stated  that  epidemics  of  the  disease  have  hroken  out  in  the  French 
convict-ships  en  rovfe  to  Xew  Caledonia  even  when  the  diet  was 


ipb' 


*  Lehrbuch  der  Constitutionskrankheitcn,  F.  A.  Hoffmann  (1898),  a  work  to  which  the 
student  is  referred  for  the  best  exposition  of  this  group  of  disorders. 


s. 


scriivY. 


828 


c'K'iiiont  ill 
absiencu  ol 
l)li'S.  Willi  t 
iirrod  holds 
•clicvc  tliiii 
I  I'l'iiits  jiiiil 
nibjcct,  1k'- 
nd  lut'tati's 
ritiiiiiiti'  di- 
dtiiilly  ])ro- 
H'eot  which 
n  excess  ol" 
1  profound 
10  urine  is 
u  nniouut. 
IS  ])cen  the 
I  improjjor 

the  disejisc 
1. 

3.     To  the 

-'d  with  it. 

it  increase 

le  the  dis- 

Ivania  the 

attacked. 

ntirely  to 

diet  was 

leets  with 

stio  cases 

lad  lived 

urvy  WMS 

Jud_ir- 

nfer  that 

linfr  cpi- 
nnw  in 
1  regard- 

•ly  phys- 
luarters, 
3  retreat 
ant  roll'. 
French 
am])ly 

which  the 


siillieient.  Nostaljria  is  soniciiiiH's  an  important  element.  It  i.s  an  inter- 
esting,' fact  that  proloiif^ed  .starvation  in  itself  docs  not  necessarily  cause 
r-ciirry.  Not  one  of  the  prol'essional  fasters  of  late  years  ha.s  ilis[)liiycd  any 
siorliutie  symptom.  'I'he  disease  attacks  all  a<,f('s,  l)ut  the  old  are  more 
susceptihle  to  it.  Se.\  has  ikj  sjx'ciiil  inlliicnce,  hut  during  the  siege  of 
I'iiris  it  was  noted  that  the  males  attacked  were  greatly  in  e.veess  of  the 
I'l'iuales. 

Morbid  Anatomy. — 'i'hc  anatomical  changes  arc  marked,  though 
hv  no  means  spccilic,  and  ari'  i-hicllv  those  associated  with  hu'inoniin'rc. 
The  blood  is  dark  and  tluid.  'J'he  microsc()|)ical  alterations  are  those  of  a 
severe  aniemia,  without  leueoeytosis.  The  bacteriological  examination  has 
not  yielded  anything  very  positive.  I'raetically  there  are  no  changes  in 
the  blood,  either  anatomical  or  chemical,  which  can  be  regarded  as  pecul- 
iar to  the  disease.  The  skin  shows  the  ecchymoses  eviih'iit  during  life, 
'i'liere  are  luemorrhages  into  tiie  muscles,  and  occasionally  about  or  even 
into  the  joints.  Iliemorrhages  occur  in  tiie  internal  organs,  i)artieularly 
on  the  serous  membranes  and  in  the  kidneys  and  bladder.  'J'he  gums  are 
swollen  and  sometimes  ulcerated,  so  that  in  advam-i'd  cases  the  teeth  are 
loose  and  have  even  fallen  out.  I  leers  are  occasionally  met  with  in  the 
ileum  and  colon,  lla'morrbages  into  the  mucous  membranes  are  extremely 
common.  The  spleen  is  enlarged  and  soft.  Parenchymatous  changes  are 
constant  in  tlie  liver,  kidneys,  and  heart. 

Symptoms. — 'J'he  disease  is  insidious  in  its  onset.  J-'arly  symptoms 
lire  loss  in  weight,  ju-ogressively  developing  weakness,  and  pallor.  \'ery 
soon  the  gums  are  noticed  to  be  swollen  and  sjiongy,  to  bleed  easdy,  ami 
in  extreme  cases  to  present  a  fungous  appearance.  These  changes,  re- 
gard(>d  as  characteristic,  are  sometimes  absent.  The  teeth  may  become 
loose  and  even  fall  out.  Actual  necrosis  of  the  jaw  is  not  common.  'J'he 
breath  is  excessively  foul.  The  tongue  is  swollen,  ])ut  may  be  red  and 
not  much  furred.  The  salivary  glands  are  occasionally  enlarged.  Iliem- 
orrhages beneath  the  mucous  membranes  of  the  mouth  are  common.  The 
skin  l)ecomes  dry  and  rough,  and  eccliymo.ses  soon  a])pear,  first  on  the  legs 
and  then  on  the  arms  and  trunk,  and  jiarticularly  into  and  about  the  hair- 
follicles.  They  are  ])etechial,  l)ut  may  l)ecome  larger,  and  when  subcu- 
taneous may  cause  distinct  swellings.  In  severe  cases,  particularly  in  the 
legs,  there  may  be  efl'usion  between  the  periosteum  and  the  bone,  forming 
irregular  nodes,  which,  in  the  case  of  a  sailor  from  a  whaling  vessel  who 
came  under  my  oliservation,  had  broken  down  and  formed  foul-looking 
sores.  The  slightest  bruise  or  injury  causes  hamiorrhages  into  the  injured 
part.  CEdema  about  the  ankles  is  common.  The  "scurvy  sclerosis,"  seen 
oftenest  in  the  legs,  is  a  remarkable  infiltration  of  the  subcutaneous  tissues 
and  muscles,  forming  a  brawny  induration,  the  skin  over  which  may  be 
blood-stained.  Hasmorrliages  from  the  mucous  membranes  are  less  con- 
stant symptoms;  epistaxis  is,  however,  frequent.  ITa^mo]itysis  and  hamatc- 
mesis  are  uncommon.  Ilannaturia  and  bleeding  from  the  bowels  may  be 
present  in  very  severe  cases. 

Palpitation  of  the  heart  and  feebleness  and  irregularity  of  the  impulse 
are  prominent  symptoms.    A  hamiic  murmur  can  usually  be  heard  at  the 


b24 


DISKASKS  oK  TIIK   I»hOOl)   AND   DICTI.KSS  (JI.ANDS. 


r 


^ 


r 
I  [ 


■ 


Idjso.  lliriii  "Tliii^iic  iiifarclinii  of  llu'  liiii;,'>t  mid  H|il('t'ii  lnw  Ik'i'Ii  <K'scril)t'(l. 
|{('s|)ir)it(iry  .>  'iii|>t()iiis  mv  tint  ciimiiiiom.  'I'Iic  a|)|it'titc  is  iininiirrd,  uihI 
iiuiii;;  tu  the  s(»r('ii<'>H  ul'  llic  ;.miiiis  the  |ijili»'iit.  is  iiiniltk'  to  (.'lu'W  IIk;  loud. 
Cuii^tipiii ion  is  iiioi'i'  ri'i'i|iii'iil  tliMit  diiit'i'lio'ii.  I'liiii,  tt'iidci'iicss,  or  swell- 
in;,'  ill  I  lie  jointH  were  |ii'i'si'iit  in  i;»  oT  McCiri'w's  ^'i  riisi.'s.  Tlif  urine  is 
olirn  idhiiiiiiiioiis.  Till'  I'iuiii^cs  in  its  coniitositioii  iin;  not  coiistiiiit;  tlio 
.-liccilic  ;^i'iivil_v  is  lii^^lr,  tlic  color  is  dci'iicr;  iiiid  tlic  |ilios[iliiiti'S  aic  in- 
fi'i'iiscd.  Till'  stiiti'iiii'iils  with  I'ciVri'iicc  to  I  lie  inor^fimi(j  const  itiK.'iits  iiii' 
tontrndictoi'v.  Soiiu!  say  tlir  iiliosplialcs  and  potash  arr  ddicifiit ;  otlii'i> 
that   they  ni't-  increased. 

Tlicic  are  mental  (lepressioii,  iiidiirereiice,  in  soiiu'  cases  headache,  ami 
ill  the  later  sta,i:('s  deliriiiiii.  Cases  of  (•<»nviilsions,  (d'  lieiiiiple,i:ia,  and  of 
iiiciiiii^^i'al  li;eiiiorrha;;e  have  hecii  descrihed.  Ileiiiaikaidc  ocular  syiiip- 
tonis  are  occasi(»iially  met  with,  such  as  ni<,dit-l)liiidness  or  day-hlindiiess. 

In  advaiicctl  cases  iiecro>is  (d'  the  hones  may  occur,  and  in  yoiiii;;  per- 
sons even  separation  of  the  epiphyses.  There  are  instances  in  which  tlii' 
cartilages  liav<'  separated  from  the  steriiiim.  The  callii.s  of  a  recently 
repaired  fracture  has  heeii  known  to  iiiiderjfo  destruction.  Fever  is  not 
presi'iit,  except  in  the  later  staj^'es,  or  when  secondary  inllaiiimations  in  the 
internal  oriraiis  apjji'ar.  The  tcniperatiire  may,  indeed,  he  sometimes  Indow 
aorinal.     .\ciite  arthritis  is  an  occasional  complication. 

Diag^nosis.  —  Nd  dillicnlly  is  met  in  the  rc(.'o«>'niti()n  of  scurvy  when 
a  niimher  of  jicrsons  arc  all'ected  to;^ctlier.  In  isolated  cases,  liowcvor,  the 
disease  is  distin,i;iiished  with  dilliciilty  from  certain  forms  of  [iiirpura.  The 
association  with  manifi'st  insiillicicncy  in  diet,  and  the  rapid  ameliora- 
tion with  suitable  I'ood,  arc  poiuts  by  which  the  diagnosiia  can  be  readily 
settled. 

Prognosis. — The  outlook  is  <,'ood,  unless  the  disease  is  far  advanced 
and  the  conditions  persist  which  lead  to  its  develo[)ment.  The  mortality 
now  is  rarely  .ureat.  Death  results  from  .uradual  heart-failure,  occasionally 
from  sudden  syiicop*'.  Menin^ical  hiemorrlia^e,  extravasation  into  the 
serous  cavities,  eiitero-colitis,  and  otiier  intercurrent  aU'ections  may  [»nnc 
fatal. 

Prophylaxis.— 'I'll e  re;^iilations  of  the  IJoard  of  Trade  reipiire  that  a 
sunicieut  supply  of  antiscorbutic  articles  of  diet  be  taken  on  each  ship;  so 
that  now,  except  as  the  result  of  accident,  the  occurrence  ot  scurvy  is  rare 
in  saihtrs. 

Treatment. — The  juice  of  two  or  three  lemons  daily  and  a  varied  diet, 
Avitli  plenty  of  fresh  vcLretr.bles,  sullice  to  cure  all  cases  of  scurvy,  unless 
far  advanced.  When  the  stomacli  is  imucIi  disordered,  small  c|uantities  of 
scraped  meat  and  milk  should  be  ^nven  at  short  intervals,  and  the  lemon- 
juice  in  jrradnally  increasin<r  (piantities.  .\  bitter  tonic,  or  a  steel  and  hark 
niixtiire,  may  be  ^iven.  As  the  patient  piins  in  stren^fth,  the  diet  may  be 
more  liberal,  and  lie  may  eat  freely  of  jiotatoos,  oahliage,  water-cresses,  and 
lettuce.  The  stomatitis  is  the  symptom  wliich  canses  the  {xreatost  distress. 
The  ])crman,iranate  of  ])otash  or  dilute  carbolic  acid  forms  the  best  mouth- 
wash. IVncillin,!;  the  swollen  sruins  with  a  tolerably  stronc:  solution  of 
nitrate  of  silver  is  very  useful.    The  scdution  is  better  than  the  solid  stick. 


s. 


SCUUVT. 


1  tit'sci'ilit'd. 
I'liircd,  ami 
w   I  lie   I'doiI. 

»,  or  bwi'll- 
lic  uriiu'  is 
iisliiiit;  till' 
ilc'H  art'  ill- 
it  limits  HIT 
(■III ;  (illici's 

"laclic,  and 
^'iii,  and  <i|' 
liar  .synij)- 
IdindiK's.s. 
vonii^f  pcr- 
wiiicli  the 
u  roeeiitly 
'vcr  is  nut 
oils  in  till' 
nies  Ijc'lou' 

irvv  when 
wcvor,  tilt' 
|»iii-a.  'I'lic 
anicliora- 
be  readily 

advanced 
iiiiu'tality 

("isionally 
into    the 

lay  provL' 

ire  that  a 
liip;  so 
■y  is  rare 

ii'(l  diet, 

y,  unless 

it i ties  of 

lenion- 

ind  hark 

may  he 

«.«es,  and 

distress. 

niouth- 

ition  of 

■  d  stick. 


a-  it  rcMchcH  lo  Ihc  crrviceH  licluccli  the  ;^'nillilliilioiiM.  Tiie  ('onsli|)iitio!i 
uliicll  is  so  coiniiioii  is  hesl  ticatetl  with  laif^e  eiiemalil.  For  oliicr  coii- 
diiioiis,  such  as  hu'inorrliiigcH  and  idccratioiis,  Miitahh'  iiicahuics  niuht  hu 
(  iii|iloyc(l. 

INFAXTIIJ':    SCrUVY    (/tiirln.r'.'i  Ihsnts,). 

As  in  adults,  scurvy  may  occur  in  children  in  coiiseijiieiice  uf  iini>er- 
Inl  I'ooil  supply. 

W.  r».  I'hcadle  and  (Jee,  in  liOiidon,  have  descrihcd  in  very  young  cliil- 
ihcii  11  cachexia  associated  with  hM'inorrha^e.  ('Iieadle  rei^nirdcd  the  cases 
as  scurvy  iii;;rafle(l  on  a  rickety  slock.  (Jee  called  his  cases  periosteal 
(;iihe\ia.     Cases  had  previously  hccn  rc^irded  as  aciile  rickets. 

.\  few  years  later  Ilarlou  made  an  exhaustive  study  of  the  conditinii 
with  careful  anatomical  ohservatioiis.  Tlu!  ii!l'ectioii  is  now  recounizcd  as 
infantile  scurvy,  and  in  (icrmany  is  called  IJarlow's  Disease.  The  Ameri- 
can Pa'diatric  Society  has  collected  (1S!»S)  in  this  country  ;»*,'.»  cases.  Of 
lliese,  the  hy;^iciiic  surroundings  were  i^ood  in  ;!().'!.  A  iiiajniily  (d'  the 
patients  were  under  IwcInc  niontlis.  'The  proprietary  fooils,  particularly 
malted  niiik  and  condensed  milk,  seem  to  he  the  most  importaiil  factors  in 
pidduciiijf  the  disease.  There  are  iiistaiie"^'  in  which  it  has  devclope<l  in 
hreast-lVd  infants,  and  in  others  l\'d  on  the  carefully  prepared  milk  (d'  tlio 
W  alkcr-(iord()ii  lahoratories. 

The  following  is  a  general  clinical  siiinmary,  taken  from  Harlow's  Hrad- 
-haw   Lecture,   IS'.M: 

"  So  long  as  it  is  left  alone  the  child  is  tolerahly  (piicl ;  the  lower  liiiihs 
are  kept  di'awii  up  and  still;  hut  when  placed  in  its  hath  or  olherwiso 
moved  tlu're  is  continuous  crying,  and  it  soon  hecoines  clear  that  the  pain 
is  conncctcil  with  the  lower  liiiihs.  At  this  ])eriod  the  upper  limhs  may 
Ite  touched  with  iinpiiiiity,  hut  any  attempt  to  move  the  legs  or  thighs 
gives  I'ise  to  screams.  Next,  some  ohscure  swelling  may  he  detected,  first 
nil  one  lowci'  liiiih,  then  on  the  other,  though  it  is  iioi  ahsoliitely  symmet- 
lical.  .  .  .  Tho  swelling  is  ill-delined,  hut  is  suggestive  (d'  thickening 
iniind  the  shafts  of  the  bones,  heginniiig  ahove  the  epiphyseal  junctions. 
<  Gradually  the  hulk  of  the  limhs  all'ectcMl  hecomes  visihiy  increased.  .  .  . 
The  position  of  the  limhs  hecomes  somewhat  dilfci'ciit  from  what  it  was  at; 
llic  outset.  Instead  of  heing  Hexed  they  lie  everted  and  imnioliile,  in  a 
slate  of  pseiido-jiaralysis \lioiil  this  time,  if  not  hefore,  great  weak- 
ness of  the  hack  hecomes  manifest.  .\  little  swelling  of  one  or  hoth  scap- 
iikc  may  appear,  and  the  upper  limhs  may  show  changes.  These  are  rai'cdy 
>o  {■(msidcrahle  as  the  alterations  in  the  lower  limlis.  There  may  he  swell- 
ing ahove  the  wrists,  extending  for  a  short  distance  up  the  forearm,  and 
^ome  swelling  in  the  neighhorhood  of  the  epiphyses  (d'  the  hiiiiu'ins.  There 
is  symmetry  of  lesions,  hut  it  is  not  ahsoliite:  and  the  limh  alfection  is 
,i!eiiei'ally  consecutive,  tlioiigh  the  iM\(dvcmcnt  (d'  one  limh  follows  very 
ilose  upon  another.  The  joints  are  free.  In  severe  cases  anolher  synip- 
lojii  may  not  lie  found — namely,  crepitus  in  the  regions  adjacent  to  the 
junctions  of  the  shafts  Mith  the  epii)hyses.  The  upper  and  lower  extromi- 
ties  of  the  femur,  and  the  n|)])er  extremity  of  the  tihia,  are  the  common 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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Hiotographic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEPSTER.N.Y.  14380 

(716)  872-4503 


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DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS, 


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It 

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If 


sites  of  sucli  i'racturos;  Ijiit  the  upper  end  oi"  tlie  liuiiierus  may  also  be  S(. 
aU'eeted.  ...  A  very  startling  apjjearanee  may  be  observed  at  this  perioil 
in  the  front  of  the  chest.  The  sternum,  with  the  adjacent  costal  carti- 
lages and  a  small  jjortion  of  the  contiguous  ribs,  seems  to  have  sunk  bodily 
back,  en  Hoc,  as  though  it  had  been  subjected  to  some  violence  which  hail 
fractured  several  ribs  in  the  front  and  driven  them  back.  Occasionally 
thickenings  of  varying  extent  may  be  found  on  the  exterior  of  the  vault 
of  the  skull,  or  even  on  some  of  the  bones  of  the  face  .  .  .  Here  also  must 
be  mentioned  a  remarkable  eye  jjlienomenon.  There  develops  a  rathci' 
sudden  pro])tosis  of  one  eyeball,  with  ])airiness  and  very  slight  staining  of 
the  ui)})er  lid.  \\'ithin  a  day  or  two  the  other  eye  presents  similar  a})i)ear- 
ances,  though  they  may  be  of  l'>ss  severity.  The  ocular  conjunctiva  may 
show  a  little  ecchymosis,  or  may  be  quite  free.  With  resjject  to  the  con- 
stitutional symjjtoms  accomjianying  the  above  series  of  events  the  most 
inijjortant  feature  is  the  profound  aniemia  which  is  developed.  .  .  .  The 
ano-'mia  is  proi)ortional  to  the  amount  of  limb  involvement.  As  the  case 
proceeds,  there  is  a  certain  earthy-colored  or  sallow  tint,  which  is  note- 
worthy in  sevrre  cases,  and  when  once  this  is  established  bruise-like  ecchy- 
moses  may  ai)})ear,  and  more  rarely  small  purpuric.  Emaciation  is  not  a 
marked  feature,  but  asthenia  is  extreme  and  suggestive  of  muscidar  failure. 
The  temperature  is  very  erratic;  it  is  often  raised  ior  a  day  or  two,  when 
successive  limbs  are  involved,  especially  during  the  tense  stage,  but  is 
rarely  above  101°  or  102°.  At  other  times  it  may  be  normal  or  subnormal." 
If  the  teeth  have  ai)i)eared  the  gums  may  be  sjjongy. 

The  condition  must  always  be  looked  for  in  young  children  with  diffi- 
culty in  moving  the  lower  limbs,  or  in  whom  paralysis  is  suspected.  "What 
is  known  sometimes  as  Parrot's  disease,  or  syphilitic  pseudo-paralysis,  may 
be  confounded  with  it.  In  it  the  loss  of  motion  is  more  or  less  sudden  in 
the  upper  or  lower  limbs,  or  in  both,  due  to  a  solution  of  continuity  and 
separation  of  the  cartilage  at  the  end  of  the  diaphysis.  There  are  usually 
crepitation  and  much  pain  on  movement. 

The  essential  lesion  is  a  subperiosteal  blood  extravasation,  which  causes- 
the  thickening  and  tenderness  in  the  shafts  of  the  bones.  In  some  in- 
stances there  is  ha-morrhage  in  the  intramuscular  tissue. 

The  prophylaxis  is  most  important.  The  various  ])roprietary  forms  of 
condensed  milk  and  preserved  foods  for  infants  should  not  be  used.  The 
fresh  cow's  milk  should  be  substituted,  and  a  teaspoonful  of  meat-juice 
or  gravy  may  l)e  given  with  a  little  mashed  potato.  Orange-juice  or  lemon- 
juice  should  ])e  given  three  or  four  times  a  day.  llecovery  is  usually  promjit 
and  satisfactory. 


VII.    STATUS    LYMPHATICUS.     LYMPHATISM. 


Much  attention  has  been  paid  lately  to  a  somewhat  rare  condition  met 
with  chiefly  in  children  and  young  persons,  in  which  the  lymphatic  glands 
and  lymph  tissues  throughout  the  body,  the  s]ileen,  the  thymus,  and  the 
lymphoid  bone  marrow  are  in  a  state  of  hyperplasia.    These  features  have 


STATUS  LYMPIIATICUS.     LVMPJiATlSM. 


827 


'  also  be  so 
this  period 
ostal  carti- 
juiilc  bodily 
whicli  bail 
jccasionally 
(i"  the  vauh 
•e  also  nuist 
[)S  a  ralhiT 
staining  ol' 
ilar  appear- 
mctiva  may 
to  the  cc)n- 
ts  the  most 
il.  .  .  .  The 
xVs  the  case 
ich  is  note- 
j-like  ccchy- 
ion  is  not  a 
Hilar  failure. 
r  two,  when 
tage,  but   is 
subnormal." 

n  with  dilTi- 
icted.  "What 
iralysis,  may 
ss  sudden  in 
tinuity  and 
are  usually 


ivhich  causes 
|ln  some  in-     ,,- 

|\ry  forms  of 

used.     Tlie 

If  meat-juice 

Ice  or  lemon- 

lally  prompt 


Lndition  met 

[hatic  glands 

lus,  and  the 

leatures  have 


been  found  associated  witli  rickets  and  with  hyjjoplasia  of  the  heart  and 
jiorta.  The  special  interest  lies  in  the  fact  that  these  pathological  condi- 
tions have  been  met  with  fre(piently  in  cases  of  sudden  death.  Paltauf 
iind  others  of  tlie  \'ieiina  school,  who  have  written  extensively  on  tlie  sub- 
ject, believe  tiiat  iiulividuals  with  tliis  hyperiilasia  iiave  h)wi'red  powers 
(il  resistance,  and  are  i)articuiarly  lialile  to  jtaralysis  of  tlie  iieart.  'i'lie 
condition  has  iu)t  receiveil  niiicii  attention  in  I'higland  and  in  this  coun- 
try. An  excellent  account  of  it,  by  James  Kwing,  ajjpeared  in  the  !Ne\v' 
York  :\Iedical  Journal  of  July  JO,  KSDT. 

Anatomical  Condition. — {a)  Lyuiph-glnnds. — The  pharyngeal,  thoracic^ 
;iii(l  alidoniinal  groups  are  most  frequently  alfected.  The  cervical,  axil- 
lai'y,  and  inguinal  are  less  conunonly  involved,  but  these  glands  may  show 
slight  enlargemeni.  The  lymi)hatic  structures  of  the  alimentary  tract,  the 
tissues  of  the  tonsils,  the  adenoid  structures  in  the  upper  i)l.arynx,  and 
the  solitary  i.nd  agminated  follicles  of  the  snuiU  and  large  '  testines  are 
usually  much  enlarged.  The  hyper})lasia  of  the  intestiiud  lyn,  natic  struc- 
tures may  1)0  the  most  remarkable,  the  individual  glands  standing  out  like 
])cas. 

(/')  Spkeu. — Enlargement  of  this  organ  is  usually  moderate  in  degree. 
The  .Malpighian  bodies  nuiy  sliow  very  prominently,  and  when  ana'mic  may 
hiok  like  large  tubercles.     The  organ  is  usually  soft  and  liyperLemie. 

(r)  The  thymits  is  enlarged,  and  may  measure  as  much  as  10  cm.  in 
length.  It  looks  swollen  and  soft,  and  on  section  may  exude  a  milky  white 
lluid. 

((/)  The  hone  iiKirruir  has  been  found  in  a  state  of  hyperplasia,  and  the 
yellow  marrow  of  the  long  bones  in  young  adults,  and  even  in  persons 
lietween  the  ages  of  twenty  and  thirty,  has  l)een  found  re])laced  by  red 
marrow.  Among  other  associated  conditions  of  this  constitulio  h/niphitica, 
as  it  has  been  called,  are  liypo])lasia  of  the  heart  and  aorta  and  enlargement 
ol'  the  thyroid  gland.  In  a  large  number  of  the  cases  in  children  rickets  is 
coincident. 

The  diagnosis  of  the  lym])hatic  constitution  is  not  always  easy.  En- 
largement of  the  superficial  glands,  with  hypertrophy  of  the  tonsils,  signs 
of  slight  swelling  of  the  thyroid,  dulncss  over  the  sternum,  with  signs  of 
enlargement  of  the  mesenteric  glands,  are  among  the  most  important  fea- 
tures. Signs  of  hy]ioi)lasia  of  the  vascular  system  are  still  more  uncertain, 
though  Quincke  believes  that  in  such  instances  the  left  ventricle  is  dilated 
and  the  ])eri])heral  arteries  may  be  much  snuiller  than  normal.  The  sul)- 
Jects  are  usually  ill-develo])ed  and  infantile  in  conformation. 

Sudden  Death  in  the  status  li/niphntirus. — What  has  directed  the  at- 
tention of  writers  more  particularly  to  this  condition  is  the  frequency  with 
which  it  has  l)een  found  in  cases  of  unex])ected  death  from  very  trifling 
and  inadequate  causes.  A  good  deal  of  attention  was  directed  to  the  sub- 
ject by  the  death  of  the  son  of  Professor  Langhans,  of  lierlin,  innnodiately 
after  the  preventive  inoculation  with  the  antitoxinc  of  di})htheria.  In 
another  child  death  occurred  under  similar  circumstances.  The  condi- 
tion has  also  been  met  with  in  a  number  of  cases  of  sudden  death  under 
an;esthetics,  and  I  know  of  one  instance  during  ana}sthcsia  for  adenoid 


828 


DISEASES  OF  TUE  BLOOD  AND  DUCTLESS  GLANDS. 


growtlis.  Ciiscs  of  siidJcn  dcalli  of  jiorsons  in  .lie  water,  who  have  fallen 
ill  and,  llioii^ii  iiimiediately  recovered,  were  dead,  or  wlio  Jiave  died  sud- 
denly while  l)atliing,  arc  referred  by  J^allauf  to  tiiis  condition.  And,  lastly, 
there  is  the  lai'«,fe  group  of  cases  of  sudden  death  in  children  without  recog- 
nizable cause,  in  whom  post  mortem  tin;  thymus  luis  been  fovnid  enlarged — 
the  so-called  " 'i'liymus  'J'od  "  (see  under  Tliymus  (.land).  It  has  also 
been  suggested  that  certain  of  the  sudden  deaths  during  convalescence 
from  the  iniectioiis  fevers  are  to  Ite  I'cferred  to  this  status  lyniphaticus. 
Kscherich  thinks  that  certain  nu^asures  usually  barndess,  such  as  hydro- 
therapy, may  have  an  untoward  efl'ect  in  children  in  this  condition  of  lyni- 
l)liatism,  and  adds  that  tetany  and  laryngismus  may  be  associated  with  it. 
The  whole  (piestion  is  o]ie  which  deserves  the  most  careful  study.  The 
anatomical  features  api)car  fairly  well  defined.  The  clinical  features  are 
by  DO  means  so  clear,  nor  is  it  at  all  certain  in  what  way  sudden  death  is 
caused  in  these  cases.  The  students  of  the  question  have,  however,  in  tlu} 
past  few  years  brought  forward  evidence  enough  to  show  that  the  subjects 
of  this  lymi)hatic  constitution  have  a  diminished  vital  resistance,  and  are 
especially  prone  to  fatal  collapse  under  ordinarily  very  inadequate  exciting 
causes. 


VIII.    DISEASES    OF   THE    SUPRARENAL    BODIES. 

1.  Addison's  Disease. 

Deflnition. — A  constitutional  affection  characterized  by  asthenia,  de- 
pressed circulation,  irritability  of  the  stomach,  and  pigmentation  of  the 
skin.  Tuberculosis  of  the  adrenals  is  the  common  anatomical  change. 
J?ecent  observations  indicate  that  the  symptoms  are  due  to  loss  of  function 
vof  the  su])rarenal  bodies. 

The  recognition  of  the  disease  is  due  to  Addison,  of  Guy's  Hospital, 
A\hose  monograph  on  The  Constitutional  and  fiocal  FJfects  of  Disease  of 
the  Su])i'ar('nal  Capsules  was  ])ublished  in  1855. 

Etiology. — ^fales  are  more  fre(piently  attacked  than  females.  In 
(ireenhow's  analysis  of  183  cases  11!)  were  males  and  (54  females.  A  ma- 
jority of  the  cases  occur  between  the  twentieth  and  the  fortieth  year.  A 
congenital  case  has  been  described  in  ■which  the  skin  had  a  yellow-gray 
tint.  The  child  lived  for  eight  weeks,  and  post  mortem  the  adrenals  were 
found  to  be  large  and  cystic.  Injury  such  as  a  blow  U])on  the  abdomen 
or  back,  and  caries  of  the  s])ine,  have  in  many  cases  ]>receded  the  attack. 
The  disease  is  rare  in  America.  The  number  of  deaths  during  the  census 
year  1890  was  00 — 50  males  and  40  females.  Twelve  cases  have  come 
undcT  my  personal  observati'-.i,  0  in  men.     One  case  was  in  a  negro. 

Morbid  Anatomy  and  Pathology. — There  is  rarely  emaciation 
or  ana'mia.  T?olleston  *  thus  summarizes  the  condition  of  the  suprarenal 
bodies  in  Addison's  disease: 

*  Gulstonian  Loptnros,  l?oyal  Collope  of  Physicians,  T?ri(ish  ^fpnical  J<iurna].  180.", 
i,  to  which  the  student  is  referred  for  an  exhaustive  consideration  of  the  entire  question. 


DISEASES  OF  THE   SUPKAUENAL   IJODIES. 


821> 


havo  fallen 
'  died  sutl- 
\iul,  laritly, 
hout  recog- 

L'lilarged — 
It  has  also 
JiivalfHCcnco 
yiiil»halii-'Uri. 
li  as  hydro- 
lion  oi"  lyni- 
Uc'd  with  it. 
study.    The 

ieatnrcs  are 
den  death  is 
Ycver,  in  the 

the  suhjeuts 
mee,  and  are 
uate  exciting 


)D1ES. 


asthenia,  de- 
lation oi  the 
ical   change, 
ol'  function 


CO 


UY 


's  TTosi)ital, 
f  Disease  of 


females.     In 

lales.     A  "li^- 

icih  year.     A 

1   yellow-gTiiy 

idrenals  were 

the  ahdomen 

od  the  attack. 

ing  the  census 

;es  have  come 

a  negro. 

ely  emaciation 

the  suprarenal 


"1.  The  (il)r()-caseou.s  lesion  due  to  tul)erculosis — far  the  commonest 
ndition  f(nm(l. 


"i.  Simple  atrophy.  ;!.  Chronic  interstitial  inllamma- 
liou  leading  U)  atrophy.  1.  Malignant  disease  invuding  the  ea}»suh's,  in- 
(hiding  Addison's  ca.<e  oi'  nmlignant  nodule  compressing  the  sui)rarenal 
\ein.  T).  JUood  extruvasated  into  tiie  suprarenal  l)odies.  G.  Mo  lesion  of 
the  sujtrarenal  hodies  themselves,  hut  pressure  or  inllauimalion  involvi 


nir. 


the  si'tni 


lunar 


aaniMia. 


al  Journal.  ISO.'i, 
!  entire  question. 


"  The  iirst  is  tlie  only  common  cause  of  Addison's  disease.  Tlie  <jthers, 
uilli  tlie  exce[ttion  of  simi)le  atrophy,  may  he  considered  as  very  rare." 

Among  other  anatomical  features  the  condition  of  the  ahdoniinal  sym- 
]iai]ietic  has  heen  specially  studied.  'J'he  nerve-cells  ol'  the  sendlunar 
ganglia  have  heen  dcscrihed  as  degenerated  and  (K'e[)ly  pignuMited, 
and  the  nerves  sclerotic.  The  ganglia  are  not  uncommonly  entangled  in 
the  cicatricial  tissue  ahout  the  adreiuUs.  The  spleen  has  occasionally 
heen  found  enlarged;  the  thymus  may  have  persisted  and  he  larger  than 
iiornuil. 

It  is  ditTicull  to  explain  satisfact)rily  all  the  symptoms  of  this  remark- 
ahle  disease.  The  two  chief  theories  which  have  been  advanced  are  briefly 
as  follows:  (a)  That  the  disease  dei)ended  upon  the  loss  of  function  of 
the  adreikiils.  This  was  the  view  of  Addison.  The  balance  of  experimental 
evidence  is  in  favor  of  the  view  that  the  adrenals  are  functional  glands,, 
which  furnish  an  internal  secretion  essential  to  the  normal  metabolism. 
Scluifer  and  Oliver  have  shown  that  the  human  adrenals  contain  a  very 
jiowerful  extract,  which  is  not  to  be  obtained  in  cases  of  Addison's  dis- 
ease; they  have  also  studied  the  toxic  elfects  on  animals  of  the  extracts  of 
the  glands.  In  the  cases  in  which  the  adrenals  have  been  found  involved! 
without  the  symptoms  of  Addison's  disease,  accessory  glands  may  have 
been  present;  while  in  the  rare  cases  in  which  the  symptoms  of  the  disease 
have  been  i)resent  with  healthy  adrenals  the  se  nilunar  ganglia  ami  adjacent 
tissues  have  been  involved  in  dense  adhesions,  which  may  have  interfered 
readily  with  the  vessels  or  ]ymi)hatics  of  the  glands.  On  this  view  Addi- 
son's disease  is  due  to  an  inadccpiate  supply  of  the  adrenal  secretion,  just 
as  myxa'dema  is  caused  l)y  loss  of  function  of  the  thyroid  gland.  "  Whether 
the  deficiency  in  th.is  internal  secretion  leads  to  a  toxic  condition  of  the 
blood  or  to  a  general  atony  and  apathy  is  a  question  which  must  renuiia 
()[)en  "  (Rolleston).  (h)  That  it  is  an  affection  of  the  abdominal  symi)a- 
thetic  system,  induced  most  commonly  by  disease  of  th-j  adrenals,  but  also 
by  other  chronic  disorders  which  involve  the  solar  plexus  and  its  ganglia. 
According  to  this  view,  it  is  an  affection  of  the  nervous  system,  and  the 
])igmentation  has  its  origin  in  changes  induced  through  the  trophic  nerves. 
The  pronounced  debility  is  the  outcome  of  disturbed  tissue  metabolism, 
and  the  circulatory,  rcs])iratory,  and  digestive  symptoms  are  due  to  im- 
plication of  the  ])neumogastric.  The  changes  found  in  the  abdominal 
sym])athetic  are  held  to  su])port  this  view,  and  its  advocates  urge  the  occur- 
rence of  pigmentation  of  the  skin  in  tuberculosis  of  the  peritonaeum,  cancer 
of  the  pancreas,  or  aneurism  of  the  abdominal  aorta.  Bramwell  thinks 
that  the  symptoms  may  be  in  part  due  to  irritation  of  the  sympathetic  and 
in  part  to  renal  inadequacy. 


830 


DISEASES  OP  THE  BLOOD  AND   DUCTLESS  OLANDS. 


Symptoms.  —  In  the  words  of  Addison,  the  c-hamctt'ristic  symptoms 
aiu  "  iinainia,  general  languor  or  debility,  remarkable  feebleness  of  the 
heart's  aetion,  irritability  of  tlie  stomach,  and  a  peculiar  change  of  color 
in  the  skin." 

I'hc  onset  is,  as  a  rule,  insidious.  The  feelings  of  weakness,  as  a  rule, 
precede  the  pigmentation.  In  other  instances  the  gastro-intestinal  symj)- 
toms,  the  weakness,  and  the  pigmentation  come  on  together.  There  are 
a  few  cases  in  the  literature  in  which  the  whole  process  has  been  acute, 
following  a  shock  or  some  special  depression.  There  are  three  important 
t-ymptoms  of  the  disease 

(1)  ritjinenlaliiiii  of  ,//e  Skin. — This,  as  a  rule,  first  attracts  the  atten- 
tion of  the  i)atient's  f' lends.  The  grade  of  coloration  ranges  from  a  light 
yellow  to  a  deep  brown,  or  even  black.  In  tyi)ical  cases  it  is  diffuse,  but 
always  deeper  on  the  ex})osed  i)arts  and  in  the  regions  where  the  normal 
])igmentation  is  more  intense,  as  the  areolie  of  the  nii)ples  and  about  the 
genitals;  also  wherever  the  skin  is  com})rcssed  or  irritated,  as  by  the  waist- 
band. At  first  it  may  be  confined  to  the  face  and  hands.  Occasionally  it 
is  absent.  I'atches  showing  atrophy  of  ])igment,  leucoderma,  may  occur. 
The  }>igmentation  is  found  on  the  mucous  mend)ranes  of  the  mouth,  con- 
junctiva", and  vagina.  A  ])atchy  pigmentation  of  the  serous  membranes  has 
often  been  found.  Over  the  dilFusely  pigmented  skin  there  may  be  little 
mole-like  s])ots  of  deeper  i)igmentation.  The  pigmentation  of  the  skin 
alone,  unless  the  mucous  meml)ranes  are  also  involved,  is  rarely  suificient 
in  itself  to  make  the  diagnosis  clear. 

(2)  Gastro-intestinal  Symptoms. — The  disease  may  set  in  with  attacks 
of  nausea  and  vomiting,  spontaneous  in  character.  Toward  the  close  there 
may  be  pain  with  retraction  of  the  abdomen,  and  even  features  suggestive 
of  ])eritonitis  (Kbstein).  An  intense  anorexia  may  be  present.  The  gas- 
tric symjrtoms  are  variable  throughout  the  course;  occasionally  they  are 
absent.  Attacks  of  diarrluea  are  frequent  and  come  on  without  obvious 
cause. 

(3)  Asthenia. — This  is  perha])s  the  most  characteristic  feature  of  the 
disease.  It  may  be  manifested  early  as  a  feeling  of  inal)ility  to  carry  on 
the  ordinary  occupation,  and  the  patient  complains  constantly  of  feeling 
tired.  The  weakness  is  s])ecially  marked  in  the  nuiscular  and  cardio- 
vascular systems.  There  may  be  an  extreme  degree  of  r\uscular  ])rostra- 
tion  in  an  individual  ap])arcntly  well  nourished  and  whose  muscles  feel 
firm  and  hard.  The  cardio-vascular  asthenia  is  manifest  in  a  feeble,  irregu- 
lar action  of  the  heart,  which  may  come  on  in  paroxysms,  in  attacks  of 
vertigo,  or  of  synco])c,  in  one  of  which  the  disease  may  ])rove  fatal.  "^Tead- 
ache  is  a  frequent  symptom;  convulsions  occasionally  occur.  !McMunn 
has  described  an  increase  in  the  urinary  pigments,  and  a  pigment  has  been 
isolated  of  very  much  the  same  character  as  the  melanin  of  the  skin. 

Anauuia  was  a  sym])tom  s]iecially  referred  to  by  Addison,  but  it  has 
been  ])resent  in  a  marked  degree  in  only  one  of  my  cases.  I  saw  an  in- 
stance, in  rhiladeli)hia,  with  J.  C.  "Wilson,  in  which  the  diagnosis  at  first 
was  not  at  all  clear  between  Addison's  disease  and  pernicious  anemia. 

The  mode  of  termination  is  either  by  syncope,  which  may  occnr  even 


c  symptoms 
iit'sri  ol'  tlie 
ige  of  color 

3,  as  a  riilo, 
tiiial  sjmi)- 
Tlioro  art' 
bot'ii  acutt', 
3  imi)oi'taiit 

^  the  atti'n- 
roin  a  lijjjlit 
dill'iiso,  but 
the  normal 
1  about  the 
{  the  waist- 
asionally  it 
may  occur, 
aouth,  cou- 
nbrancrt  has 
ay  be  little 
»i'  the  skin 
y  sulficient 

ith  attacks 

close  there 

sujJCgostive 

The  gas- 

they  arc 

ut  obvious 

re  of  the 
carry  on 
of  feeling 
ul  cartlio- 
ir  ])rostra- 
isclcs  feel 
le,  irrcgu- 
iil  tacks  .<f 
I.  "read- 
^rc]\Iunn 
lias  been 

mt  it  has 
iw  an  i Il- 
ls at  first 
jT^mia. 
3cur  even 


DISEASES  OP  THE  SUPRAKENAL   I'.ODIES. 


831 


<'arly  in  the  disease,  by  gradual  ]irogressive  asthenia,  or  by  the  development 
of  tuljcrculous  lesions.  Jn  two  cases  i  have  known  a  noisy  delirium  with 
uigent  dys])n(ea  to  precede  the  fatal  event. 

Diagnosis. — I'igmentatiou  of  the  skin  is  not  confined  to  Addison's 
<lisease.  The  iollowing  are  the  conditions  which  may  give  rise  to  an  in- 
crease in  the  pigment: 

(1)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tubercu- 
losis of  the  peritomeum  i)igmentation  is  not  uncommon. 

(2)  Pregnancy,  in  which  the  discoloration  is  usually  limited  to  the  face, 
I  lie  so-called  masque  dvs  fcinuies  eiK^cinlcs.  Uterine  disease  is  a  common 
cause  of  a  patchy  melasma. 

(3)  Hepatic  disease,  which  may  induce  definite  pigmentation,  as  in  the 
diabetic  cirrhosis.  More  commonly  in  overworked  persons  of  constipated 
liiibit  and  with  sluggish  livers  there  is  a  patchy  staining  about  the  face 
and  forehead. 

(4)  The  vagabond's  discoloration,  caused  by  the  irritation  of  lice  and 
viirt,  which  may  reach  a  very  high  grade,  and  has  sometimes  been  mis- 
taken for  Addison's  disease. 

(5)  In  rare  instances  there  is  deep  discoloration  of  the  skin  in  mela- 
notic cancer,  so  deep  and  general  that  it  has  been  confounded  with  melasma 
suprarenale. 

(6)  In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation 
occurs,  as  noted  by  Drummond  and  others. 

(7)  In  a  few  rare  instances  the  pigmentation  common  in  scleroderma 
may  be  general  and  deep. 

(8)  In  the  face  there  may  be  an  extraordinary  degree  of  pigmenta- 
tion due  to  innumerable  small  black  comedones.  If  not  seen  in  a  very 
good  light,  the  face  may  suggest  argyria.  rigmentation  of  an  advanced 
grade  may  occur  in  chronic  ulcer  of  the  stomach  and  in  dilatation  of  the 
organ. 

(5))  Argyria  could  scarcely  be  mistaken,  and  yet  I  was  consulted  this 
year  by  a  woman  in  whom  the  diagnosis  of  Addison's  disease  liad  l)cen 
made  by  several  good  observers,  but  the  character  of  tlie  pigmentation, 
the  length  of  time  it  had  lasted,  and  her  freedom  from  al'   symptoms 

jiointed  undoubtedly  to  argj-ria,  though,  so  far  as  she  or  iihysician 

knew,  she  had  never  taken  nitrate  of  silver  medicinally. 

In  any  case  of  uniisual  ])igmcntation  these  various  conditions  must  be 
sought  for;  the  diagnosis  of  Addison's  disease  is  scarcely  justifiable  with- 
out the  asthenia.  In  many  instances  it  is  difficult  early  in  the  disease  to 
arrive  at  a  definite  conclusion.  The  occurrence  of  fainting  fits,  of  nausea, 
and  gastric  irritability  are  im])ortant  indications.  As  the  lesion  of  the 
capsules  is  almost  always  tuberculous,  in  doubtful  cases  the  tulierculin 
test  may  be  used,  In  a  recent  case,  a  robust,  healthy-looking  man  with 
symptoms  of  Addison's  disease,  the  characteristic  reaction  was  obtained. 

Prognosis. — The  disease  is  usually  fatal.  The  cases  in  which  the 
bronzing  is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are 
occasionally  acute  cases  which,  with  great  weakness,  vomiting,  and  diar- 
rhoea, prove  fatal  in  a  few  weeks.    In  a  few  cases  the  disease  is  much  pro- 


832 


DISEASES  OF  TIIK  BLOOD  AND  DUCTLKSS  GLANPS. 


.  \ 
/ 


lim^vil,  even  to  six  or  ten  yeai'rt.  In  rare  iiistaiiet'S  recovery  lias  taken  place, 
and  periods  ui'  iniproveiiient,  lastinj^'  many  months,  may  occur. 

Treatment. — 'I'he  causal  iiulicalions  cannot  be  met.  When  there  i,- 
])rot'(Uind  asthenia  the  |iati(ii(  .should  he  coiilined  to  bed,  as  fatal  syncope 
may  at  any  time  occur.  In  three  of  my  cases  death  was  sudden.  When 
aiKcnna  is  |ii'cscnt  ii'oii  may  be  ^iven  in  tidl  dfjscs.  Arsenic  and  strychnia 
are  useful  tonics.  l'"or  the  diarrlnea  large  doses  of  bismuth  should  be 
given;  J'or  the  iri'itability  of  the  stomach,  creasolc,  hydrocyanic  acid,  ict', 
and  cham]iagne.  The  diet  slnndd  be  lig''t  and  nutritious,  ^lany  patients 
thrive  best  on  a  strict  milk  diet. 

Trealmenl  by  Suprurcnul  Exlracl. — Following  the  researches  of  Schiifer 
and  Oliver,  the  latter  used  the  gland  in  the  treatment  of  the  disease.  Kinni- 
cutt  has  collected  48  cases  treated  with  adrenal  [)reparati()ns.  Of  these, 
G  were  reported  as  cured  and  'i'i  as  improved.  1  have  used  it  in  i  cases,  of 
■which  onc!  has  been  already  reported.  The  ])atient  was  greatly  benelited, 
gained  11)  pounds,  the  symptoms  of  asthenia  disappeared,  and  he  was  alive 
two  years  subscipiently,  but  was  still  pigmented.  'JMie  3  otlier  ca.ses  were 
not  benchted  in  the  slightest  degree.  The  gland  may  be  given  raw  or  i)ar- 
tially  cooked  or  in  a  glycerin  extract.  Tabloids  of  the  dried  extract  are 
used,  one  grain  of  which  corresponds  to  fifteen  of  the  gland.  Three  of  the 
tabloids  may  be  given  daily.  Operation  has  heen  suggested,  but  has  not 
been  carried  out  on  any  undoubted  case. 


2.  Otiikr  Diseases  of  the  Suprarenal  Capsules. 

Ilcemorrliagc  into  the  gland  is  not  uncommon,  ])articularly  in  new-born 
children  (Spencer).  Tuhcrculuais  may  occur  without  the  symptoms  of  Ad- 
dison's disease.  Among  157  cases  of  tuberculous  disease  in  various  parts 
of  the  body,  caseous  tuberculous  foci  were  found  in  20  in  the  suprarenals 
without  signs  of  Addison's  disease  (Rolleston). 

Tiiinors  of  the  Suprarenals. — Adenomata  arc  common,  ]iarticularly  tlic 
small  yellowish  nodules.    Fibromata  and  fallij  tumors  occur,  but  are  rare. 

Of  inal'ujnant  (jrouitis  secondary  tumors  are  not  uncommon.  In  G3  cases 
of  secondary  carcinoma,  in  7  the  su])rarcnal  bodies  were  the  seat  of  growths 
(Kolleston).  Of  the  ]n'imary  growths,  both  sarcoma  and  carcinoma  may 
occur.  Aflleck  and  Leith  have  collected  20  cases  of  primary  sarcoma. 
Ramsay  informs  me  that  we  liave  had  3  cases  of  primary  tumor  of  the 
su]irarenals  at  the  Johns  Hopkins  Hospital — 3  in  females  and  1  in  a  male. 
Two  were  sarcomata  and  1  a  carcinoma.  The  diagnosis  in  all  was  malig- 
nant tumor  of  the  kidney.  The  cases  were  operated  upon,  1  with  com- 
plete recovery. 


IX.    DISEASES    OF   THE    SPLEEN,* 

Ayiart  from  the  acute  swelling  in  fever,  the  chronic  enlargement  of  the 
organ  in  paludism,  Icuka-mia,  cirrhosis  of  the  liver,  and  heart-disease,  we 

*  For  a  pood  disonssion  of  the  general  pathology  of  the  spleen,  see  Rolleston  in 
AUbutt's  System  of  Medicine. 


•s. 

tukon  pluco, 

UMl  tlujfo  i.- 
itul  syncoj)!' 
It'll.  Wlieii 
id  .strvclmiu 
L  sliuuld  be 
ic  acid,  ice, 
my  patients 

i  ol'  ScliiU'er 
ise.  Kiiiiii- 
Of  these, 
1  i  cases,  of 
y  benefited, 
le  was  alive 
"  cases  were 
raw  or  jiar- 
extraet  are 
.'liree  of  the 
ut  lias  uut 


s. 

n  new-born 
onis  of  Ad- 
irious  parts 
suprarenals 

cularly  tlie 

t  are  rare. 

In  G3  cases 

of  growths 

iiioma  may 

y   sarcoma. 

nor  of  the 

in  a  male. 

was  malig- 

with  com- 


D1SKASK«  OF  TllK  SPLKHxV. 


8;)3 


sec  V  ■/  few  instances  of  disease  of  tiie  spleen.  'I'liese  iiU'eel  ions  bave  i)eeii 
tiiily  described,  but  tliere  remain  several  eoiHbtioiis.  to  wbieli  briet'  rel'erenee 
may  be  made. 

1.  ^lov.vui.K  Si'i,i:i;.v. 

Movabb'  or  wandering  s[)leen  is  seen  most  tic(|iiei'l  ly  in  women  tbe 
subjects  of  entero[)tosis,  it  is  oeeasioiiaily  met  wilb  uitboiil  signs  of  dis- 
plaeement  ol'  otiier  organs,  it  may  be  found  aeeiilentally  in  individuals 
who  present  no  symptoms  wbatever.  Jn  otber  cases  tliiTt;  are  dragging, 
uneasy  feelings  in  tbe  back  and  side.  All  gradi's  are  nn't  witb,  from  a 
.spleen  tbat  can  be  felt  e(unpletely  below  tbe  margin  of  tbe  ribs  to  a  >ondi- 
tiou  in  which  tbe  tumor  is  felt  as  low  as  tbe  pelvis;  indeed,  tbe  organ  has 
been  fonnd  in  an  inguinal  liernia!  In  tbe  large  majority  of  all  I'ases  tbe 
s[)leeii  is  enlarged.  Sometime, ^  it  ai)[)ears  that  the  enlai'gement  has  caused 
relaxation  of  tbe  ligaments;  in  otber  instances  tbe  relaxation  seems  con- 
genital, as  movable  s[)leens  have  been  found  in  diU'erent  members  of  the 
same  family.  Possibly  traumatism  may  account  for  some  of  the  cases. 
A[)art  from  tbe  dragging,  uneasy  sensations  and  the  worry  in  nervous  pa- 
tients, wandering  s[)leen  causes  very  few  serious  symptoms.  Torsion  of 
the  pedicle  may  produce  a  very  alarming  and  serious  condition,  leading 
to  great  swelling  of  the  organ,  high  fever,  or  even  to  necrosis.  A  young 
Moman  was  adnntted  to  my  colleague  Kelly's  ward  with  a  tumor  supposed 
to  be  ovarian,  but  which  iiroved  to  be  a  wandering,  moderately  enlarged 
spleen.  She  was  transferred  to  tbe  medical  ward,  wbere  she  develo[)ed 
suddenly  very  great  pain  in  tbe  abdomen,  a  large  swelling  in  the  left  ilanlc, 
and  much  tenderness.  Ilalsted  o|)erated  and  found  an  enormously  enlarged 
spleen  in  a  condition  of  necrosis,  adlierent  to  llu!  adjacent  parts  and  to 
tbe  abdominal  wall,  lie  laid  it  open  freely,  and  large  necrotic  masses  of 
spleen  tissue  discharged  for  some  time.    She  made  a  good  recovery. 

The  (liafjiwsis  of  a  wandering  s])leen  is  nsually  easy  unless  tbe  organ 
becomes  fixed  and  is  deformed  by  adhesions  and  ])eris[)lenitis.  '^Fbe  sha|)e 
of  tbe  organ  and  tlu^  diarp  margin  with  the  notches  are  the  i)oints  to  bo 
specially  noted. 

The  frenlment  of  the  condition  is  important.  Occasionally  the  organ 
nijiy  be  kei)t  in  ])osition  l)y  a  ])roporly  adapted  belt  and  a  pad  under  the  left 
costal  margin.  Removal  of  tbe  displaced  organ  has  been  advised  and  car- 
ried out  in  many  cases,  and  nowadays  it  is  not  a  very  serious  operation.  It 
is,  however,  as  a  rule  unnecessary.  In  2  cases  of  enlarged  spleen  under  my 
care,  with  great  mobility,  causing  much  discomfort  and  uneasiness,  Ilalsted 
completely  relieved  the  condition  by  replacing  the  spleen,  packing  it  in 
])osition  with  gauze,  and  allowing  firm  adhesions  to  take  place.  Both  these 
])atients  were  seen  more  than  eighteen  months  after  the  operation  and  the 
organ  had  remained  in  position. 


ent  of  the 
disease,  we 

Rolleston  in 


2.    Rl'TTrRK    OF    TUK    SPT.KEN'. 

This  is  of  interest  medically  in  connection  with  the  spontaneous  rnp- 
ture  in  cases  of  acute  enlargement  during  typhoid  fever  or  malaria.  The 
condition  seems  very  rare  in  this  country.    We  have  had  instances  of  nip- 


834 


DlSKASKri  OF  THE   liLOOD  AND  DUCTLESS  ULANDS. 


^ili: 


turc  of  a  imiliiriiil  spU'cii  fnlldwiiij,'  n  Mow,  Ijiit  lu'illu'r  in  this  disonsc  nor 
ill  tviilioid  liiivc  we  had  an  iii>taiicc'  of  spoiitaticous  r'lptiire.  Jn  India  and 
in  Alauritiiis  niplnic  of  tlu'  spleen  is  stated  to  he  very  eoniinon.  J-'alid 
Inenioniiajic  may  i'oljow  piineture  of  a  swolli'U  s|>k'en  with  a  hypodennie 
needle.  Oeeasionally  the  rupture  results  from  the  hreaking  of  an  infarct 
or  of  an  ahseess.  The  symptoms  are  those  (d'  Inemorrha^t;  into  the  peri- 
t(jjia'um,  and  the  condition  demands  immediate  laparotomy. 


I 


/ 


'.].  Im'vhct  .VXD  AnHCKss  OK  Till':  SrM:i:.v. 

I'lmholi  in  the  splenic  arteries  causin^f  infarcts  may  he  either  infective 
•or  simjile.  They  are  seen  most  frcMpiently  in  ulcerative  endocarditis  and 
in  septic  conditions,  infarcts  may  also  follow  tho  formation  of  thromhi 
in  tho  hranches  of  the  splenic  artery  in  cases  of  fever.  They  are  not  very 
infre(pient  in  typhoi<l.  Jn  a  few  instances  the  infarcts  have  followed 
thrond)osis  in  the  splenic  veins.  Tliey  are  chiefly  of  pathological  interest. 
Tho  infarct  of  tho  sideon  may  ho  sus])ected  in  cases  of  soptictemia  or  pyie- 
mia  when  there  is  ])ain  in  the  s|»lenic  region,  tenderness  on  j)ressuro,  and 
slight  swelling  of  the  organ;  on  several  occasions  I  have  heard  a  well-marked 
l)oritoneal  friction  ruh.  Occasionally  in  the  infective  infarcts  largo  ah- 
scesses  are  formed,  and  in  rare  instances  the  whole  organ  may  be  converted 
into  a  sac  of  pus. 

Tumors  of  the  spleen,  hijdalid  and  other  cysls  of  the  organ,  and  (juninuiln 
are  rare  conditions  of  amitoniical  interest,  for  an  acconnt  of  which  the 
reader  is  referred  to  ItoUeston's  article  and  to  the  section  on  tho  si)leen, 
by  G.  E.  Lockwood,  in  Loomis  and  Thompson's  System  of  Medicine. 


4.   Sl'LEXIC  An.timia. 

This  condition,  nsnally  regarded  as  the  splenic  form  of  ITodgkin's  dis- 
ease, as  snch  was  well  described,  in  1871,  by  H,  C.  Wood.  Striimpcll, 
Banti,  and  others,  however,  think  it  shonld  he  separi.ted  and  regarded  as 
a  S])Ocial  form.  It  is  a  disease  ciiaracterized  by  great  enlargement  of  the 
organ,  jirofound  anaemia,  withoiit  lencocytosis  and  without  the  coexistence 
of  malaria,  rickets,  or  other  states  in  which  enlargement  of  the  spleen  is 
.secondary;  hence  it  is  often  s])oken  of  as  priinilivc  spleno-megali/.  While 
trne  jirimitivo  cases  are  rare,  in  this  region,  at  least,  an  anannia  associat.'d 
with  enlargement  of  tho  spleen  is  not  very  nncommon,  particnlarly  as  a 
result  of  the  elfects  of  ])rolonged  residence  in  malarial  rcginns.  As  I  write 
a  ])aticnt  from  South  Carolina  is  in  the  wards  with  an  enlarged  spleen  and 
great  ])allor.  The  anannia  is  of  a  distinctly  chlorotic  type,  as  his  hlood- 
conni  is  noiU'ly  4.000.000,  bnt  the  liaMnoglobin  is  only  40  ])cr  cent.  He  has 
no  Icni-ocytosis.  Ho  has  not  had  chills  and  fever  for  fifteen  years,  bnt  has 
been  living  in  a  malarial  region.  Tlioro  are  cases,  too,  in  which  the  en- 
larged spleen  persists  for  many  years  with  no  ana?mia,  good  color,  and  a 
fair  mnscnlar  vigor.  I  remember  a  soldier  invalided  from  India,  admitted 
to  tho  Montreal  General  Hospital  with  an  enormons  s])leen  and  slight 
anaaraia.     He  died  shortly  after  admission  of  a  profuse  haemorrhage  from 


DISKASKS  OF  TIIK  TIIYIIOIF)  (il.AND. 


S35 


the  stdiiiiicli.  A  putu'iit  I'lniii  ,ljiiiiiiic;i,  rclVrrcil  (d  me  a  few  yours  ji^'o  Ity 
IIoikU  rsoii,  of  Kingston,  witlionl  any  malarial  liistitry,  had  an  cnornioUH 
s|ika>n,  liail  had  suvoral  attacks  of  ])r()r(>und  anu'niia,  l)Ut  at  tlit<  time  of 
(ihscrvation  Inid  a  hlood-connt  nearly  normal.  I  wt'  numy  more  cases  of 
primitive  spleiio-mef^^aly  without  than  with  anu'mia. 

S.  West,  in  Allbntt's  System,  j,Mves  the  following  as  the  main  i'eatureri 
of  sjilenic  ana'niiu:  "The  disease  may  be  divided  into  three  stages:  In  the 
initial  stage  the  symptoms  are  those  of  extreme  ana'mia,  with  great  loss  of 
niuseular  power  and  some  wasting  of  muscle,  though  usually  without  emaci- 
ation. As  in  this  stage  the  disease  presents  no  specific  features,  it  can 
rarely  he  recognized.  The  second  stage  is  characterized  hy  progressive  en- 
largement of  tile  spleen  and  hy  attacks  of  severe  j)aii  in  the  splenic  region; 
the  ana'mia  is  more  profound,  the  loss  of  strengtii  is  extreme,  and  the  ]ni- 
tieiits  arc!  liable  to  repeated  attacks  of  bleeding,  especially  from  the  nose; 
the  temperature  is  now  usually  raised  anil  of  hectic  character,  reaching 
10'^°  or  more  in  the  evening.  It  is  in  this  second  stage  that  the  disease  is 
first  recognized. 

"  In  the  last  stage  the  condition  is  one  of  progressive  asthenia,  which 
ends  in  death;  there  is  in  it  nothing  especially  characteristic." 

The  blood  condition  is  one  simply  of  ])rofound  ana'mia  without  in- 
crease in  the  lencocytes  and  not  always  with  marked  poikilocytosis.  The 
tendency  to  Invmorrhage  is  marked,  both  from  the  mucous  surfaces  and  in 
the  skin. 

Anatomically,  the  only  special  changes  that  have  been  noted  have  been 
a  pecidiar  atrophy  of  the  Malj)ighian  corpuscles  in  some  cases. 

The  tr::.iment  of  the  condition  is  tluit  of  other  forms  of  profound 


.ana'mia. 


X.    DISEASES    OF    THE    THYROID    GLAND. 


1.  Goitre. 

Definition. — Tlypertroidiy  of  .the  thyroid  gland,  occurring  sporad- 
ically or  endemically. 

In  this  country  sr'^radic  eases  are  common.  The  endemic  centres  re- 
ferred to  in  Bartoii  monograph  (1810)  and  in  ITirsch's  C}eogra])liical 
Pathology  no  longer  cxist.  The  disease  is  very  prevalent  about  the  eastern 
end  of  Lake  Ontario,  and  in  parts  of  ]\[ichigan  (Dock).  Endemically  it 
is  found  particularly  in  the  mountainous  regions  of  Switzerland  and  in 
Itiirts  of  Italy.  Xo  satisfactory  exjdanation  has  been  given  of  the  ex  ce 
of  the  disease  in  this  form. 

Anatomically  the  following  varieties  may  be  distinguished:  (a)  Paren- 
'^liymatoup,  in  which  the  enlargement  is  general  and  the  follicles,  usually 
newly  formed,  contain  a  gelatinous  colloid  material,  (h)  A^'ascular,  in 
which  the  enlargement  is  chiefly  due  to  dilatation  of  the  blood-vessels 
without  the  new  formation  of  glandular  tissue,  (r)  Cystic  goitre,  in  which 
the  enlarged  gland  is  occupied  by  large  cysts,  the  walls  of  which  often 
undergo  calcification. 


830 


DISKASKS  OF  TITK    nf.OOI)   ANI)    DL'CTLKSS  (il.AN'DS. 


Symptoms.  'Tin'  t'lilai'^'ciiiriit  iiimv  Im'  iinirunn  lliroiii^Mioiil  tlic  cii- 
tiru  ^laiiil,  or  iill'icl  only  one  liihc,  or  llic  istliimis  nloiic.  Wlu'ii  siiuill,  n 
jroilrc  ciiiiscs  Mo  iiicoiivi'iiicncc.  In  its  ;,'id\\lli  it  niiiv  conipicss  I  lie  traclioa, 
caiisin;,'  (lys|)no'a,  or  may  pass  bciicalli  llu-  sIithumi  and  i'oni|iirs,s  the  veins. 
Tliese,  liowever,  ni't'  I'xt'eptioiial  circninstaru'es,  and  in  a  lar<,'(.'  proportion 
of  all  (jisi's  MO  serious  symptoms  are  noted,  'riic  atVe<'tion  nsnjdiy  comes 
under  tilt'  care  ol'  the  siir<,'eon.  Sudden  death  occasionally  occurs  in  larjfc 
hronchoceles.  In  sonu'  instances  it  may  he  ditlicult  to  deterrrnne  the  cause, 
and  it  has  heen  thought  to  Ix  associated  with  pressure  on  the  va^i.  1  have 
reporleil  an  instance  in  wliiin  it  resulted  from  lucmorrha^'o  into  the  glaml 
and  into  the  adjacent  tissues.  The  hlood  passed  into  the  celluh:'-  tissues 
of  tin;  lU'ck  and  under  the  slernum,  covering'  the  aorta  and  pericardium. 
In  re<,'i()iis  in  which  |,'oitre  prevails  the  drinUin<,f-\vater  should  h;;  hoiled. 
Chanj^e  of  locality  is  soMietimes  followed  hy  cure.  The  nu'dicir.al  treat- 
ment is  very  unsatisfactory.  Jodine  and  various  counlerirrilants  exter- 
nally, iodide  of  ])otash,  er^^ot,  and  maMy  other  drugs  are  recoMiiuended  hy 
wi'ilcrs.  The  thyroid  extract  has  heen  used  with  success  hy  IW'unii  in  !) 
ol'  1^  eases. 

2.  TiMoits  ()!•'  TJii':  Thvuoid. 

These  arc  very  varied,  (a)  A<lenoniata,  either  simple  or  nuilignant. 
The  latter  may  form  extensive  metastases.  A  case  is  re[)orted  hy  llay- 
ward  in  which  growths  resemhiing  thyroid  tissue  occurred  in  the  lungs  and 
various  bones  of  the  ])ody.  (b)  Cancer,  of  which  several  forms  have  been 
described,  (r)  Sarcoma.  .\ll  of  these  have  a  surgical  rather  than  a  medi- 
cal interest. 

It  may  he  mentioned  that  the  aheri'ant  or  accessory  thyroid  gland  may 
form  large  tumors  in  the  mcdiastinnni  or  in  the  pleura.  Cases  liave  been 
reported  hy  F.  A.  Packard  and  myself,  and  an  instance  is  on  record  in 
which  an  enormous  cystic  accessory  thyroid  occupied  the  eulire  right 
pK'ura. 

Ungual  goitre  occasionally  develojjs  at  the  l)ase  of  the  tongue,  and  is 
an  enlarged  accessory  thyroid  in  that  situation.  It  nuiy  lead  to  dilficult  deg- 
lutition and  interference  with  articulation. 

Thyroid  dhsrcss  is  rare.  In  liavel's  nu)nogra|)h  on  Strunutis  (18i)2) 
cases  are  given  after  nearly  every  one  of  the  speciiic  diseases,  and  he  re- 
ports 18  cases  from  Kocher's  clinic,  nearly  all  secondary  or  metastatic. 

3.  ExopnTiiALMic  CoiTBR  (Parry's  Disease). 

Definition. — A  disease  characterized  by  exophthalmos,  enlargement 
of  the  thyroid,  and  functional  disturbance  of  the  vascular  system.  It  is 
very  possibly  caused  by  disturbed  function  of  the  thyroid  gland  (hyper- 
thyroidism). 

Historical  Note. — Tn  the  posthumous  writings  of  Caleb  Hillier  Parry 
(1825)  is  a  description  of  8  cases  of  Enlargement  of  the  Thyroid  Gland 
in  Connection  with  Enlargement  or  Palpitation  of  the  Heart.  In  the  first 
case,  seen  in  17SG,  lie  also  describes  the  exophthalmos:  "  The  eyes  were  pro- 


DISKASKS  OK  TIIK  TIIYUOlD  (JLAND. 


837 


it  tlic  cu- 
ll sinall,  u 
ic  traclicu, 
the  veinn. 
n'opurt  iuii 
illy  t'Kint'rf 
•s  in  liiijfL' 
till'  cillldi', 
(i.  1  liuve 
the  gliUKJ 
li'.''  tissues 
ricanliiim. 
1k)  ho  ill)!  I. 
ii'.al  troat- 
iiits  extor- 
iiciidcd  by 
W'liiitf  in  1) 


malignant. 
1  t)y  Ilay- 

I lings  and 

llilVG    hl'l'll 

111  a  modi- 
land  may 
lavo  bci'n 
record  in 
ire    right 

lie,  and  la 
•nit  dcg- 


tis 

IK 


(1892) 
1  he  re- 
tatic. 


argement 
l^ni.  It  is 
d  (liypor- 

ior  Parry 
)id  Gland 
the  first 
were  pro- 


irndcd  fmni  their  sockets,  and  llie  coiinleminci'  exhihited  nn  n|t|MMirnnc«> 
III*  agitation  and  distress,  c.-pccially  in  any  niiisciilar  mnveineiit."  'I'lie 
Italians  claim  that  l''lajaiii  descrihed  the  diseasi'  in  1m(MI.  1  have  not  been 
able  to  see  his  (nigiiial  accoiint,  but  Moebins  states  that  it  is  meagre  and 
inaccurate,  and  bears  no  com|iarison  with  that  of  I'arry.  1 1'  the  name  of 
any  physician  is  to  be  associated  with  the  disease,  undoubtedly  it  shmild 
he  that  ol'  tiie  distinguished  old  Hath  |»liysician.  Uraves  described  the  dis- 
ease in  IHU")  am!  Ilascdow  in  is  10. 

Etiology. — The  disease  is  more  rie(|neiit  in  women  than  in  men.  Of 
20(»  cases  tabulated  by  Mshncr,  tlii're  were  Kil  J'emales.  '!'lie  age  <d'  onset 
is  usually  from  the  tweJitieth  to  the  thirtieth  yi'ar.  It  is  sometimes  seen  in 
seveial  members  of  the  same  family.  Worry,  fright,  and  depressing  emo- 
tions ])recede  the  devciopnicnt  of  the  disease  in  a  iiiiiiiber  of  cases. 

'J'jie  disease  is  regarded  by  some  as  a  pure  neiin-sis,  in  hivor  of  which  is 
urged  the  onset  after  a  profound  emotion,  the  absence  of  lesions,  and  the 
cure  which  has  followed  in  a  few  cases  after  operations  npon  the  nose.  Others 
believe  that  it  is  caused  h  a  ceiit''al  lesion  in  the  medulla  oblongata.  In 
siijiport  of  this  there  is  a  certain  amount  of  experimental  evideiu.-e,  and  in 

Sa  few  autopsies  changes  have  been  fonm!  in  the  medulla.  Of  late  years 
the  view  has  been  urged,  partiiularly  by  Moebiiis  and  l>y  (ireeiilield,  that 
exo])htlialmic  goitre  is  ju'imarily  a  disease  id'  tlii'  thyroid  gland  (liijiicr- 
lln/ira),  in  antithesis  to  myxiedema  (iillii/rrd).  The  clinical  contrast  be- 
tween these  two  disea.scs  is  most  suggestive — the  increased  excitability  of 
the  nervous  system,  'he  ilushed,  moist  skin,  the  vascular  erytliism  in  the 
one;  the  dull  apathy,  the  low  temperature,  slow  pulse,  and  dry  skin  of  the 
other.  The  cluuiges  in  the  gland  in  exophthalmic  goitre  are,  as  shown  by 
(Ireenfield,  those  of  an  oigan  in  active  evolution — viz.,  increased  prolifera- 
tion, with  the  production  of  newly  formed  tubular  spaces  and  alisorpticui 
of  the  colloid  material  which  is  replaced  by  a  more  mucinous  lliiid  (I'.rad- 
sliaw  Lectuic,  lH!t.'?).  The  thyroid  extract  given  in  excess  produces  symp- 
toms not  nnlike  those  of  Parry's  disease — tachycardia,  tremor,  headache, 
sweating,  and  prostration.  Ueclere  lias  recently  reported  a  case  in  which 
exophthalmos  developed  after  an  overdose.  I'se  of  the  thyroid  extract 
usually  aggravates  the  symptoms  of  exo))litlialmic  goitre.  The  most  siic- 
<essfiil  line  of  treatment  has  been  that  directed  to  diiniiiish  the  bulk  of 
the  goitre.  'J'hese  are  some  of  the  considerations  which  favor  the  view 
that  the  symptoms  are  due  to  disturbed  function  of  the  thyroid  gland, 
probably  to  a  hy|)erseci-ction  of  certain  materials,  which  induce  a  sort  of 
chronic  intoxication.  Myxiedema  may  dexelop  in  the  late  stages,  and 
there  are  transient  (edema  and  in  a  few  cases  scleroderma,  wliicli  indicate 
that  the  nntrition  of  the  skin  is  involved.  IVrsistence  of  the  thymus  is 
almost  the  rule  (Ifeclor  .Mackenzie),  but  its  significance  is  nnknown. 

Symptoms. — Acute  and  chronic  foi'nis  may  be  recognized.  In  the 
acute  form  the  disease  may  develo])  with  grei-'  ra])idity.  In  a  patient  of 
.T.  II.  Lloyd's,  of  Pliiladeli)hia,  a  woman,  aged  thirty-n'ne.  ■v\  ho  had  been 
considered  pcfcclly  healthy,  hnt  whose  friends  had  noticed  that  for  .«ome 
time  her  eyes  looked  rather  large,  Avas  suddenly  st  'zcd  with  intense  vomit- 
ing and  diarrhcea,  ra})id  action  of  the  heart,  and  .jreat  throbbing  of  the 


i,  ' 


888 


DISKASES  OF  THE   BLOOD  AND   DUCTLPXS  GLANDS, 


.  I 
/ 


artpriop.  TIic  cyos  wore  prominent  nnd  staring  and  the  thyroid  gland  was 
found  much  enkirged  and  soft.  The  gastro-intostinal  symptoms  contiu- 
nod,  the  pulse  became  more  rapid,  the  vomiting  was  incessant,  and  the 
patient  died  on  tiie  third  day  of  tlie  illness.  Only  the  abdominal  aiitl 
tlioracic  organs  could  l)e  examined  and  no  changes  were  found.  Two 
rapidly  fatal  cases  occurred  at  tlie  Philadelphia  llosi)ital,  one  of  which, 
under  F.  W  Henry's  care,  had  marked  cerebral  symptoms.  The  acute  cases 
are  not  always  associated  with  delirium.  In  a  case  reported  by  Siitclitf 
death  occurred  within  three  months  from  the  onset  of  the  symptoms,  owing 
to  rei)eated  and  uncontrollable  vomiting.  More  frequently  the  onset  is 
gradual  and  the  disease  is  chronic.  There  are  four  characteristic  symptoms 
of  the  disease — exophthalmos,  tachycardia,  enlargement  of  the  thyroid, 
and  tremor. 

Tachijcdrdid. — IJai)id  heart  action  is  only  one  of  a  series  of  remarkable 
vascular  phenomena  in  the  disease.  The  pulse-rate  at  first  may  be  not 
more  than  1)5  or  100,  but  when  the  disease  is  established  it  may  be  from 
140  to  1(J0,  or  even  higher.  Irregularity  is  not  common,  except  toward 
the  close.  In  a  well-develo})ed  case  the  visible  area  of  cardiac  pulsation  is 
much  increased,  the  action  is  heaving  and  forcible,  and  the  shock  of  the 
heart-sounds  is  well  felt.  The  large  arteries  at  the  root  of  the  neck  throb 
forcibly.  There  is  visible  pulsation  in  the  peripheral  arteries.  The  capil- 
lary })ulse  is  readily  seen,  and  there  are  few  diseases  in  which  one  may  see 
at  times  with  greater  distinctness  the  venous  i)ulse  in  the  veins  of  the  hand. 
The  throl)))ing  pulsation  of  the  arteries  may  be  felt  even  in  the  linger  tii)s. 
On  auscultation  murmurs  are  usually  heard  over  the  heart,  a  loud  apex 
systolic  and  loud  bruits  at  the  base  and  over  the  manubrium.  The  sounds 
of  the  heart  may  be  very  intense.  In  rare  instances  they  may  be  heard 
at  some  distance  from  the  i)atient;  according  to  Graves,  as  far  as  four- 
feet. 

Exnphthalninx,  which  may  be  unilateral,  usually  follows  the  vascular 
disturbance.  It  is  readily  recognized  by  the  protrusion  of  the  balls,  and 
partly  by  the  fact  that  the  lids  do  not  completely  cover  the  sclerotics,  so' 
that  a  rim  of  white  is  seen  above  and  below  the  cornea.  The  protrusion 
may  become  very  great  and  the  eye  may  even  be  dislocated  from  the  socket,. 
or  both  eyes  may  be  destroyed  by  panophthalmitis,  a  condition  jiresent  in 
one  of  Basedow's  cases.  The  vision  is  normal.  Graefe  noted  that  when 
the  eyeball  is  moved  downward  the  up])er  lid  does  not  follow  it  as  in  health. 
This  is  known  as  Graefe's  sign.  It  seems  to  be  rare;  it  was  not  present 
in  any  one  of  17  cases  examined  at  my  clinic  (Oppenheimer).  The  palpebral' 
aperture  is  wider  than  in  health,  owing  to  spasm  or  retraction  of  the  upper 
lid  (Stellwag's  sign).  The  patient  winks  less  frequently  than  in  health. 
!Moebius  has  called  attention  to  the  lack  of  convergence  of  the  two  eyes. 
Changes  in  the  pupils  and  in  the  optic  nerves  are  rare.  Pulsation  of  the 
retinal  arteries  is  common. 

Enlargement  of  the  thi/rnid  commonly  develops  with  the  exophthalmos. 
It  may  be  general  or  in  only  one  lobe,  and  is  rarely  so  large  as  in  ordinary 
goitre.  The  vessels  are 'usually  much  dilated,  and  the  whole  gland  may 
be  seen  to  pulsate.    A  thrill  may  be  felt  on  palpation  and  on  auscultation; 


DISEASES  OP  THE  THYROID   GLAND. 


83(^ 


gland  was 
lis  contiu- 
,  and  the 
niaal  ami 
nd.     Two 

of  which, 
iciito  cases 
)y  Siitcliir 
)nis,  owing 
c  onset  is 

symptoms 
10   thyroid, 

remarkable 
lay  be  not 
ly  be  from 
ept  toward 
)ulsation  is 
LOck  of  the 
neck  throb 
The  capil- 
ne  may  see 
f  the  hand, 
finger  tii)S. 
loud  apex 
riie  sounds 
y  be  heard 
'ar  as  four- 
lie  vascular 
balls,  and 
erotics,  so' 
]n-()trusion 
the  socket,, 
])resent  in 
that  when 
s  in  health, 
not  present 
e  palpebral' 
f  the  upper 
in  health, 
e  two  eyes, 
tion  of  the 

)plithalmos. 
in  ordinary 
gland  may 
.uscultatioR 


a  loud  systolic  murmur,  or  more  commonly  a  hriiil  de  (linhlc.  A  double 
iiiurmur  is  common  and  is  patliognomouic  ((Juttnuinii). 

Trcmiir  is  tiie  fourth  cardinal  symptom,  and  was  really  first  described 
by  Basedow.  It  is  involuntary,  line,  about  eight  to  the  second.  Jt  is  of 
great  imiiortance  in  the  diagnosis  of  the  early  cases. 

Among  other  symptoms  which  may  develop  are  anaunin,  eniaciatiiui, 
iiiid  slight  fever.  Attacks  of  vomiting  and  diarrho-a  may  occur.  The 
latter  may  be  very  severe  and  distressing,  recurring  at  intervals.  The  great- 
est comi)laint  is  of  the  forcible  throbbing  in  the  arteries,  often  acconi|)anied 
with  uni)leasant  flushes  of  heat  and  jjrofuse  ])ersj)i rations.  Skin  symptoms 
are  not  infrequent — pigmentation,  which  may  be  intense  and  simulate 
A<ldison's  disease,  })atches  of  leucodcrnui,  or  atrophy  of  i)igment,  and 
urticaria.  Patches  of  solid  anlema  ha^.e  been  seen.  Occasionally  myx- 
o'denia  has  been  present.  In  the  very  acute  case  above  referred  to  urticaria 
was  a  ])rominent  symptom.  Occasionally  ])ruritus  is  an  early  and  most 
distressing  symptom.  1  have  seen  one  case  in  which  it  persisted  and  became 
almost  unbearal)le.  Irritability  of  temper,  change  in  disposition,  ami  great 
mental  depression  have  been  described.  An  important  complication  is 
acute  mania,  in  which  the  jjatient  may  die  in  a  few  days.  Weakness  of 
the  muscles  is  not  uncommon,  jjarticularly  a  feeling  of  "giving  way"  of 
the  legs.  If  the  patieiit  holds  the  head  down  and  is  asked  to  look  up  with- 
out raising  the  head,  the  forehead  renuiins  smooth  and  is  not  wrinkled,  as 
in  a  normal  individual  (Jotfroy).  A  feature  of  interest  noted  by  Charcot 
is  the  great  diminution  in  the  electrical  resistance,  which  may  be  due  to  tlie 
saturation  of  the  skin  with  moisture  owing  to  the  vaso-motor  dilatation 
(llirt).  Bryson  has  noted  the  fact  that  the  chest  expansion  may  be  greatly 
diminished.  The  emaciation  may  be  extreme.  Glycosuria  and  albuminuria 
are  not  infrequent  complications.     True  diabetes  may  also  develop. 

The  course  of  the  disease  is  usually  chronic,  lasting  several  years.  After 
persisting  for  six  months  or  a  year  the  symptoms  may  disapjjcar.  There 
are  remarkable  instances  in  which  the  symi)toiiis  have  come  on  with  great 
intensity,  following  fright,  and  have  disa])peared  again  in  a  few  days.  A 
certain  pro])ortion  of  the  cases  get  well,  but  when  the  disease  is  well  de- 
velojied  recovery  is  rare. 

Treatment. — Medicinal  measures  arc  notoriously  uncertain.  The 
oftmbination  of  digitalis  and  iron  may  be  tried,  and,  when  there  is  anamiia, 
often  does  good.  I  have  never  seen  any  advantage  from  the  use  of  aco- 
nite or  veratrum  viride.  The  tincture  of  stro])hantluis  will  sometimes 
reduce  the  rapidity  of  the  heart's  action.  Ergot  is  warmly  recommended 
by  some  writers.  Belladonna  gives  relief  occasionally,  and  should  be  ad- 
ministered until  the  dryness  of  the  throat  is  obtained.  I  have  seen  one  case 
"f  apparent  cure  under  its  use.  Xo  measures  are  so  successful  as  rest  in 
bed  with  an  ice-bag  or  Leiter's  tube  a]i])lied  occasionally  over  the  heart,  or, 
what  is  sometimes  more  agreeable,  over  the  lower  part  of  the  neck  and 
manubrium  sterni.  I  have  known  the  pulse  to  bo  reduced  in  this  way 
from  140  to  90.  Flectricity  has  been  much  lauded  and  instances  of  euro 
have  been  re])orted.  In  many  cases  temiiorary  im])rovement  certainly 
follows  the  use  of  the  galvanic  current.    Erb  states  that  the  anode  should 


840 


DISEASES  OF  Till-:   BLOOD  AND  DUCTLESS   GLANDS. 


1)0  placed  over  llic  cervical  spine  and  the  cathode  upon  the  peripheral 
nerves.  The  iis(f  ol'  llie  thyroid  extract  has  not  Ix'eii  succes.<rul.  'J'he  tliy- 
nnis  extract  has  not  proveil  satisfactory.  The  treatment  oi'  the  disease  hy 
small  (h)ses  ol'  o])ium  lias  been  successful  in  some  cases  (Musser).  Opera- 
tive ii'casiires  seem  Id  oll'er  the  jrreatest  ri'liei'.  JJenioval  oi'  one  lobe  ol'  the 
gland,  tying  the  arteries  of  the  gland,  and  exothyro])le.\ia  have  all  been 
tried.  The  ])atienls,  as  a  rule,  stand  the  auicsthetic  badly;  death  on  the 
table  is  more  fre(iuent  than  the  ])ul)lishc(l  records  indicate,  liecently  good 
results  have  been  reported  from  the  division  of  the  c(n'ds  of  the  cervical 
synipatliclic. 

4.  ]\[vx(EDi:ma   {Mhijrca). 

Definition.— A  conslitulional  aU'eetion,  due  to  llie  loss  of  function 
of  the  thyroid  gland.  The  disease,  which  was  described  by  Sir  William 
Ciull  as  a  cretinoid  change,  and  later  by  Ord,  i^  characterized  clinically  by 
ji  myxa'demiitous  condition  of  tiie  subcutaneous  tissues  and  mental  failure, 
and  anatomically  by  atrophy  of  the  thyroid  gland. 

Clinical  Forms. — Three  groiii)s  of  cases  may  be  recognized — cretinism, 
niyxeedeina  pi'oper,  and  operative  niyxo'denia. 


Cretinism. 

This  remarkable  im])airment  of  nutrition  follows  absence  or  loss  of 
function  of  the  tliyroid  gland,  either  congenital  or  appearing  at  any  time 
before  ])uberty.  There  is  remarkable  retardation  of  development,  reten- 
tion of  the  infantile  state,  and  an  extraordinary  disjjroportion  between  the 
different  parts  of  the  body.  Two  forms  of  cretinism  are  recognized,  the 
sporadic  and  the  cudcniic.  In  the  sporadic  form  the  gland  may  be  con- 
genitally  a1)sent,  it  may  be  atrophied  after  one  of  the  si)ecific  fevers,  or  the 
condition  may  develop  with  goitre.  Since  we  have  learned  to  recognize  the 
disease  it  is  surprising  how  many  cases  have  been  reported.  I  was  able  to 
collect  GO  cases  in  this  country  to  ]\Iay  1,  1897.* 

The  condition  is  rarely  recognized  before  the  infant  is  six  or  seven 
months  old.  '^^riien  it  is  noticed  that  the  child  does  not  grow  so  rapidly 
and  is  not  bright  mentally.  The  tongue  looks  large  and  hangs  out  of  the 
mouth.  The  hair  may  be  thin  and  the  skin  very  dry.  Usually  by  the  end 
of  the  first  year  and  during  the  second  year  the  signs  of  cretinism  l)CCome 
very  marked.  The  face  is  large,  looks  bloated,  the  eyelids  are  pulTy  ami 
swollen;  the  alu'  nasi  are  tliick,  the  nose  looks  depressed  and  flat.  Denti- 
tion is  delayed,  and  the  teeth  which  appear  decay  early.  The  abdomen 
is  swollen,  the  legs  are  thick  and  short,  and  the  hands  and  feet  are  undevel- 
oped and  ])udgy.  The  face  is  pale  and  sometimes  has  a  waxy,  sallow  tint. 
Thv  fontanelles  remain  ojien;  there  is  much  muscular  weakness,  and  the 
child  cannot  support  itself.  In  the  supraclavicular  regions  there  are  large 
pads  of  fat.  The  child  docs  not  develop  mentally;  there  are  various  grades 
of  idiocy  and  imbecility. 

*  Sporadic  orotinism  in  America,  Transactions  of  tlio  Congress  of  American  Physi- 
cians and  Surgeons,  vol,  iv. 


).S. 

0  peripheral 
1.  'I'he  tliy- 
0  disease  hy 
or).  Opera- 
i  lobe  ol'  the 
ive  uU  been 
eivth  on  the 
,'cently  good 
the  eervieiil 


of    fuilctidll 

Sir  W'illiiim 
L'liiiieiilly  by 
ntal  failure, 

—  jretinisiii. 


'■  or  loss  of 

fit  any  time 

lent,  reten- 

jetween  tlie 

rnized,  the 

iiy  be  con- 

ers,  or  the 

cognize  the 

was  able  to 

X  or  seven 

so  rapidly 

out  of  tlie 

)y  the  end 

iin  become 

JiilTy  and 
it.  Denti- 
3  abdomen 
0  undevel- 
illow'  tint. 
S  and  tlie 

are  lar<:v 
ous  grade? 

'ican  Phvsi- 


DISEASE.S  OP  THE  THYROID  OLAND. 


841 


A  very  interesting  form  is  that  in  wliich,  after  the  child  has  thriven 
and  develoj)ed  until  its  fourth  or  fiftli  year,  or  even  later,  the  symptoms 
begin  after  a  fever,  in  consequence  of  an  atropiiy  of  the  gland.  I'arker 
suggests  for  this  variety  the  name  juvenile  myxeedema. 

Endemic  crctiiiisin  develojjs  under  local  conditions,  as  yet  unknown,  in 
association  with  goitre.  It  is  met  with  chielly  in  Switzerland  and  [larts 
of  Italy  and  France.  The  common  opinion  is  that  it  too  is  associated  with 
loss  of  function  of  the  thyroid. 

The  diaynosis  of  cretinism  is  very  easy  after  one  has  seen  a  case  or  good 
illustrations.  Infants  a  year  or  so  old  sometimes  become  llabby,  lose  their 
vivacity,  or  show  a  protuberant  abdomen  and  lax  skin  with  slight  cretinoid 
aj)pearance.  These  milder  forms,  as  they  have  been  termed,  are  probably 
due  to  transient  functional  disturbance  in  the  gland.  There  is  rarely  any 
diilicidty  in  r'H-ognizing  the  different  other  types  of  idiocy.  The  condi- 
tion known  as  faial  rid-ets,  achondroplasia,  or  the  chondrodj/alrophiii  ftctalis, 
is  more  likely  to  be  mistaken  for  cretinism.  The  children  which  survive 
■  irth  grow  up  as  a  remarkable  form  of  dwarfs,  characterized  by  shortness 
of  the  limbs  (micromelia)  and  enormous  enlargement  of  the  articulations, 
due  to  hyperplasia  of  the  cartilaginous  ends  of  the  bones.  Infantilism — 
the  condition  characterized  by  a  preservation  in  the  adult  of  the  exterior 
form  of  infancy  with  the  non-appearance  of  the  secondary  sexual  char- 
acters— could  scarcely  be  mistaken  for  cretinism. 

Myxoidema  of  Adults  {GtilVs  Disease), 

In  this,  women  are  very  much  more  frequently  affected  than  men — in 
a  ratio  of  6  to  1.  The  disease  may  affect  several  members  of  a  family,  and 
it  may  be  transmitted  through  the  mother.  In  some  instances  there  has 
been  first  the  appearance  of  exophthalmic  goitre.  Though  occurring  most 
commonly  in  women,  it  seems  to  have  no  special  relation  to  the  catamenia 
or  to  pregnancy;  the  symptoms  of  myxeedema  may  disappear  during  preg- 
nacy  or  may  develop  post  partum.  Myxeedema  and  exophthalmic  goitre 
may  occur  in  sisters.  It  is  not  so  common  in  this  country  as  in  England. 
The  symptoms  of  this  form,  as  given  by  Ord,*  are  marked  increase  in 
the  general  bulk  of  the  body,  a  firm,  inelastic  swelling  of  the  skin,  which 
does  not  pit  on  pressure;  dryness  and  roughness,  which  tend,  with  the 
swelling,  to  obliterate  in  the  face  the  lines  of  expression;  imperfect  nutri- 
tion of  the  hair;  local  tumefaction  of  the  skin  and  subcutaneous  tissues, 
])articularly  in  the  supraclavicular  region.  The  physiognomy  is  altered 
in  a  remarkable  way:  the  features  are  coarse  and  broad,  the  lips  thick,  the 
nostrils  broad  and  thick,  and  the  month  is  enlarged.  Over  the  cheeks, 
sometimes  the  nose,  there  is  a  reddish  patch.  There  is  a  striking  slowness 
of  thonght  and  of  movement.  The  memory  becomes  defective,  the  patients 
grow  irritable  and  suspicious,  and  there  may  be  headache.  In  some  in- 
stances there  are  delusions  and  hallucinations,  leading  to  a  final  condition 
of  dementia.    The  gait  is  heavy  and  slow.    The  temperature  may  be  below 

*  Report  on  Myxoedema,  Clinical  Society's  Transactions,  1888. 


842 


DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 


/ 


nonnnl.  The  functions  of  the  heart,  lungs,  and  ahdominal  organs  are 
normal,  llii'iuorrhnge  sonictinics  occurs.  Albuminuria  is  sometimes  pres- 
ent, more  rarely  glycosuria.  Death  is  usually  due  to  some  intercurrent 
disease,  most  I'reciuently  tuberculosis  ((jreenlield).  The  thyroid  gland  is 
diminished  in  size  and  may  become  completely  atro{)hied  and  converted 
into  a  fibrous  mass.  The  subcutaneous  fat  is  abundant,  and  in  one  or  two 
instances  a  great  increase  in  the  mucin  has  been  found. 

The  course  of  the  disease  is  slow  but  progressive,  and  e.vtends  over  ten 
or  fifteen  years.  A  condition  of  acute  and  temporary  myxcedema  may 
develop  in  connection  witli  enlargement  of  the  thyroid  in  young  persons. 
Myxcedema  may  follow  exo])hthalmic  goitre.  In  other  instances  the  sym[)- 
toms  of  the  two  diseases  have  been  combined.  1  have  rei)orted  a  case  in 
which  a  young  man  became  bloated  and  increased  in  weight  enormously 
during  three  months,  then  developed  tachycardia  with  tremor  and  active 
delirium,  and  died  within  six  months  of  the  onset  of  the  symptoms. 


Operative  MvxtEDEMA ;  Cachexia  Strumipriva. 

TTorslcy,  in  a  series  of  interesting  experiments,  showed  that  complete 
removal  of  the  thyroid  in  monkeys  was  followed  by  the  production  of  a 
condition  similar  to  that  of  myxcedema  and  often  associated  with  spasms 
or  tetanoid  contractures,  and  followed  by  apathy  and  coma.  When  the 
monkeys  were  kept  warm  myxa3dema  was  averted,  and,  instead  of  an  acute 
myxa'dema,  the  animals  developed  a  condition  which  closely  resembled 
cretinism.  An  identical  condition  may  follow  extirpation  of  the  thyroid 
in  man.  Kocher,  of  Bern,  found  that  after  complete  extirpation  a  cachectic 
condition  followed  in  many  cases,  the  symptoms  of  which  are  practically 
identical  with  those  of  myxanlema.  The  disease  follows  only  a  certain 
number  of  total  and  a  much  smaller  proportion  of  partial  removals  of  the 
thyroid  gland.  Of  408  cases,  in  69  the  operative  myxcedema  developed. 
It  his  l)een  thought  that  if  a  small  fragment  of  the  thyroid  remains, 
or  .here  are  accessory  glands,  which  in  animals  are  very  common, 
these  symptoms  do  not  clevelop.  It  is  possible  that  in  men,  in  the  cases 
of  com])lete  removal,  the  accessory  fragments  subserve  the  function  of 
the  gland.  Operative  myxcedema  is  very  rare  in  America;  I  have  been 
able  to  find  only  2  cases  in  this  country.  McOraw's  case,  referred  to  in 
previous  editions  of  this  work,  has  since  been  cured  with  the  thyroid 
extract. 

The  diagiiffiis  of  myxcedema  is  easy,  as  a  rule.  The  general  aspect  of 
the  patient — the  subcutaneous  swelling  and  the  pallor — suggests  Bright's 
disease,  which  may  be  strengthened  by  the  discovery  of  tube-casts  and  of 
albumin  in  the  urine;  but  the  solid  character  of  the  swelling,  the  exceed- 
ing dryness  of  the  skin,  the  yellowish-white  color,  the  low  temperature, 
the  loss  of  hair,  and  the  dull,  listless  mental  state  should  suffice  to  differ- 
entiate the  two  conditions.  In  dubious  cases  not  too  much  stress  should 
be  laid  upon  the  snpraclavicidar  swellings.  There  '  .  y  be  marked  fibro- 
fatty  enlargements  in  t'his  situation  in  healthy  persons,  the  supraclavicular 
pseudo-lipomata  of  Verneuil. 


i. 


DISEASES  OP  THE  THYMUS  GLAND. 


843 


organs  are 
times  pres- 
ntorcurrt'iit 
id  gland  is 
I  converted 
one  or  two 

ds  over  ton 
)dema  may 
iig  persons, 
i  the  symp- 
d  a  case  in 
enormously 
and  active 
toms. 


it  complete 

iction  of  a 

'ith  spasms 

When  the 

of  an  acute 

resembled 

he  thyroid 

a  cachectic 

practically 

a  certain 

vals  of  the 

developed. 

remains, 

common, 

the  cases 

mction  of 

lave  been 

rred  to  in 

le  thyroid 

aspect  of 
s  Bright's 
sts  and  of 
le  exceed- 
iiperatiire, 
to  diffor- 
ss  should 
ed  fibro- 
clavicular 


Treatment. — The  patients  sulfer  in  cold  and  improve  greatly  in  warm 
weatlier.  They  should  therefore  he  kept  at  an  even  temiu'rature,  and 
should,  if  2)ossible,  move  to  a  warm  dinuite  during  the  winter  montiis.  Ke- 
peated  warm  baths  with  shampooing  are  useful.  Our  art  has  made  no 
more  brilliant  advance  than  in  the  cure  of  tiiese  disorders  (hu;  to  (listurl)ed 
function  of  the  thyroid  gland.  That  we  can  to-day  rescue  children  otlier- 
wise  doomed  to  helpless  idiocy — that  we  can  restore  to  life  the  hopeless 
victims  of  myxo'denui — is  a  triumph  of  experimental  medicine  for  which  we 
are  indebted  very  largely  to  Victor  llorsley  and  to  his  i)upil  Murray.  Trans- 
plantation of  the  gland  was  first  tried;  then  Murray  used  an  extract  sub- 
(utaneously.  Hector  Mackenzie  in  London  and  IJowitz  in  Copenhagen 
introduced  the  method  of  feeding.  We  now  know  tiiat  thr  gland,  taken 
either  fresh,  or  as  the  watery  or  glycerin  extract,  or  dried  and  powdered, 
is  e(pially  elHcacious  in  a  majority  of  all  the  cases  of  myxuMlema  in  infants 
or  adults.  Many  prei)arations  are  now  on  the  nuirket,  but  it  makes  little 
difference  how  the  gland  is  administered.  The  dried  jjowdered  gland  and 
the  glycerin  extract  are  most  convenient.  It  is  m'cU  to  begin  with  the 
powdered  gland,  1  grain  three  times  a  day,  of  the  Parke-Davis  preparation, 
or  one  of  the  Hurroughs  and  Welcome  tablets.  The  dose  may  be  increased 
gradually  until  the  patient  takes  10  or  15  grains  in  the  day.  In  nuiny  cases 
there  are  no  unj)leasant  symptoms;  in  others  there  are  irritation  of  the 
skin,  restlessness,  rapid  pulse,  and  delirium;  in  rare  instances  tonic  spasms, 
the  condition  to  which  the  term  ihyroiclism  is  applied.  The  results,  as  a 
rule,  are  most  astounding — unparalleled  by  anything  in  the  whole  range 
of  curative  measures.  Within  six  weeks  a  poor,  feeble-minded,  toad-like' 
caricature  of  humanity  may  be  restored  to  mental  and  bodily  health.  Loss, 
of  weight  is  one  of  the  first  and  most  striking  effects;  one  of  my  patients 
lost  over  30  pounds  within  six  weeks.  The  skin  becomes  moist,  the  urinC' 
is  increased,  the  perspiration  returns,  the  temperature  rises,  the  pidse-rate 
([uickens  and  the  mental  torpor  lessens.  Ill  effects  are  rare.  Two  or  three 
cases  with  old  heart  lesions  have  died  during  or  after  the  treatment;  in  one 
instance  a  temporary  condition  oi  Graves'  disease  was  induced. 

The  treatment,  as  Murray  suggests,  must  be  carried  out  in  two  stages — 
one,  early,  in  which  full  doses  are  given  until  the  cure  is  effected;  the  other,, 
the  permanent  use  of  small  doses  sufficient  to  preserve  the  normal  metab- 
olism. The  literature  of  thyroid  therapy  and  a  list  of  all  the  cases  of  myx- 
redema  and  cretinism  treated  to  December  31,  1894,  are  given  by  Ileins- 
heimer.* 


XI.    DISEASES    OF   THE   THYMUS    GLAND. 

The  functions  of  this  gland  arc  unknown.  It  is  a  suggestive  fact  that 
BrUimann  found  in  it  minute  quantities  of  a  compound  containing  iodine. 
It  has  been  thought  that  its  internal  secretion  has  an  influence  in  com- 
bating infective  agents.  The  weight  of  the  organ  is  about  14  grammes 
at  birth,  about  20  at  the  ninth  month,  and  25  to  30  at  the  second  year. 

*  Die  Schilddrllsenbchandlung,  Mllnchen,  1895. 


844 


DISEASES  OF  THE   IJLOOD  AND   DUCTLP]SS  GLANDS. 


/ 


The  orpin,  nftor  reaching  its  largest  size  about  the  end  of  the  second 
year,  gradiiMlly  wastes,  until  at  the  tiiuc  of  puhcrty  it  is  a  iiuTe  i'atty  reni- 
ru»!it,  in  which,  however,  there  are  "  traces  of  its  origiiuil  structure  in  the 
form  of  snuill  nuisses  of  thymus  corpuscles,  and  even  of  eonceutrie  cor- 
puscles "  ((^uain).  A  complete  consideration  of  the  all'ections  of  this  gland 
is  to  l)e  found  in  Friedlciieu's  remarkable  monograph.  Die  Physiologic  der 
Thymusdriise,  iH^yH.     The  following  are  tlie  nu)st  important  conditions: 

I.  Persistence  of  the  organ  after  the  fifteenth  year,  met  with  occa- 
sionally, but  under  circumstances  so  varied  that  a  satisfactory  exph' nation 
cannot  be  olfered.  It  is  said  that  the  existence  of  the  gland  nuiy  be  deter- 
mined by  the  })rcsence  of  an  area  of  dulness  along  the  left  sternal  border 
from  the  second  to  the  fourth  ribs. 

II.  Hypertrophy  of  the  Thymus. — Tlie  size  of  the  gland  varies  widely, 
so  that  it  is  dillicult  to  define  exactly  the  limits  between  persistence  and 
enlargement.  The  condition  is  of  interest  from  three  standjjoiuts:  {n)  The 
suj)p()sed  occurrence  of  tlnjmic  asthma,  due  to  pressure  from  the  enlarged 
gland.  A  nundier  of  observers  have  attributed  the  symptoms  of  laryngisnuis 
stridulus  to  pressure  exerted  by  the  enlarged  thymus.  Many  German  writers 
consider  thymic  asthma  identical  with  the  laryngismus  stridulus  of  English 
authors,  who,  as  a  rule,  have  laid  no  stress  whatever  on  the  association. 
There  can  l)e,  I  think,  no  qxiestion  that  the  ordinary  laryngismus  seen  in 
rickety  children  is  a  convulsive  affection  and  is  not  the  result  of  compression. 
But  a  very  greatly  enlarged  thymus  may  seriously  hamper  the  structures 
within  the  thorax.  Jacobi,  in  his  monograidi  on  the  gland  (Transactions  of 
the  Association  of  American  Physicians,  vol.  iii),  states  that  in  an  infant  of 
eight  months  the  distance  between  the  manubrium  sterni  and  the  vertebral 
column  is  2.2  cm.,  a  sjjace  which  he  thinks  might  be  completely  filled  by 
an  enlarged  and  congested  thymus.  Siegel's  case  also  points  to  the  possi- 
bility of  this  comi)repsion.  A  boy  aged  two  years  and  a  half  had  had  for 
two  weeks  cough  and  bronchial  rales  with  dyspnci'a,  which  \vas  more  or 
less  constant  with  nocturnal  exacerbations.  Laryngismus  stridulus  was 
diagnosed.  Tracheotomy  was  performed  shortly  after  admission  without 
relief,  but  when  subsequently  the  anterior  mediastinum  was  opened  from 
above  by  extending  the  incision  from  the  tracheotomy  wound,  a  ])iece  of 
the  thymus  as  large  as  a  hazel-nut  appeared  with  each  inspiration.  The 
gland  was  drawn  up  with  forceps  and  fastened  by  three  stitches  to  the 
fascia  over  the  sternum.  The  child  rested  quietly  after  the  operation,  had 
no  dyspncea,  and  made  a  complete  recovery  (Berl.  klin.  Woch.,  ISUC),  No. 
40).  Lrom  a  child  aged  two  months  (dyspnceic  from  the  eighth  day) 
Koenig  removed  a  portion  of  the  thymus,  leaving  the  substernal  part. 
These  are  cases  that  go  far  to  disprove  Friedleben's  dictum — es  gieht  l-cin 
asthma  thy  minim. 

(1))  Thymus  Enlargement  and  Sudden  Death. — In  considering  the  ques- 
tion of  the  so-called  lymphatic  constitution,  with  which  an  enlarged  thy- 
mus is  usually  associated,  we  have  spoken  of  the  occurrence  of  sudden  doatii. 
Two  groups  of  cases  are  met  with  in  the  literature:  First,  such  instances 
as  tho.«e  described  by  Grawitz,  Jacobi,  and  others,  in  which  young  infants 
have  been  either  found  dead  in  bed  or  have  been  attacked  suddenly  with 


>s. 


DISKASKS  OF  TIIK  THYMUS  GLAND. 


845 


the  second 
J  Ititty  reiu- 
L'ture  ill  the 
centric  cor- 
r  this  ghmd 
.siologie  der 
)nditi<)n8: 
;  with  occa- 
e.\[)h' nation 
ay  be  deter- 
jinal  border 

iries  widely, 

sistenee  and 

its:  (rt)  The 

he  enhirged 

hiryngisn'iis 

■man  writers 

s  of  English 

association. 

nuis  seen  in 

compression. 

e  structures 

msactions  of 

m  infant  of 

he  vertebral 

}ly  filled  by 

o  the  possi- 

ad  had  for 

IS  more  or 

dulus  was 

on  without 

ened  from 

a  piece  of 

ition.     The 

ics  to  the 

•ation,  had 

1S96,  No. 

ghth    day) 

ernal   part. 

gieht  Irin 

X  the  ques- 
argcd  thy- 
lon  doaLh. 
in  stances 
ng  infants 
lenly  with 


(lyspn(ra,  have  hecome  cyanotic  and  died  in  a  few  minutes.  In  such  cases 
the  thyniMs  has  been  I'ound  greatly  enlarged,  and  (h'ath  has  been  thought 
to  be  directly  due  either  to  j)ressiire  on  (he  air-passage.^  pressure  on  the 
pneumogustrie  (causing  spasm  of  the  glottis),  or  pressure  on  the  great  ves- 
.-els.  To  the  second  group  belong  the  cases  in  adults  which  have  been  de- 
fcribed  of  late  by  Nordmann,  I'altauf,  Oiilmacher,  and  others,  in  wliicli 
the  sudden  death  has  occurred  under  such  coiulitions  as  ana'sthesia  or 
while  bathing.  In  a  nund)er  of  these  cases  not  only  has  the  thymus  been 
found  enlarged,  but  the  spleen  and  lymphatic  tissues  generally.  The  ques- 
tion is  one  of  considerable  medico-legal  interest,  and  has  been  spoken  of 
under  Lymphatism. 

KoUeston  reixuts  a  case  of  sudden  death  after  signs  of  cardiac  failure 
lusting  for  only  twenty  minutes,  in  which  there  was  hyi)eri)lasia  of  a  per- 
sistent thymus.    The  gland  with  the  trachea  weighed  11  ounces. 

{(■)  Thijrmis  Gland  and  Exophtlialntic  (loitre. — That  there  is  some  asso- 
ciation between  these  conditions  is  urged  on  two  grounds:  First,  the  per- 
sistence of  the  gland  in  Graves'  disease.  W.  W.  Ord  and  Hector  Mac- 
kenzie state  that  it  has  been  found  enlarged  in  all  the  cases  recently  exam- 
ined at  8t.  Thomas's  lios})ital.  Ilektoen  concludes  from  a  very  thorough 
.-liidy  of  the  question  that  the  coe.vistenee  is  nu)re  than  accidental.  Sec- 
(indly,  the  good  results  which  are  stated  to  follow  the  feeding  of  the  thymus 
j^land  in  Graves'  disease  are  held  to  bear  out  the  idea  that  the  enlargement 
(luring  life  is  compensatory.  The  general  conclusion,  however,  reached  by 
Hector  Mackenzie  and  by  Kinnicutt  is  that  the  thymus  feeding  has  at  best 
only  slight  influence  upon  Graves'  disease. 

It  is  interesting  to  note  in  connection  with  the  question  of  enlarged 
thymus  and  sudden  death  that  two  of  Hale  White's  cases  of  exophthalmic 
goitre  died  suddenly,  and  autopsy  showed  no  reasonable  cause  of  death. 

Among  other  conditions  \\ith  which  enlarged  thymus  has  been  associ- 
ated may  lie  mentioned  epilepsy  (Ohlmacher). 

III.  Other  Morbid  Conditions  of  the  Thymus. — Ilamorrlmges  are  not 
micommon,  and  are  found  particularly  in  children  who  have  died  of 
asphyxia. 

Tnmnrs  of  the  gland,  particularly  sarcoma  and  lympho-sarcoma,  have 
lieen  frequently  described.  Many  mediastinal  tumors  originate  in  the  rem- 
nants of  the  thymus.  Dermoid  tumors  and  cysts  have  also  been  met  with. 
Tuberculosis  of  the  gland,  chiefly  in  the  form  of  miliary  nodules,  is  well 
described  in  Jacobi's  monograph.  There  is  a  well-authenticated  case  in 
which  it  was  primary.  Focal  necroses  in  diphtheria  have  also  been  de- 
scribed by  Jacobi. 

Abscess  of  the  Thymus. — Dubois,  in  1850,  noted  the  occurrence  of  foci 
of  suppuration  in  the  gland  in  sul)jects  of  congenital  syphilis.  Throughout 
it  round  or  fissure-like  cavities  are  seen  filled  with  a  purulent  fluid.  Chiari 
states  that  some  of  these  supposed  abscesses  are  areas  of  post-mortem  soften- 
ing, or  cysts  lino*''  with  flattened  epithelium  containing  detritus  of  thymus 
cells.    In  one  ca^c  Jacobi  found  a  small  gumma. 


SECTION  IX. 


DISEASES  OF  THE   KIDNEYS. 


I.   MALFORMATIONS. 

Newman  olnssifics  the  nialfoniiations  of  the  kidney  as  follows:  A.  Dis- 
placements without  mol)ility — (1)  congenital  displacement  without  de- 
formity; (2)  congenital  displacement  with  deformity;  (3)  acquired  dis- 
])lacements.  B.  Malformations  of  the  kidney.  I.  Yarialious  in  numljcr — 
(a)  su[;ernumerary  kidney;  (l>)  single  kidney,  congenital  absence  of  one 
kidney,  atropliy  of  one  kidney;  (c)  absence  of  both  kidneys.  II.  Varia- 
tions in  form  and  size — (a)  general  variations  in  form,  lobulation,  etc.;  {1)) 
hypertrophy  of  one  kidney;  (c)  fusion  of  two  kidneys — horseshoe  kidney, 
sigmoid  kidney,  disk-shaped  kidney.  C.  Variations  in  pelvis,  ureters,  and 
blood-vessels. 

The  fused  kidneys  may  form  a  large  mass,  which  is  often  displaced,  being 
either  in  an  iliac  fossa  or  in  the  middle  line  of  the  abdomen,  or  even  in  the 
pelvis.  Under  these  circumstances  it  may  be  mistaken  for  a  new  growth. 
In  Polk's  case  the  organ  was  removed  under  the  belief  that  it  was  a  floating 
kidney.*  The  patient  lived  eleven  days,  had  complete  anuriar  and  it  was 
found  post  mortem  that  a  single  unsymmetrical  kidney,  as  this  form  is 
called,  had  been  removed. 


11.    MOVABLE    KIDNEY. 

(Floating  Kidney  ;  Palpable  Kidney ;  Renmohilis;  Nephroptosis). 

The  kidney  is  held  in  position  by  its  fatty  capsule,  by  the  peritonjeum 
which  passes  in  front  of  it,  and  by  the  blood-vessels.  Normally  tlie  kidney 
is  firmly  fixed,  but  under  certain  circumstances  one  or  another  organ,  more 
rarely  both,  becomes  movable.  In  very  rare  cases  the  kidney  is  surrounded, 
to  a  greater  or  less  extent,  by  the  peritona?um,  and  is  anchored  at  the  hilus 
by  a  mcsonephron.  Some  would  limit  the  term  floating  kidney  to  this  con- 
dition. 

Movable  kidney  is  almost  always  acquired.     It  is  more  common  in 


846 


*  New  York  Medical  Journal,  1883. 


ovvs:  A.  Dis- 

witliout    (Ic- 

icquircHl  dis- 

in  number — 

ionee  of  one 

II.  Vnriii- 

ion,  etc.;  (b) 

shoe  kidney, 

ureters,  and 

)laced,  bein^f 
even  in  the 

lew  growtli. 

IS  a  floating 
and  it  was 
lis  form  is 


eritonfenm 
the  kidney 
[•gan,  more 
irroiinded, 
;  the  hiliis 
this  con- 

immon  in 


MOVABLE  KIDNEY. 


847 


women.  Of  the  fifiT  cases  collected  in  the  literature  by  Kuttner,  r)84  were 
ill  women  and  oidy  83  in  men.  It  is  more  common  on  the  right  than  on 
the  left  side.  Of  T;i'7'  cases  analyzed  i)y  this  author,  it  occurred  on  the  right 
in  ^)^)'>i  cases,  on  the  left  in  HI,  and  on  both  sides  in  !>;J.  The  greater  fre- 
(jucncy  of  tiie  condition  in  woUkU  may  be  attributed  to  com[)ression  of  the 
lower  thoracic  zone  by  tight  lacing,  and,  more  important  still,  to  the  rela.xa- 
tion  of  the  al^dominal  walls  which  follows  reja'ated  pregmmcies.  This  (h  s 
not  account  for  all  tiic  cases,  as  movable  kidney  is  by  no  means  uncommon 
in  nullipara".  Drummoiul  believes  that  in  a  majority  of  the  cases  there  is 
a  congenitally  relaxed  condition  of  the  peritoneal  attachments.  The  condi- 
tion has  been  met  with  in  infants.  Wasting  of  the  fat  about  the  kidney 
may  be  a  pause  in  some  instances.  Trauma  and  tlu;  lifting  of  heavy  weights 
are  occasionally  factors  in  its  production.  The  kidney  is  sometimes  dragged 
down  by  tumors.  The  greater  frequency  on  the  right  side  is  probably  asso- 
ciated with  the  position  of  the  kidney  just  beneath  the  liver,  and  the  de- 
pression to  which  the  organ  is  subjected  with  each  descent  of  the  diaphragm 
in  inspiration. 

And,  lastly,  movable  kidney  is  met  with  in  many  cases  which  ])resent 
that  combination  of  neurasthenia  with  gastro-intestinal  disturbance  which 
has  been  described  by  Olenard  as  enteroptosis  (see  p.  541). 

To  determine  the  presence  of  a  movable  kidney  the  patient  should  be 
jilaced  in  the  dorsal  })osition,  with  the  head  moderately  low  and  the  ab- 
dominal walls  relaxed.  The  left  hand  is  placed  in  the  lumbar  region  behind 
the  eleventh  and  twelfth  ribs;  the  right  hand  in  the  hyjjochondriac  region, 
in  the  nipple  line,  just  under  the  edge  of  the  liver.  IJimanual  i)alpation 
may  detect  the  presence  of  a  firm,  rounded  body  just  below  the  edge  of  the 
ribs.  If  "othing  can  be  felt,  the  patient  should  be  asked  to  draw  a  deep 
breath,  wiien,  if  the  organ  is  palpable,  it  is  touched  by  the  fingers  of  the 
right  hand.  Various  grades  of  mobility  may  be  recognized.  It  may  be 
possible  barely  to  feel  the  lower  edge  on  deep  palpation — palpable  kitlncy — • 
or  the  organ  may  be  so  far  displaced  that  or  drawing  the  deepest  breath 
the  fingers  of  the  right  hand  may  be,  in  a  thin  person,  slipjied  above  the 
upper  end  of  the  orgar,  which  can  be  readily  held  down,  but  cannot  be 
pushed  below  the  level  of  the  navel — movable  kidney.  In  a  third  group  of 
cases  the  organ  is  freely  movable,  and  may  even  be  felt  just  above  Pou])art's 
ligament,  or  may  ho  in  the  middle  line  of  the  abdomen,  or  can  even  be 
pushed  over  beyond  this  point.  To  this  the  term  floaling  kidney  is  appro- 
priate. 

The  movable  kidney  is  not  painful  on  pressure,  except  when  it  is  grasped 
very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickening  sensation. 
Examination  of  the  patient  from  behind  may  show  a  distinct  flattening 
in  the  lumbar  region  on  the  side  in  which  the  kidney  is  mobile. 

Symptoms  — In  a  large  majority  of  eases  there  are  no  symptoms,  and 
if  detected  accidentally  it  is  well  not  to  let  the  patient  know  of  its  presence. 
Far  too  much  stress  has  been  laid  upon  the  condition  of  late  years.  In 
other  instances  there  is  pain  in  the  lumbar  region  or  a  sense  of  dragging 
and  discomfort,  or  there  may  be  intercostal  neuralgia.  In  a  large  group 
the  symptoms  are  those  of  neurasthenia  with  dyspeptic  disturbance.     In 


848 


DISKASES  OF  THE   KIDNEYS. 


woiiicii  the  liyslcriciil  sympioiiis  muy  Ix*  inarkccl,  and  in  nicn  various  fjradcs 
(if  liy|t()(li()ii(lriasis.  Tlu'  ^'aslric  (listiiihniict'  is  usually  a  form  ol'  iutvous 
(lys|it'j)sia.  Dilatation  of  tlio  stoniacli  lias  Ix-cn  observed,  o\vin<,s  as  suj,'«;ested 
by  liartelrt,  to  pressure  of  the  disioeated  kidney  upon  the  duodeiuiui.  This 
view  has  been  su|)porte(l  by  Oser,  Ijandau,  and  Mwald.  On  the  other  hand, 
liillen  holds  that  the  dilatation  of  the  stomach  is  the  eause  (d'  the  niol)ility 
(d'  the  ki<lney,  and  he  found  in  10  eases  of  depression  and  dilatation  of  the 
Ktoiuaeh  22  instances  of  dislocation  of  the  kidney  on  the  right  side.  My 
own  experience  coincides  with  that  of  Druinniond,  wlio  has  very  excep- 
tionally found  the  two  conditions  to  coexist.  The  association,  however, 
with  a  (Ifjiirssnl  stonuich  is  certaiidy  not  uncommon  in  women.  Constipa- 
tion is  not  iiifret[uent.  Some  writers  have  deseribed  [)ressurc  upon  the 
gall-ducts,  with  jaundice,  but  it  is  not  very  likely  to  occur.  Fa'cal  accumu- 
hition  and  even  obstruction  nuiy  be  associated  with  the  displaced  organ. 

DirlTs  Crises. — ^In  lloating  kidney  theic  are  attacks  characterized  ])y 
severe  abdominal  pain,  chills,  nausea,  vomiting,  fever,  and  collapse.  Scarcely 
any  mention  is  made  of  such  symptoms,  which  were  first  described  by  Dietl 
in  1(S()4,  and  a  more  widespread  knowledge  of  their  occurrence  in  connec- 
tion with  this  condition  is  desirable.  My  attention  was  called  to  them  in 
IHcSO  by  Palmer  Howard  in  the  case  of  a  stout  lady,  who  suil'ered  repeatedly 
with  the  most  severe  attacks  of  abdominal  j)ain  and  vomiting,  which  con- 
stantly required  morj)hia.  A  tumor  was  discovered  a  little  to  the  right  of 
the  navel,  and  the  diagnosis  of  probable  neoplasm  was  concurred  in  by 
Flint  (Sr.)  and  fJaillard  Thomas.  The  jjaticnt  lost  weight  rapidly,  became 
emaciated,  and  in  the  s})ring  ol  IHSl  again  went  to  New  York,  where  she 
saw  Van  Buren,  who  diagnosed  a  floatinj;  kidney  and  said  that  those  parox- 
ysms were  associated  with  it  in  a  gouty  person.  lie  cut  off  all  stimulants, 
reassured  the  lady  that  she  had  no  cancer,  and  from  that  time  she  rai)idly 
recovered,  and  the  attacks  have  been  few  and  far  l)elwccn.  In  this  patient 
any  overindulgence  in  eating  or  in  drinking  is  still  liable  to  be  followed 
by  a  very  severe  attack.  These  attacks  may  also  be  mistaken  for  renal  colic, 
and  the  operation  of  nephrotomy  has  been  performed. 

In  other  instances  the  attacks  of  ])ain  may  be  thought  to  be  due  to  in- 
testinal disease  or  to  recurring  ai)pcndicitis.  The  cause  of  these  parox- 
ysmal attacks  is  not  quite  clear.  Dietl  thought  they  were  due  to  strangu- 
lation of  the  kidney  or  to  twists  or  kinks  in  the  renal  vessels  due  to  the 
extreme  mol)ility.  During  the  attacks  the  urine  is  sometimes  high-colored 
and  contains  an  excess  of  uric  acid  or  of  the  oxalates.  It  is  stated,  too, 
that  blood  or  jms  may  be  present.  The  kidney  may  be  tender,  s"wollen, 
and  less  freely  movable. 

InfcnniHeiif  hi/droncplirosis  is  sometimes  associated  with  movable  kidney. 
Three  cases  are  reported  in  my  Lectures  on  Abdominal  Tumors.  Tn  two  the 
condition  has  been  completely  relieved  l)y  a  well-adapted  pad  and  belt;  in 
the  third,  attacks  recur  at  long  intervals. 

The  diofjttosis  is  rarely  doubtful,  as  the  shape  of  the  organ  is  \isually 
distinctive  and  the  mobility  marked.  Tumors  of  the  gall-hhidder,  ovarian 
growths,  and  tumors  of  the  bowels  may  in  rare  instances  he  confounded 
with  it. 


CIIICULATOUY   DISTUUHAXCl 


849 


rioiis  jjrnclcs 
ol'  nervous 

iniiii.     This 

other  hfiiid, 

lie  iii()l)ility 

ition  of  the 

t  side.     My 

very  excep- 

II,   however, 

Constipa- 

e  upon  the 

'111  aeeuimi- 

1  orpin. 

cterized   by 

ic.  Scarcely 

cd  ])y  Diell 

in  conncc- 

to  them  in 

repeatedly 

which  con- 

he  rijfht  of 

rred   in   hy 

lly,  hecanie 

where  she 

lose  i)arox- 

<timidants, 

he  ra|)idly 

lis  i)atient 

e  followed 

enal  colic, 

due  to  in- 
2se  parox- 
>  stranjTu- 
uo  to  the 
;h -colored 
ated,  too, 
s-wollen, 

'  kidney, 
n  two  the 
l)clt;  in 

s  usually 
ovarian 
ifounded 


Treatment. — The  kidney  has  heen  extirpated  in  many  instance.",  hut 
Ihe  operation  is  not  wit  hunt  risk,  and  there  have  heen  si'veral  fatal  i-ases. 
Stitching  of  the  kidney — nephrorrhaphy — m  recoinniended  hy  Ilahn,  is  tlu! 
most  «uital)le  procedure,  and  statistics  published  by  Keen  show  that  relief 
is  alforded  in  many  cases  by  the  iirocedure.  It  does  not,  however,  always 
riiccecd. 

In  many  instances  the  greatest  relief  is  ex|)crienced  from  a  bandage  and 
|iiid.  It  should  lie  applied  in  the  morning,  with  tlu;  patient  in  the  recuni- 
licnt  posture,  and  she  should  be  taught  how  to  push  up  the  kidney.  An  air 
pid  may  l»e  usimI  if  the  organ  is  si-nsitive.  in  other  cases  a  broad  bandage 
well  padded  in  the  lower  abdominal  zone  pushes  up  the  intestines  and 
makes  them  act  as  a  su])port.  In  the  attacks  of  severe  colic  morphia  is 
i('(iuircd.  When  dependent,  as  seems  sometimes  the  case,  upon  an  excess 
of  uric  aciil  or  the  oxalates,  the  diet  must  be  carefully  regulated. 

Koran  exhaustive  consideration  of  all  aspects  of  the  sulgeet,  see  l-'isclier, 
in  Nos.  1-5  of  the  (Jentralblatt  f.  d.  (ircnzgebiete  der  Mcdiciu  und  Chirur- 
^Mc,  lHi)8. 

III.  CIRCULATORY  DISTURBANCES. 

Normally  the  secretion  of  urine  is  accomplished  by  the  maintenance 
of  a  certain  blood-pressure  within  the  glomeruli  and  by  the  activity  of 
the  renal  (>|»itheliuin.  IJowman's  views  on  this  ciiiestion  bave  been  gen- 
erally accepted,  and  the  watery  elements  are  held  to  be  liltered  from  the 
gl(  meruli;  the  amonnt  depending  on  the  ra})idity  and  the  pressure  of  the 
Mood  current;  the  quality,  whether  normal  or  abnormal,  dc|)ending  upon 
tlie  condition  of  the  cai)illary  and  glomerular  e|)ithelium;  wliile  the  greater 
)poition  of  the  solid  ingredients  are  excreted  by  the  e])ithelium  of  the  con- 
voUitcd  tubules.  The  integrity  of  the  e])ithelinm  covering  the  capillary 
tufts  within  Bowman's  capsule  is  essential  to  the  production  of  a  normal 
urine.  If  under  any  circumstances  their  uutrition  fails,  as  when,  for  e.x- 
am|)le,  the  rajtidity  of  the  blood  current  is  lowered,  so  that  they  are  deprived 
of  the  necessary  amount  of  oxygen,  the  material  which  filters  through  is 
no  longer  normal  (i.  e.,  water),  but  contains  serum  albumin.  Cohnheim 
lias  shown  that  the  renal  e])ithelium  is  xtremely  sensitive  to  circulatory 
changes,  and  tliat  com])ression  of  the  renal  artery  for  only  a  few  minutes 
causes  serious  disturbance. 

The  circulation  of  the  kidney  is  remarkably  influenced  by  reflex  stimuli 
coming  from  the  skin.  Ex])osure  to  cold  causes  heightened  blood-pressure 
within  the  kidneys  and  increased  secretion  of  urine.  Bradford  has  shown 
that  after  excision  of  portions  of  the  kidney,  to  as  much  as  one  third  of 
the  total  weight,  there  is  a  remarkable  increase  in  the  tlow  of  urine. 

Congestion  of  the  Kidneys.— (1)  Active  Congestion  ;  Hypemmin. — 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  cold  or  to  the  action  of  poisons  and  severe  irritants.  Tur- 
pentine, cubebs,  cantharides,  and  co]iaiba  arc  all  stated  to  cause  extreme 
liypera>mia  of  the  organ.  The  most  ty]iical  congestion  of  the  kidney  which 
we  see  post  mortem  is  that  in  the  early  stage  of  acute  Bright's  disease,  when 


850 


DIHKASES  OF  TIIK   KIDNKYS. 


^ 


tlie  organ  may  be  large,  Boft,  of  a  dark  coldr,  and  on  Hcction  hlood  drip>i 
from  it  freely. 

It  lins  lieeri  held  tliiit  in  all  the  neiite  fevers  the  kidlieyn  are  eoiij:esteil. 
and  that  this  explained  the  seiiiity,  high-eolured,  and  ofuui  allMiiniu(iu> 
nrint'.  On  the  other  hand,  hy  Koy'n  (ineometer,  Walter  Mendelsoii  hi.s 
HJiown  that  the  kidney  in  aente  fever  in  in  a  Htate  of  extreme  anaimia,  Hiiiall. 
pale,  and  hjoodless;  and  that  this  anainia,  increasing  with  the  pyrexia  and 
interfering  with  the  nutrition  of  the  glomerular  epithelium,  accounts  toi 
the  scanty,  dark-colored  urine  of  fever  and  for  the  presenee  of  alhumiii. 
In  llie  jirolonged  feverH,  liowever,  it  is  prohahle  that  relaxation  of  the 
arteries  again  lakes  place.  Certainly  it  Ih  rare  to  iind  post  mortem  such 
a  condition  of  the  kidney  as  is  descrihed  '  v  Mendelson.  On  the  contrary, 
the  kidney  (d'  fever  is  common'y  swollen  *!ie  hlood-vessels  are  congested, 
and  the  cortex  fretiuently  shows  traces  of  cloudy  swelling.  However,  tlie 
circulatory  disturbances  in  acute  fevers  are  prohahly  less  important  than 
the  irritative  ell'ects  of  either  the  s|)eei(ic  agents  of  the  disease  or  the  prod- 
nets  produced  in  their  growth  or  in  the  altered  metaliolism  of  the  tissues. 
The  urine  is  diminisl  '  in  amount,  and  nuiy  contain  albumin  and  tube- 
casts. 

(2)  Passii'fl  Coiuji'slioii ;  McrlKinicdl  U fifieramUi. — This  is  found  in  eases 
of  chronic  di.sease  of  the  heart  or  lung,  with  impeded  circulation,  and  as  a 
result  of  pressure  upon  the  renal  veins  by  tumors,  the  pregniint  uterus,  or 
ascitic  fluid.  In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic  induration 
associated  with  chronic  heart-disease,  the  organs  arc  enlarged  and  firm, 
the  capside  strips  oif,  as  a  rule,  readily,  the  cortex  is  of  a  deej)  red  color, 
and  the  pyramids  of  a  purple  red.  The  section  is  coarse-looking,  the  sub- 
stance is  very  firm,  and  resists  cutting  and  tearing.  The  interstitial  tissue 
is  increased,  and  there  is  a  small-celled  infiltration  between  the  tubules. 
Here  and  there  the  Afalpighian  tnl'ts  have  become  sclerosed.  The  blood- 
vessels are  usually  thickened,  and  there  nuiy  be  more  or  less  granular,  fatty, 
or  hyaline  changes  in  the  epithelium  of  the  tubules.  The  condition  is  in- 
deed a  difTnse  nej)hritis.  The  nrine  is  usually  reduced,  is  of  high  specific 
gravity,  and  contains  more  or  less  albumin.  Hyaline  tube-casts  and  blof)d- 
corpupcles  are  not  uncommon.  In  uncomplicated  cases  of  the  cyanotic  in- 
duration nra'uiia  is  rare.  On  the  other  hand,  in  the  cardiac  cases  with  ex- 
tensive arterio-sclcrosis,  the  kidneys  are  more  involved  and  the  renal  func- 
tion is  likely  to  be  disturbed. 


IV.    ANOMALIES    OF   THE    URINARY   SECRETION. 

1.  Anuria. 

Total  suppression  of  urine  occurs  under  the  following  conditions: 

(1)  As  an  event  in  the  intense  congestion  of  acute  ne]ihritip.     For  a 
time  no  urine  may  be  formed;  more  often  the  amount  is  greatly  reduced. 

(2)  More  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 
fragments  of  which  block  both  ureters.    Sir  William  Roberts  calls  the  con- 


ANOMALIKS  OF  TIIR   URINARY  SK('RKTI«>N. 


861 


(lition  "  latent  uiipniia."  Tlu'ri'  may  lie  very  little  (lisri>rnl'<irt,  ami  the 
"MiililoiiiH  are  very  unlike  tlmne  of  orilinary  iinemia.  C'i»n\  nlsunis  oceurreil 
in  only  ft  of  41  cuHeH  (Ilorter);  headache  in  (inly  (!;  vomiting  in  only  1*^. 
CcMHeioUHneKH  Ih  retained;  the  pupils  are  Uhnully  eontraeted;  thu  tempera- 
ture may  he  low;  ther«'  are  twitchin^^s  aixl  perhaps  ocensional  vomitinj^. 
(»!'  II  eases  in  the  literature,  .'{T)  occurred  in  nudes.  Of  \\(\  cases  in  wliicii 
there  was  ahsolute  anuria,  in  11  the  condition  lasted  more  than  four  days, 
in  18  caneH  from  seven  to  fourteen  days,  and  in  7  caHCH  longer  than  four- 
teen days  (lierter). 

(."{)  Cases  occur  occasionally  in  which  the  su|)pression  is  prer'nal.  The 
following  are  anutng  the  more  impo>'*ant  conditions  'vith  which  this  form 
of  anuria  may  be  associateil  (Ilenslc),  Fevers  and  inllamnuitit.ns;  acute 
poisoning  hy  phosphorus,  lead,  and  turpentine;  in  the  collapse  after  severe 
injuries  or  after  operations,  or,  indeed,  after  the  passing  of  u  catheter;  in 
the  collapse  stage  of  cholera  aiul  yellow  fever;  and,  lastly,  there  is  an 
hysterical  anuria,  of  which  Charcot  reports  a  case  in  which  the  su|)pression 
lusted  for  eleven  days.  Bailey  reports  the  case  of  a  young  girl,  aged  eleven, 
iiiiiuite  of  an  (trphan  asylum,  who  passed  no  tiriiie  froju  ()ctt)lier  lOth  to 
Pccemher  I'^th  (when  H  ouiu-es  were  withdrawn),  and  again  from  this  date  to 
March  1st!    The  (|ue8tion  of  hysterical  deception  was  considered  in  the  case. 

A  patient  may  live  for  from  ten  days  to  two  weeks  with  complete  sup- 
pression. In  I'olk's  case,  in  which  the  only  kidney  was  removed,  the  pa- 
tient lived  eleven  days.  It  is  renuirkahle  that  in  nuiiiy  instances  there  are 
no  toxic  features.  Adams  reports  a  case  of  recovery  after  nineteen  days  of 
sup|)ression. 

In  the  ohstrnctive  cases  surgical  interference  should  be  resorted  to. 
Tn  tlie  non-o])struetive  cas  s,  ])articularly  when  due  to  extrenu'  congestion 
of  the  kidiu>y,  cupping  over  the  loins,  hot  applications,  free  purging,  aiul 
sweating  with  ])ilocarpine  aiul  hot  air  are  indicated.  When  the  secretion  is 
once  started  diuretin  often  acts  well.  Large  hot  irrigations,  with  normal 
salt  solution,  with  Kemp's  double-current  rectal  tubes,  should  bo  tried,  as 
they  are  stated  to  stimulate  the  activity  of  the  kidneys  in  a  remarkable  way. 


2.    n-li:MAT(RIA. 

The  followin'r  division  may  he  made  of  the  causes  of  hfrmaturia: 

(1)  General  Diseases. — The  malignant  forms  of  the  acute  specific  fevers. 
Occasionally  in  leuka}mia  ha^maturia  occurs. 

(2)  Renal  Causes. — Acute  congestion  and  inflammation,  as  in  Bright's 
disease,  or  the  effect  of  toxic  agents,  such  as  turjientine,  carliolic  acid,  and 
cantharidcs.  "When  the  car])olic  spray  was  in  use  many  surgeons  suffered 
from  ha^maturia  in  consequence  of  this  poison.  Eenal  infarction,  as  in 
ulcerative  endocarditis.  New  growths,  in  wliich  the  bleeding  is  usually 
profuse.  In  tuberculosa ,  at  the  onset,  when  the  papillne  are  involved,  there 
may  he  bleeding.  Stone  in  the  kidney  is  a  frequent  cause.  Parasites:  The 
Filaria  sanguinis  Iwminis  and  the  Bilharzia  cause  a  form  of  ha^maturia  met 
with  in  the  tropics.  The  echinococcus  is  rarely  associated  with  haemor- 
rhage. 


852 


DISEASES  OP  THE  KIDNEYS. 


(n)  Ajfrrltdns  of  the  Criiiari/  Passarirs. — Stoiio  in  tlio  uivtor,  iumor  or 
lilc'cratioii  of  tlu'  liliiddcr,  tlic  prcsciu'e  ol"  a  CiiU'iilus,  parasitt'S,  ami,  vory 
rarely,  ruptured  veins  in  the  l)l!idder.  IMcediu^  from  ti»c  urethra  ocea- 
sionally  oeeurs  in  ^oiiorrluea  aiul  as  a  result  of  the  lodgment  of  a  cal- 
culus. 

(4)  Tnninidtisin. —  Injuries  may  })roduec  bleeding  from  any  part  of  the 
urinary  passages.  l»y  a  I'all  or  blow  on  the  back  the  kidney  may  be  rup- 
tured, and  this  may  be  followed  by  very  free  bleeding;  less  commonly  the 
blood  conies  from  injury  td'  the  bladder  or  of  the  jirostute.  JJlood  from 
the  urethra  is  fre(|uently  due  to  injury  by  the  i)assage  of  a  catheter,  or 
sometimes  to  falls  or  blows. 

And,  lastly,  tlieie  is  a  very  interesting  group,  carefully  studied  of  late 
years,  ))artieularly  l)y  Kleniperer  and  M.  Ij.  Harris,  in  which  no  known 
lesions  have  been  found.  It  is  probably  in  this  group  of  cases  that  (julTs 
''renal  ej)istaxis  "oeeurs.  ]larris  has  recently  collected  18  of  these  cases 
from  the  literature.  'J'he  lirst-iuimed  author  th' '.ks  it  is  a  form  of  angio- 
neurotic haMuaturia.  An  interesting  point  is  that  in  Hxe  18  cases  collected 
by  Harris  ne]»hrotoniy  was  done;  of  these,  9  cases  were  comidetely  re- 
lieved. 

Of  special  interest  is  the  malarial  luvmaturia  which  i)revails  in  certain 
districts  and  has  already  been  considered  in  the  section  on  paludism. 

The  (Jiiinnosis  of  luvmaturia  is  usually  easy.  The  color  of  the  urine 
varie;-  from  a  light  smoky  to  a  bright  red,  or  it  nuiy  have  a  dark  porter 
color.  K.xamined  with  the  n'"croscoi)e,  the  blood-cor])uscles  are  readily 
recognized,  either  ])lainly  visible  and  retaining  their  color,  in  which  case 
they  are  usually  crcjiated,  or  simply  as  shadows.  In  ammoniaeal  urine 
or  urines  of  low  specific  gravity  the  haemoglobin  is  rapidly  dissolved  from 
the  corpuscles,  but  in  normal  urine  they  remain  for  many  hours  unchanged. 

For  other  tests  the  student  is  referred  to  the  works  on  Clinical  Diag- 
nosis, by  Simon  and  by  von  Jaksch. 

It  is  important  to  distinguish  between  blood  coming  from  the  bladder 
and  from  the  kidneys,  though  this  is  not  always  easy.  From  the  bladder 
the  blood  may  be  found  only  with  the  last  ])ortions  of  urine,  or  only  at  the 
termination  of  micturition.  In  luvmorrhagc  from  the  kidneys  the  blood 
and  urine  are  intimately  mixed.  Clots  are  more  connnonly  found  in  the 
blood  from  the  kidneys,  and  may  f(n'm  moulds  of  the  ])elvis  or  of  the  ureter. 
"When  the  seat  of  the  bleeding  is  in  the  bladder,  on  washing  out  this  organ, 
the  water  is  more  or  less  blood-tinged;  but  if  the  source  of  the  bleeding  is 
higher,  the  water  comes  away  clear.  In  many  instances  it  is  dilficult  to 
settle  the  question  by  the  examination  of  the  urine  alone,  and  the  symp- 
toms and  the  physical  signs  must  also  be  taken  into  account.  Cystoscopic 
examination  of  the  bladder  and  catheterization  of  the  ureters  may  aid  in 
the  diagnosis  in  obscure  cases. 


3.    lI.EMOGLOBIXrniA. 

This  condition  is  characterized  by  the  presence  of  blood-pigment  in 


the  urine. 


The  blood-cells  arc  either  absent  or  in  insignificant  numbers. 


ANOMALIES  OP  THE  URINARY  SECRETION. 


853 


or,  tumor  or 
is,  ami,  vory 
irctlim  (K'c'ii- 
nt  of  II  cal- 

'  part  of  the 
may  bo  riip- 
mmouly  the 
.Uh)()d  from 
catheter,  or 

<liocl  of  lato 
1  no  known 
that  (J nil's 
those  cases 
in  of  angio- 
5es  collected 
npletely  re- 

s  in  certain 
1(1  ism. 

f  the  urine 
dark  porter 
are  readily 
which  case 
iacal  urine 
olved  from 
unchanged, 
lical  Diag- 

hc  bladder 

le  bladder 

)nly  at  the 

the  blood 

ind  in  the 

the  ureter. 

his  orcan, 

leeding  is 

ilTicult  to 

he  symp- 

ystoscopic 

ay  aid  in 


,nnent  in 
numbers. 


Tlie  coloring  matter  is  not  Inematin,  as  indicated  i)y  the  old  name,  luvma- 
tinuria,  nor  in  reality  always  ha'ni(»gl<)i)in,  hut  it  is  most  Ireiinently  nulhaj- 
iiioglohin.  The  urine  has  a  red  or  brownish-red,  smnetinu'S  ipiile  black 
(olor,  and  usually  deposits  a  very  heavy  brownish  sediment.  When  the 
liiemoglobin  occurs  only  in  snudl  (piantities,  it  may  give  a  lake  or  smoky 
color  to  the  urine.  Microscopical  examination  shows  tiie  pri'sence  of  granu- 
liir  pigment,  sometimes  fragnu'uts  of  blood-disks,  epithelium,  and  very  oltcii 
(liirkly  pigmented  urates.  The  urine  is  also  ali)uniinous.  The  nund)er  of 
red  blood-cor|)uscles  bears  no  i)roportion  whatever  ttt  the  intensity  of  the 
color  of  the  urine.  K.xamined  speclrosco|>ically,  there  are  either  the  two 
absorption  bands  of  oxylucmoglobin,  which  is  rare,  or,  more  conunoidy, 
there  are  the  three  absori)tion  bands  of  methicmoglobin,  of  which  the  one 
in  the  red  near  C  is  characteristic.  Two  clinical  groups  may  be  distin- 
guished. 

(1)  Toxic  HaBmoglobinuria. — This  is  caused  by  poisons  which  produce 
ra]>id  dii^solution  of  the  blood-cor[)Uscles,  such  as  chlorate  of  potash  in  large 
(loses,  pyrogallic  acid,  carbolic  acid,  arseniuretted  hydrogen,  carbon  mon- 
oxide, naphtliol,  and  muscarine;  also  the  poisons  of  scarlet  fever,  yellow 
lever,  typhoid  fever,  malaria,  ami  syphilis.  According  to  IJastianelli,  luvnu)- 
globinuria  due  to  the  administration  of  quinine  never  occurs  cxce|)ting  in 
jiatients  who  are  suH'ering  or  who  have  recently  suifcred  from  malarial 
lever.  It  has  also  followed  severe  burns.  Kxposurc  to  excessive  cold  and 
violent  muscular  exertion  are  stated  to  produce  lucmoglobinuria.  A  most 
renuirkablc  toxic  form  occurs  in  horses,  coming  on  with  great  suddenness 
and  associated  with  ])aresis  of  the  hind  legs.  Death  may  occur  in  a  few 
hours  or  a  few  days.  The  animals  are  attacked  only  after  being  stalled 
for  some  days  and  then  taken  out  and  driven,  particularly  in  cold  weather. 
The  form  of  liaMuoglobinnria  from  cold  and  exertion  is  extremely  rare.  Xo 
instance  of  it,  even  in  association  with  frost-bitos,  came  under  my  observa- 
tion in  Canada.  lUood  transfused  from  one  nunnmal  into  another  causes 
dissolution  of  the  corpuscles  with  the  ])roduction  of  liaMuoglobinuiia;  and, 
lastly,  there  is  the  epidemic  luvmixjlohiuuria  of  the  new-born,  associated  with 
jaundice,  cyanosis,  and  nervous  symptoms. 

(2)  Paroxysmal  HsBmoglobinViria. — This  rare  disease  is  characterized 
by  the  occasional  ])assage  of  bloody  urine,  in  which  the  coloring  nuitter 
only  is  present.  It  is  more  fre(;;ucnt  in  males  than  in  females,  and  occurs 
cliieily  in  adults.  It  seems  specially  associated  with  cold  and  exertion,  and 
has  often  been  brought  on,  in  a  susceptible  person,  by  the  use  of  a  cold 
foot-bath.  Paroxysmal  liaMuoglobinuria  has  been  found,  too,  in  ])ersons 
subject  to  the  various  forms  of  Raynaud's  disease.  Many  regard  the  rela- 
tion between  these  tw*T  affections  as  extremely  close:  sonu>  hold  that  they 
are  manifestations  of  one  and  the  same  disorder.  Druitt,  the  author  of  the 
well-known  Surgical  Vade-mecum,  has  given  a  graphic  description  of  his 
sulTerings,  which  lasted  for  many  years,  and  were  accom])anied  with  local 
asphyxia  and  local  syncope.  The  connection,  however,  is  not  very  common. 
In  only  one  of  the  cases  of  Raynaud's  disease  which  I  have  >ccn  was  parox- 
ysmal ha^moglobinuria  present,  and  in  it  cpile])tic  attacks  occurred  at  the 
same  time.    The  relation  of  the  disease  to  malaria  is  not  so  close  as  has  been 


854 


DISEASES  OF  THE  KIDNEYS. 


/ 


thought  by  many  writers.  Bastianclli  assorts  tliat  it  is  practically  proved 
tiiat  malarial  ha'nioglobinuria  occurs  ouly  in  infections  witii  the  a'stivo- 
autuninal  iiarasito.  Jt  rarely,  if  ever,  occurs  in  the  lirst  attack,  usually 
appearing  with  the  first  relapse  or  after  repeated  relapses.  No  doubt  it  has 
been  frequently  confounded  with  a  malarial  lueniaturia. 

The  attacks  may  come  on  suddenly  after  exj)osurc  to  cold  or  as  a  result 
of  mental  or  bodily  exhaustion.  They  may  be  preceded  by  chills  and 
pyrexia.  In  other  instances  the  temperature  is  subnormal.  There  may  be 
vomiting  and  diarrha'a.  Pain  in  the  lumbar  region  is  not  uncommon.  The 
ha'moglobinuria  rarely  persists  for  more  than  a  day  or  two — sometimes, 
indeed,  not  for  a  day.  There  are  instances  in  which,  even  in  the  course  of 
a  single  day,  there  have  been  two  or  three  paroxysms,  and  in  the  intervals 
clear  urine  has  been  passed.  Jaundice  has  been  present  in  a  number  of 
cases.  According  to  Ralfe,  paroxysmal  luKmoglobinuria  may  alternate  with 
general  symjjtoms  of  the  same  character,  but  associated  only  with  the  pas- 
sage of  albumin  and  an  increased  quantity  of  urea  in  the  urine.  In  such 
cases  he  su])poses  that  the  toxic  agent,  whatever  its  nature,  has  destroyed 
only  a  limited  number  of  the  corpuscles,  tlu  ■  >ring  matter  of  which  is 
readily  dealt  with  by  the  spleen  and  liver,  ^,  the  globulin  is  excreted 
in  the  urine.    The  cases  are  rarely  if  ever  fatal. 

The  essential  pathology  of  the  disease  is  unknown,  and  it  is  difficult 
to  form  a  theory  which  will  meet  all  the  facts — particularly  the  relation 
with  Raynaud's  disease,  which  is  rightly  regarded  as  a  vaso-motor  disorder. 
Increased  haemolysis  and  solution  of  the  ha?moglobin  in  the  blood-serum 
(hannoglobinamiia)  precedes,  in  each  instance,  the  appearance  of  the  color- 
ing matter  in  the  nrine.  A  full  discussion  of  the  subject  is  to  be  found 
in  F.  Chvostek's  monograph. 

Treatment. — In  all  forms  of  ha^matnria  rest  is  essential.  In  that  pro- 
duced by  renal  calculi  the  recumbent  posture  may  suffice  to  chock  the 
bleeding.  Full  doses  of  acetate  of  lead  and  opiym  should  be  tried,  then 
ergot,  gallic  and  tannic  acid,  and  the  dilute  sulphuric  acid.  The  oil  of 
turpentine,  which  is  sometimes  recommended,  is  a  risky  remedy  in  hema- 
turia. Extr.  hamamelis  virgin,  and  oxtr.  hydrastis  canad.  are  also  recom- 
mended.    Cold  may  be  applied  to  the  loins  or  dry  cups  in  the  lumbar 


region. 


The  treatment  of  ha^moglobinuria  is  unsatisfactory.  Amyl  nitrite  will 
sometimes  cut  short  or  prevent  an  attack  (Chvostek).  During  the  paroxysm 
the  patient  should  be  kept  warm  and  given  hot  drinks.  Quinine  is  recom- 
mended in  large  doses,  on  the  supposition — as  yet  unwarranted — that  the 
disease  is  specially  connected  with  malaria.  If  there  is  a  syphilitic  history, 
iodide  of  potassium  in  full  doses  may  be  tried.  In  a  warm  climate  the 
attacks  are  much  less  frequent. 

4.  Albuminuria. 


The  presence  of  albumin  in  the  urine,  formerly  regarded  as  indicative 
of  Bright's  disease,  is  now  recognized  as  occurring  under  many  circum- 
stances without  the  existence  of  serious  organic  change  in  the  kidney.    Two 


ANOMALIES  OF  TOE  URINARY  SECRETION. 


855 


^ally  proved 

llio  a!stiv()- 

ick,  usually 

ioubt  it  has 

r  as  a  result 

chills  and 

lere  may  be 

nmon.    The 

-sometimes, 

le  course  ol' 

he  intervals 

number  of 

ernate  witii 

ith  the  pas- 

e.     In  such 

IS  destroyed 

of  which  is 

is  excreted 

is  difficult 
;he  relation 
or  disorder, 
jlood-serum 
f  the  color- 
0  be  found 

n  that  pro- 
check  the 
ried,  then 

The  oil  of 

in  hivma- 

Iso  recom- 

le  lumbar 

nitrite  will 

paroxysm 

is  recom- 

-that  the 

ic  history, 

imate  the 


indicative 
y  circum- 
ley. 


Two 


groups  of  cases  may  be  recor,Miizi'd — those  in  which  the  kidneys  show  no 
coarse  lesions,  and  those  in  which  there  are  evident  anatomical  changes. 

Albuminuria  without  Coarse  Renal  Lesions. — (o)  Fumiiunul,  s.i-calkd 
rinjsioluyical  Albuminuria. — in  a  normal  condition  of  the  kidney  only  the 
water  and  the  salts  are  allowed  to  pass  from  the  blood.  When  albuminous 
hiilistances  transude  there  is  probably  disturbance  in  the  nutrition  of  the 
(']iit helium  of  the  ca[)illaries  of  the  tuft,  or  of  the  cells  surrounding  the 
glomerulus.  This  statement  is  still,  however,  in  dispute,  and  Senator, 
(iiaingcr  Stewart,  and  others  hold  that  there  is  a  })hysiological  albuminuria 
which  may  follow  muscular  work,  the  ingestion  of  food  rich  in  all)umin, 
violent  emotions,  cold  bathing,  and  dyspejjsia.  The  diiferences  of  opinion 
on  this  point  are  striking,  and  observers  of  equal  thoroughness  and  relia- 
liility  have  arrived  at  directly  ojjposite  conclusions.  The  presence  of  albu- 
min in  the  urine,  in  any  form  and  \inder  any  circumstance,  may  be  regarded 
as  indicative  of  change  in  the  renal  or  glomerular  epithelium,  a  change, 
however,  which  may  be  transient,  slight,  and  unimportant,  depending  upon 
variations  in  the  circulation  or  upon  the  irritating  effects  of  substances 
taken  with  the  food  or  tem])orarily  present,  as  in  febrile  states. 

Albuminuria  of  adolescence  and  cyclic  albuminuria,  in  which  the  albu- 
min is  present  only  at  certain  times  during  the  day,  are  interesting  forms. 
A  majority  of  the  cases  occur  in  young  persons — boys  more  commonly  than 
girls — and  the  condition  is  often  discovered  accidentally.  The  urine,  as  a 
ndo,  contains  only  a  very  small  quantity  of  albumin,  but  in  some  instances 
large  quantities  are  present.  The  most  striking  feature  is  the  variability. 
It  may  be  absent  in  the  morning  and  only  present  after  exertion,  or  it  may 
lie  greatly  increased  after  taking  food,  particularly  proteids.  The  quan- 
tity of  urine  may  be  but  little,  if  at  all,  increased,  the  specific  gravity  is 
usually  normal,  and  the  color  may  be  high.  Occasionally  hyaline  casts 
may  be  found,  and  in  some  instances  there  has  been  transient  glycosuria. 
As  a  rule,  the  pulse  is  not  of  high  tension  andsthe  second  aortici  sound  is 
not  accentuated. 

Various  forms  of  this  affection  have  been  recognized  by  writers,  such 
as  neurotic,  dietetic,  cyclic,  intermittent,  and  paroxysmal — names  which 
indicate  the  characters  of  the  different  varieties.  A  large  proportion  of 
the  cases  get  well  after  the  condition  has  persisted  for  a  variable  period. 
This  in  itself  is  an  evidence  that  the  changes,  whatever  their  nature,  were 
transient  and  slight.  In  these  instances  the  all)]iimin  exists  in  small  quan- 
tity, tube-casts  are  rarely  present,  and  the  arterial  tension  is  not  increased. 
In  a  second  group  the  albumin  is  more  persistent,  the  amount  is  larger, 
though  it  may  vary  from  day  to  day,  and  the  pulse  tension  is  increased. 
In  such  instances  the  persisten'  albuminuria  probably  indicates  actual 
organic  change  in  the  kidney. 

(h)  Febrile  Albuminuria. — Pyrexia,  by  whatever  cau:^e  produced,  may 
cause  slight  albuminuria.  The  presence  of  the  albumin  is  due  to  slight 
changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swelling, 
which  cannot  be  regarded  as  an  organic  lesion.  It  is  extremely  common, 
occurring  in  pneumonia,  diphtheria,  typhoid  fever,  malaria,  and  even  in 
the  fever  of  acute  tonsillitis.     The  amount  of  albumin  is  slight,  and  it 


850 


DISEASES  OF  TDE  KIDNEYS. 


/ 


n.eiiiilly  (lisnpponrs  from  the  urine  with  the  ccgsation  of  the  fever.  TTyalJTio 
and  even  epitlieliiil  casts  accompany  the  condition. 

(r)  llivmic  Changes. — Purjxira,  scurvy,  chronic  poisoning  l)y  lead  m' 
mercury,  syi)hilis,  leukieniia,  and  ))rol'oiind  anicniia  may  be  associatid 
with  slight  albuminuria.  Abnormal  ingredients  in  the  blood,  such  as 
bile-pigment  and  sugar,  may  cause  the  passage  of  small  anujunts  of  al- 
bumin. 

The  transient  albuminuria  of  pregnancy  may  belong  to  this  hrDuiic 
group,  although  in  a  nuijority  of  such  cases  there  are  changes  in  the  renal 
tissue.  All)umin  may  be  found  sometimes  after  the  inhalation  of  ether  or 
chloroform. 

(d)  Albuminuria  occurs  in  certain  affections  of  the  nervous  syslein.  Tliis 
so-called  neurotic  albuminuria  is  seen  after  an  epile])tic  seizure  and  in  apo- 
plexy, tetanus,  exojdithalmic  goitre,  and  injuries  of  the  head. 

Albuminuria  with  Definite  Lesions  of  the  Urinary  Organs.— («)  Con- 
gestion of  the  kidney,  either  active,  such  as  follows  ex])osure  to  cold  and 
is  associated  with  the  early  stages  of  nei)hritis,  or  i)assive,  due  to  obstructol 
outflow  in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veil  s 
by  the  pregnant  uterus  or  tumors. 

(h)  Organic  disease  of  the  kidneys — acute  and  chronic  Bright's  disease, 
amyloid  and  fatty  degeneration,  suppurative  no])hritis,  and  tumors. 

(c)  Affections  of  the  pelvis,  ureters,  and  bladder,  when  associated  w.ih 
the  formation  of  pus. 

^'ests  for  Albumin. — Both  morning  and  evening  urine  should  be 
examined,  and  in  doubtful  cases  at  least  three  specimens.  If  turbid,  the 
urine  should  be  filtered,  though  turbidity  from  the  urates  is  of  no  moment, 
since  it  disappears  at  once  on  the  application  of  heat. 

Heat  and  Nitric-acid  Test. — The  urine  is  boiled  in  a  test-tube  over  a 
spirit-lamp,  and  a  drop  of  nitric  acid  is  then  added.  If  a  cloudiness  occurs 
on  boiling,  it  may  be  due  to  phosphates,  which  are  dissolved  on  the  addition 
of  an  acid.    Persistence  of  the  cloudiness  indicates  albumin. 

Heller's  Test. — A  small  quantity  of  fuming  nitric  acid  is  poured  into 
the  test-tube,  and  with  a  pipette  the  urine  is  allowed  to  flow  gently  down 
the  side  upon  the  acid.  At  the  line  of  junction  of  the  two  fluids,  if  albumin 
is  present,  a  white  ring  fs  formed.  This  contact  method  is  trustworthy, 
and,  for  the  routine  clinical  work,  is  probably  the  most  satisfactory.  A 
diffused  haze,  due  to  mucin  (nuclco-albumin),  is  sometimes  seen  just  above 
the  white  ring  of  albumin;  and  in  very  concentrated  urines,  or  after  the 
taking  of  balsamic  remedies,  a  slight  cloudiness  may  be  due  to  urates  or 
uric  acid,  which  clears  on  heating  or  warming.  A  colored  ring  at  the  junc- 
tion of  the  acid  and  the  urine  is  due  to  the  oxidation  of  the  coloring  matters 
in  the  urine. 

Ferroryanide-nf-pdassinm  and  Acetic-acid  Test. — Fill  an  ordinary  test- 
t\ibe  half  full  of  urine,  and  add  5  or  6  cc.  of  ]iotassium-ferrocyanide  solu- 
tion (1  in  20).  Thoroughly  mix  the  urine  and  reagent  and  add  10  to  1") 
drops  of  acetic  acid.  If  albumin  be  present,  a  cloudiness  varying  in  de- 
gree according  to  the  amount  of  albumin  will  be  produced.  This  is  a  very 
reliable  test,  as  it  precipitates  all  forms  of  albumin,  acid  and  alkaline,  but 


cr.    ITyaliiio 

:  by  lead  nr 
>e  associated 
)()(!,  siu'li  as 
luiintsJ  of  al- 

this  hflcniit' 

in  tlie  renal 

1  of  ether  or 

tysfein.  This 
!  and  in  apo- 

18. — (a)  Con- 
to  c'oUl  ami 
to  ob.strncl(Ml 
e  renal  veil  s 

gilt's  disease, 
I  mors, 
jociated  \v,ih 

le  shonhl  Ix' 

f  turhid,  tlio 

no  moment, 

-tube  over  a 

din  ess  occnrs 

the  addition 

ponred  into 
gently  down 
;,  if  albnmin 
rnstworthy, 
factory.     A 
n  just  above 
or  after  the 
to  urates  or 
at  the  Juno- 
ring  matters 

dinary  test- 
vanide  solu- 
dd  10  to  I") 
•ying  in  de- 
lis  is  a  very 
ilkaline,  but 


ANOMALIES  OF  TUK  URINARY  SECRETION. 


857 


does  not  precipitate  mucin,  lu'ptones,  phosphates,  urates,  vegetable  alkaloids, 
or  tlie  pine  acids. 

Sir  William  Koberts  strongly  recommends  tlie  maf/ncsi inn-nitric  test. 
One  volume  of  strong  nitric  acid  is  mixed  with  five  volumes  of  the  satu- 
rated .solution  of  sulphate  of  magnesium.  This  is  u.<ed  in  the  same  way  as 
the  nitric  acid  in  Heller's  test. 

Picric  acid,  introduced  by  George  Johnson,  is  a  delicate  and  useful 
lest  for  albumin.  A  saturated  solution  is  used  and  employed  as  in  the 
(ontact  method.  It  has  been  urged  against  this  test  that  it  throws  down 
the  mucin,  peptones,  and  certain  vegetable  alkaloids,  but  these  are  dis- 
solved by  heat. 

For  minute  traces  of  albumin  the  trichloracetic  acid  may  be  used,  or 
Millard'g  fluid,  which  is  extremely  delicate  and  consists  of  i,dacial  (  arbolic 
aci<l  (95  per  cent),  2  drachms;  pure  acetic  acid,  7  drachms;  liquor  potassai, 
2  ounces  6  drachms. 

A  quantitative  estimate  of  the  albnmin  can  be  made  by  means  of  I'^s- 
bach's  tube,  but  the  rough  method  of  heating  and  boiling  a  certain  quan- 
tity of  acidulated  urine  in  a  test-tube  and  allowing  it  to  stand,  is  often 
employed.  The  depth  of  deposit  can  then  bo  compared  with  the  whole 
amount  of  urine,  and  the  proportion  is  expressed  as  a  mere  trace,  almost 
solid — one  fourth,  one  half,  and  so  on.  This,  of  course,  does  not  give  an 
accurate  indication  of  the  proportion  of  albumin  in  the  total  quantity  of 
urine.  For  the  more  elaborate  methods  the  reader  is  referred  to  the  works 
on  urinalysis.  • 

The  above  tests  refer  entirely  to  serum  albumin.     Other  albuminous' 
substances  occur,  such  as  albumosc,  serum  globulin,  jjcptones,  and  hemi- 
albumose  or  propepton.    They  are  not  of  much  clinical  importance. 

Albumosuria. — Traces  of  peptones  (albumoses)  are  found  in  the  urine 
in  many  febrile  diseases  and  in  chronic  stippuration.  Albumosuria  has  but 
little  clinical  significance  except  in  one  connection.  In  1848  Bence-Jones 
described  a  case  of  osteo-malacia  in  which  he  found  a  modified  form  of 
albumin  in  the  urine.  Of  late  years  renewed  interest  has  been  taken  in 
the  subject  by  the  discovery  of  the  association  of  albumose  with  multiple 
myelomata  of  the  bones.  As  Kahler  called  special  attention  to  it,  the  Ital- 
ians have  given  the  condition  his  name.  Fitz  reported  an  instance  at  the 
last  meeting  (1898)  of  the  Association  of  American  Physicians,  the  only 
one  recognized,  so  far  as  I  know,  in  this  country.  In  Bradshaw's  case  the 
patient  passed  at  intervals  for  a  year  a  turbid,  milky  urine,  which  deposited 
a  copious  white  sediment.  On  adding  nitric  acid  to  a  urine  containing 
albumose  a  white  precipitate  is  formed,  which  is  dissolved  when  the  speci- 
men is  boiled,  but  reappears  on  cooling. 

Crlotndin  rarely  occurs  in  the  urine  alone,  but  generally  in  association 
with  serum-albumin.  The  latter  is  usually  present  in  greater  quantity,  but 
in  severe  organic  renal  disease  and  in  diabetes  Maguire  has  found  that  the 
proportion  of  globulin  to  albumin  is  often  2.5  to  1.  Senator  states  that 
more  globulin  is  present  in  lardaceous  kidney  than  in  other  forms  of 
nejihritis.  The  clinical  significance  of  globulin  is  the  same  as  that  of  serum- 
albumin. 

63 


858 


DISEASES  OF  THE   KTONEYS, 


Prognosis.— Til  is  dciu'iuls,  of  course,  t'liliivly  upon  tlio  caiiPP.  Vo- 
bi'ik'  iiliiuiiiiiiiiriii  is  traiisiiMit,  and  in  a  majority  oi'  thu  cases  (ie|>(>n(]in<; 
upon  lia-mic;  caiisos  tlic  condition  disaii[H'ars  and  leaves  the  kidneys  intact. 
An  occasional  trace  of  all)iiinin  in  a  man  over  forty,  witli  or  witiiout  a  fi'U 
hyaline  i-asis,  and  with  increased  tension  and  thick  vessel  walls,  usually 
indicates  clian<,a's  in  the  kidneys.  'IMie  ))ersistenee  of  a  slight  amount  of 
ulhiiniin  in  young  men  without  increasi'd  arterial  tension  is  less  serious, 
us  even  after  continuing  for  years  it  may  disappi'ar.  1  luive  already  spoken 
of  the  outlook  in  the  so-called  cyclic  albuminuria. 

J'ractically  in  all  cases  the  presence  of  albumin  indicates  a  change  of 
some  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  which  it  is 
dilllcult  to  estimate;  so  that  other  considerations,  such  as  the  presence  of 
tube-casts,  the  existence  of  increased  tension,  the  general  condition  of  the 
])atient,  and  the  inlluence  of  digestion  u])on  the  albumin,  must  be  carefully 
considered. 

The  physician  is  daily  consulted  as  to  the  relation  of  albuminuria  and 
life  assurance.  As  his  function  is  to  protect  the  interests  of  the  company, 
he  slnudd  reject  all  cases  in  which  albumin  occurs  in  the  urine.  It  is  even 
doubtful  if  an  exception  shoidd  be  made  in  young  persons  with  transient 
albuminuria.  JUiturally,  companies  lay  great  stress  upon  the  presence  or 
absence  of  albumin,  but  in  the  nu)st  serious  and  fatal  malady  with  which 
they  have  to  deal — chronic  interstitial  nephritis — the  albumin  is  often  ab- 
sent or  transient,  even  when  the  disease  is  well  develojjed.  After  the  forti- 
eth year,  from  a  standj)oint  of  life  insurance,  the  state  of  the  art'M'ies  is  far 
'nuire  imi)ortant  than  the  condition  of  the  urine. 

With  reference  to  the  signilicance  of  albuminuria  in  aciults,  I  quite 
agree  with  the  following  conclusions  of  F.  C.  Shattuck: 

(1)  Kenal  albuminuria,  as  proved  by  the  presence  of  both  albumin  and 
casts,  is  much  more  connnon  in  adults,  quite  apart  from  Bright's  disease 
or  any  obvious  source  of  renal  irritation,  than  is  generally  su])posed. 

(v')  The  frequency  increases  steadily  and  progressively  with  advancing 
age. 

(3)  This  increase  with  age  suggests  the  explanation  that  the  albumi- 
nuria is  often  an  iiulication  of  senile  degeneration. 

(4)  Thongb  it  cannot  be  regarded  as  yet  as  absolutely  proved,  it  is 
liigbly  ])robab]e  that  faint  traces  of  albumin  and  hyaline  and  finely  granu- 
lar casts  of  small  diameter  are  often,  especially  in  those  past  fifty  years  of 
age,  of  little  or  no  practical  importance. 


5.  Pyuria  (Pus  in  the  Urine). 

Causes. — (l)  ri/elitis  and  Pyelonephritis. — Tn  large  abscesses  of  the  kid- 
ney, pyonephrosis,  the  pus  may  be  intermittent,  and  for  days  or  even  weeks 
the  urine  is  free.  In  calculous  and  tuberculous  pyelitis  the  pyuria  is  usu- 
ally continuous,  though  varying  in  intensity.  In  these  cases,  as  a  rule,  the 
pus  is  mixed  with  the  urine,  which  is  acid  in  reaction.  In  the  early  stages 
of  pyelitis  the  transitional  epithelium  may  be  abundant,  but  is  not  in  any 
way  distinctive.     In  the  pyelitis  and  pyelonephritis  following  cystitis  the 


ANOMALIES  OP  TDK   URINARY  SFX'RETION. 


859 


cniipp.  Vo- 
s  (it'pi'iuliiij; 
Incys  iiitacl. 
illioiit  11  few 
alls,  usually 
:  uinuuiit  (if 
li'ss  serious, 
cady  spoken 

a  change  ol" 

whieh  it  is 

])resenc'e  ol' 

itiou  ol'  the 

be  carefully 

ninuria  and 
e  company. 
It  is  even 
;h  transient 
l)resence  or 
with  which 
is  often  ah- 
n'  the  I'orti- 
t'n-ies  is  far 

ts,  I  quite 

)nmin  and 
it's  disease 
losed. 
advancing 

le  albunii- 

3ved,  it  is 
ely  granu- 
y  years  of 


f  the  kid- 
ven  weeks 
ia  is  usu- 
rnle,  the 
rly  stages 
ot  in  any 
ostitis  the 


urino  is  usunlly  alkaline,  and  contains  niore  mucus;  micturition  is  usually 
more  frecpient,  and  the  history  points  to  a  previous  blad(U;r  alfection. 

{'i)  Ci/slilis. — ^rhe  urine  is  alkaline,  ol'len  fetid,  the  pus  roj)y,  and  the 
amount  of  urine  greatly  increased.  The  ropy,  thick  mucMis  usually  comes 
with  the  last  portions  of  the  urine.  Triple  phosphate  crystals  may  he  pres- 
ent in  the  freshly  j)assed  urine. 

(;{)  I'n'lhritis,  particularly  gonorrluca.  The  piis  ajipears  first,  is  in 
small  (juantities,  ami  there  are  signs  of  local  inllammation. 

(1)  in  Iciirurrlnva  the  (piantity  of  jms  is  usually  small,  and  large  Hakes 
of  vaginal  epithelium  are  numerous.  Jn  douhtful  cases,  when  leucorrluea 
is  present,  tlie  urine  should  he  withdraw  through  a  catheter. 

(5)  IkUjiitire  of  Ahsrcsscti  into  llic  IJriiuinj  J'asKoi/cs. — In  su(;li  cases  as 
pi'lvic  or  perityphlitic  abscess  there  have  bei'ii  previous  symptoms  of  pus 
formation.  A  hirge  amount  is  })as.sed  within  a  short  time,  then  the  dis- 
charge stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

]'ns  gives  to  the  urine  a  white  or  yellowish-white  ajjpearance.  On  set- 
tling there  is  a  heavy  grayish  sediment,  and  the  supernatant  fluid  is  usually 
turbid.  The  sedimeiit  is  often  tenacious  aiul  ropy.  The  reaction  is  gen- 
erally alkaline,  and  the  odor  may  be  ammoniacal  even  when  passed.  Kx- 
ajnination  with  the  microscope  fevcals  the  presence  of  a  large  number  of 
pus-corpuscles,  which  are  usually,  when  the  pus  comes  from  the  bladder, 
well  formed;  the  protoplasm  is  granular,  and  often  shows  many  translucent 
})rocesses. 

The  only  sediment  likely  to  be  confounded  with  ])us  is  that  of  the 
])hoRphates;  but  it  is  whiter  and  less  dense,  and  is  distinguished  immedi- 
ately by  microscopical  examination. 

With  the  pus  there  is  always  more  or  less  epithelium  from  the  bladder 
and  pelves  of  the  kidneys,  but  since  in  these  situations  the  forms  of  cells 
are  practically  identical,  they  afford  no  information  as  to  the  locality  from 
which  the  pus  has  come. 

The  treatment  of  pus  in  the  urine  is  considered  under  the  conditions 
in  which  it  occurs. 

6.  Chyltjria — Non-parasitic. 

This  is  a  rare  affection,  occurring  in  temperate  regions  and  unassoci- 
ated  with  the  FiJaria  Bancrofti.  The  urine  is  of  an  opaque  white  color; 
it  resembles  milk  closely,  is  occasionally  mixed  with  blood  (hnematochy- 
luria),  and  sometimes  coagulates  into  a  firm,  jelly-like  mass.  In  other 
instances  there  is  at  the  bottom  of  the  vessel  a  loose  clot  which  may  be 
distinctly  blood-tinged.  Under  the  microscope  the  turbidity  seems  to  l)e 
caused  by  numerous  minute  granules — more  rarely  oil  droplets  similar  to 
those  of  milk.  In  Montreal  I  made  the  dissection  of  a  case  of  thirteen  years' 
duration  and  could  find  no  trace  of  parasites. 

7.  LiTHURiA  {Litlimmia;.  Lithic-acid  Diathesis). 

The  general  relations  of  uric  acid  have  already  been  considered  in  speak- 
ing of  gout. 


860 


DISKASKS  OP  THE  KIDNEYS. 


/ 


Oecurrrnre  in  llic  I'riiie. — TIu'  uric  acid  occurs  in  coinhination  cliicny 
witli  uininoniiiin  and  Hodiuiii,  I'orniing  tlic  acid  urates,  in  Kuiallcr  quan- 
tities art'  the  i)()tassiuni,  calcium,  and  lithium  salts.  The  uric  acid  may 
be  separated  from  its  bases  and  crystallizes  in  rhombs  or  prisms,  whiih 
are  usually  of  a  deep  red  color,  owinj,'  to  the  staining  of  the  urinary  pij;- 
meiits.  Tiu;  sediment  formed  is  granular  and  the  groups  of  crystals  look 
like  grains  of  Cayenne  pepper.  It  is  very  important  not  to  mistake  a  de- 
j)osit  of  uric  acid  for  an  excess.  The  dejjosition  of  numerous  grains  in  the 
urine  within  a  few  hours  after  passing  is  more  likely  to  be  due  to  condi- 
tions which  diminish  the  solvent  power  than  to  increa.se  in  the  ((uantity. 
Of  the  conditions  which  cause  precipitation  of  the  uric  acid  Roberts  gives 
the  following:  "(1)  High  acidity;  (2)  poverty  in  mineral  salts;  (;J)  low 
pigmentation;  and  (t)  high  percentage  of  uric  acid."  The  grade  of  acid- 
ity is  probably  the  most  im[)ortant  element. 

In  health  the  weight  of  uric  acid  excreted  bears  a  fairly  constant  ratio 
to  the  weight  of  nrea  eliminated.  According  to  von  Noorden,  the  average 
ratio  is  1  to  50,  while  the  average  ratio  of  the  nitrogen  of  uric  acid  to  the 
total  nitrogen  eliminated  in  the  urine  is  1  to  70.  In  several  of  the  cases 
of  gout  in  my  wards  Futcher  found  that  in  the  intervals  between  the  acute 
arthritic  attacks  the  uric  acid  was  reduced  to  a  much  greater  extent  than 
the  urea,  so  that  the  ratio  of  the  former  to  the  latter  often  varied  between 
1  to  300  up  to  (in  one  case)  1  to  1,500,  a  return  to  about  the  normal  jjropor- 
tions  occurring  during  the  acute  attacks. 

More  common  is  the  precipitation  of  amorphous  urates,  forming  the 
so-called  brick-dust  or  latcritious  deposit,  which  has  a  pinkish  color,  due 
to  the  presence  of  urinary  pigment.  It  is  composed  chiefly  of  the  acid 
sodium  urates.  It  occurs  particularly  in  very  acid  urine  of  a  high  specific 
gravity.  As  the  urates  are  more  soluble  in  warm  solutions,  they  frequently 
deposit  as  the  urine  cools.  Here,  too,  the  deposition  does  not  necessarily, 
indeed  usually  does  not,  mean  an  excessive  excretion,  but  the  existence  of 
conditions  favoring  the  deposit. 

Litha'viin. — In  addition  to  what  has  already  been  said  under  gout,  we 
may  consider  here  the  hypothetical  condition  known  as  litluvmia,  or  the 
uric-acid  diathesis.  Murchison  introduced  the  term  to  designate  certain 
symptoms  due,  as  he  supposed,  to  functional  disturbance  of  the  liver.  Not 
only  have  his  views  been  widely  adopted,  but,  as  is  so  often  the  case  when 
we  give  the  rein  to  tlieorctical  concc])tions  of  disease,  the  so-called  mani- 
festations of  this  state  have  so  multiplied  that  some  authors  attribute  to 
this  cause  a  considerable  proportion  of  the  ailments  affecting  the  various 
systems  of  the  body.  Thus  one  writer  enumerates  not  fewer  than  thirty- 
nine  separate  morl)id  conditions  associated  with  litlurmia!  From  our  lack 
of  knowledge  of  the  mode  of  formation  and  elimination  of  uric  acid  it  is 
very  evident  that  the  physiology  of  the  subject  must  be  widely  extended 
before  we  are  in  a  position  to  draw  safe  conclusions.  Thus  it  is  by  no 
means  sure  that,  as  Murchison  supposed,  the  essential  defect  is  in  a  func- 
tional disorder  of  the  liver,  disturbing  the  metabolism  of  the  all)uminous 
ingredients,  nor  is  it  at  all -certain  that  the  only  ofTending  substance  is  ur'c 
acid.     In  the  present  imperfect  state  of  knowledge  it  is  impossible  with 


ANOMALIES  OF  TOE  URINARY  SECRETION. 


801 


at  ion  cliicfl}- 
iiiilliT  4iiaii- 
ic  lU'id  iiiuy 
•isms,  wliicli 
urinary  pig- 
:;rystaLs  look 
listiiko  u  (If- 
:rainw  in  llic 
le  to  condi- 
le  quantity, 
obortri  gives 
Its;  (;})  l„w 
ido  of  acid- 

nstant  ratio 
tlio  averagu 
acid  to  tilt" 
)f  tlie  cases 
n  tlie  acute 
:!xtont  than 
od  between 
nal  propor- 

^riiiing  the 
color,  due 
•  f  the  acid 
gh  specific 
frcvjuently 
lecessarily, 
cistence  of 

r  gout,  we 
ia,  or  the 
to  certain 
iver.  Not 
3ase  wlien 
led  mani- 
ribute  to 
0  various 
n  thirty- 

our  lack 
acid  it  is 
extended 
is  by  no 

a  func- 
uiniinous 
e  is  nr'c 
blc  with 


any  clearness  to  define  the  pathology  of  the  so-called  uric-acid  diathesirt. 
We  may  say  that  certain  syinijtonis  arise  in  connection  with  di'leclive  food 
or  tissue  nietabolisni,  more  particularly  of  tlie  nitrogenous  elements.  De- 
ficient oxidation  is  probably  the  most  essential  factor  in  the  process,  with 
tbe  result  of  the  formation  of  li'ss  readily  soluble  and  less  readily  climinat''d 
jtroducts  of  retrograde  metamorphosis.  This  faulty  nu'tabolism  if  long 
continued  may  lead  to  gout,  with  uratic  dej)osits  in  the  joints,  acute  in- 
llanunations,  and  arterial  and  renal  disease.  Jn  a  large  grou|)  of  cases  the 
disturbed  nu'tabolism  |)roduces  high  tension  in.  the  arteries  (probably  as  u 
direct  siMpieiu-e  of  interference  with  the  capillary  circulation)  and  ulti- 
mately degenerations  in  various  tissues,  particularly  the  scleroses. 

Overeating  and  overdrinking,  when  combined  with  deficient  muscular 
exercise,  lie  at  the  basis  of  this  nutritional  disturbance.  The  symptoms 
which  are  believed  to  characterize  the  uric-acid  diathesis  have  already  been 
briefly  treated  of  imder  the  section  on  irregular  gout,  and  the  (question  of 
diet  and  exercise  has  also  been  there  considered. 

8.    OXALURIA. 

Oxalic  acid  occurs  in  the  urine,  in  combination  with  lime,  forming  an 
oxalate  which  is  held  in  solution  by  the  acid  ])h()sphate  of  soda.  About 
.01  to  .02  gramme  is  excreted  in  the  day.  It  never  forms  a  heavy  deposit, 
but  the  crystals — usually  octahedral,  rarely  dumb-bell-shaped — collect  in  the 
mucus-cloud  and  on  the  sides  of  the  vessel.  'JMie  amount  varies  extremely 
with  the  diet,  and  it  is  increased  largely  when  such  fruits  and  vegetables 
as  tomatoes  and  rhubarb  are  taken.  It  is  also  a  product  of  incomplete  oxi- 
dation of  the  organic  substances  in  the  body,  and  in  conditions  of  increased 
metabolism  the  amount  in  the  urine  becomes  larger.  It  is  stated,  also  to 
result  from  the  acid  fermentation  of  the  mucus  in  the  urinary  passages, 
and  the  crystals  are  usually  abundant  in  spernuxtorrhrea. 

When  in  excess  and  jjresent  for  any  considerable  time,  the  condition  is 
known  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  crys- 
tals may  be  deposited  before  the  urine  is  voided,  and  form  a  calculus.  It 
is  held  by  many  that  there  is  a  special  diathesis  associated  with  this  state 
and  manifested  clinically  by  dyspepsia,  particularly  the  nervous  form,  irri- 
tability, depression  of  spirits,  lassitude,  and  sometimes  marked  hypochon- 
driasis. There  may  be  in  addition  neuralgic  pains  and  the  general  symp- 
toms of  neurasthenia.  The  local  and  general  sym])toms  are  probably  de- 
pendent upon  some  disturbance  of  metabolism  of  which  the  oxaluria  is  one 
of  the  manifestations.  It  is  a  feature  also  in  many  gouty  persons,  and  in 
the  condition  called  lithoemia. 

9.  Cystixuria. 

Stadthogen  claims  that  normal  urine  does  not  contain  cystin,  though 
Baumann  and  Goldmann  succeeded  in  separating  it  in  very  small  quan- 
tities from  healthy  urine  as  a  benzoyl  compound.  It  is  associated  with 
elimination  of  diamines  both  in  the  faeces  and  urine.    It  is  very  rarely  met 


I 


862 


DISKASKS  OP  THE   KIDNEYS. 


with,  niul  its  cliiof  iiitcri'st  is  owinj,'  to  the  fact  that  it  may  form  n  cnlou- 
liis.  Its  prcsciici'  in  the  iiriiu'  has  \nv\\  (h'tcrmiiicd  in  many  mcmlxTs  of 
the  sanu'  liimily,  and  the  condition  appears  sonictinics  to  \>v  hcicditary. 
As  it  contains  sulphur,  it  is  thought  to  be  iormcd  from  the  tuurin  of  the 
bile. 

10.   PjIOSI'II.VTURIA. 

The  phop[)lioric  acid  is  excreted  from  the  body  in  combination  with 
])otassium,  sodiuni,  calcium,  and  magnesium,  forming  two  classes,  the  alka- 
line phosphates  of  sodium  and  potassium  and  the  earthy  phosphates  ot 
lime  and  magnesia.  The  amount  of  phosphoric  acid  (1^0;,)  excreted  in  the 
twenty-four  hours  varies,  according  to  Jlammarsteu,  l)etween  1  and  5 
gramnu's,  with  an  average  of  21)  grammes.  Jt  is  derived  maiidy  from  the 
l)hosphoric  acid  taken  in  the  food,  but  also  in  part  as  a  decomposition  prod- 
uct from  nuclein,  protagon,  ami  lecithin.  Of  the  alkaline  ])hos|)hates,  those 
in  cond/ination  with  sodium  are  the  most  abuiulant.  The  alkaline  pho.s- 
l)hatcs  of  the  urine  are  more  abundant  than  the  earthy  phosphates. 

Of  the  earthij  phosphalcs,  those  of  lime  are  abundant,  of  magnesium 
f«cnnty.  In  urine  which  has  undergone  the  ammoniacal  fermentation,  either 
inside  or  outside  the  body,  there  is  in  addition  the  anunonio-magncsiuni 
or  triple  phosi)hate,  which  occurs  in  triangular  prisms  or  in  feathery  or 
stellate  crystals;  hence  the  term  given  to  this  form  of  stellar  })hosphates. 
The  earthy  phosphates  occur  as  a  sediment  in  the  urine  when  the  alka- 
linity is  due  to  a  fixed  alkali,  or  under  certain  circumstances  the  deposit 
may  take  jjlace  within  the  bladder,  and  then  the  phosi)hates  are  pas.sed 
at  the  end  of  micturition  as  a  whitish  fluid,  which  is  popularly  confounded 
with  spermatorrluca.  The  calcium  ])hosphate  may  be  precipitated  by  heat 
•and  ])roduce  a  cloudiness  which  may  be  mistaken  for  albumin,  but  is  at 
•once  dissolved  upon  making  the  urine  acid.  This  condition  is  very  fre- 
quent in  ])crsons  sidfering  from  dyspepsia  or  from  debility  of  any  kind. 
The  phoP])hates  may  be  in  great  excess,  rising  in  the  twenty-four  hours  to 
from  7  to  9  grammes  (Tessier),  whereas  the  normal  amount  is  not  more 
than  2.5  grammes.  And,  lastly,  the  phosphates  may  be  deposited  in  urine 
which  has  undergone  decomposition,  in  which  the  carbonate  of  ammonia 
from  the  urea  combines  with  the  magnesium  phosphates,  forming  the  trii)le 
salt.  This  is  seen  in  cystitis,  and  is  due  to  the  introduction  of  a  bacterial 
ferment. 

The  clinical  significance  of  an  excess  of  ])hosphates,  to  which  the  term 
phos])haturia  is  apjdied,  has  been  much  discussed.  It  must  he  remeni- 
hered  that  a  de])osit  does  not  necessarily  mean  an  excess,  to  determine 
which  a  careful  analysis  of  the  twenty-four  hours'  secretion  should  be  made. 
It  has  long  been  thought  that  there  is  a  eolation  between  the  activity  of 
the  nerve-tissues  and  the  output  of  phosphoric  acid;  but  the  question  can- 
not yet  he  considered  settled.  The  amount  is  increased  in  wasting  diseases, 
such  as  phthisis,  acute  yellow  atrophy  of  the  liver,  leukirmia,  rnd  severe 
anaemia,  Avhercas  it  is  diminished  in  acute  diseases  and  during  pregnancy. 

In  a  condition  termed  by  Tessier,  Ralfe,  and  others,  ]ihosphatic  dia- 
betes there  are  polyuria,  thirst,  emaciation,  and  a  great  increase  in  the 


ANOMALIKS  OP  THE   URINAUY  SE(^RETION. 


803 


orni  a  rnloii- 

nit'iiilxTs  (»!' 

'  licrc'ditary. 

uiiriii  of  till' 


♦  xcrction  of  pliospliutcs,  wliidi  iiiiiy  lie  iis  nuich  as  from  1  to  !»  jTrammcs  in 
till'  (lay.  Tlic  urine  is  usually  acid  and  frc;*  from  sugar;  the  patients  aro 
nervous;  in  some  instanees  sugar  has  been  present  in  the  urine,  and  iu 
(ithera  it  subsequently  nuikes  its  appeuranec. 


nation  witli 
t's,  the  alku- 
lospliates  ol 
reted  in  tiie 
M  1  and  ."i 
ly  from  the 
'sition  prod- 
•hates,  tliosi; 
valine  pho.s- 
e.s. 

m;ignesiuiii 

ition,  either 

■magnesiuui 

feathery  or 

l)hosphate,s. 

11  the  alka- 

the  deposit 

are  passed 

'on  founded 

cd  by  heat 

but  is  at 

very  fre- 

any  kind. 

■  hours  to 

not  more 

in  urine 

ammonia 

(he  tri])]e 

bacterial 

the  term 
p  remem- 

etermine 

bo  made. 
'tivity  of 
tion  can- 

di senses, 
id  severe 
nancy, 
atic  dia- 
c  in  the 


11.  Indicanukia. 

The  substance  in  the  urine  which  has  received  tliis  nnmc  is  the  indo.xyl- 
sulphate  of  potassium,  in  whicli  form  it  ap|>ears  in  the  urine  and  is  color- 
less. When  concentrated  acids  or  strong  oxidizing  .gents  are  added  to 
the  urine,  this  substance  is  decomposed  and  the  indigo  set  free.  It  is  pres- 
ent only  in  snuill  (puintities  in  healthy  urine.  It  is  derived  from  the  indol, 
a  product  formed  in  the  intestine  by  the  decom|)osition  of  the  albumin 
under  the  inducnce  of  bacteria.  When  absorbed,  this  is  oxidized  in  the 
tissues  to  indo.vyl,  which  combines  with  the  potassium  sulphate,  forming 
the  above-named  substance. 

The  (juantity  of  indican  is  diminislied  on  a  milk  (and  a  Kefir)  diet. 
It  is  iiu-reased  in  all  wasting  diseases,  as  carcinoimi,  and  whenever  any 
large  quantities  of  albuminous  substances  are  undergoing  rapid  decompo- 
sition, as  in  the  severer  forms  of  peritonitis  and  empyema.  It  is  not  usually 
increased  in  constipation,  but  is  met  with  in  ileus,  particularly  in  obstruc- 
tion of  the  small  intestij^e.  Indican  has  occasionally  been  found  in  calculi. 
Though,  as  a  rule,  the  urine  is  colorless  when  j)ass('d,  there  are  instances 
in  which  the  decomjiosition  has  taken  place  within  th.;  body,  and  a  blue 
color  has  been  noticed  innnediately  nftc-r  the  urine  was  voided.  Sometimes, 
too,  in  alkaline  urine  on  exposure  there  is  a  bluish  dim  on  the  surface. 

To  test  for  indican,  ])lace  4  or  5  cc.  of  nitric  or  hydrochloric  acid  in  a 
test-tube;  boil,  and  add  an  ecpuil  ipiantity  of  urine.  A  bluish  ring  develops 
at  the  point  of  contact.  Add  1  or  2  cc.  of  chloroform  and  shake  the  test- 
tube;  on  separation  the  chloroform  has  a  violet  or  bluish  color  due  to  the 
presence  of  indican. 

12.  Melanuhia. 

In  melanotic  cancer  the  nrine,  cither  at  the  time  of  voiding  or  after 
ex])osnre  to  the  air,  may  present  a  dark  color.  This  pigment  is  known  as 
melanin,  and  it  may  occur  in  solution  or  in  the  form  of  snuill  granules. 
The  urine  may  be  voided  clear,  and  subsequently,  on  ex|)osure  to  the  air 
or  on  the  addition  of  oxidizing  substances,  becomes  dark.  In  these  cases 
it  contains  a  chromogen  called  melanogen,  which  turns  dark  by  oxidation. 
Von  Jaksch  has  found  that  "in  urine  containing  melanin  or  its  precursor, 
melanogen,  Prussian  blue  is  formed  by  adding  a  nitroprusside,  acjueous 
potash.,  and  an  acid.  This  reaction,  however,  does  not  seem  to  de])end  on 
the  presence  of  melanin,  as  it  is  not  given  by  that  sid)stance  when  sep- 
arated from  the  urine,  but  apparently  by  some  other  at  present  unknown 
substance,  which  is  present  in  traces  in  normal  urine  and  is  increased  in 
cases  of  melanuria,  and  also  in  those  conditions  where  excess  of  indigo 
occurs  in  the  urine  "  (Halliburton). 


864 


DISEASES  OP  THE  KIDNEYS. 


13.  Pnkumatuhia. 


CiiiH  may  Ik-  pftsHt'd  with  the  uriiu;  — 

1.  AI'ItT  iiit'clmiiical  ii\lnMlu(ti(»n  of  air  in  vosical  irrigation  or  cysto- 
8cu{iic  I'xainiiiatioii  iti  tiic  kiiff-clliow  position. 

2.  As  u  result  of  till'  iiilroiliulion  of  {,'as-forniinj;  orj^nmisnitt  in  catlu'ter- 
i/ation  or  other  operation,  (ilyeosuriu  has  hcen  present  in  a  majority  of 
the  eases.  The  yeast  fungus,  the  coir)n  ImeilluH,  and  the  baeillus  aerogenes 
ea|)sulatus  have  been  found. 

;{.   In  eases  of  vesieo-enterie  fistula. 

In  gas  production  within  the  bladder  the  symptoms  are  those  of  a  mild 
cystitis,  with  the  passage  of  gas  at  the  end  of  micturition,  sometimes  with 
a  l(»ud  sound.  The  diagnosis  is  readily  made  hy  causing  the  patient  to 
urinate  in  a  bath  or  by  plunging  the  end  of  the  catheter  under  water. 


/ 


14.    OtIIKH    SrUHTANCKS. 

Fat  in  the  urine,  or  lipuria,  occurs,  according  to  Halliburton,  first,  with- 
out disease  of  the  kidneys,  as  in  excess  of  fat  in  the  food,  after  the  adnun- 
istration  of  cod-liver  oil,  in  fat  enibcdism  occurring  after  fractures,  in  the 
fatty  degeiKTiition  in  phosphorus  [)oisoniug,  in  |)rolonged  suppuration,  as 
in  phthisis  and  pyiemia,  in  the  lipicmia  of  diabetes  mellitus;  secondly,  v;ith 
di.«ease  of  the  kidneys,  as  in  the  fatty  stage  of  chronic  ^right's  disease,  in 
which  fat  easts  are  sometimes  present,  and,  according  to  Kbstein,  in  pyo- 
nephrosis; ai.<l,  thirdly,  in  the  alVei^tioii  known  as  chyluria.  The  urine 
is  usually  turbid,  but  there  may  be  fat  drops  as  well,  and  fatty  crystals  have 
been  found. 

Lipariduria  is  a  term  applied  by  von  Jaksch  to  the  condition  in  which 
there  are  volatile  fatty  acids  in  the  urine,  such  as  acetic,  butyric,  formic, 
and  ])ro[)ionic  acid. 

Accldiniria. — Von  Jaksch  distinguishes  the  following  forms  of  patho- 
logical acetonuria:  The  febrile,  the  diabetic,  the  acetonuria  with  certain 
forms  of  cancer,  the  form  associated  with  inanition,  acetonuria  in  psychoses, 
and  the  acetonuria  which  residts  from  auto-intoxication.  It  is  doubtful, 
however,  whether  the  symptoms  in  these  are  really  due  to  the  acetone.  It 
may  be  the  sid)stances  from  which  this  is  formed,  ])articularly  the  diacetic 
acid  or  the  /8-oxy-butyric  acid.  The  odor  of  the  acetone  may  be  marked 
in  the  breath  and  evident  in  the  urine.  The  tests  have  been  given  in  the 
section  on  diabetes. 

Diacclic  acid  is  probably  never  present  in  the  urine  in  health.  With 
a  solution  of  ferric  chloride  it  gives  a  Bnrgundy-rcd  color.  A  similar  re- 
action is  given  by  acetic,  formic,  and  oxy-butyric  acids;  it  may  be  present 
in  the  urine  of  patients  who  are  taking  antipyrin,  thallin,  and  the  sali- 
cylates. Ilamniarsten  states  that  if  the  reaction  be  due  to  the  presence  of 
diacetic  acid,  it  will  not  be  obtained  in  carrying  out  the  test  with  a  second 
specimen  of  nrine  which  has  been  boiled  and  allowed  to  cool.  The  ethereal 
extract  of  the  acidulated  urine  gives  the  reaction  if  diacetic  acid  bo  present, 
whereas  the  other  substances  which  mpv  be  mistaken  for  diacetic  acid  are 
insoluble  in  ether. 


URJEMIA. 


805 


an  or  cysto- 

in  ciillu'tcr- 
iiiiijority  oi 


^0  of  n  mild 
ctiint's  witli 
!  patient  tu 

WllltT. 


,  first,  w'itli- 
tlu!  tuliiiiii- 
iirt'8,  ill  liic 
)iiniti()ii,  lis 
ondly,  with 
i  (lisoiiHo,  ill 
!in,  ill  pyo- 
'Vho  urine 
•ystals  lijivo 

n  ill  wliicli 
ric,  I'onnic, 

of  patlin- 
Ui  c't'i'lain 
psychoses, 

(louhtfnl, 
^'otono.  Jt 
10  (liaeelic 
)e  inarlced 
von  in  the 

til.  Witli 
similar  re- 
be  present 
I  the  sali- 
resenee  of 
1  a  second 
e  ethereal 
)e  present, 
c  acid  are 


/8-nxy-))iilyri('  aeid  '\t>  helieved  liy  Stadeliiiniiii,  Kiilz,  and  Minkowski  to 
.>e  tiiu  cause  of  diiilielie  c(  ma.  Jt  Ih  a  product  of  tiie  decoiuposition  of  tliu 
ii.<4siit>  ullniniinH,  and  from  it  diacetic  ucid  id  reuUily  I'ormed  by  u.xidutiun. 
lis  tcsis  have  already  heeii  j^Mveii. 

Aliapliiiiurid. — Aromatic  compounds  occur  after  the  administration  of 
(arhidic  acid  or  gallic  acid,  and  the  urine  on  exposure  to  air  becomes  dark. 
In  carboluriu  the  Bubstance  causing  the  black  color  is  known  us  hydro- 
rhiiion.  Many  years  ago  IloiMlekcr  met  with  cascH  in  whi(;h  tho  urine  be- 
( ame  dark,  owing  to  the  |)rescnce  of  an  aromatic  compound  which  lu!  calle(l 
alcapt(jn.  'i"he  urine  is  clear  on  passing,  and  then  darkens  on  exposure  to 
llie  air,  or  on  the  addition  of  li(|Uor  potassie.  Kallmann  isolated  a  substanco 
troin  the  urine  of  a  case  of  alcaptoiiuria,  to  which  he  gave  the  name  of 
lioiiiogentisinic  acid.  Later  observers  have  isolated  this  substance  in  other 
cases.  Kirk  believed  the  reaction  in  his  case  was  due  to  uroleucinic  acid. 
Ill  several  instances  more  than  one  member  of  a  family  has  hIiovvii  this 
urinary  change,  'i'he  substance  is  apparently  without  clinical  Hignilicance 
excejit  in  so  far  as  it  Ih  caj  '"  of  reducing  tho  I'Y'liling  solution,  and  may 
lie  mistaken  foi  sugar.  Alcajiioii  uriii(>  may  be  distinguished  from  diabetic 
iiiiiie  from  the  fact  that  it  does  not  ferment  nor  reduce  alkaline  bisiiuitli 
solutions,  and  because  it  is  optically  inactive  (see  Alcaptoiiuria,  by  T.  li. 
I'litcher,  New  York  Mc(l.  Jour.,  ISiir,  ii). 

Clioliiria  and  glycosuria  have  already  been  considered  under  jaundice 
and  diabetes. 

Jhrntalfiixirphi/rin  occasionally  occurs  in  the  urine.  Tt  was  first  recog- 
nized by  ]Ioi)i)e-Seyler.  Neiicki  and  Sieler  determined  its  exact  formula, 
and  the  former  demonstrated  that  the  only  chemical  dill'ereii(!e  between 
lianiatin  and  luematoporphyrin  is  that  tlie  latter  is  simply  liaMiiatin  fice 
from  iron.  It  has  been  found  in  the  urine  in  imlmonary  tuberculosis, 
pleurisy  with  eirusion,  acute  rheiiniatisni,  lead  poisoning,  and  intestinal 
liu'inorrhages.  This  pigment  has  been  found  very  freij^uently  after  the  ad- 
ministration of  suli)lional,  and  sonietiines  imjiarts  a  very  dark  color  to  the 
urine. 

V.    URiCMIA. 

Definition. — A  toxannia  developing  in  tho  course  of  nephritis  or  in 
conditions  associated  with  anuria.  The  nature  of  the  poison  or  poisons  is 
as  yet  unknown,  whether  they  are  the  retained  normal  products  or  the 
])roducts  of  an  abnormal  metabolism. 

Theories  of  Ursemia. — The  view  most  widely  held  is  that  nnpiiiia 
is  due  to  the  accumulation  in  the  blood  of  excrementitious  material — body 
poisons — which  should  be  thrown  off  by  the  kidneys.  "  If,  however,  from 
any  cause,  these  organs  make  default,  or  if  there  bo  any  prolonged  obstruc- 
tion to  the  outflow  of  urine,  accumulation  of  some  or  of  all  the  poisons 
takes  place,  and  the  characteristic  symptoms  are  manifested,  but  the  ac- 
cumulation may  bo  very  slow  and  the  earlier  symptoms,  corresponding  to 
the  comparatively  small  dose  of  poison,  may  be  very  slight;  yet  they  are  in 
kind,  though  not  in  degree,  as  indicative  of  nreemia  as  are  the  more  alarm- 


8G6 


DISEASES  OF  THE  KIDNEYS. 


/ 


I  lift- 


ing, which  appear  toward  tlic  end,  and  to  wliich  alom^  the  name  nrirmia  is 
often  given"  (Carter),  llerter  and  others  liave  shown  that  the  toxicity  ol" 
the  blood-serum  in  uriemie  states  is  increased.  Tlie  part  played  by  urea 
itself,  by  the  salts,  and  by  the  nitrogenous  extractives  has  not  been  deter- 
mined. 

Another  view  is  that  unicmia  depends  on  tlie  products  of  an  ahnormal 
metabolism.  JJrown-Sequard  suggested  that  the  kidney  has  an  internal 
secretion,  and  it  is  urged  that  the  syini)toins  of  ura'mia  are  due  to  its  dis- 
turbance. Bradford's  experiments  show  that  the  kidneys  do  influence  pro- 
foundly the  metah»)lism  of  the  tissues  of  the  body,  particularly  of  the  mus- 
cles. If  more  than  one  third  of  the  total  kidney  weight  be  removed,  there 
is  an  extraordinary  increase  in  the  production  of  urea  and  of  the  nitrogenous 
hodies  of  the  creatin  class.  lie  favors  this  view,  hut  acknowledges  that  W(! 
are  still  ignorant  of  the  nature  of  the  poison.  From  a  careful  study  of  the 
question,  Hughes  and  Carter  concluded  that  the  poison  was  an  albuminous 
I)roduct  quite  different  from  anything  in  normal  urine.  In  Bradford's  (Jul- 
stonian  Lectures  (1898)  will  be  fouml  a  full  discussion  of  the  (piestion. 

Trauhe  helieved  that  the  sym])toms  of  ura'mia,  particularly  the  coma 
and  convulsions,  were  due  to  localized  a'dema  of  the  brain. 

Symptoms. — Cliuically,  we  may  recognize  latent,  acute,  and  chronic 
forms  of  ura'mia.  The  latent  form  has  been  considered  under  the  section 
on  anuria.  Acute  uraemia  may  develop  in  any  form  of  ne]>hritis.  It  is 
more  common  in  the  post-febrile  varieties.  Bradford  thinks  that  it  is  spe- 
cially associated  with  a  form  of  contracted  white  kidney  in  young  subjects. 
Chronic  forms  of  ura'mia  are  more  frequent  in  the  arterio-sclerotic  and 
granidar  kidney.  For  convenience  the  symptoms  of  iira'mia  may  be  de- 
scribed under  cerebral,  dyspnocie,  and  gastro-intestinal  manifestations. 

Among  the  cerebral  sym})toms  of  uramiia  may  be  doscribed: 

(a)  Mania. — This  may  come  on  abruptly  in  an  individual  who  has 
shown  no  ])revious  indications  of  mental  trouble,  and  who  may  not  be 
known  to  have  Bright's  disease.  In  a  remarka])le  case  of  this  kind  which 
came  under  :nj  observation  the  patient  became  suddenly  maniacal  and  died 
in  six  days.  More  corimonly  the  delirium  is  less  violent,  but  the  patient 
is  noisy,  talkative,  restless,  and  slee])less. 

{h)  Delusional  Insaiiili/  {Folic  Briijliliqtie). — Cases  are  by  no  means  un- 
common, and  excellent  clinical  reports  have  been  issued  on  the  subject 
from  several  of  the  asylums  of  this  country,  particularly  by  Bremer,  Chris- 
tian, and  Alice  Bennett.  Delusions  of  persecution  are  common.  One  of 
my  eases  committed  suicide  ])y  jumjjing  out  of  a  window.  The  condition 
is  of  interest  medico-legally  because  of  its  bearing  on  testamentary  capacity. 
Profound  melancholia  may  also  supervene. 

(r)  Conrvlsions. — These  may  come  on  unexpectedly  or  be  preceded  by 
pain  in  the  head  and  restlessness.  The  attacks  may  be  general  and  iden- 
tical with  those  of  ordinary  epilepsy,  though  the  initial  cry  may  not  ])e 
present.  The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is 
usually  unconscioiis.  Sometimes  the  temperature  is  elevated,  but  more 
frequently  it  is  depressed,  and  may  sink  rapidly  after  the  attack.  Local 
or  Jacksonian  epilepsy  may  occur  in  most  characteristic  form  in  ura'mia. 


I  ill 


rii^MiA. 


867 


10  unrniia  is 

e  toxicity  of 

ycd  by  uroji 

been  detcr- 

in  abnormal 
an  internal 
10  to  its  dis- 
iliionco  pro- 
of the  nuis- 
loved,  there 
nitrogenous 
Igos  that  we 
<tiidy  of  the 
albuminous 
Iford's  Gul- 
iiostion. 
y  the  coma 

md  clironi(' 
the  section 
ritis.  It  is 
lit  it  is  spe- 
ig  subjects, 
lorotic  and 
nay  be  de- 
ations. 

t  who  has 
ay  not  be 
ind  which 
1  and  died 
he  patient 

means  nn- 
10  subject 
ler,  Chris- 
One  of 
condition 
r  capacity. 

ocoded  by 
and  id  on- 
ly not  be 
patient  is 
but  more 
k.  Local 
urfcmia. 


A  remarkable  so(iuenco  of  the  convulsions  is  Idindnoss — ura'mic  omanrosis 
-  uiiicli  may  persist  for  several  days.  This,  however,  may  occur  apart  from 
the  convulsions.  It  usually  pusses  oil'  in  a  day  or  two.  There  are,  as  a  rule, 
no  oi)hthalmoscopic  changes.  Sometimes  uramiic  deafness  sui)ervenes,  and 
is  probably  also  a  cerebral  manifestation.  It  may  also  occur  in  connection 
with  persistent  headache,  nausea,  and  other  gastric  symptoms. 

(d)  Coma. — Unconsciousness  invariably  accom|)anies  the  general  con- 
vulsions, but  a  coma  may  develop  gradually  without  any  convulsive  seizures. 
iMCipiently  it  is  preceded  l)y  headache,  and  the  patient  gradually  becomes 
(lull  and  apathetic.  In  these  cases  there  nuiy  have  been  no  previous  indi- 
cations of  renal  disease,  and  unless  the  urine  is  examined  the  nature  of  the 
lase  may  be  overlooked.  Twitchings  of  the  muscles  occur,  particularly  in 
the  face  and  hands,  but  there  are  many  eases  of  coma  in  which  the  muscles 
are  not  involved.  In  some  of  these  cases  a  condition  of  torpor  persists  for 
weeks  or  even  months.  The  tongue  is  usually  furred  and  the  breath  very 
foul  and  heavy. 

(e)  Local  Palsies. — In  the  course  of  chronic  r)right's  disease  hemiplegia 
or  monoplegia  may  come  on  spontaneously  or  follow  a  convulsion,  and  post 
mortem  no  gross  lesions  of  the  brain  be  found,  but  only  a  localized  or  dif- 
fused redema.  These  cases,  which  are  not  very  uncommon,  may  simulate 
almost  every  form  of  organic  paralysis  of  cerebral  origin. 

(f)  Of  other  cerebral  symptoms,  headache  is  imi)ortant.  It  is  most 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  and 
associated  with  giddiness.  Other  nervous  symptoms  of  ura'mia  are  intense 
itching  of  the  skin,  numbness  and  tingling  in  the  iingers,  and  cramps  in 
the  muscles  of  the  calves,  particularly  at  night.  An  erythema  may  be 
present. 

Urcemic  dt/spna'a  is  classified  by  Palmer  Howard  as  follows:  (1)  Con- 
tinuous dyspnoea;  (2)  paroxysmal  dyspnanv;  (3)  both  types  alternating;  and 
(4)  Cheyne-Stokes  breathing.  The  attacks  of  dysj)nuea  are  most  commonly 
nocturnal;  the  patient  may  sit  up,  gasp  for  breath,  and  evince  as  much 
distress  as  in  true  asthma.  Occasionally  the  breathing  is  noisy  and  stridu- 
Idus.  The  Cheyne-Stokes  ty])e  may  persist  for  weeks,  and  is  not  necessarily 
associated  with  coma.  I  have  seen  it  in  a  man  who  travelled  over  'nn- 
dred  miles  to  consult  a  ])hysician.  In  another  instance  a  i)ationt,  up  and 
about,  could  only  when  at  meals  feed  himself  in  tiie  a])n(ea  period.  Though 
usually  of  serious  omen  and  occurring  with  coma  and  other  symptoms,  re- 
covery may  follow  oven  after  jiorsistonce  for  weeks  or  oven  months. 

The  gastro-infestitial  manifestations  of  ura'mia  often  set  in  with  abrupt- 
ness. Uncontrollable  vomiting  may  come  on  and  its  cai  -e  be  quite  un- 
recognizable. A  young  married  Avoman  was  admitted  to  my  wards  in  the 
Montreal  General  IIosi)ital  with  persistent  vomiting  of  four  or  five  days' 
duration.  The  urine  was  slightly  albuminous,  but  she  had  none  of  the 
usual  signs  of  nrasmia,  and  the  case  was  not  regarded  as  one  of  ^right's 
disease.  The  vomiting  persisted  and  caused  death.  The  post  mortem 
showed  extensive  sclerosis  of  both  kidneys.  The  attacks  may  be  preceded 
by  nausea  and  may  1)0  associated  with  diarrluva.  In  some  instances  the 
diarrhoea  may  come  on  without  the  vomiting;  sometimes  it  is  profuse  and 


868 


DISEASES  OF  THE  KIDNEYS. 


associated  with  an  intense  catarrlial  or  even  diphtheritic  inflammation  of 
tlie  colon. 

A  special  uiwniic  stuviatilis  has  been  descril)od  (Baric)  in  which  tlio 
mucosa  of  the  lijjs,  gums,  and  tongue  is  swollen  and  erythcuiatous.  The 
saliva  may  be  increased,  and  there  is  dilliculty  in  swallowing  and  in  mas- 
tication. The  tongue  is  usually  very  i'oul  and  the  breath  heavy  and  fetid. 
A  cutaneous  erythema  may  be  jirescnt  in  uraunia. 

Fever  is  not  uncommon  in  uncmic  states,  and  may  occur  with  the  acute 
nephritis,  with  the  com])lications,  and  as  a  manifestation  of  the  ura;mia 
itself  (Stengel). 

Very  many  patients  with  chronic  uraemia  succumb  to  what  I  have  called 
terminal  infections — acute  peritonitis,  pericarditis,  pleurisy,  meningitis,  or 
endocarditis. 

Diagnosis. — ITerter  calls  attention  to  the  value  of  the  clinical  deter- 
mination of  the  urea  in  the  blood  (for  which  purpose  only  a  few  cubic  centi- 
metres are  required)  as  an  index  of  the  degree  of  renal  inadequacy.  So  far 
as  the  urine  is  concerned,  the  volume  and  specific  gravity  indicate  the  total 
solids,  and  the  determination  of  the  urea  itself  in  the  urine  gives  no  indica- 
tion of  the  quantity  jn  the  blood.     Uraemia  may  be  confounded  with: 

(a)  Cerebral  lesions,  such  as  ha;morrhage,  meningitis,  or  even  tumor. 
In  apoplexy,  which  is  so  commonly  associated  with  kidney  disease  and 
stiff  arteries,  the  sudden  loss  of  consciousness,  particularly  if  with  convul- 
sions, may  simulate  a  urajmic  attack;  but  the  mode  of  onset,  the  existence 
of  complete  hemii)legia,  with  conjugate  deviation  of  the  eyes,  suggest 
htcmorrhage.  As  already  noted,  there  are  cases  of  ura^mic  hemiplegia  or 
monoplegia  which  cannot  be  separated  from  those  of  organic  lesion  and 
which  post  mortem  show  no  trace  of  coarse  disease  of  the  brain.  I  know 
of  an  instance  in  which  a  consultation  was  held  upon  the  propriety  of  opera- 
tion in  a  case  of  hemiplegia  believed  to  be  due  to  subdural  lucmorrhagc 
which  post  mortem  was  shown  to  be  ura?mic.  Indeed,  in  some  of  these  cases 
it  is  quite  impossible  to  distinguish  between  the  two  conditions.  So,  too, 
cases  of  meningitis,  in  a  condition  of  deep  coma,  with  perhaps  slight  fever, 
furred  tongue,  and  without  localizing  symptoms,  may  readily  be  confounded 
with  ur.Tmia. 

(b)  With  certain  infectious  diseases.  Uraemia  may  persist  for  weeks 
or  months  and  the  patient  lies  in  a  condition  of  torpor  or  even  uncon- 
sciousness, with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twitchings, 
a  rapid  feeble  pulse,  with  slight  fever.  This  state  not  unnaturally  suggests 
the  existence  of  one  of  the  infectious  diseases.  Cases  of  the  kind  are  not 
uncommon,  and  I  have  known  them  to  be  mistaken  for  typhoid  fever  and 
for  miliary  tuberculosis. 

(r)  Ura}mic  coma  may  be  confounded  with  poisoning  by  alcohol  or 
opium.  In  opium  poisoning  the  pupils  are  contracted;  in  alcoholism  they 
are  more  commonly  dilated.  In  uraemia  they  are  not  constant;  they  may 
be  either  wjdely  dilated  or  of  medium  size.  The  examination  of  the  eye- 
ground  should  be  made  to  determine  the  presence  or  absence  of  albuminuric 
retinitis.  The  urine  should  be  drawn  off  and  examir  ;d.  The  odor  of  the 
breath  sometimes  gives  an  important  hint. 


lamination  of 

n   wliich  tin; 

natoiis.     'JMic 

and  in  niiis- 

vy  and  fetid. 

itli  the  acute 
the  urajmiii 

I  liave  called 
leningitis,  or 

linical  deter- 
cubic  centi- 
lacy.    So  far 
ate  the  total 
PS  no  indica- 
ed  with: 
even  tumor, 
disease  and 
^'ith  convul- 
he  existence 
^'cs,   suggest 
miidegia  or 
lesion  and 
n.     I  know 
ty  of  opera- 
annorrhage 
these  eases 
>.     So,  too, 
light  fever, 
confounded 

for  weeks 
en  uncon- 
witchingp, 
y  suggests 
id  are  not 
fever  and 

deohol  or 
)lism  they 
they  may 
f  the  eyo- 
)uminurie 
or  of  the 


ACUTE   BRIGIIT'S  DISEASE. 


869 


The  condition  of  the  heart  and  arteries  should  also  be  taken  into  ac- 
count. Sudden  uremic  coma  is  more  common  in  the  chronic  '.nterstitial 
nephritis.  The  character  of  the  delirium  in  alcoholism  is  son.etimes  im- 
portant, and  the  coma  is  not  so  deep  as  in  urannia  f)r  o])ium  {joisoning. 
It  may  for  a  time  be  impossible  to  determine  whether  the  condition  is 
due  to  uriemia,  profound  alcoholism,  or  haMuorrhage  into  the  pons  Varolii. 

And  lastly,  in  connection  with  sudden  coma,  it  is  to  be  remembered 
tliat  insensibility  may  occur  after  prolonged  muscular  exertion,  as  after 
running  a  ten-mile  race.  In  some  instances  unconsciousness  has  come  on 
rapidly  with  stertorous  breathing  and  dilated  puj)ils.  Cases  have  occurred 
under  conditions  in  which  sun-stroke  could  be  excluded;  and  Poore,  who 
reports  a  case  in  the  Lancet  (1894),  considers  that  the  condition  is  due  to 
the  too  ra})id  accumulation  of  waste  products  in  the  blood,  and  to  hyper- 
l)yrexia  from  suspension  of  sweating. 

The  treatment  will  be  considered  under  Chronic  Bright's  Disease. 


VI.    ACUTE    BRIGHT'S    DISEASE. 

Definition. — Acute  diffuse  nephritis,  due  to  the  action  of  cold  or  of 
toxic  agents  upon  the  kidneys. 

In  all  instances  changes  exist  in  the  epithelial,  vascular,  and  inter- 
1ul)ular  tissues,  which  vary  in  intensity  in  dill'erent  forms;  hence  writers 
have  described  a  tubular,  a  glomerular,  and  an  acute  interstitial  nephritis. 
Delafield  recognizes  acute  exudative  and  acute  prcductive  forms,  the  latter 
characterized  by  proliferation  of  tlie  connective-tissue  stroma  and  of  the 
cells  of  the  Malpighian  tufts. 

litlology. — The  following  are  the  principal  causes  of  acute  nephritis: 

(1)  Cold.  Exposure  to  cold  and  wet  is  one  of  the  most  common  causes. 
It  is  particularly  prone  to  follow  exposure  after  a  drinking-bout. 

(2)  The  poisons  of  the  specific  fevers,  particularly  scarlet  fever,  less 
commonly  tyjdioid  fever,  measles,  (li])litheria,  small-pox,  chicken-])ox,  ma- 
laria, cholera,  yellow  fever,  meningitis,  and,  very  rarely,  dysentery.  As 
already  mentioned,  acute  nephritis  may  ])e  associated  with  syphilis.  In 
acute  tiiberculosis  nephritis  is  not  uncommon.  It  may  also  occur  in  sep- 
ticemia. The  frequency  of  acute  nephritis  in  malaria  has  been  emphasized 
by  Thayer  in  a  recent  analysis  of  the  cases  at  the  Johns  Hopkins  Hospital. 
Among  1,832  cases  there  were  26  of  nephritis. 

(3)  Toxic  agents,  such  as  turpentine,  cantharides,  chlorate  of  potash, 
and  carbolic  acid  may  cause  an  acute  congestion  which  sometimes  terminates 
in  ne})hritis.     Alcohol  probably  never  excites  an  acute  nephritis. 

(i)  Pregnancy,  in  which  the  condition  is  thought  by  some  to  result 
from  compression  of  the  renal  veins,  although  this  is  not  yet  finally  settled. 
The  condition  may  in  reality  be  due  to  toxic  jiroducts  as  yet  undetermined. 

(5)  Acute  nephritis  occurs  occasionally  in  connection  with  extensive 
lesions  of  the  skin,  as  in  burns  or  in  chronic  skin-diseases. 

Morbid  Anatomy. — The  kidneys  may  present  to  the  naked  eye  in 
mild  cases  no  evident  alterations.    When  seen  early  in  more  severe  forms 


870 


DISEASES  OF  TOE  KIDNEYS. 


tlio  organs  are  congested,  swollen,  dark,  and  on  section  may  drip  blood. 
In  other  instances  the  surface  is  pale  and  mottled,  the  capsule  strips  oil' 
readily,  and  the  cortex  is  swollen,  turbid,  and  of  a  grayish-red  color,  while 
(he  i)yraniids  have  an  intense  beefy-red  tint.  The  glomeruli  in  some  in- 
stances stand  out  j)lainly,  being  deeply  swollen  and  congested;  in  other 
instances  they  are  j)ale. 

The  histology  may  be  thus  summarized:  (a)  Glomerular  changes.  In 
a  majority  of  the  eases  of  nephritis  due  to  toxic  agents,  which  reach  tlu; 
kidney  through  the  blood-vessels,  the  tufts  suffer  first,  and  there  is  either 
an  acute  intraeapillary  glonierulitis,  in  which  the  capillaries  become  filled 
with  cells  and  thrombi,  or  involvement  of  the  epithelium  of  the  tuft  and 
of  Bowman's  capsule,  the  cavity  of  which  contains  leucocytes  and  red 
blood-cor|  cles.  Hyaline  degeneration  of  the  contents  and  of  the  walls 
of  the  ca])illaries  of  the  tuft  is  an  extremely  common  event.  These  pro- 
cesses are  perhaps  best  marked  in  scarlatinal  nei)hritis.  There  nuiy  be 
proliferation  about  Bowman's  cai)sule.  These  changes  interfere  with  the 
circulation  in  the  tufts  and  seriously  influence  the  nutrition  of  the  tubular 
structures  beyond  them. 

(b)  The  alterations  in  the  tubular  epithelium  consist  in  cloudy  swelling, 
fatty  change,  and  hyaline  degeneration.  In  the  convoluted  tubules,  the 
accumulation  of  altered  cells  with  leucocytes  and  blood-corpuscles  causes' 
the  enlargement  and  swelling  of  the  organ.  The  epithelial  cells  lose  their 
striation,  the  nuclei  are  obscured,  and  hyaline  droplets  often  accumulate 
in  them. 

(c)  Interstitial  changes.  In  the  milder  forms  a  simple  inflammatory 
exudate — serum  mixed  with  leucocytes  and  red  blood-corpuscles — exists 
bef  tveen  the  tubules.  In  severer  cases  areas  of  small-celled  infiltration 
occur  about  the  capsules  and  between  the  convoluted  tubes.  These  changes 
may  be  widespread  and  uniform  throughout  the  organs  or  more  intense 
in  certain  regions. 

Councilman  has  described  an  acute  interstUial  nepliritis  occurring  chiefly 
in  children  after  fevers,  characterized  by  the  presence  of  cells  similar  to 
those  described  by  Unna  as  plasma  cells.  He  thinks  that  these  cells  are 
formed  in  other  organs,  chiefly  the  spleen  and  bone  marrow,  and  are  car- 
ried to  the  kidneys  in  the  blood  current. 

Symptoms. — The  onset  is  usually  sudden,  and  when  the  nephritis 
follows  cold,  dropsy  may  l)e  noticed  within  twenty-four  hours.  After  fevers 
the  onset  is  less  abrupt,  but  the  patient  gradually  becomes  pale  and  a  pufTi- 
ness  of  the  face  or  swelling  of  the  ankles  is  first  noticed.  In  children  there 
may  at  the  outset  be  convulsions.  Chilliness  or  rigors  initiate  the  attack 
in  a  limited  number  of  cases.  Pain  in  the  back,  nausea,  and  vomiting  may 
be  present.  The  fever  is  variable.  Many  cases  in  adults  have  no  rise  in 
tcmjierature.  In  young  children  with  nephritis  from  cold  or  scarlet  fever 
the  temperature  may,  for  a  few  days,  range  from  101°  to  103°. 

The  most  characteristic  symptoms  are  the  urinary  changes.  There  may 
at  first  be  suppression;  more  commonly  the  urine  is  scanty,  highly  colored, 
and  contains  blood,  albumin,  and  tube-casts.  The  quantity  is  reduced  and 
only  4  or  5  ounces  may  be  passed  in  the  twenty-four  hours;  the  specific 


ACUTE   BRIG  I  ITS  DISEASE. 


871 


drip  blood, 
le  strips  oil' 
color,  whih; 
in  somo  iii- 
d;  in  other 

langes.  In 
li  roach  tlu; 
Te  is  either 
3come  lilk'd 
le  tuft  and 
OS  and  rod 
f  tho  walls 
Those  })ro- 
To  may  bo 
■c  with  tho 
the  tubular 

ly  swelling, 
ubulos,  tho 
icles  causos " 
3  lose  thoir 
accumulato 

lammatory 
des — exists 
infiltration 
se  changes 
re  intense 

ing  chiefly 
similar  to 
3  cells  are 
d  are  car- 
nephritis 
tor  fevers 
d  a  puffi- 
ren  there 
he  attack 
ting  may 
10  rise  in 
rlet  fever 

here  may 
1  colored, 
need  and 
|G  specifiG 


gravity  is  high — 1.025,  or  even  more;  the  color  varies  from  a  smoky  to  a 
(hop  porter  color,  but  is  seldom  bright  red.  On  standing  there  is  a  heavy 
deposit;  microsco[)i('ally  there  are  blo()d-eorj)usolos,  oi)itholium  from  the 
urinary  j)assages,  and  hyaline,  blood,  and  epithelial  tui)o-casls.  Tho  ali)U- 
luin  is  abundant,  forming  a  curdy,  thick  i)rocii)itate.  The  total  e.xcrotiou 
of  urea  is  reduced,  though  the  percentage  is  high. 

Ana'nua  is  an  early  and  marked  symptom.  In  cases  of  extensive  dropsy, 
('(fusion  may  take  place  into  the  jdoune  and  })eritonioum.  There  are  ca^e.s 
of  scarlatinal  noi)hritis  in  which  tho  drojjsy  of  the  extremities  is  trivial  and 
olfusion  into  the  pleura?  extensive.  The  lungs  may  become  a'dematous.  In 
rare  cases  there  is  a'doma  of  the  glottis.  Epistaxis  may  occur  or  cutaneous 
eeehymoses  may  develop  in  the  course  of  tho  disease. 

Tho  pulse  may  be  hard,  the  tension  increased,  and  the  second  sound 
in  the  aortic  area  accentuated.  Occasionally  dilatation  of  the  heart  comes 
on  rapidly  and  may  cause  sudden  death  (Uoodhart).  The  skin  is  dry  and 
it  may  bo  didicult  to  induce  sweating. 

Ura'mic  symi)toms  develop  in  a  limited  number  of  cases.  They  may 
occur  at  the  onset  with  suppression,  more  commonly  later  in  the  disease. 
Ocular  changes  are  not  so  common  in  acute  as  in  chronic  ^right's  disease, 
but  ha-morrhagic  retinitis  may  occur  and  occasionally  pajnllitis. 

The  course  of  acute  Bright's  disease  varies  consiilerably.  The  doscri[)- 
tion  just  given  is  of  the  form  which  most  commonly  follows  cold  or  scarlet 
fever.  In  many  of  the  febrile  cases  dropsy  is  not  a  prominent  symptom, 
and  the  diagnosis  rests  rather  with  the  examination  of  the  urine.  More- 
over, the  condition  may  be  transient  and  loss  serious.  In  other  cases,  as 
in  the  acute  nephritis  of  typhoid  fever,  there  may  bo  hivmaturia  and  pro- 
nounced signs  of  interference  with  the  renal  function.  The  most  intense 
acute  nephritis  may  exist  without  anasarca. 

In  scarlatinal  neidiritis,  in  which  the  glomeruli  are  most  seriously  af- 
fected, suppression  of  the  urine  may  be  an  early  symptom,  the  dropsy  is 
apt  to  be  extreme,  and  uriEmic  manifestations  are  common.  Acute  Bright's 
disease  in  children,  however,  may  set  in  very  insidiously  and  be  associated 
with  transient  or  slight  oedema,  and  the  symptoms  may  point  rather  to 
affection  of  the  digestive  system  or  to  brain-disease. 

Diagnosis. — It  is  very  important  to  bear  in  mind  that  the  most  seri- 
ous involvement  of  the  kidneys  may  be  manifested  only  by  slight  oedema 
of  the  feet  or  puffiness  of  the  eyelids,  without  impairment  of  the  general 
health.  The  first  indication  of  trouble  may  bo  a  unomic  convulsion.  This 
is  particularly  tho  case  in  the  acute  ne])hritis  of  ]iregnancy,  and  it  is  a  good 
ride  for  tho  practitioner,  when  engaged  to  attend  a  case,  invariably  to  ask 
that  during  the  seventh  and  eighth  months  the  urine  should  occasionally 
be  sent  for  examination. 

In  nephritis  from  cold  and  in  scarlet  fever  the  symptoms  are  usually 
marked  and  the  diagnosis  is  rarely  in  doubt.  As  already  mentioned,  every 
case  in  which  albumin  is  present  must  not  be  called  acute  Bright's  disease, 
not  oven  if  tube-casts  be  present.  Thus  the  common  febrile  albuminuria, 
although  it  represents  the  first  link  in  the  chain  of  events  leading  to  acute 
Bright's  disease,  should  not  be  placed  in  tho  same  category. 


872 


DISEASES  OF  THE  KIDNEYS. 


There  are  opcasiojial  cases  of  acute  liiiglit's  dieease  with  anasarca,  in 
wliieh  albumin  is  eitlier  absent  or  jjresent  only  as  a  trace.  This  is  a  rare 
condition.  Tube-casts  are  usually  found,  and  the  absence  of  albumin  is 
rarely  permanent.    The  urine  may  be  reduced  in  amount. 

The  character  of  the  casts  is  of  use  in  the  diagnosis  of  the  form  of 
Kright's  disease,  but  scarcely  of  such  extreme  value  as  has  been  stated. 
Thus,  the  hyaline  and  granular  casts  are  common  to  all  varieties.  The 
blood  and  epithelial  casts,  particularly  those  made  up  of  leucocytes,  are 
most  common  in  the  acute  cases. 

Prognosis. — The  outlook  varies  somewhat  with  the  cause  of  the  dis- 
ease. Jk'coveries  in  the  form  following  exposure  to  cold  are  much  more 
frequent  than  after  scarlatinal  nephritis.  In  young  children  the  mortality 
is  high,  amounting  to  at  least  one  third  of  the  cases.  Serious  symptoms 
are  low  arterial  tension,  the  occurrence  of  ura-mia,  and  etl'usion  into  the 
eerous  sacs.  The  jiersistence  of  the  dropsy  after  the  first  nu)nth,  intense 
pallor,  and  a  large  amount  of  albumin  indicate  the  possibility  of  the  dis- 
ease becoming  chronic.  For  some  months  after  the  disappearance  of  the 
droi)sy  there  may  bo  traces  of  albumin  and  a  few  tube-casts. 

In  a  week  or  ten  days,  in  a  case  of  scarlatinal  nephritis,  if  the  progress 
is  favorable,  the  dropsy  diminishes,  the  nrine  increases,  the  albumin  lessens, 
and  by  the  end  of  a  month  the  dropsy  has  disapi)eared  and  the  urine  is 
nearly  free.  In  very  young  children  the  course  may  be  rapid,  and  I  have 
known  the  urine  to  be  free  from  albumin  in  the  fourth  week.  Other  cases 
are  more  insidious,  and  though  the  dropsy  may  disappear,  the  albumin  per- 
sists in  the  urine,  the  ansemia  is  marked,  and  the  condition  becomes  chronic, 
or,  after  several  recurrences  of  the  dropsy,  improves  and  complete  recovery 
takes  place. 

Treatment. — The  patient  should  be  in  bed  and  there  remain  until 
all  traces  of  the  disease  have  disappeared.  As  sweating  i)lays  such  an  im- 
portant part  in  the  treatment,  it  is  well,  if  possible,  to  accustom  the  patient 
to  blankets.    He  should  also  be  clad  in  thin  Canton  flannel. 

The  diet  should  consist  of  milk  or  butter-milk,  gruels  made  of  arrow- 
root or  oat-meal,  barley  water,  and,  if  necessary,  beef  tea  and  chicken  broth. 
It  is  better,  if  possible,  to  confine  the  patient  to  a  strictly  milk  diet.  As 
convalescence  is  established,  bread  and  butter,  lettuce,  water-cress,  grapes, 
oranges,  and  other  fruits  may  be  given.  The  return  to  a  meat  diet  should 
be  gradual. 

The  patient  should  drink  freely  of  alkaline  mineral  waters,  ordinary 
water,  or  lemonade.  The  fluids  keep  the  kidneys  flushed  and  wash  out  the 
dchris  from  the  tubes.  A  useful  drink  is  a  drachm  of  cream  of  tartar  in  a 
pint  of  boiling  water,  to  which  may  be  added  the  juice  of  half  a  lemon  and 
a  little  sugar.  Taken  when  cold,  this  is  a  pleasant  and  satisfactory  dihtent 
drink. 

No  remedies,  so  far  as  known,  control  directly  the  changes  which  are 
going  on  in  the  kidneys.  The  indications  are:  (1)  To  give  the  excretory 
function  of  the  kidney  rest  by  utilizing  the  skin  and  the  bowels,  in  the  hope 
that  the  natural  processes  msiy  be  sufficient  to  effect  a  cure;  (3)  to  meet 
the  symptoms  as  they  arise. 


nusarca,  in 
is  is  a  rare 
albumin  is 


le  form  of 
L»cn  stated. 
Jties.  The 
ocytc's,  arc 

of  the  dis- 
iiueh  more 
.'  mortality 
sym[)toiiis 
n  into  the 
th,  intense 
of  the  dis- 
nce  of  the 

le  progress 
lin  lessens, 
le  urine  is 
md  I  have 
)ther  eases 
)umin  per- 
ps  chronic, 
e  recovery 

nain  until 
ch  an  im- 
he  patient 

of  arrow- 

cen  broth. 

diet.    As 

s,  grapes, 

iet  should 

ordinary 
h  out  the 
Eirtar  in  a 
?mon  and 
■y  diluent 

vliich  are 

excretory 

the  hope 

to  meet 


ACUTE  nillOITT'S   DISKASE. 


873 


In  a  ease  of  scarlet  fever  it  may  occfisionally  lie  possililc  to  avert  an 
aiiaek,  the  jn-emonitory  symptoms  of  which  are  marked  increase  in  the 
iirteriai  tension  and  the  jjresence  of  hloud  cdioiiiiL;  iiiatlcr  in  the  urine 
(Mnhomed).  An  active  Siiline  cathartic  may  ciini|>li'tcly  relieve  this  c(in- 
liiiion. 

At  the  onset,  when  llieic  is  pain  in  the  hack  or  JKcnint  nria.  the  Pnipi'lin 
ciiiitery  or  tlie  (h'V  <»i'  wet  cnps  give  relief.  The  hist  shuuld  not  he  u>c(l 
ill  children.  Warm  ponltices  are  often  grateful.  In  cases  wliicli  set  in 
uilh  suppi'cssion  of  urine,  these  measures  should  l»e  adopted,  and  in  addi- 
tion the  hot  hath  with  suhsecpient  [)ack,  copious  diluents,  and  a  fi'e(>  purge. 
Tile  (lro])sy  is  best  treated  hy  hydrotherapy — either  the  hot  hath,  the  wet 
piick,  or  the  hot-air  hath.  In  children  the  wet  jmek  is  usually  satishu'tory. 
Il  is  aj)[)lied  hy  wringing  a  blanket  out  of  hot  water,  wrapping  the  child 
ill  it,  covering  this  with  a  dry  blanket,  and  then  with  a  rubber  cloth.  In 
this  the  child  may  remain  for  an  hour.  It  nuiy  he  repeated  daily.  In  the 
(■use  of  adults,  the  hot-air  bath  or  the  vapor  bath  may  be  conveniently  given 
by  allowing  the  vapor  or  air  to  pass  from  a  funnel  beneath  the  bed-clothes, 
which  are  raised  on  a  low  cradle.  JMore  eiricient,  as  a  rule,  is  a  hot  bath  of 
troin  tifteen  or  twenty  minutes,  after  which  the  patient  is  wrai»ped  in 
blankets.  The  sweating  jiroduced  by  these  measures  is  usually  })rofuse, 
rarely  exhausting,  and  in  a  majority  of  eases  the  dropsy  can  in  this  way  he 
relieved.  There  are  some  cases,  however,  in  which  the  skin  does  not  re- 
spond to  the  baths,  and  if  the  symptoms  are  serious,  ])articularly  if  ura'inia 
supervenes,  jaborandi  or  its  active  i)rinci])]e,  iiilocarpine,  may  be  used. 
The  latter  may  be  given  hypodermically,  in  doses  of  from  a  sixth  to  an 
eighth  of  a  grain  in  adults,  and  from  a  tw^'utieth  to  a  twi'lfth  of  a  grain  in 
children  from  tMo  to  ten  years. 

'J'lie  bowels  should  be  kept  open  by  a  nun-ning  saline  purgi-;  in  children 
the  fluid  magnesia  is  readily  taken;  in  adults  the  sul[)hate  of  magnesia  may 
be  given  hy  Hay's  method,  in  concentrated  form,  in  the  morning,  beb)re 
jinythiiig  is  taken  into  the  stoinach.  In  Uright's  disease  it  not  infre(piently 
causes  vomiting.  The  compound  jjowder  of  Jala]),  in  half-drathni  doses, 
ni'.  if  necessary,  elaterium  may  be  used.  If  the  dropsy  is  not  extreme,  the 
urine  not  very  concentrated,  and  uriemic  sym))toms  are  not  ])resent,  the 
bowels  should  he  kept  loose  without  active  ])urgation.  If  these  measures 
fail  to  reduce  the  drojjsy  and  il  has  become  extreme,  the  skin  may  be  ])un(;- 
tiircd  with  a  lancet  or  drained  1)y  a  small  silver  canula  (Southey'i  tube), 
which  is  inserted  beneath  it.  A  fine  as]iirator  needle  may  be  used,  and  the 
lluid  allowed  to  drain  through  a  ])iece  of  long,  narrow  rubber  tubing  into 
a  vessel  beneath  the  bed.  If  the  dyspno'a  is  marked,  owing  to  ])ressure  of 
lluid  in  the  ])leuriv,  aspiration  should  be  j)erformed.  In  rare  instances  the 
ascites  is  extreme  and  may  require  ])aracentesis,  or  a  Southey's  tube  may 
lie  inserted  and  the  fluid  gradually  withdrawn.  If  nrannic  convulsions 
occur,  the  intensity  of  the  ])aroxysms  may  be  limited  by  the  use  of  chloro- 
form; to  an  adult  a  pilocar])ine  injection  should  be  at  once  given,  and 
from  a  robust,  strong  man  20  ounces  of  blood  may  be  withdrawn.  In  chil- 
dren the  loins  may  be  dry  cupped,  the  wet  pack  used,  and  a  brisk  purgative 
given.  Bromide  of  potassium  and  chloral  sometimes  prove  u.seful. 
54 


BU 


DISEASES  OF  THE  KIDNEYS. 


.  \ 
/ 


Vomiting  may  bo  relieved  by  ice  and  by  restricting  the  amount  of  foni|. 
Drop  (loses  of  (Tcasole,  iodine,  and  carbolic  acid  may  be  given.  The  diliiU' 
liydrocyanic  acid  with  bismuth  is  often  cll'ectual. 

The  question  of  the  use  of  diuretics  in  acute  Ijright's  disease  is  not  yd 
settled.  The  best  diuretic,  after  all,  is  water,  whicli  may  be  taken  freely 
with  the  citrate  of  potash  or  the  benzoate  of  soda,  salts  which  are  held  \n 
favor  the  conversion  of  the  urates  into  less  irritating  and  more  easily  t'\- 
creted  conii)oun(ls.  Digitalis  and  strophanthus  are  useful  diuretics,  ainl 
may  be  cmj)loyed  without  risk  when  the  arterial  tension  is  low  and  the  car- 
diac impulse  is  not  forcible.  I  have  never  seen  any  injurious  eirocts  from 
their  employment  after  the  early  symi)toms  had  lessened  in  intensity. 

For  the  i)ersistent  albuminuria,  1  agree  with  lioberts  and  Itosensteiii 
that  we  have  no  remedy  of  the  slightest  value.  Nothing  indicates  mure 
clearly  our  heli)lessnes8  in  controlling  kidney  metabolism  than  inaljility  to 
meet  this  common  symptom.  Astringents,  alkalies,  nitroglycerin,  and  mer- 
cury have  been  recommended. 

For  the  anaemia  always  associated  with  acute  Bright's  disease  iron  should 
be  employed.  It  should  not  be  given  until  the  acute  symptoms  have  sub- 
sided. In  the  adult  it  may  be  used  in  the  form  of  the  perchloride  in  in- 
creasing doses,  as  convalescence  proceeds.  In  children,  the  syrup  of  the 
iodide  of  iron  or  the  syruj)  of  the  phosphate  of  iron  are  better  preparations. 
Tyson  has  recently  urged  caution  in  the  too  free  use  of  iron  in  kidney 
disease.  The  dilatation  of  the  heart  is  best  treated  with  digitalis,  strophan- 
thus, and  strychnia. 

In  the  convalescence  from  acute  Bright's  disease,  care  should  be  taken 
to  guard  the  patient  against  cold.  The  diet  should  still  consist  chiefly  of 
milk  and  a  return  to  mixed  food  should  be  gradual.  A  change  of  air  is 
often  beneficial,  particularly  a  residence  in  a  warm,  equable  climate. 


VII.    CHRONIC    BRIGHT'S    DISEASE. 

•  Here,  too,  in  all  forms  we  deal  with  a  diffuse  process,  involving  ejii- 
thelial,  interstitial,  and  glomerular  tissues.  Clinically  two  groups  are  recoii- 
iiized — (a)  the  chronic  panmchymatous  nephritis,  which  follows  the  acuti' 
attack  or  comes  on  insidiousdy,  is  characterized  by  marked  dropsy,  and  post 
mortem  by  the  lorfje  \vh\ic  n-i<hiri/.  In  the  later  stages  of  this  ])rocess  tlic 
kidney  may  be  smaller — a  condition  known  as  the  small  tvhite  l-idney ;  (M 
chronic  interstitial  nephritis,  in  which  dro])sy  is  not  common  and  the  cardin- 
vascular  changes  are  pronounced.  Delafield  recognizes  a  chronic  difl'usc 
nephritis  Avith  exudation  and  a  chronic  productive  diffuse  nephritis  with- 
out exudation,  the  latter  corresponding  to  the  contracted  kidney  of  authoi>. 
The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  Bright's  di- 
ease,  but  in  reality  it  is  a  degeneration  which  may  accompany  any  form 
of  nej)hritis. 


CnilONlC  BUIOllT'rf  DISEASE. 


875 


.lilt  of  fodil. 

The  dilute 

0  is  not  }( t 
akcn  freely 
uro  held  Id 
•e  easily  ex- 
iiretics,  and 
ind  the  eai- 
L'lrocts  from 
iiisity. 

Kosenstein 
icates  more 
inability  to 
11,  and  nier- 

iron  should 
IS  have  siih- 
oride  in  in- 
yrup  of  the 
•reparations. 

1  in  kidney 
is,  strophiin- 

Id  he  taken 
at  chiefly  of 
ge  of  air  i^ 
nate. 


'olving  c]ii- 
s  are  recot:- 
s  the  acute 
;V,  and  post 
])rocoss  the 
Ixidney ;  (/') 

the  cardie- 
)nic  dift'iise 

iritis  witli- 

of  authors. 

right's  dis- 
any  form 


Chronic  rAiiKxciiYMATors  Ximmiuitis 

(Chronic  Desquamative  and  Chronic  Tubal  Xi-jthritis;  Chronic  Diffuse  Nvphril in  with 

Exudation). 

etiology. — 111  many  cases  the  di.sease  follows  the  aeiitt;  nephritis  of 
<()1(1,  scarlet  fever,  or  pregnancy.  .More  frecpii'iitly  thiin  is  usually  stated 
the  disease  has  an  insidious  onset  and  occurs  independently  of  any  acute 
altacdc.  The  fevers  may  play  an  imi)ortant  roh  in  ct'rtaiii  of  these  cases. 
Ii'osenstcin,  JJartels,  and,  in  this  country,  1.  \\.  Atkinson  and  Tliayer  have 
laid  special  stress  ujion  malaria  as  a  cause.  JJeer  and  alcohol  are  lielieved 
to  lead  to  this  form  of  nephritis.  Jii  chronic  suppuration,  syphilis,  and 
tuberculosis  the  diU'use  imrcnchymatous  nephritis  is  not  uncommon,  and  is 
usually  associated  with  amyloid  disease.  .Males  are  rather  more  subject  to 
the  aU'ection  than  females.  It  is  met  with  most  commonly  in  young  adults, 
and  is  by  no  means  infrequent  in  children  as  a  sequence  of  scarlatinal 
nephritis. 

Morbid  Anatomy. — Several  varieties  of  this  form  have  been  recog- 
nized. The  most  common  is  the  hinje  while  l-idiici/  of  Wilks,  in  whicdi  the 
organ  is  enlarged,  the  ca])siile  is  thin,  and  the  surface  white  with  the  stellate 
veins  injected.  On  section  the  cortex  is  swollen  and  yellowish  white 
ill  color,  and  often  jn-esents  opa(pie  areas.  The  jjyramids  may  be  deeply 
congested.  On  microscopical  examination  it  is  seen  that  the  ei)ithelium 
is  granular  and  fatty,  and  the  tubules  of  the  cortex  are  distended,  and  con- 
tain tube-casts.  Hyaline  changes  are  also  present  in  the  ei)itlielial  cells. 
The  glomeruli  are  large,  the  capsules  thickened,  the  cajiillaries  show  hyaline 
changes,  and  the  epithelium  of  the  tuft  and  of  the  capsule  is  extensively 
altered.  The  interstitial  tissue  is  everywhere  increased,  though  not  to  an 
extreme  degree. 

The  second  variety  of  this  form  results  from  the  gradual  increase  in 
the  connective  tissue  and  the  subsequent  shrinkage,  forming  what  is  called 
the  small  white  I'idncy  or  the  ])ale  granular  kidney.  It  is  doubtful  whether 
this  is  always  preceded  by  the  large  white  kidney.  Some  observers  hold 
that  it  may  be  a  primary  independent  form.  The  cajisule  is  thickened  and 
the  surface  is  rough  and  granular.  On  section  the  resistance  is  greatly 
increased,  the  cortex  is  reduced  and  presents  numerous  o])aque  white  or 
whitish-yellow  foci,  consisting  of  accumulations  of  fatty  ei)ithelium  in  the 
convoluted  tubules.  This  combination  of  contracted  kidney  with  the  areas 
of  marked  fatty  degeneration  has  given  the  name  of  small  granular,  fatty 
kidney  to  this  form.  The  interstitirl  changes  are  marked,  many  of  the 
glomeruli  are  destroyed,  the  degeneration  of  ejiithelium  in  the  convoluted 
tubules  is  widespread,  and  the  arteries  are  greatly  thickened. 

Belonging  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the 
chronic  hcrmorrhaqic  nephritis,  in  which  the  organs  are  enlarged,  yellowish 
white  in  color,  and  in  the  cortex  are  many  brownish-red  areas,  due  to  ha'mor- 
rhage  into  and  about  the  tubes.  In  other  respects  the  changes  are  identical 
Mith  those  in  the  large  white  kidney. 

Of  changes  in  the  other  organs  the  most  marked  are  thickening  of  the 
blood-vessels  and  hypertrophy  of  the  left  heart. 


870 


DISEASES  OF  TUE  KIDNEYS, 


/ 


Symptoms. —  I'dl lowing'  «n  ncutc  lu'iiliritis,  the  cliHcasc  tuny  itroscni, 
in  fi  iiKxIilinl  wiiy,  tlif  s_viii|it<»iiis  of  llnit  aU'rctioii.  In  nuiiiy  lasfs  it  sti- 
ill  insidiously,  tind  al'tcr  an  attack  of  (lys|>('|isia  or  a  pci'iod  of  jailing  licallli 
and  loss  of  s(ri'M|"tli  tlir  |ialicnt  licconics  pale,  and  i>idlinc>s  ol'  tjic  cyi'iid, 
or  swollen  I'ct'l  arc  not  iced  in  the  niornin;;. 

'i'lic  symptoms  are  as  i'oliows:  Tlie  urine  is  as  a  rule,  diniiruslicd  in 
(jnantily,  often  scanty.  It  has  a  dirty-yellow,  sometimes  smoky, "t'cdor,  and 
is  tiirhid  from  the  presence  of  urates.  On  Ktanding,  a  heavy  sediment  lulls, 
in  which  are  found  niimcrou.s  tube-easts  of  vurioiis  forms  and  sizus,  hyuiine, 
li<itli  lar;;c  and  small,  epithelial,  ;.;rannlar,  and  I'atty  casts.  Jicueocytes  aic 
idiundant;  red  blood-corpuscles  are  fi'ccpiently  met  with,  and  epithelitnn 
i'rom  the  kidiieys  and  pchcs.  The  albumin  is  abundiint  and  may  amount 
to  one  half  or  one  third  of  the  urine  boiled.  It  is  more  abundani  in  tlir 
urine  passed  durin-if  the  day.  The  speciHe  ^navity  may  be  hifih  in  the  earlv 
sta^'es — from  l.(l'.M)  to  l.O'.T)— though  in  the  hilcr  sta;.;cs  it  is  lower,  'j'lir 
urea  is  always  re<luce(|  in  quantity. 

Dropsy  is  a  marked  and  obstinate  symptom  of  this  form  ol"  J5rif;ht"s 
di.seaso.  'JMie  face  is  pale  and  pull'y,  and  in  the  morniu<i'  the  eyelids  aic 
(edematous.  The  anasarca  is  ;^-eneral,  and  there  may  l)c  involvement  of  the 
serous  .sacs,  in  these  chronic  cases  associated  with  lar^^c  white  kidney  theic 
is  often  a  distinctive  appcararu'c  in  the  face;  the  complexion  is  pasty,  tlu; 
|)all()r  imu'ked,  and  the  eyelids  are  (edematous.  The  dropsy  is  peculiarly 
obstinate,  rru-mic  sym|)tonis  are  common,  though  convulsions  are  perhaps 
less  fre(|uent  than  in  the  interstitial  ne|)hritis. 

The  tension  of  the  pulse  is  usually  increased;  the  vessels  ultimately 
become  stiff  and  the  heart  hypertrophied,  though  there  are  instances  of 
this  form  of  nephritis  in  which  the  heart  is  not  enlar<;ed.  The  aortic  second 
sound  is  accentuated.  Ifetinal  chan<ies  though  less  fre(pu'nt  than  in  the 
chronic  interstitial  nephritis,  occur  in  a  considerable  nundjer  of  cases. 

(Jastro-intestinal  symptoms  are  C(,mmon.  A'omiting  is  frequently  a 
distressinfjj  and  serious  sym])tom,  and  diarrheea  may  be  profuse.  Ulcera- 
tion of  the  colon  may  occur  and  ])rove  fatal. 

It  is  sometimes  ini])ossible  to  determine,  even  by  the  most  careful  ex- 
anunation  of  the  urine  or  by  analysis  of  the  symptoms,  whether  the  con- 
dition of  the  kidney  is  that  of  the  lar<;e  white  or  of  the  small  M'liite  form. 
In  cases,  however,  which  have  lasted  for  several  years,  with  the  progressive 
increase  in  the  remd  connective  tissue  and  the  cardio-vascular  changes,  the 
clinical  ])ieture  may  approach,  in  certain  respects,  that  of  the  contracted 
kidney.  The  urine  is  increased,  with  low  s])ecific  gravity.  It  is  often  turbid, 
may  contain  traces  of  hlood,  the  tube-casts  are  numerons  and  of  every 
variety  of  form  and  size,  and  the  albnmin  is  abundant.  Dro])sy  is  usually 
])resent,  thougb  not  so  extensive  as  in  the  early  stages. 

The  ])r<)(jn(isis  is  extremely  grave.  In  a  case  whicli  has  persisted  for 
more  than  a  year  recovery  rarely  takes  place.  Death  is  caused  either  by 
great  effusion  with  oedema  of  the  lungs,  by  nrannia,  or  by  secondary  inflam- 
mation of  the  serous  membranes.  Occasionally  in  children,  even  wben  thr 
disease  has  persisted  for  two  years,  the  symptoms  disappear  and  recovery 
takes  place. 


nay  prosoni, 

I'llMi'H   it   Bt'ts 
lililtg   llCilllh 

the  eyelid, 

iniiii.siied  in 
■,^'<)l()r,  ainl 
liiiieiit  I'lills, 
Zfs,  liyaliiic, 
iieoeytes  are 
e|iitlieliiiiii 
iiiiy  illlioillil 
<liiMt  in  the 
ill  llio  e;irly 
ower.     TJie 

uJ'  JJri^Iifs 
eyelids  iii'e 
iiieiit  of  the 
idney  tlieio 
^  |i:isty,  tin; 
^  peeulifii'ly 
are  perliiips 

nltiinately 
iislauces  of 
•  rtie  second 
luin  in  till' 

cases. 

oquently   a 
.'.      L'leera- 

carel'id  ex- 
r  the  con- 
liite  I'orni. 
)rogi'essivc 
ian<>es,  the 
contracted 
ten  turl)id. 
I  of  everv 
is  usually 

[visted  for 
either  by 

ry  inflani- 
when  the 

i  recover^- 


CIlllONIC   HHKJIirs   DISKASR. 


877 


Treatment, — I'lsHentinlly  the  suiiie  treutineiit  should  ho  eurrietl  out  iw 
in  acute  ilrijfht's  dir-ease.  .MdU  or  hutter-iuilk  shr)uld  countitute  the  ehiel" 
article  of  food.  The  dropsy  should  he  treated  hy  hydrotherapy.  Iron  prep- 
iiiiilioiis  should  he  j^Mveii  when  there  is  inarlieil  aiia'Uiia.  It  is  to  he  reiueni- 
Ih  red  that  the  pallor  ol'  (he  face  may  not  he  a  ^^jod  inde.\  of  the  hlood  .011- 
dition.  Tynon  thinks  that  the  prot'ession  Inia  been  niueh  too  free  in  the 
n-e  of  iron  in  these  cases.  The  acetate  (d'  potash,  dij,dtalis,  and  diuretin 
Mre  UHi'i'ul  in  increasini,'  tin.'  How  of  urine.  Ihishain's  nii.\ture  given  in  plenty 
dl'  water  will  he  found  heiielicial. 

CHHONK;    I.NTi:ilSTITIAI.    NlM'lIIIITIS 

{('intlvacted   h'idnnij ;    (irdnnlar   h'itlni'!/ ;    Cirr/ioHiM  nf  l/iit   Kiilmij;    Uuulij   KidniMj ; 

litiiud  SclvniHis), 

Sclerosis  of  tin.'  kidney  is  met  with  {<i)  as  a  se(pu'nce  of  tlu'  large  white 
kidney,  forming  the  so-called  pale  granular  or  secondary  contracted  kidney; 
(A)  as  an  independent  primary  all'ection;  (r)  as  a  seciuence  of  arterio- 
xlerosis. 

Etiology. — The  primary  form  is  chronic  from  the  oulsel,  and  is  a 
.-Inw,  cree|)ing  degeneration  of  the  kidney  suhslance — in  many  respects 
iinlv  !in  anticipation  of  the  gradual  changes  which  take  place  in  the  organ 
in  extreme  old  age.  In  many  cases  no  satisfactory  cause  can  lie  assigned. 
In  others  there  are  hereditary  iidlueiices,  as  in  the  remarkahle  family  studied 
hy  Dickinson,  in  which  a  pronounced  tendency  to  chronic  IJright's  disease 
(i((iiri'e(l  ill  four  generations,  l-'amilics  in  which  the  arteries  tend  to  d.'- 
geiierate  early  are  more  j)roiie  to  interstitial  nephritis.  Syphilis  is  held 
liy  some  to  he  a  causi'.  Alcohol  pi'ohahly  plays  an  impoi'tant  part,  par- 
ticularly in  conjunction  with  other  factors.  Among  the  lietter  classes  in 
liiis  country  chronic  I'.right's  disease  is  very  common,  and  is,  I  helieve, 
ciiiised  more  freipiently  hy  overeating  than  hy  excesses  in  alcolud.  Some  he- 
lieve excessive  use  of  meat  is  injurious,  since  it  increases  the  materials  out 
id'  which  uric  acid  is  formed.  I>y  many  a  functional  disorder  of  the  livt.'r, 
leading  to  litluvmia,  is  regarded  as  the  nu)st  efficient  factor.  It  is  quite 
possihle  that  in  ])er.sons  who  hahitually  eat  and  drink  too  much  the  work 
thrown  upon  this  organ  is  excessive,  and  the  elahoration  of  certain  mate- 
riiils  is  .so  def(>ctive  that  in  their  excretion  from  the  general  circulation  they 
irritate  the  kidneys. 

Actual  gout,  which  in  England  is  a  comnion  cause  of  interstitial  ne- 
phritis, is  not  an  important  factor  here.  On  the  other  hand,  the  nutri- 
tional disorder  known  as  litha'inia  is  very  common,  either  with  or  without 
ilyspepsia.  Lead,  as  is  well  known,  may  jiroduce  renal  sclerosis,  hut  it  is  a 
minor  factor  in  comparison  with  other  causes.  It  is  doubtful  if  climate 
lias  any  influence.  Purdy  regards  the  cold,  moist  regions  of  the  Xortheast- 
ern  States  as  specially  favorable  to  the  disease. 

Other  factors  which  may  account  for  the  prevalence  of  clironic  Bright's 
disease  in  the  better  classes  in  this  country  may  be  the  intense  worrv  and 
strain  of  business,  cond)ined,  as  they  often  are,  with  habits  of  hurried  and 
excessive  eating  and  a  lack  of  proper  exercise.     jMales  are  inor<   commonly 


878 


DISKASKS  OP  TIIK   KIDNEYS. 


atfiickcd  tliMii  rfiiiiilcs.  CikKt  twciity-fivi'  yvnn*  of  np*  it  in  ii  rare  (liscii-r; 
Ititwccii  t\\i'rit_v-li\t'  iiinl  luily  a  lew  wi'll-iiiaikcd  (•a.<t'.s  ocriir;  hclwccii  ii)i\\ 
aii*l  sixty  it  is  ('uiiiiikiii. 

Morbid  Anatomy. — Tin-  kidiu'ys  arc  usually  Hsnall,  and  toj^'i'thcr 
may  wci^di  no  nioL'e  than  an  oiiiu-e  and  a  half.  'I'liu  capsulo  in  tliii-k  and 
a<lli('i'('nl ;  tlu' surface  of  iln' orHan  irrc^ndar  and  covered  with  small  nodides, 
which  have  jiiveii  to  it  the  name  of  ^^ranular  kidney.  In  stripping'  oil  the 
capsule,  portions  (d'  tho  kidney  snl)stance  are  removed.  Small  cysta  are 
l're(|uently  seen  on  the  surl'ace.  The  color  is  usually  reddish,  often  a  very 
dark  red.  On  section  the  substance  is  tou;,di  and  resists  cutlin<,';  the  corte\ 
is  thin  and  nuiy  measure  no  more  than  a  c(Miple  of  millimctrt's.  'J'he  pyra- 
mids are  less  wasted.  The  small  arteries  are  greatly  thickened  and  stand 
out  prominently.    The  fat  about  the  j)elvis  is  greatly  increased. 

Microscopically  there  is  seen  a  marked  increase  in  the  conneetivo  tissue 
and  degeneration  and  atrophy  of  the  secreting  structures,  glomerular  and 
tubal,  the  former  predominating  and  giving  the  main  characters  to  the 
lesion.    The  following  are  the  most  important  changes: 

{(i)  An  increase  in  the  fibrous  elements,  widely  distribiited  throughout 
the  organ,  but  more  advanced  in  the  cortex,  particularly  in  the  tissue  be- 
tween the  medullary  rays.  In  the  pyraiiuds  the  distribution  of  new  growth 
is  less  jiatchy  and  more  dilfuse,  Jn  the  early  stages  of  the  process  there 
is  a  small-celled  infiltration  between  the  tubes  and  around  the  glomeruli, 
and  finally  this  becomes  librillated  and  is  seen  encircling  the  tubules  and 
JJowiuan's  capsules,  around  the  latter  often  forming  concentric  layers. 

(/))  The  changes  in  the  glomeruli  are  striking,  and  in  advanced  cases 
a  very  considerable  number  of  them  have  undergone  complete  atrophy  and 
are  represented  as  densely  encapsulated  hyaline  structures.  The  atro])liy 
is  i)artly  due  to  changes  in  the  capillary  walls  and  multiplication  of  cells 
between  the  loops,  i)artly  to  extensive  hyaline  degeneration,  and  in  i)arl, 
no  doubt,  to  the  alterations  in  the  all'erent  vessels.  The  normal  glomeruli 
usually  show  some  thickening  of  the  capsule  and  increase  in  the  cells  of  the 
tufts. 

((')  The  tubules  show  changes  in  the  e]>ithi'lium,  which  vary  a  good 
deal  in  different  localities.  Where  the  connective-tissue  growth  is  most 
advanced  they  arc  greatly  atrophied  and  the  e|)ithelium  may  be  repre- 
sented by  small  cubical  cells.  In  other  instances  the  epithelium  has  entirely 
disa])i)eared.  On  the  other  hand,  in  the  regions  re])resentcd  by  the  ])rojecting 
granules  the  tubules  are  usually  dilated,  and  the  ei)ithelium  shows  hyaline, 
fatty,  and  granular  changes.  Very  many  of  them  contain  dark  masses  of 
o])ithelial  ch'hris  and  tube-casts.  In  the  interstitial  tissue  and  in  the  tubules 
there  may  be  ])igmentary  changes  due  to  ha>niorrhage.  The  dilatation  of 
the  tubules  may  reach  an  extreme  grade,  forming  definite  cysts. 

((])  The  arteries  show  an  advanced  sclerosis.  The  intima  is  greatly 
thickened  and  there  are  changes  in  the  adventitia  and  in  the  media,  con- 
sisting in  increase  in  the  thickness  duo  to  proliferation  of  the  connective 
tissue,  in  the  latter  coat  at  the  expeni-'^  of  the  muscular  elements. 

The  view  most  generally  entertained  at  present  is  that  the  essential 
lesion  is  in  the  secreting  tissues  of  the  tubules  and  the  glomeruli,  and  that 


cmiONK!   HUKMITS   DISKASK. 


879 


ijirt'  (liHt'usc; 
t'twi'on  forty 

iikI  lf»;,'(.tlu.|- 
is  tliit'k  and 
iiiill  iiudiilcs, 
I'iiiK  oil"  tlic 
ill  cystH  iiiv 
ulU'ii  u  very 
;  the  cortex 
'J'lie  ])yra- 
I  aiul  fcitaiKJ 

L'ctivo  tissue 
nenilar  and 
•tors  to  the 

throughout 
e  tissue  be- 
nt'w  growl  1 1 
■ocess  there 
KlonuTuli. 
uhules  and 
!iyers. 

nieed  cases 
trophy  and 
le  atro])hy 
on  of  cells 
id  in  ])art, 
glomeruli 
ells  of  the 

ry  a  good 
li  is  most 
he  ropre- 
iis  entirely 
irojecting 
■s  hyaline, 
masses  of 
10  tubules 
itation  of 

is  greatly 

dia,  con- 

onnective 

essential 
and  that 


the  connective-tissue  overgrowth  is  secondary  to  this,  (irci'ulield  holds  that 
the  primary  change  is  in  most  instances  in  the  glomeruli,  to  which  both  the 
digeueratiou  in  the  epithelium  id'  the  convolutetl  tubules  and  the  increase 
111  the  intertubnlar  eonneetive  tissue  are  secondary. 

Associated  with  ciuiliiicted  kidiu'yare  general  arterio-selerosis  and  hyper- 
iKiphy  of  the  heart.  'J'he  changes  in  the  arteries  have  already  been  de- 
-rribe(l  in  the  section  on  arterio-siderosis.  The  liy[>ertrophy  ol"  the  heart  is 
(uustanl,  and  the  enlargenu'id  may  reach  an  extreme  grade.  \'arialions 
ilcpeud,  no  doubt,  in  part  upon  the  extent  of  the  diU'use  arterial  degenera- 
iinn,  but  there  arc  instances  in  which  the  term  cor  horiniim  may  be  applied 
|(>  the  enlarged  organ.  In  siudi  eases  the  hypertro|)hy  is  not  conlined  to 
the  left  ventricle,  but  involves  the  entire  heart.  'J'he  explanation  of  this 
hypertrophy  has  been  much  discussed.  It  was  at  (irst  held  to  be  (lu(  to 
llie  increased  work  thrown  upon  the  organ  in  driving  the  impure  blood 
through  the  cai)illary  system.  Uasing  his  ojiinion  U|)on  the  supposed  mus- 
<iilar  increase  in  the  smaller  arteries,  Johnson  regarded  the  hypertrophy  as 
;m  elTort  to  overccuue  a  sort  of  stop-cock  action  of  these  vessels,  which,  under 
iho  inlluence  of  the  irritating  iiigrodicnt  in  the  blood,  c(»ntracted  and  in- 
<  leased  greatly  the  i>ori|>heral  resistance.  Traubo  b.'lieved  that  the  oblitera- 
tion of  a  large  nundjor  of  capillary  territories  in  the  kidney  nuitorially  raised 
the  arterial  pressure,  and  in  this  way  led  to  the  hypertrophy  of  the  heart; 
;m  additiomd  factor,  he  thought,  was  the  diminished  excretion  of  water, 
which  also  heightoiu'd  the  jjressuro  within  the  blood-vessels. 

With  our  present  knowledge  the  most  satisfactory  explanation  is  that 
given  by  Cohnheim,  which  is  thus  clearly  and  succinctly  ])ut  by  Faggo: 
"  lie  gives  reasons  for  thinking  that  the  activity  of  the  circulation  through 
I  ho  kidneys  at  any  nu)mcr.t — in  other  words,  the  state  of  the  smaller  renal 
arteries  as  regards  contraction  or  dilatation — depends  not  (as  in  the  case 
of  the  tissues  generally)  ujjon  the  need  of  those  organs  for  blood,  but 
solely  upon  the  amount  of  material  for  the  urinary  secretion  that  the  cir- 
cidatory  fluid  happens  then  to  contain.  This  suggestion  has  bearings  .  .  . 
upon  the  development  of  hypertrophy  in  one  kidney  when  the  other  has 
been  entirely  destroyed.  But  another  consecjuence  deduciblo  from  it  is 
that  when  parts  of  both  kidneys  have  undergone  atrophy,  the  blood-tlow 
to  the  parts  that  remain  nnist,  rn'frrls  /xtrilmK,  be  as  groat  as  it  would  have 
been  to  the  whole  of  the  organs  if  they  had  boon  intact.  But  in  order  that 
such  a  quantity  of  blood  should  ])ass  through  the  restricted  capillary  area 
}\()w  open  to  it,  an  excessive  ])ressure  must  obviously  l)e  necessary.  This 
can  be  brought  to  l)oar  only  by  the  exertion  of  more  than  the  normal  degree 
of  force  on  the  ])art  of  the  loft  ventricle,  combined  with  the  nuiintenance 
of  a  corresponding  resistance  in  all  other  districts  of  the  arterial  .system. 
And  so  one  can  account  at  once  for  the  high  arterial  pressure  and  for  the 
cardio-vascular  changes  that  are  secondary  to  it." 

Symptoms. — I'orhaps  a  majority  of  the  cases  are  latent,  and  are  not 
recognized  nntil  the  occurrence  of  one  of  the  serious  or  fatal  complications. 
Even  an  advanced  grade  of  contracted  kidney  may  he  compatible  with  great 
mental  and  bodily  activity.  There  may  have  been  no  symptoms  whatever 
to  ir-uggest  to  the  patient  the  existence  of  a  serious  malady.    In  other  cases 


880 


DISEASES  OF  THE   KIDNEYS. 


till'  <i;i'ii(.'riil  lu'iiltli  is  distiirht'd.  The  pfiticnt  coiiiijlniiiH  of  lus.sitiulc,  i> 
slfi'pli'ss,  1ms  to  g(-'(.  up  at  iiiglit  to  iiiicluiiitc;  tlic  (li<;i'stiou  is  disordcivd, 
Mk'  toiigiiL"  is  furrt'd;  tlicro  are  coinplamts  of  iiciidaclK',  Tailing  vision,  and 
bR'atlilc'ssiU'ss  on  I'XtTlion. 

So  complex  and  variod  is  the  flinical  [)i('tiir('  of  chronic  l)i'i«;ht's  disea.-c 
that  it  will  be  best  to  consider  the  s_vnii)t()nis  under  the  various  systems. 

I'l-inanj  Si/slcin. — The  amount  ol'  urine  is  usually  increased,  and  from 
2  to  4  litres  may  bo  passed.  J<'reqnently  tiie  patient  has  to  get  up  two  oi' 
tliri'e  times  during  the  night  to  empty  the  l)la(lder,  and  there  is  increased 
thirst.  It  is  for  these  symjjtoms  occasionally  th.at  relief  is  sought,  it  is 
to  l)e  remembered,  however,  that  freipient  nncturition  at  night  may  be 
associated  with  irritability  of  the  ])rostate  and,  in  certain  cases,  with  su|)er- 
acidity  of  the  uriius.  The  secretion  is  clear,  the  mucous  cloud  is  well  marked, 
but  there  is  no  delinite  sediment.  The  cohn-  is  a  light  yellow,  and  the  spe- 
cific gravity  rangi's  from  1.U05  to  1.01:3.  J'ersistent  low  specific  gravity 
is  one  of  the  most  constant  and  im])ortant  features  of  the  disease.  Traces 
of  albumin  are  found,  but  may  be  absent  at  times,  {)arlicularly  in  the  early 
morning  urine.  Jt  is  often  simply  a  slight  cloudiness,  and  may  be  a])parent 
only  with  the  nu)re  delicate  tests.  'J'he  sediment  is  scanty,  and  in  it  a  few 
hyaline  or  granular  casts  are  fouiul.  The  cpiantity  of  the  solid  constituents 
of  the  nrine  is,  as  a  rule,  diminished,  though  in  some  instances  the  urea 
may  be  excreted  in  full  anionnt.  In  attacks  of  dyspepsia  or  bronchitis,  or 
in  the  later  stages  -when  the  heart  fails,  the  (piantity  of  albunun  may  be 
greatly  increased  and  the  urine  diminished.  Occasionally  blood  occurs 
in  the  uriiu',  and  there  may  even  be  ha'maturia  (S.  West).  Slight  leakage, 
represented  by  the  constant  ])resence  of  a  few  red  cells,  may  be  present  early 
in  the  disease  and  ])ersist  for  years.  In  other  instances  there  may  be,  })ar- 
ticularly  after  exercise,  Hecks  of  blood  in  a  pale,  smoky  urine. 

Cirnildlari/  Si/slciii. — The  ])nlse  is  hard,  the  tension  increased,  and  the 
vessel  wall,  as  a  rule,  thickened.  As  already  mentioned,  a  distinction  must 
be  made  between  increased  tension  and  tliickening  of  the  arterial  wall.  'J'he 
tension  may  be  ])lns  in  a  normal  vessel,  but  in  chronic  Briglit's  disease  it  is 
more  common  to  have  increased  tension  in  a  stiff  artery. 

A  pnlse  of  increased  tension  has  the  following  characters:  It  is  hai'd 
and  iucomi)ressible,  requiring  a  good  deal  of  force  to  overcome  it;  it  is  per- 
sistent, and  in  the  intervals  between  the  beats  the  vessel  feels  fnll  and  can 
he  rolled  beneath  the  finger.  These  characters  may  be  present  in  a  vessel 
the  walls  of  which  are  little,  if  at  all,  increased  in  thickness.  To  estimate 
the  latter  the  ])ulse  wave  shonld  he  obliterated  in  the  radial,  and  the  vessel 
wall  felt  beyond  it.  In  a  ])erfectly  normal  vessel  the  arterial  coats,  nnder 
these  circumstances,  cannot  be  differentiated  from  the  surrounding  tissue; 
whereas,  if  thickened,  the  vessel  can  be  r-^Med  beneath  the  linger.  Per- 
sistent high  tension  is  one  of  the  earliest  and  most  important  symptoms  of 
interstitial  nephritis.  The  cardiac  featnres  are  eqnallv  important,  though 
often  loss  obvious.  TTypertro])hy  of  the  left  ventricle  occurs  to  overcome 
the  resistance  offered  in  the  arteries.  The  enlargement  of  the  heart  nlti- 
mately  becomes  more  general.  The  apex  is  displaced  downward  and  to  tln' 
left;  the  impulse  is  forcible  and  may  be  heaving.    In  elderly  persons  with 


CHRONIC  niilGIIT'S  DIKEASK. 


881 


lussituck',   is 

i  (iisorderc'd, 

vision,  and 

flit's  diseuffc 
systems. 
I,  uiid  I'loni 
t  up  two  oi- 
is  incTwiircd 
i^dit.     It  is 
;lit  may   be 
witii  su|)t'r- 
ell  marked, 
nd  tJie  spe- 
ific  gravity 
se.     Traces 
II  tlie  early 
)e  apparent, 
in  it  a  lew 
oiistituents 
's  tlie  urea 
ineJiitis,  or 
in  may  be 
)od   occurs 
it  leai^a^^c, 
■sent  early 
y  be,  ])ar- 

1,  and  the 
tion  must 
kiill.  Tlie 
sease  it  is 

t  is  liai'd 
it  is  per- 

1  and  can 

1  a  vessel 
estimate 

lie  vessel 
s,  under 

IK  tissne; 

?r.     Per- 

ptoms  of 

,  though 

)vorconie 

art  ulti- 

d  to  the 

3ns  witli 


1  nipliysema,  tlie  displacement  of  the  a[)ex  may  not  1)0  evident.  The  first 
M)und  at  tlie  apex  may  be  duplicated;  more  commonly  the  second  sound 
at  the  aortic  cartilnjic  is  accentuated,  a  very  characiterislic  si,<i;n  of  increased 
tension.  The  sound  in  extreme  cases  may  have  a  IxiU-like  (piality.  In  many 
cases  a  systolic  murmur  develo|)s  at  tlu;  apex,  probably  as  a  result  of  rclativt? 
ii.suilieieney.  It  may  be  loud  and  transmitted  to  tlu?  axilla.  Finally  the 
liypertr()i)hy  fails,  the  heart  heeoines  dilated,  ffallop  rliyllim  is  [)resent,  and 
the  jfcneral  condition  is  that  of  a  chronic  heart-lesion. 

liespiratonj  Sijslcni. — Sudden  (edema  of  the  glottis  may  occur.  I'^lfu- 
sion  into  the  pleurae  or  sudden  tedema  oi!  the  lungs  may  prove  fatal.  Acute 
pleurisy  and  j)neumonia  are  not  uncommon.  Bronchitis  is  a  frecpuMit  ac- 
companiment, particularly  in  the  winter.  Sudden  attacks  of  ()[)pressed 
liieathing,  particularly  at  night,  are  not  infrc(pient.  This  is  often  a  unemie 
symptom,  but  is  sometimes  cardiac.  The  patient  may  sit  up  in  bed  and 
gasp  for  breath,  as  in  true  asthma.  C'heyne-Stokes  breathing  may  be  |)res- 
ent,  most  commonly  toward  the  cle^o,  but  the  patient  may  be  walking  about 
and  even  attending  to  his  oceu])ation. 

])i(ji'stii'e  i^i/slrm. —  l)yspei)sia  and  loss  of  a])petiti!  are  couinion.  Severe 
and  uncontrollable  vondting  may  be  the  first  symptom.  This  is  usually 
regarded  as  a  manifestation  of  uraiuiia,  but  it  may  be  present  without  any 
other  indications,  and  1  hav"  known  it  to  prove  fatal  without  any  suspicion 
that  chronic  IW'ight's  disease  was  ])resent.  Severe  and  even  fatal  diar- 
rluea  nuiy  develop.  The  tongue  may  be  coated  and  the  breath  heavy  and 
iii'iiious. 

NcrvDVs  t^i/slcm. — Various  cerebral  manifestations  have  already  been 
mentioned  under  uruMuia.  Headache,  sometimes  of  the  migraine  ty|)e,  may 
be  an  early  and  persistent  feature  of  thronic  l>riglit's  disease.  Cerebral 
apoplexy  is  closely  related  to  interstitial  nephritis.  The  hannorrhage  may 
take  place  into  the  meninges  or  the  cerebrum.  It  is  usually  associated  with 
marked  changes  in  the  vessels.  Neuralgias,  in  various  regions,  are  not  un- 
common. 

Special  Senses. — Trouldes  in  vision  may  be  the  first  symptom  of  the 
disease.  It  is  remarkable  in  how  many  cases  of  interstitial  nephritis  the 
condition  is  diagnosed  first  by  the  ophthalmic  surgeon.  The  llame-shaped 
I'ctinal  luemorrhages  are  the  most  common.  Less  frecpient  is  dilfuse  retinitis 
or  ])apillitis.  Sudden  blindness  may  su])ervene  without  retinal  changes — 
unemie  amaurosis.  Di|)lopia  is  a  rare  event.  I  have  seen  but  one  case. 
Knies  says  that  it  is  fre([uent.  Auditory  troubles  are  by  no  means  infre- 
(juent  in  chronic  TJright's  disease.  Hinging  in  the  ears,  with  dizziness,  is 
not  uncommon.    Various  forms  of  deafness  may  occur. 

Shin. — Qulema  is  not  common  in  interstitial  ne])hritis.  Slight  putriness 
of  the  ankles  may  lu>  i)resent,  but  in  a  majority  of  the  cases  dropsy  does 
not  supervene.  When  extensive,  it  is  almost  always  the  result  of  gradual 
failure  of  the  hy])ertro])hied  heart.  The  skin  is  often  dry  and  pale,  and 
sweats  are  not  common.  In  some  instances  the  sweat  may  deposit  a  white 
frost  of  urea  on  the  surface  of  the  skin.  >]ezema  is  a  common  accom]Vrini- 
ment  of  chronic  interstitial  ne])hritis.  Tingling  of  the  fingers  or  numb- 
ness and  pallor — the  dead  fingers — are  not,  as  some  suppose,  in  any  way 


882 


DISEASES  OF  THE  KIDNEYS. 


m 


/ 


lioculiar  to  r>ri<ilit's  disease.  Intolerahle  itcliin*,'  of  the  skin  may  l)e  present, 
and  cramps  in  the  ninscles  are  hy  no  means  rare. 

Hseniorrliages  are  not  infret[nent;  thus,  epistaxis  may  occur  and  prove 
ficrious.  l*ur])iira  may  deveh)]).  Broncho-puhnonary  ha.'morrliages  are  said, 
hy  some  Freneli  Avriters,  to  he  connnon,  hut  no  instance  of  it  has  come 
under  my  ohservation.  Ascites  is  rare  except  in  association  with  cirrliosis 
of  tlie  liver. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  dis- 
ease, one  of  tiie  many  intercurrent  atl'ections  of  which  nuiy  have  proved 
fatal.  The  early  stages  of  interstitial  nephritis  are  not  recognizahle.  In 
a  i)atient  with  increased  pulse  tension  (particularly  if  the  vessel  wall  is 
sclerotic),  with  the  apex  heat  of  the  heart  dislocated  to  the  left,  the  second 
aortic  sound  ringing  and  accentuated,  the  urine  ahundant  and  of  low  spe- 
cific gravity,  with  a  trace  of  alhumin  and  an  occasional  hyaline  or  granular 
cast,  the  diagnosis  of  interstitial  nephritis  may  he  safely  made.  Of  all  the 
indications,  that  offered  hy  the  pulse  is  the  most  important.  Persistent 
high  tension  with  thickening  of  the  arterial  wall  in  a  man  under  fifty  means 
that  serious  mischief  has  already  taken  place,  that  cardio-vascular  changes 
are  certainly,  and  renal  most  prohahly,  present.  It  is  important  in  the  diag- 
nosis of  this  condition  not  to  rest  content  with  a  single  examination  of  the 
urine.  Both  the  evening  and  the  morning  secretion  should  he  studied. 
The  sediment  should  he  collected  in  a  conical  glass,  and  in  looking  for 
tube-casts  a  large  surface  should  he  examined  with  a  tolerably  low  power 
and  little  light.  The  arterio-sclerotic  kidney  may  exist  for  a  long  time 
without  the  occurrence  of  albumin,  or  the  albumin  may  be  in  very  small 
quantities.  In  many  cases  it  is  impossible  to  differentiate  the  primary  inter- 
stitial nephritis  from  an  arterio-sclerotic  kidney,  nor  clinically  is  it  of  any 
special  value  so  to  do.  In  persons  under  forty,  with  very  high  tension, 
great  thickening  of  the  superficial  arteries,  and  marked  hypertrophy  of  the 
heart,  the  renal  are  more  likely  to  be  secondary  to  the  arterial  changes. 

Prognosis. — Chronic  Bright's  disease  is  an  incurable  affection,  and 
the  anatomical  conditions  on  which  it  depends  are  quite  as  much  beyond 
the  reach  of  medicines  as  wrinkled  skin  or  gray  hair.  Interstitial  nephritis, 
however,  is  compatible  with  the  enjoyment  of  life  for  many  years,  and  it  is 
now  universally  recognized  that  increased  tension,  thickening  of  the  arterial 
walls,  and  polyuria  with  a  small  quantity  of  albumin,  neither  doom  a  man 
to  death  within  a  short  time  nor  necessarily  interfere  with  the  pursuits  of 
an  active  life  so  long  as  proper  care  be  taken.  I  know  patients  who  have 
had  high  tension  and  a  little  albumin  in  the  urine  with  hyaline  casts  for 
ten,  twelve,  and,  in  one  instance,  fifteen  years.  Serious  indications  are  the 
develo]jment  of  uremic  symptoms,  dilatation  of  the  heart,  the  onset  of 
serous  effusions,  the  development  of  Cheyne-Stokes  breathing,  persistent 
vomiting,  and  diarrha^a. 

Treatment. — Patients  without  local  indications  or  in  whom  the  con- 
dition has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet 
life  witliout  mental  worry,  with  gentle  but  not  excessive  exercise,  and  resi- 
dence in  an  equable  climate,  should  be  recommended.     In  addition  they 


CllliUl^lC  BRIOIIT'S  DISEASE. 


883 


1)0  present, 

■  and  prove 
,a\s  are  saitl, 
t  has  come 
til  cirrhosis 

of  the  cli.<- 
ave  proved 
izable.     In 
!sel  wall  is 
the  second 
)t  low  spe- 
)r  granular 
Of  all  the 
Persistent 
ifty  means 
iir  changes 
1  the  diag- 
;ion  of  the 
e  studied. 
)oking  for 
low  poMer 
long  time 
ery  small 
ary  inter- 
it  of  any 
.  tension, 
hy  of  the 
anges. 
tion,  and 
h  beyond 
nephritis^, 
and  it  i.s 
e  arterial 
m  a  man 
irsuits  of 
rho  have 
casts  for 
3  are  the 
onset  of 
ersistent 

the  con- 
'es  as  to 
A  quiet 
nd  resi- 
on  they 


.-liould  be  told  to  keep  the  bowels  regular,  the  skin  active  l)y  a  daily  te|ii(l 
hath  with  friction,  and  the  urinary  secretion  free  by  drijd<ing  daily  a  deli- 
jiite  amount  of  either  distilled  water  or  some  i)leasant  mineral  water.  Ak'O- 
lioi  .siiould  be  strictly  jjrohibited.    Tea  and  colfee  are  allowable. 

The  diet  should  be  light  and  nourishing,  and  the  patient  should  be 
warned  not  to  eat  excessively,  and  not  to  take  meat  more  than  once  a  day. 
(  are  in  food  and  driidc  is  probably  the  most  important  element  in  the  treat- 
ment of  these  early  cases, 

A  patient  in  good  circumstances  may  bo  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  eciuable  cli- 
mate, like  that  of  Southern  California.  There  is  no  doubt  of  the  value  in 
these  cases  of  removal  from  the  changeable,  irregular  weather  which  pre- 
vails in  the  temperate  regions  from  November  until  Ai)ril. 

At  this  ])eriod  medicines  are  not  required  unless  for  certain  special 
.symptoms.  Patients  derive  much  benefit  from  an  annual  visit  to  certain 
mineral  springs,  such  as  Poland,  Bedford,  Saratoga,  in  this  country,  and 
N'ichy  and  otliers  in  Europe.  Mineral  waters  have  no  curative  inlhience 
iijton  chronic  Bright's  disease;  they  simply  help  the  interstitial  circulation 
and  keep  the  drains  flushed.  In  this  early  stage,  when  the  patient's  con- 
dition is  good,  the  tension  not  high,  and  the  quantity  of  albumin  small, 
medicines  are  not  indicated,  since  no  remedies  are  known  to  have  the  slight- 
est influence  upon  the  progress  of  the  disease.  Sooner  or  later  symj)toms 
arise  which  demand  treatment.  Of  these  the  following  are  the  most  im- 
portant: 

(a)  Greatly  Increased  Arterial  Tension. — It  is  to  be  remembered  that 
a  certain  increase  of  tension  is  not  only  necessary  but  unavoidable  in  chronic 
Bright's  disease,  and  probably  the  most  serious  danger  is  too  great  lowering 
of  the  blood  tension.  The  happy  medium  must  be  sought  between  such 
heightened  tension  as  throws  a  serious  strain  upon  the  heart  and  risks  rup- 
ture of  the  vessels  and  the  low  tension  which,  under  these  circumstances, 
is  specially  liable  to  be  associated  with  serous  effusions.  In  cases  with  per- 
r^istent  high  tension  the  diet  should  be  light,  an  occasional  saline  purge 
should  be  given,  and  sweating  promoted  by  means  of  hot  air  or  the  hot 
l)ath.  If  these  measures  do  not  suffice,  nitroglycerin  may  be  tried,  begin- 
ning with  1  minim  of  the  1-per-cent  solution  tlirce  times  a  day,  and  grad- 
ually increasing  the  dose  if  necessary.  Patients  vary  so  much  in  suscepti- 
bility to  this  drug  that  in  each  case  it  must  be  tested,  the  limit  of  dosage 
being  that  at  which  the  patient  experiences  the  physiological  effect.  As 
much  as  10  minims  of  the  1-pcr-cent  solution  may  be  given  three  times  a 
day.  In  many  case  I  have  given  it  in  much  larger  doses  for  weeks  at  a 
time.  I  have  never  seen  any  ill  effects  from  it.  If  the  dose  is  excessive  the 
]tatients  complain  at  once  of  flushing  or  headache.  Its  use  may  be  kept  up 
for  six  or  seven  Aveeks,  then  stopped  for  a  week  and  resumed.  Its  value 
is  seen  not  only  in  the  reduction  of  the  tension,  but  also  in  the  striking 
manner  in  which  it  relieves  the  headache,  dizziness,  and  dyspnoea. 

(t>)  !^[ore  or  less  ano'mia  is  present  in  advanced  cases,  and  is  best  met 
by  the  use  of  iron.  Weir  Mitchell,  who  has  had  a  unicpie  experience  in 
■certain  forms  of  chronic  Bright's  disease,  gives  the  tincture  of  the  per- 


884r 


DISEASES  Off  TUE  KIDNEYS. 


/ 


cliloridc  of  iron  in  liir<j[o  (Iohoh — from  half  a  drachm  to  a  (Irattlim  tliroc  tinn  s 
a  (liiy.  Jlc  thini<s  liiat  it  not  only  bcnrlits  tiio  anu'iiiia,  Ixit  that  it  also  is 
an  imj)ortant  means  of  reducing  the  arterial  tension. 

{(•)  iMany  imtionts  witli  Bright's  disease  present  themselves  for  treat- 
ment with  signs  of  eardiae  dilatation;  there  is  a  gallop  rhythm  or  the  heaii 
soniids  have  a  fo'tal  eliaraeter,  the  breath  is  short,  the  urine  scanty  and 
highly  alhiinunoiis,  and  there  are  signs  of  local  dropsy.  In  these  cases  the 
treatment  must  he  directi'd  to  the  heart.  A  morning  dose  of  salts  or  calo- 
mel may  be  given,  and  digitalis  in  lU-minim  doses,  three  or  four  times  a 
day.  Strychnia  may  be  used  with  benefit  in  this  condition.  In  some  in- 
stances other  cardiac  tonics  may  be  necessaiy,  Init  as  a  rule  the  digitalis  acts 
l)romptly  and  well. 

{(I)  Cnvmlc  Symplunis. — Even  before  marked  manifestations  are  present 
there  may  be  extreme  restlessness,  mental  wandering,  a  heavy,  foul  breath, 
and  a  coated  tongue.  Ileadaclie  is  not  often  complained  of,  though  intense 
frontal  headache  nuiy  be  an  early  symptom  of  ura'uiia.  in  this  condition, 
too,  the  })atient  may  com[)lain  of  i)alpitation,  feelings  of  ninnbness,  and 
sometimes  nocturnal  cramjjs.  For  these  symptoms  the  saline  })urgatives 
should  be  ordered,  and  hot  baths,  so  as  to  induce  copious  sweating.  (Irandin 
states  that  irrigation  of  the  bowel  with  water  at  a  temi)(>rature  from  T'O" 
to  lt){)°  is  most  useful.  Nitroglycerin  also  may  be  freely  used  to  reduce  the 
tension.  For  the  nntmic  convulsions,  if  severe,  inhalations  of  chloroform 
may  be  used.  If  the  patient  is  robust  and  full-blooded,  from  1;^  to  30  ounces 
of  blood  should  be  removed.  '^^Fbe  ])atient  should  be  freely  sweated,  and  if 
the  convulsions  tend  to  recur  cldoral  may  be  given,  either  by  the  mouth  or 
per  rectum,  or,  lieffer  still,  morphia.  Tra^mic  coma  must  be  treated  by 
active  ])urgation,  and  sweating  should  be  ])romoted  by  the  use  of  pilocar- 
])ine  or  the  ]u)t  l)ath.  For  the  restlessness  and  delirium  morphia  is  indis- 
]u"'nsal)le.  Since  its  recommendation  in  ura-mic  states  some  years  ago,  by 
Stei)hcn  ]\racKenzie,  I  have  used  this  remedy  extensively  and  can  speak  of 
its  great  value  in  these  cases.  I  have  never  seen  ill  effects  or  any  tendency 
to  conui  follow.  It  is  of  special  value  in  the  dyspnoea  and  Clieyne-Stokes 
breathing  of  advanced  arterio-sclerosis  with  chronic  nra?mia. 


VIII.    AMYLOID    DISEASE. 

Amyloid  (lardaccons  or  waxy)  degeneration  of  the  kidneys  is  sim])ly  an 
event  in  the  process  of  chronic  Brighfs  disease,  most  commonly  in  the 
chronic  parenchymatous  ne])hritis  following  fevers,  or  of  cachectic  states. 
It  has  no  claim  to  be  regarded  as  one  of  the  varieties  of  Bright's  disease. 
The  affection  of  the  kidneys  is  generally  a  part  of  a  widespread  amyloid 
degeneration  occurring  in  prolonged  suppuration,  as  in  disease  of  the  bone, 
in  sy])hilis,  tid)erculosis,  and  occasionally  leukaemia,  lead  poisoning,  and 
gout.    It  varies  curiously  in  frequency  in  different  localities. 

Anatomically  the  amyloid  kidney  is  large  and  pale,  the  surface  smooth, 
and  the  vena}  stellata^  well  mai'ked.  On  section  the  cortex  is  largo  and 
may  show  a  peculiar  glistening,  infiltrated  appearance,  and  the  glomeruli 


a) 
a 
( I 


AMYLOID  DISEASE. 


885 


lirco  tinu.s 
:.  it  also  is 

for  trciil- 
'  tliu  lu'iiri 
winty  and 
!  cases  llic 
ts  or  ca lo- 
ir tiiiu-'s  a 
soiuo  iii- 
;italis  acts 

ro  present 

ul  brcatli, 

;h  intense 

condition, 

noss,  and 

)ur<;atives 

(irandin 

roni  I'Hr 

educe  the 

ilorol'onn 

ii)  ounces 

id,  and  if 

mouth  or 

•eated  l)y 

pilocar- 

is  indis- 

ago,  l)y 

speak  of 

endency 

le-Stokes 


mply  an 
in  tlie 
c  states, 
disease, 
amyloid 
10  bono, 
ng,  and 


are  very  distinct.  Tlio  ])yrainids,  in  striking  contrast  to  the  cortex,  are  of 
a  deep  red  color.  A  section  soaked  in  dilute  tincture  of  iodine  shows  spots 
of  a  walnut  or  nudiogany  brown  color.  The  Mnlpighian  tufts  and  the 
>li'Miglit  vessels  may  he  most  alTecled.  In  laidaceous  disease  of  the  kidneys 
ihi'  oi'gans  are  not  always  enlarged.  'I'hey  nuiy  he  nornud  in  size  or  siniill, 
pale,  and  granular.  The  amyloid  change  is  lirst  seen  in  the  Malpighian 
lufts,  ami  then  involves  the  airerent  and  elfercnt  vessels  and  the  straight 
\fsscls.  Jt  nuiy  be  confined  cntii'cly  to  ttiem.  In  later  stages  of  the  dis- 
cMse  the  tuhules  are  alfi'ctecl,  I'hielly  the  nH'nd)rane,  rai'cly,  if  ever,  the  cells 
liu'Uiselves.  Jn  addition,  the  kidneys  always  show  signs  of  diifuse  nephritis. 
The  JJowman's  capsules  are  thickened,  there  nuiy  he  ghnnerulitis,  and  the 
liihal  epithelium  is  swollen,  granular,  and  fatty. 

Symptoms. — The  renal  features  alone  nuiy  not  indicate  the  ]»rosence 
(if  this  tlegencration.  L'sually  the  associated  condition  gives  a  hint  of  the 
nature  of  tiie  ])rocess.  The  urine,  as  a  I'lile,  shows  important  changes; 
the  qnantity  is  increased,  and  it  is  pale,  clear,  and  of  low  specific  gravity. 
The  albumin  is  usually  ahundant,  but  it  may  be  scanty,  and  in  rare  in- 
stances absent.  J'ossibly  the  variations  in  the  situation  of  the  amyloid 
changes  may  account  fen*  this,  since  albiimin  is  less  likely  to  be  present 
when  tlie  cliange  is  confined  to  the  vasa  recta,  in  addition  to  ordinary 
alb\imin  globulin  may  be  present.  The  tube-casts  are  variable,  usually 
hyaline,  often  fatty  or  finely  granular.  Occasionally  the  amyloid  reaction 
can  be  detected  in  the  hyaline  casts.  Drojjsy  is  present  in  many  instances, 
]iarticularly  when  there  is  much  ana^nua  or  profound  cachexia.  It  is  not, 
liowever,  an  invariable  symptom,  and  there  are  ca.'cs  in  which  it  does  not 
develoji.     Diarrluca  is  a  connnon  accompaniment. 

Increased  arterial  tension  and  cardiac  hy|)ertro])hy  arc  not  nsnally  pres- 
ent, except  in  those  cases  in  ■which  amyloid  degeneration  occurs  in  the 
secondary  contracted  kidney;  nnder  Avhich  circumstances  there  may  be 
uraemia  and  retinal  changes,  Avhich,  as  a  rule,  are  not  met  with  in  other 
forms. 

Diagnosis. — Uy  the  condition  of  the  urine  alone  it  is  not  ])ossible  to 
recognize  amyloid  changes  in  the  kidney.  I'snally,  liowever,  there  is  no 
(lillicnlty,  since  the  Bright's  disease  comes  on  in  association  Avith  syphilis, 
prolonged  Rn]ipuration,  disease  of  tlie  bone,  or  tuberculosis,  and  tliere  is 
evidence  of  enlargement  of  the  liver  and  s])leen.  A  sus]iicions  circum- 
stance is  the  existence  of  ]iolyuria  with  a  large  amount  of  albumin  in  the 
urine,  or  when,  in  these  constitutional  affections,  a  large  quantity  of  clear, 
]iale  nrino  is  passed,  even  without  the  presence  of  all)umin. 

The  prognosis  depends  rather  on  the  condition  with  which  the  nephritis 
is  associated.    As  a  rule  it  is  grave. 

The  treatment  of  the  condition  is  that  of  chronic  Bright's  disease. 


smooth, 
rge  and 
omoruli 


886 


DISEASES  OF  THE  KIDNEYS. 


IX.    PYELITIS 


/ 


{Consecutive  Nephritis;  Pyelonephritis ;  Pyonephrosis), 

Definition. — Infliunination  of  the  pelvis  of  the  kidney  and  the  con- 
ditions which  result  from  it. 

Etiolog^y. — Pyelitis  is  induced  by  many  causes,  among  which  tin 
following  are  the  most  important:  («)  The  irritation  of  calculi — a  vciv 
frequent  cause,  {h)  Tubercle,  (r)  The  infectious  ])yelitis  which  develo|)^ 
in  fevers,  in  which  an  acute  inflammation  of  the  pelvis  of  the  kidney  ninv 
occur,  sometimes  luemorrhagic  in  character,  more  frequently  diphtheritic. 
{(})  The  i)resence  of  decomposing  nrine,  following  pressure  upon  the  uretci' 
by  tumors  or  bladder-disease.  By  far  the  most  frequent  form  of  pyelitis  i~ 
that  which  is  consecutive  to  cystitis,  from  whatever  cause.  In  these  casc- 
the  inflamnuition  may  not  be  confined  to  the  pelvis,  but  pass  to  the  kidney, 
inducing  pyelone})hriti8.  (e)  Occasional  causes  are  cancer,  liydatids,  tlir 
ova  of  certain  parasites,  and,  according  to  some,  the  irritation  of  the  sac- 
charine urine  of  diabetes,  and  the  irritation  of  turpentine  or  cubebs.  (/') 
A  ])rimary  pyelitis  or  pyelonephritis  has  been  described  as  coming  on  afti  r 
cold  or  overexertion,  but  such  cases  are  extremely  rare.  The  condition  i.- 
met  with  in  children  (Holt),  and  in  one  case  \^ich  I  saw  with  Holmes,, 
of  Chatham,  the  pus  and  the  chills,  after  recurrmg  at  intervals  for  many 
months,  disappeared  after  circumcising  the  boy,  who  had  a  very  narrow 
prepuce,  {(j)  Following  attacks  of  Dietl's  crises  in  movable  kidney  i)yeliti> 
may  be  present. 

Morbid  Anatomy. — In  the  early  stages  of  pyelitis  the  mucous  mem- 
brane is  turbid,  somewhat  swollen,  and  may  show  ecchymoses  or  a  grayish 
pseudo-membrane.  The  urine  in  the  pelvis  is  cloudy,  and,  on  examina- 
tion, numbers  of  epithelial  cells  are  seen. 

In  the  calculous  pyelitis  there  may  be  only  slight  turbidity  of  the  mem- 
brane, which  ^as  been  called  by  some  catarrhal  pyelitis.  More  commonly 
the  mucosa  is  roughened,  grayish  in  color,  and  thick.  Under  these  circum- 
stances there  is  almost  always  more  or  less  dilatation  of  the  calyces  and 
flattening  of  the  papilltp.  Following  this  condition  there  may  be  {a)  ex- 
tension of  the  su])purative  process  to  the  kidney  itself,  forming  a  pyelo- 
nephritis; (h)  a  gradual  dilatation  of  the  calyces  with  atrophy  of  the  kidney 
substance,  and  finally  the  production  of  the  condition  of  pyonephrosis,  in 
which  the  entire  organ  is  represented  by  a  sac  of  pus  with  or  without  ;i 
thin  shell  of  r^-nal  tissue,  (c)  After  the  kidney  structure  has  been  destroyed 
by  suppuratit  n,  if  the  obstruction  at  the  orifice  of  the  pelvis  persists,  the 
fluid  portions  may  be  absorbed  and  the  pus  become  inspissated,  so  that  the 
organ  is  re])resented  by  a  series  of  sacculi  containing  grayish,  putty-liki' 
masses,  which  may  become  impregnated  with  lime  salts. 

Tuberculous  pyelitis,  as  already  described,  usually  starts  upon  the  apices 
of  the  pyramids,  and  may  at  first  be  limited  in  extent.  Ultimately  the 
condition  produced  may  be  similar  to  that  of  calculous  pyelitis.  Pyone- 
phrosis is  quite  as  frequent  a  sequence,  while  the  final  transformation  of 


1  the  con- 

which  tlir 
li — a  vciv 
li  devol()|t> 
idney  iimy 
phtlit'ritic. 
tlie  ureter 
pyelitis  i- 
these  ciise^ 
,he  kidney, 
thitids,  tile 
of  the  sae- 
ubebs.  (/") 
ig  on  aiUv 
ondition  is 
:h  Holmes. 
3  for  many 
ery  narrow 
ley  i)yeliti> 

cons  meni- 
a  grayish 
1  examina- 

the  meni- 

eommonly 

;se  cirenm- 

ilyces  and 

ie  (a)  ex- 

g  a  pyelo- 

the  kidney 

)hrosis,  in 

without  ii 

destroyi^l 

;rsists,  the 

;o  that  the 

pntty-like 

the  apices 
nately  the 
3.  Pyonc- 
mation  of 


PYELITIS. 


887 


the  pus  into  a  putty-like  material  impregnated  with  salts,  forming  the  so- 
culled  scrofidous  kidney,  is  even  commoner. 

The  pyelitis  consecutive  to  cystitis  is  usually  bilateral,  and  the  kidney 
is  apt  to  be  involved,  forming  the  so-called  siin/iail  kidtinj — acute  sup- 
purative nephritis.  There  are  lines  of  sujjpuration  extending  ahuig  the 
|iyramids,  or  small  al)sce.sses  in  the  cortex,  often  just  beneath  tiie  capsule; 
or  there  nuiy  be  wedge-shaped  abscesses.  The  pus  organisms  either  pass 
up  the  tubules  or,  as  Steven  has  shown,  through  the  lym[)hatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any 
symptoms,  even  when  the  process  is  extensive.  In  mild  grades  there  is 
pain  in  the  back  or  there  may  be  tenderness  on  deep  pressure  on  the  af- 
fected side.  The  urine  is  turbid,  contains  a  few  mucous  and  i)us  cells,  and 
(leeasionally  blood-corpuscles.  The  urine  is  acid,  and  there  may  be  a  trace 
(if  albumin. 

Before  the  condition  of  jjyuria  is  established  there  may  be  attacks  of 
pain  on  the  aifected  side  (not  amounting  to  the  severe  agony  of  renal  colic)^ 
rigors,  high  fever,  and  sweats.  Under  these  circumstances  the  urine,  which 
may  have  been  clear,  becomes  turbid  or  smoky  from  the  ]iresence  of  blood,, 
and  may  contain  large  numbers  of  mucus  cells  and  transitional  epithelium. 
These  cases  are  not  common,  but  I  have  twice  had  opijortunity  of  studying 
such  attacks  for  a  prolonged  period.  In  one  patient  the  occurrence  of  the 
rigor  and  fever  could  sometimes  be  predicted  from  the  change  in  the  con- 
dition of  the  urine.  Such  cases  occur,  I  believe,  in  association  with  calculi 
in  the  pelvis. 

The  statement  is  not  infrequently  made  that  the  epithelium  in  the 
urine  in  pyelitis  is  distinctive  and  characteristic.  This  is  erroneous,  as 
may  be  readily  demonstrated  by  comparing  scrapings  of  the  mucosa  of  the 
renal  pelvis  and  of  the  bladder.  In  both  the  ei)ithelium  belongs  to  Avhat  is 
called  the  transitional  variety,  and  in  both  regions  the  same  conical,  fusi- 
form and  irregular  cells  with  long  tails  are  found. 

When  the  pyelitis,  whether  calculous  or  tuberculous,  has  become  chronic 
and  discharges,  the  symptoms  are: 

(1)  Pyuria. — The  pus  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  often  the  case  when  only  one  kidney  is  involved,  the  ureter 
may  be  temporarily  blocked,  and  normal  urine  is  ])asscd  for  a  time;  then 
there  is  a  sudden  outflow  of  the  pent-up  pus  and  the  urine  becomes  puru- 
lent. Coincident  with  this  retention,  a  tumor  mass  may  be  felt  on  the 
side  alTected.  The  pus  has  the  ordinary  characters,  but  the  transitional 
epithelium  is  not  so  abundant  at  this  stage  and  comes  from  the  bladder  or 
from  the  pelvis  of  the  healthy  side.  Occasionally  in  rajndly  advancing 
])yelonephritis,  portions  of  the  kidney  tissue,  particularly  of  the  a])ices  of 
the  pyramids,  may  slough  away  and  api)ear  in  the  urine;  or,  as  in  a  re- 
markable specimen  shown  to  me  by  Tyson,  solid  cheesy  moulds  of  the 
calyces  are  passed.  Casts  from  the  kidney  tid)ulos  are  sometimes  ])resent. 
The  reaction  of  the  urine  is  at  first  acid,  and  may  remain  so  even  when 
the  pus  is  passed  in  large  quantities.  If  it  remains  any  time  in  the  blad- 
der or  if  cystitis  exists  it  becomes  ammoniacal.  Micturition  may  be  A'cry 
frequent  and  irritability  of  the  bladder  may  be  present. 


888 


DISHASKS  OF  THE  KIDNKYS. 


/ 


['■i)  Intcnniltcnt  fcviT  nssocintcd  \\\\\\  rijjors  is  ii.snally  ]»r<'sont  in  cason 
of  su|i|»iiralivi,'  pyi'lilis.  'I'lic  ciiills  iiiny  ivt-iir  at  r('j;iilar  iiilcrvals,  and 
the  cases  arc  often  mistaken  lor  malaria.  Owen-Uees  called  attention  tu 
llie  rr('<|iiciit  occiin'ciicc  of  these  rigors,  which  form  a  characteristic  feature 
of  holli  calculous  aud  tuhercidous  |»yelitis.  I'ltimutely  the  fever  ussiunes 
a  hectic  type  and  the  rigors  juay  cease. 

(;{)  The  f^i'iieral  condition  t>f  the  patient  usually  indicates  ])rolonged 
suppuration.  There  is  more  or  less  \vastin<^  with  ana-mia  and  a  pr()<,'ressiv(! 
failure  of  health.  Secondary  ahscesses  may  develop  anil  the  clinical  jiicturr 
liOcoiucs  that  of  iiyu'mia.  \\\  some  instances,  particularly  of  tul)erculou- 
|iyclitis,  the  clinical  course  may  resemble  that  of  ty|)hoid  fever.  There  aiv 
instances  of  pyuria  I'ccurrin;;,  at  intervals,  for  many  years  without  ini[)air- 
ment  (d'  the  hodily  vi^or. 

(I)  riiysical  cMuuiiiation  in  chroiuc  ])yelitis  usually  reveals  tenderness 
on  the  alVected  side  or  a  definite  swelling',  whicli  may  vary  much  in  size 
and  ultimately  attain  larj^e  dimensions  if  tiie  kidney  becomes  enormously 
distended,  as  in  pyonejihrosis. 

(5)  Uccasiojially  nervous  synii)toms,  -wliich  may  be  associated  with 
dyspncea,  supervene,  or  the  termination  may  bo  by  conui,  not  unlike  thai 
of  diabetes.  These  have  been  attributed  to  the  absorption  of  the  dec(jm- 
})osinf>f  uuiterials  in  tlie  urine,  whence  the  so-called  ammonia>mia.  A  form 
of  paraple^^ia  has  been  described  in  connection  with  some  cases  of  abscess 
of  the  kidney,  Init  whethei'  due  to  a  myelitis  or  to  a  peripheral  neuritis  has 
iu)t  yet  been  determined. 

In  sui)i)urative  ne|)hritis  or  surgical  kidney  following  cystitis,  the  p;i- 
tient  complains  of  ])aiii  in  the  back,  the  fever  becomes  high,  irregular,  and 
associated  with  chills,  and  in  acute  cases  a  typhoid  state  develops  in  whicli 
death  occurs. 

'Diagnosis. — between  the  tuberculous  and  the  calculous  forms  of 
pyelitis  it  may  lie  dillicult  or  imi)ossib]e  to  distinguish,  e.\ce])t  by  the  de- 
tection of  tubercle  bacilli  in  the  pus.  The  examinatiou  for  bacilli  shoidd 
be  made  systematically  in  all  suspicious  cases.  The  tuberculin  test  may 
be  used  with  advantage.  From  ])erine[)hric  abscess  jjyonejjhrosis  is  distin- 
guished by  the  more  definite  character  of  the  tumor,  the  absence  of  a'de- 
matous  swelling  in  the  lumbar  region,  and,  most  im]iortant  of  all,  the  his- 
tory of  the  case.  The  urine,  too,  in  ])erinephric  abscess  may  be  free  from 
pus.  There  are  cases,  however,  in  which  it  is  difFicult  indeed  to  make  a 
satisfactory  diagnosis.  A  ])atient,  whom  I  saw  with  Fussell,  had  had  cystitis 
through  her  pregnancy,  subsequently  ])us  in  the  urine  for  several  months, 
and  then  a  large  fluctuating  abscess  developed  in  the  right  lumbar  region. 
It  did  not  seem  ])ossible,  either  before  or  during  the  o]ieration,  to  deter- 
mine whether  the  case  was  a  sim])le  pyone])hrosis  or  whether  there  had  been 
a  ])erine])hric  abscess  caused  by  the  jiyolitis. 

Sup]iurative  pyelitis  and  cystitis  are  frequently  confounded.  I  have 
known  in.'^tances  of  the  former  in  which  perineal  section  was  performed  on 
the  supposition  of  tlie  existence  of  an  intractable  cystitis.  The  two  condi- 
tions n::iy,  of  coiirse,  coexist  and  prove  puzzling,  but  the  history,  the  acid 
character  of  the  pus  in  many  instances,  the  less  frequent  occurrence  of  am- 


III 

ill 
1V( 


lie 
(■II 

th 

(Ir 
tlu 


^\■ 


nYDRONEPIIROSIS. 


8S9 


nt  in  cases 
L'l'vuls,  tind 
ttciitioii  to 
?tic  JVatnrc 
or  ussuiiio 

prolonged 

l)n)<,'rt,'.ssiv(' 
cal  ])ictiiiv 
uljorc'iiloiis 
Tlu'io  arc 
lilt  ini|)air- 

tonclerno.ss 
icli  in  size 
inormously 

ated  with 
uilike  thai 
ho  (k'coiii- 
.  A  form 
ol'  abscess 
ciiritiri  lias 

s,  the  pa- 

L!jular,  and 

in  which 

forms    (J  I' 

>y  the  de- 

lli  shoidd 

test  may 

is  distiii- 

2  of  (I'de- 

,  tlie  liis- 

ree  from 

)  make  a 

d  cystitis 

iiiontlis. 

r  rcpfion. 

to  deter- 

uul  been 

I  have 
rrned  on 
0  condi- 
the  acid 
2  of  am- 


iiioniacal  decomposition,  the  local  siji^ns  in  one  lumbar  region,  and  llio 
iiltsenco  of  pain  in  the  bladder  shoidd  l)e  siilliciont  to  diirerentiale  the  af- 
fections. In  women,  by  catheterization  of  the  ureters,  it  may  be  dclinilely 
(Ittermined  whether  tlie  pus  comes  I'rom  the  kidneys  or  from  the  bladder. 
'I'lie  cystoscope  may  be  used  for  this  purpose. 

Prognosis. — Cases  coming  on  during  the  fevers  usually  rocovor.  Tu- 
licrculous  pyelitis  may  terminate  favoral)ly  by  inspissation  of  the  pus  and 
(•(inversion  into  a  putty-like  substance  with  deposition  of  lime  salts.  When 
|)V(»ncphrosis  develops  tiie  (hingers  are  increased.  IVrforation  may  occur, 
the  patient  may  be  worn  out  by  the  hectic  fever,  or  amyloid  disea.se  may 
develop. 

Treatment. — In  mild  cases  fluids  should  bo  taken  freely,  particularly 
the  alkaline  jiiineral  waters,  to  which  the  citrate  of  ])()tash  may  i)e  adde(l. 

The  treatment  of  the  calculous  form  will  be  considered  later.  Practi- 
cally there  are  no  remedies  which  have  much  influence  upon  the  pyuria. 
Astringents  in  no  way  control  the  discharge,  nor  have  I  seen  the  slightest 
benefit  from  buchu,  co])aiba,  sandal-wood  oil,  or  uva  ursi.  Tonics  should 
he  given,  a  notirishing  diet,  and  milk  and  butter-milk  may  be  taken  freely. 
^\■hen  the  tumor  has  formed  or  even  before  it  is  per(!e])tible,  if  the  symp- 
toms are  serious  and  severe,  the  kidney  should,  be  explored,  and,  it  neces- 
sary, nephrotomy  should  be  performed. 


X.    HYDRONEPHROSIS. 

Definition. — Dilatation  of  the  pelvis  and  calyces  of  the  kidney  with 
atro])hy  of  its  substance,  caused  by  the  accumulation  of  non-i)urulent  fluids, 
tlie  result  of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  abnor- 
mality in  the  ureter  or  urethra.  The  tumor  jiroduccd  may  be  large  enough 
to  retard  labor.  Sometimes  it  is  associated  with  other  malformations.  There 
is  a  condition  of  moderate  dilatation,  apparently  congenital,  which  is  not 
connected  with  any  obstruction  in  the  ducts.  A  case  of  the  kind  was  shown 
at  the  Philadelphia  Pathological  Society  by  Daland. 

In  some  instances  there  has  been  contraction  or  twisting  of  the  ureter, 
or  it  has  been  inserted  into  the  kidney  at  an  acute  angle  or  at  a  high  level. 
In  adult  life  the  condition  may  be  due  to  lodgment  of  a  calculus,  or  to  a 
cicatricial  stricture  follo^^  ing  ulcer. 

New  growths,  such  as  tubercle  or  cancer,  occasionally  induce  hydro- 
nephrosis; more  commonly,  pressure  upon  the  ureter  from  without,  par- 
ticularly tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bands 
compress  the  ureter.  Obstruction  within  the  bladder  may  result  from  can- 
cer, from  hypertrophy  of  the  prostate  with  cystitis,  and  in  the  urethra  from 
stricture.  It  is  stated  that  slight  grades  of  hydronephrosis  have  been  found 
in  patients  with  excessive  polyuria. 

In  whatever  way  produced,  when  the  ureter  is  blocked  the  secretion  ac- 
cumulates in  the  pelvis  and  infundibula.  Sometimes  acute  inflammation 
follows,  but  more  commonly  the  slow,  gradual  pressure  causes  atrophy  of 
55 


890 


DISKASKS  OF  TUB  KIDNEYS. 


/ 


the  impillim  witli  pradiial  distcntinti  and  wistinp  of  the  organ.  Tn  no(|uii((l 
CHHcs  Iroiii  iircssiirc,  even  wlieii  dilalation  is  extreme,  there  n\ay  usually  he 
si'en  a  tliin  layer  of  renal  struetiirc.  In  the  most  extreme  Htages  the  kid- 
ney is  represented  hy  ti  large  cyst,  which  may  perlmpH  show  on  ita  inner 
surface  imperfect  se|)ta.  The  lluid  is  tliin  and  yellowitth  in  color,"  nnd  con- 
tains (races  of  urinary  sails,  urea,  uric  acid,  and  sometimes  alhumin.  'V\\r 
iseerction  may  he  turhid  from  admixture-  with  small  ((uantities  of  pus. 

Total  occlusion  does  not  always  lead  to  a  hydronephrosis,  hut  may  lie 
followed  hy  atrophy  of  the  kidney,  it  appears  that  when  the  ohstructinn 
is  intermittent  or  not  complete  the  greatest  dilatation  is  apt  to  follow.  The 
Hac  may  he  enormous,  and  causi'  an  alxlominal  tumor  of  the  largest  size. 
The  condition  has  even  heen  mistaken  f(»r  ascites.  I"]nlurgement  of  the 
other  kidney  nmy  compensate  for  the  defect.  lly[)ertrophy  of  the  left  side 
of  the  heart  usually  follows. 

Symptoms. — When  small,  it  may  not  he  noticed.  The  congenitnl 
cases  when  bilateral  usually  prove  fatal  within  a  few  days;  when  unilateral, 
the  tumor  may  not  be  noticed  for  some  time.  It  increases  progressively 
and  has  all  the  characters  of  a  tumor  in  the  renal  region.  In  adult  life 
many  of  the  cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  uterus 
and  eidargement  of  the  prostate,  etc.,  give  rise  to  no  symptoms. 

'JMiere  are  remarkable  instances  of  infcrniillciit  hydronephrosis  in  which 
the  tumor  suddenly  disa|)pears  with  the  discharge  of  a  large  (piantity  «( 
clear  fluid.  The  sac  gradually  relills,  and  the  process  may  be  repeated  for 
years.  In  these  cases  the  obstruction  is  unilateral;  a  cicatricial  stricture 
exists,  or  a  valve  is  i)rescnt  in  the  ureter,  or  the  ureter  enters  the  u])p(  r 
part  of  the  pelvis.  Many  of  the  eases  are  in  women  and  associated  with 
movable  kidney. 

The  examination  of  the  al)domen  shows,  in  unilateral  hydrono|)hrosis, 
a  tumor  occupying  the  renal  region.  When  of  moderate  size  it  is  readily 
recognized,  but  when  large  it  may  be  confounded  with  ovarian  or  other 
tumors.  In  young  cliildren  it  may  be  mistaken  for  sarcoma  of  the  kidney 
or  of  the  retroperitoneal  glands,  the  common  cause  of  abdominal  tumor 
in  early  life.  Aspiration  alone  would  enable  us  to  difYerentiate  between 
hydroneidirosis  and  tumor.  The  large  hydronephrotie  sac  is  frequently 
mistaken  for  ovarian  tumor.  The  latter  is,  as  a  rule,  more  mobile,  and 
rarely  fills  the  deeper  portion  of  the  lumbar  region  so  thoroughly.  The 
ascending  colon  can  often  bo  detected  passing  over  the  renal  tumor,  and 
examination  ])er  vaginam,  particularly  under  ether,  will  give  important 
indications  as  to  the  condition  of  the  ovaries.  In  doubtful  cases  the  sac 
should  be  asjjirated.  The  fluid  of  the  renal  cyst  is  clear,  or  turbid  from  the 
presence  of  cell  elements,  rarely  colloid  in  character;  the  specific  gravity 
is  low;  albumin  and  traces  of  urea  and  uric  acid  are  usually  present;  and 
the  epithelial  elements  in  it  may  be  similar  to  those  found  in  the  pelvis  of  the 
kidney.  In  old  sacs,  however,  the  fluid  may  not  be  characteristic,  since  the 
urinary  salts  disappear,  but  in  one  case  of  several  years'  duration  oxalate 
of  lime  and  urea  were  found. 

Perhaps  the  greatest  difficulty  is  offered  by  the  condition  of  hydro- 
nephrosis in  a  movable  kidney.     Here,  the  history  of  sudden  disappear- 


[n  acciuired 

UHUully   lie 

:c8  the  kiil- 
II  it8  iiiiiM' 
!',■  niul  coii- 
iniiii.    Tlic 

f  |)US. 

lilt  limy  lie 
oltslnu'tinii 
.How.  Thr 
iirjfL'st  size. 

H'lll     of    tllf 

lie  kil't  si(l(! 

conj^c'iiitiil 

uiiilatcnil, 

rotrrcssivcly 

1  iulult  lilc 

the  uterus 

is  in  which 
iiuantity  of 
e pea led  for 
al  strictui'e 
tlie  U])|)er 
jiated  with 

onophrosis', 
is  readily 
n  or  otiuT 
;he  kidney 
nal  tumor 
te  between 
frequently 
ohile,  anil 
hly.  The 
umor,  and 
important 
es  the  sac 
1  from  the 
\c.  gravity 
?sent;  and 
vis  of  the 
,  since  the 
an  oxalate 

of  hydro- 
disappear- 


NEPIIROLITITIASIS. 


801 


nnce  of  the  tumor  with  the  jtaHsage  of  a  large  (luanlity  <>f  cloar  fluid  would 
lie  a  |)()int  of  great  iin|)ortanee  in  tin-  diagnoHis.  In  those  rare  iiistunees 
of  an  enormous  sac  filling  the  entire  uhdomen,  and  sometimes  mistaken 
for  ascites,  the  character  of  the  fluid  might  he  the  only  point  of  dilVcrenee. 
The  tumor  of  pyonephrosis  may  he  piactically  the  same  in  physical  char- 
;i(  leristics.  Fever  is  usually  present,  and  pus  is  (d'teii  found  in  the  urine, 
111  tht'He  cases,  when  in  douhl,  exploratory  puncture  should  be  made. 

The  outlook  in  hydronephrosis  depends  much  upon  the  cause.  When 
single,  the  condition  may  never  produce  serious  trouble,  and  the  inti'rmit- 
tent  cast's  may  p(!rsist  for  years  and  liiially  disappear.  Occasionally  the  cyst 
ruptures  into  the  peritomeum,  more  rarely  through  the  diaphragm  into  the 
lung.  A  remarkable  case  of  this  kind  was  under  the  care  of  my  colleague, 
llalsted.  A  man,  aged  twenty-one,  had,  from  his  second  year,  attacks  of 
abdominal  pain  in  which  a  swelling  would  ap[»ear  bctwi'cn  the  hip  and 
costal  margin  and  subside  with  the  passage;  of  a  large  amount  of  urine. 
In  January,  1HH8,  the  sac  discharged  through  the  right  lung.*  lieaccumu- 
lations  occurred  on  several  occasions,  and  on  June  i),  1H!)1,  the  sa(!  was 
opened  and  draiiuKl.  Tie  remains  well,  though  then;  is  still  a  sinus  through 
which  a  clear,  ])robably  urinous,  fluid  is  discharged. 

The  sac  may  discharge  spontaneously  through  the  ureter  and  the  fluid 
never  reaccumulate.  In  bilateral  hydronejihrosis  there  is  a  danger  that 
uitvuiia  may  supervene,  '^^i'here  are  instances,  too,  in  which  l.locking  of 
the  ureter  on  the  sound  side  by  calculus  has  been  followed  by  uruMiiia. 
.\nd,  lastly,  the  sac  may  suppurate,  and  the  condition  change  to  one  of 
))yonej)hro8is. 

Treatment. — Cases  of  intermittent  liydronephrosis  which  do  not  cause 
serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of  moderate 
size,  the  ol)struction  has  been  overcome  by  shampooing.  If  practised,  it 
should  be  done  with  great  care.  When  the  sac  reaches  a  large  size  as|)ira- 
tion  may  be  performed  and  repeated  if  necessary.  Puncture  sb.ouid  be 
made  in  the  flank,  midway  between  the  ilium  and  the  last  rib.  ]f  the  fluid 
reaccumulates  and  the  sac  l)eeomes  large,  it  may  be  incised  and  drained,  or, 
as  a  last  resort,  the  kidney  may  be  removed.  In  women  a  carefully  adapted 
l)ad  and  bandage  will  sometimes  prevent  the  recurrence  of  an  intermittent 
hydronephrosis.! 


Xf      NEPHROLITHIASIS  (Renal  Calculus). 

Definition. — The  formation  in  the  kidney  or  in  its  pelvis  of  con- 
cretions, by  the  deposition  of  certain  of  the  solid  constituents  of  the  urine. 

Etiology  and  Pathology. — In  the  kidney  substance  itself  the  sej)a- 
ration  of  the  urinary  salts  prodiices  a  condition  to  which,  unfortunately, 
the  term  infarct  has  been  applied.  Three  varieties  may  be  recognized:  (1) 
The  uric-acid  infarct,  usually  met  with  at  the  apices  of  the  pyramids  in 

*  Sowers,  New  York  Medical  Record,  1888. 

f  See  illustrative  cases  in  my  Lectures  on  Abdominal  Tumors,  1894. 


802 


DISIA8KS  OP  THK  KIDNKYS. 


/ 


rn'w-l)orn  children  nnd  iliirin^'  the  firnt  weeks  (tf  life.  It  in  rnadily  rocoj,'- 
iii/('<l  as  II  yellowish  linear  streak  in  the  pyramids  and  is  <d'  no  si^Miilieaiirr; 
(v)  the  urate  of  soda  inl'ai'ct,  Honietiines  associated  with  mate  of  aniinoni.i. 
whicii  forms  whitish  lines  at  the  apices  of  tho  |)yraniids  and  is  mot  with 
chielly,  hut  not  always,  in  ^'outy  persons;  and  (U)  the  linic!  infarcts,  form- 
ing' very  opa(|Ue  while  lines  in  the  pyramids,  usually  in  old  people. 

Jn  the  pelvis  and  calyces  concretions  of  the  followiii;,'  loriiis  occur:  (a) 
Small  gritty  particles,  rcnul  sand,  ranginj^  in  size  from  the  individual  j^raiiis 
of  the  uric-acid  sediment  to  hodies  1  or  '^  mm.  in  diameter.  These  may  he 
jtas.sed  in  Ihe  urine  r(»r  lonj,'  periods  without  pniducing  any  sym[)toms, 
since  they  are  too  line  to  be  arrested  in  thei.'  downward  passai^e. 

(h)  Larj^cr  concretions,  ranging  in  size  from  a  small  pea  to  a  hean,  and 
eith(!r  solitary  or  multiple  in  the  cal^  's  and  pelvis.  It  is  the  smaller  of 
these  calculi  which,  in  their  passage,  |)roduce  the  attacks  of  renal  colic. 
They  may  he  rounded  and  smooth,  or  present  numerous  incgular  projec- 
tions. 

(r)  Tho  dendriti<!  form  of  calculus.  'I'he  'o-iace  of  tho  ureter  may  he 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  nuiy  be  occu[)ied  by  the 
concretion,  which  forms  a  mor(>  or  less  distinct  mould.  'IMiese  are  the  re- 
markable coral  (■(ilriili,  which  form  in  the  pelvis  complete  moulds  of  iii- 
fundibula  and  calyces,  the  latter  even  |)resenting  ciip-like  depressions  corre- 
sponding to  the  apices  of  the  papilla?.  Some  of  these  casts  in  stone  of 
the  renal  jjelvis  arc  as  beautifully  moulded  as  ITyrtl's  corrosion  prepara- 
tions. 

Chemically  the  varieties  of  calculi  are:  (1)  Uric  acid,  by  far  tho  most 
important,  which  may  form  the  renal  sand,  the  small  solitary,  or  tho  largo 
dendritic  stones.  They  are  very  hard,  the  surface  is  smooth,  and  the  color 
reddish.  IMie  larger  stones  are  usually  stratified  and  very  dense.  Usually 
the  uric  acid  and  the  urates  are  mixed,  but  in  children  stones  comi)osed  of 
urates  alone  may  occur. 

(2)  Oxalate  of  lime,  which  forms  mulberry-shaped  calculi,  studded  with 
points  and  spines.  They  are  often  very  dark  in  color,  intensely  hard,  and 
are  a  mixture  of  oxalate  of  lime  and  uric  acid. 

(3)  Phosphatic  calculi  are  composed  of  the  phosphate  of  lime  and  the 
ammonio-magnesium  phos])hate,  sometimes  mixed  with  a  small  amount  of 
carbonate  of  lime.  They  arc  not  common,  since  the  phos])hatic  salts  are 
oftener  deposited  about  the  uric  acid  or  the  oxalate  of  linu^  stoaes. 

(1)  Rare  forms  of  calculi  are  made  up  of  cystine,  xanthine,  "iarbonatc  of 
limo,  indigo,  and  urostealith. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  They  may 
be  produced  by  an  excess  of  a  sjjaringly  soluble  abnormal  ingredient,  such 
as  cystine  or  xanthine;  more  frequently  by  the  presence  of  uric  acid  in  a 
very  acid  urine  which  favors  its  deposition.  Sir  William  Roberts  thus 
briefly  states  the  conditions  which  lead  to  the  formation  of  the  uric-acid 
concretions:  high  acidity,  poverty  in  salines,  low  pigmentation,  and  high 
percentage  of  uric  acid.  The  presence  of  albumin  and  mucus  may  deter- 
mine, as  Ord  suggests,  the  deposition  of  the  uric  acid  and  thus  form  the 
starting  point  of  a  stone.    Ova  of  parasites,  blood-clots,  casts,  and  shreds  of 


NKIMIIIOLITIIIAHIS. 


893 


i<Iily  rocoj,'- 
iKiiilicanci'; 
I'  lllllliloiii:i, 

s  met  with 
ints,  I'onn- 
)le. 

occur:  (^0 
(Iiiul  f^niiiK 
icHo  iiiiiy  lie 

symptoms, 

I  lican,  1111(1 

siimllcr  of 

renal  colic. 

ilur  i)rojc'c- 

ler  may  he 
)ie(l  hy  the 
nro  the  re- 
iilds  oi'  iii- 
■<ioiis  corre- 
n  stouo  ol' 
m  prepura- 

r  the  most 
r  the  Iar<,'e 

1  the  color 
Usually 

m posed  of 

iddcd  with 
luird,  and 

e  and  the 
imount  of 

2  salts  are 

3. 

rhonate  of 

They  may 

lent,  such 
acid  in  a 

)orts   thus 

uric-acid 

and  high 

lay  deter- 
form  the 
shreds  of 


(|iith('lium  may  form  tlio  niu'lci  of  bIoium.  The  quoHlion  of  haotorial  in- 
i'eetioM  has  tu  1)0  considered,  m  in  tiio  case  of  }:all-8tone8. 

Ifemil  calculi  are  most  common  in  the  early  and  later  periods  of  life. 
They  are  moderately  fretpient  in  (his  country,  hut  thert'  do  n»)t  appear  to 
he  special  districts,  corrcHpondinj;  to  the  "stone  counties"  in  l'in;;hind. 
Men  are  more  often  alFccted  tium  wonu-n.  Sedentary  K-cdations  Boem  to 
predispose  to  stoiu'. 

The  cltrcts  of  the  calculi  are  varied.  It  is  hy  no  nu-ans  uiu'ommon  to 
lind  u  dozen  or  nu)re  st(UieH  of  vari(UiH  sizes  in  the  calyces  wilhniit  any 
destruction  of  the  mucous  memhrane  or  dilatation  of  the  pelvis.  A  tur- 
liid  urine  (ills  llie  jK'lvis  in  which  there  are  numerous  cells  from  the  epi- 
thelial lining.  There  are  cases  of  this  sort  in  which,  ap|»arently,  the  stones 
may  go  on  forming  and  are  passed  for  years  without  seriously  impairing 
the  health  ami  without  iiu-onvcnicnce,  except  the  attacks  of  renal  colic. 
Still  n)jre  renuirkahle  are  the  lases  of  eoral-like  calculi,  which  nuiy  occupy 
the  entire  pelvis  and  calyces  without  causing  pyelitis,  hut  which  gradually 
lead  to  more  or  less  in(l\irati(Mi  of  the  kidney.  The  most  serious  ell'cts 
aiv'  when  the  stone  excites  a  suppurative  pyelitis  and  pyonephrosis. 

Symptoms. — Patients  may  pass  gravel  for  years  without  having  an 
attai'k  of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter.  In  other 
instances,  'he  formation  of  calculi  goes  on  year  hy  year  and  the  ]tatient  has 
recurring  attacks  such  as  have  htien  »<•  graphically  descrihed  hy  Montaigne. 
in  his  own  case.  A  jjatient  nuiy  pass  an  enormous  num])er  of  calculi. 
Some  years  ago  I  was  consulted  by  a  commercial  traveller,  an  extremely 
vigorous  man,  wlio  for  numy  years  had  had  repeated  attacks  of  renal  colic, 
and  had  i)assed  several  hundred  calculi  of  various  sizes.  His  collection  tilled 
an  ounce  bottle.  A  patient  may  pass  a  single  calculus,  and  never  he  trou- 
bled again.  The  large  coral  calculi  may  excite  no  symptoms.  In  a  re- 
nuirkahle specimen  of  the  kind,  presented  to  the  ^IcCill  Medical  Museum 
by  J.  A.  Ma(!(l()nald,  the  j)atient,  a  middle-aged  woman,  died  suddeidy  with 
ura'mic  symptoms.     There  was  no  pyelitis,  but  the  kidneys  were  sclerotic. 

Renal  colic  ensues  when  a  stone  enters  the  ureter.  An  attack  may  set 
in  abruptly  without  ap])arent  cause,  or  may  follow  a  strain  in  lifting. 
It  is  characterized  by  agonizing  pain,  which  starts  in  the  flank  of  the 
affected  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle  and  along 
the  inner  side  of  the  thigh.  The  pain  may  also  radiate  t'^'oudi  the  ab- 
domen and  chest,  and  be  very  intense  in  the  back.  In  severe  attacks  there 
are  nausea  and  vomiting  and  the  patient  is  collapsed.  The  pcrs[)iration 
breaks  out  upon  the  face  and  the  pulse  is  feeble  and  quick.  A  chill  may 
precede  the  outbreak,  and  the  temperature  may  rise  as  high  as  103°.  No 
one  has  more  graphically  described  an  attack  of  "  the  stone  "  than  ^lon- 
taigne,*  who'  was  a  sufferer  for  many  years:  "  Thou  art  seen  to  sweat  with 
pain,  to  look  pale  and  red,  to  tremble,  to  vomit  well-nigh  to  blood,  to  suffer 
strange  contortions  and  convulsions,  by  starts  to  let  tears  drop  from  thine 
eyes,  to  urine  thick,  black,  and  friglitful  water,  or  to  have  it  suppressed 
by  some  sharp  and  craggy  stone,  that  cruelly  pricks  and  tears  thee."     The 

*  Essays,  Book  III,  13. 


894 


DISEASES  OF  THE  KIDNEYS. 


/ 


syiiipioms  persist  for  a  variable  period.  In  sliort  attacks  they  do  not  Inst 
longer  than  an  hour;  in  other  instances  they  continue  for  a  day  or 
more,  with  temporary  relief.  iMieturition  is  frecjuent,  oceadionaliy  painful, 
and  the  urine,  as  a  rule,  is  bloody.  There  are  instances  in  which  a  largo 
amount  of  clear  urine  is  passed,  probably  from  the  other  kidney.  In  rare 
cases  the  secretion  of  urine  is  comi)Ietely  suppressed,  even  when  the  kidney 
on  the  ojiposite  side  is  normal,  and  deatli  may  occur  from  uraemia.  This 
most  frecjuently  hai)pcns  when  the  second  kidney  is  extensively  diseased, 
or  wlien  only  a  single  kidney  exists.  A  number  of  cases  of  this  kind  have 
been  recorded.  The  condition  has  been  termed,  by  Sir  William  lioberts, 
obstructive  suppression.  It  is  met  with  also  when  cancer  compresses  both 
ureters  or  involves  their  orifices  in  the  bladder.  The  patient  may  not  ap- 
pear to  be  seriously  ill  at  first,  and  ura^mic  symptoms  may  not  develop  for 
a  week,  when  twitching  of  the  muscles,  great  restlessness,  and  son^'^timcs 
drowsiness  supervene,  but,  strange  to  say,  neither  convulsions  no.  joma. 
Death  takes  place  usually  within  twelve  days  from  the  onset  of  the  ob- 
struction. 

After  the  attack  of  colic  has  passed  there  is  more  or  less  aching  on  the 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stone 
has  come.  Examination  during  the  attack  is  usually  negative.  Very  rarely 
the  kidney  becomes  pali)able.  Tenderness  on  the  affected  side  is  common. 
In  very  thin  persons  it  may  be  possible,  on  examination  of  the  abdomen, 
to  feel  the  stone  in  the  ureter;  or  the  patient  may  complain  of  a  grating 
sensation. 

When  the  calculi  remain  in  the  kidney  they  may  produce  very  definite 
and  characteristic  symptoms,  of  v.'hich  the  following  are  the  most  im- 
l)()rtant: 

(1)  Pain,  usually  in  the  back,  which  is  often  no  more  than  a  dull  sore- 
ness, but  which  may  be  severe  and  come  on  in  paroxysms.  It  is  usually  on 
the  side  affected,  but  may  be  referred  to  the  opposite  kidney,  and  there  are 
instances  in  which  the  pain  has  been  confined  to  the  sound  side.  Pains 
of  a  similar  nature  may  occur  in  movable  kidneys,  and  there  are  several 
instances  on  record  in  which  surgeons  have  incised  the  kidney  for  stone 
and  found  none.  In  an  instance  in  which  pain  was  present  for  a  couple 
of  years  the  exploration  revealed  only  a  contracted  kidney. 

(2)  Ilccmatiiria. — Although  this  occurs  most  frequently  when  the  stone 
becomes  engaged  in  the  ureter,  it  may  also  come  on  when  the  stones  are 
in  the  pelvis.  The  bleeding  is  seldom  profuse,  as  in  cancer,  but  in  some 
instances  may  persist  for  a  long  time.  It  is  aggravated  by  exertion  and 
lessened  by  rest.  Frequently  it  only  gives  to  the  urine  a  smoky  hue.  The 
urine  may  be  free  for  days,  and  then  a  sudden  exertion  or  a  prolonged  ride 
may  cause  smokiness,  or  blood  may  be  passed  in  considerable  quantities. 

(3)  Pi/clilis. — (a)  There  may  be  attacks  of  severe  pain  in  the  back,  not 
amounting  to  actual  colic,  Avhich  Jire  initiated  by  a  heavy  chill  followed 
by  fever,  in  which  the  temperature  may  reach  104°  or  105°,  followed  by 
profuse  sweating.  The  urine,  which  has  been  clear,  ma^  ^  come  turbid 
and  smoky  and  contain  blood  and  abundant  epithelium  from  the  pelvis. 
Attacks  of  this  description  may  recur  at  intervals  for  months  or  even 


do  not  Inst 
a  (lay  or 
lly  painful, 
it'll  a  larj^o 
y.  In  raro 
the  kidney 
inia.  This 
y  diseased, 
kind  have 
n  lioberts, 
resses  both 
ay  not  ap- 
levelop  for 
son'otimes 
no.  jonia. 
of  the  ob- 

ing  on  the 
'  the  stone 
levy  rarely 
s  common, 
abdomen, 
a  grating 

ry  definite 
most  im- 

dull  sore- 
Lisnally  on 

there  are 
le.     Pains 

re  several 

for  stone 
a  couple 

the  stone 
itones  are 

in  some 
rtion  and 
ue.  The 
iiged  ride 
itities. 
back,  not 

followed 
lowed  by 
le  turbid 
le  pelvis. 

or  even 


NEPHROLITHIASIS. 


896 


vcars,  and  are  generally  mistaken  for  malaria,  unless  special  attention  is 
paid  to  the  urine  and  to  the  existence  of  the  pain  in  the  back.  This  renal 
intermittent  fever,  due  to  the  presence  of  calculi,  is  analogous  to  ttie  hepatic 
intermittent  fever,  due  to  gall-stones,  and  in  l)oth  it  is  im])()rtant  to  remem- 
ber that  the  most  intense  paroxysms  may  occur  without  any  evidence  of 
suppuration. 

(b)  More  frequently  the  symptoms  of  purulent  pyelitis,  which  have  al- 
ready been  described,  are  present;  pain  in  the  renal  region,  recurring  chills, 
and  pus  in  the  urine,  with  or  without  indications  of  pyonephrosis. 

(4)  Pyuria. — There  are  instances  of  stone  in  the  kidney  in  which  pus 
occurs  continuously  or  intermittently  in  the  urine  for  many  years.  On 
many  occasions  between  1875  and  1884  I  examined  the  urine  of  a  j)hysician 
who  had  passed  calculi  when  a  student  in  1845,  and  has  had  ])us  in  the 
urine  at  intervals  to  1891.  In  spite  of  the  prolonged  suppuration  he  has  had 
remarkabJe  mental  and  bodily  vigor. 

Patients  with  stone  in  the  kidney  are  often  robust,  high  livers,  and 
gouty.  A  ;tacks  of  dyspepsia  are  not  uncommon,  or  they  nuiy  have  severe 
headaches. 

Diagnosis. — Renal  may  be  mistaken  for  intestinal  colic,  particularly 
if  the  distention  of  the  bowels  is  marked,  or  for  biliary  colic.  The  situa- 
tion and  direction  of  the  pain,  the  retraction  and  tenderness  of  the  testicle, 
the  occurrence  of  hematuria,  and  the  altered  character  of  the  urine  are 
distinctive  features.  Attention  may  again  be  called  to  the  fact  that  at- 
tacks simulating  renal  colic  are  associated  with  movable  kidney,  or  even, 
it  has  been  supposed,  without  mobility  of  the  kidney,  with  the  accumu- 
lation of  the  oxalates  or  uric  acid  in  the  pelvis  of  the  kidney.  The  diag- 
nosis between  a  stone  in  the  kidney  and  stone  in  the  bladder  is  not  always 
easy,  though  in  the  latter  the  pain  is  particularly  about  the  neck  of  the 
bladder,  and  not  limited  to  one  side.  Important  points  are  the  reaction 
of  the  urine,  which  in  stone  in  the  bladder  is  almost  invariably  alkaline, 
and  the  abundance  of  mucus  with  the  pus.  It  is  stated  that  certain  differ- 
ences occur  in  the  symptoms  produced  by  different  sorts  of  calculi.  Tl>e 
large  uric-acid  calculi  less  frequently  produce  severe  symptoms.  On  the 
other  hand,  as  the  oxalate  of  lime  is  a  rougher  calculus,  it  is  apt  to  pro- 
duce more  pain  (often  of  a  radiating  character')  than  the  lithic-acid  form, 
and  to  cause  haemorrhage.  In  both  these  forn.ri  the  urine  is  acid.  The 
phosphatic  calculi  are  stated  to  produce  the  most  intense  pain,  and  the  urine 
is  commonly  alkaline.  In  a  few  cases  the  Roentgen  rays  have  been  of  use  in 
determining  the  presence  of  a  stone. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced 
by  the  hot  bath,  which  is  sometimes  sufficient  to  relax  the  spasm.  When 
the  pain  is  very  intense  morphia  should  be  given  hypodermically,  and  in- 
halations of  chloroform  may  be  necessary  until  the  efl'ects  of  the  anodyne 
are  manifest.  Local  applications  are  sometimes  grateful — hot  poultices,  or 
cloths  wrung  out  of  hot  water.  The  patient  may  drink  freely  of  hot  lem- 
onade, soda  water,  or  barley  water.  Occasionally  change  in  posture  will 
give  great  relief,  and  inversion  of  the  patient  is  said  to  be  followed  by  im- 
mediate cessation  of  the  pain. 


896 


DISEASES  OF  THE  KIDNEYS. 


/ 


In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  quiet  life, 
avoiding  sudden  exertion  of  all  sorts.  The  essential  feature  in  tlie  treat- 
ment is  to  keep  tlie  urine  abundant  and,  in  a  majority  of  the  cases,  alka- 
line. The  patient  should  drink  daily  a  large  but  definite  quantity  of  min- 
eral waters  *  or  distilled  water,  which  is  just  as  satisfactory.  The  citrat(> 
or  bicarbonate  of  j)otash  may  be  added.  The  aching  pains  in  the  back  luv. 
often  greatly  relieved  by  this  treatment.  Many  patients  find  benefit  from 
a  stay  at  Saratoga,  Bedford,  Poland,  or  other  mineral  springs  in  this  coun- 
try, or  at  Vichy  or  Ems  in  Europe. 

The  diet  siiould  be  carefully  regulated,  and  similar  to  that  indicated  in 
the  early  stages  of  gout.  Sir  William  Kobcx-ts  recommends  what  is  known 
as  the  solvent  treatment  for  uric-acid  calculi.  The  citrate  of  potash  is 
given  in  large  doses,  half  a  drachm  to  a  drachm,  every  three  hours  in  a 
tumblerful  of  water.  This  should  be  kept  up  for  several  months.  I  have 
had  no  success  with  this  treatment,  nor,  when  one  considers  the  character 
of  the  uric-acid  stones  usually  met  with  in  the  kidney,  does  it  seem  likely 
that  any  solvent  action  could  be  exercised  upon  them  by  changes  in  the 
urine.  This  treatment  should  be  abandoned  if  the  urine  becomes  am- 
moniacal. 

The  value  of  piperazine  as  a  solvent  of  uric-acid  gravel  or  of  iiric-acid 
stones  has  been  much  discussed  of  late.  While  outside  the  body  a  watery 
solution  of  the  drug  has  this  power  in  a  marked  degree,  the  amount  ex- 
creted in  the  urine  as  given  in  the  ordinary  doses  of  15  grains  daily  seems 
to  have  very  little  influence.  Several  observers  have  shown  that  the  per- 
centage of  piperazine  excreted  in  the  urine,  when  taken  in  doses  of  from 
1  to  2  grammes,  has,  when  tested  outside  of  the  body,  little  or  no  influence 
as  a  solvent  (Fawcett,  Gordon). 


XII.    TUMORS    OF   THE    KIDNEY. 


These  are  benign  and  malignant.  Of  the  benign  tumors,  the  most 
common  are  the  small  nodular  fibromata  which  occur  frequently  in  the 
pyramids,  the  aberrant  adrenals,  which  Grawitz  has  described,  and  occa- 
sionally lipoma,  angioma,  or  lymphadenoma.  The  adenomata  may  be  con- 
genital. In  one  of  my  cases  the  kidneys  were  greatly  enlarged,  contained 
small  cysts,  and  numerous  adenomatous  structures  throughout  both  organs. 

Malignant  growths — cancer  or  sarcoma — may  be  either  primary  or  sec- 
ondary. The  sarcomata  are  the  most  common,  either  alveolar  sarcoma  or 
the  remarkable  foim  containing  striped  muscular  fibres — rhabdo-myoma. 
They  are  very  common  tumors  in  children.  G.  Walker  (Annals  of  Sur- 
gery, 1897)  has  analyzed  the  literature  of  the  subject  to  date.  Carcinoma 
is  less  frequent,  and  is  of  the  encephaloid  variety. 

The  tumors  attain  a  very  large  size.  In  one  of  my  cases  the  left  kidney 
weighed  13  pounds  and  almost  filled  the  abdomen.     In  children  they  may 

*  Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  the  waters  of 
Corsena,  declared  by  Montaigne  to  be  "  powerful  enough  to  break  stones." 


.  quiet  life, 

1  the  treat- 
cases,  alkii- 
ity  of  min- 
riio  citrate 
le  back  ain 
eneiit  from 

this  couu- 

idicated  in 
t  is  known 
'  potasli  is 
iiours  in  a 
IS.     I  have 

2  cliaractcr 
icom  likely 
ges  in  the 
comes  am- 

f  uric-acid 
y  a  watery 
mount  ex- 
laily  seems 
it  the  per- 
3s  of  from 
)  influence 


TUMORS  OP  THE  KIDNEY. 


S91 


the  most 
ly  in  the 
and  occa- 
ly  be  con- 
contained 
th  organs, 
ry  or  sec- 
ircoma  or 
o-mvoma. 
s  of  Sur- 
'arcinoma 

'ft  kidney 
they  may 

e  waters  of 


reach  an  enormous  size.  Morris  states  that  in  a  boy  at  the  Middlesex  Hos- 
pital the  tumor  weighed  31  pounds.  They  grow  rapidly,  are  often  soft, 
;ind  lutmorrhage  frequently  takes  place  into  them.  In  the  sarcomata,  in- 
vasion of  the  ])elvis  or  of  the  renal  vein  is  common.  The  rhabdo-myomas 
rarely  form  very  large  tumors,  and  death  occurs  shortly  after  birth.  In  one 
of  my  cases  the  child  lived  to  the  age  of  three  years  and  a  half.  The  tumor 
nrew  into  the  renal  vein  and  inferior  cava.  A  detached  fragment  passed 
as  an  embolus  into  the  pulmonary  artery,  and  a  portion  of  it  blocked  the 
tricuspid  orifice. 

Symptoms. — The  following  are  the  most  important:  (1)  Ilasraaturia. 
This  may  be  the  first  indication.  The  blood  is  fluid  or  clotted,  and  there 
may  be  very  characteristic  moulds  of  the  pelvis  of  the  kidney  and  of  the 
ureter.  It  would  no  doubt  be  possible  for  such  to  form  in  the  ha^maturia 
from  calculus,  but  I  have  never  met  with  a  case  of  blood-casts  of  the  pelvis 
and  of  the  ureter,  either  alone  or  together,  except  in  cancer.  It  is  rare 
indeed  that  cancer  elements  can  be  recognized  in  the  urine. 

(8)  Pain  is  an  uncertain  symptom.  In  several  of  tlie  largest  tumors 
which  have  come  under  my  observation  there  has  been  no  discomfort  from 
beginning  to  close.  When  present,  it  is  of  a  dragging,  dull  character,  situ- 
ated in  the  flank  and  radiating  down  the  thigh.  The  passage  of  the  clots 
may  cause  great  pain.  In  a  recent  case  the  growth  was  at  first  upward, 
and  the  symptoms  for  some  months  were  those  of  pleurisy. 

(3)  Progressive  emaciation.  The  loss  of  flesh  is  usually  marked  and 
advances  rapidly.  There  may,  however,  be  a  very  large  tumor  witliout 
emaciation. 

Physical  Signs. — In  almost  all  instances  tumor  is  present.  Wlien 
small  and  on  the  right  side,  it  may  be  very  movable;  in  some  instances, 
occupying  a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian 
tumor.  The  large  growths  fill  the  flank  and  gradually  extend  toward  the 
middle  line,  occupying  the  right  or  left  half  of  the  abdomen.  Inspection 
may  show  two  or  three  hemispherical  projections  corresponding  to  dis- 
tended sections,  of  the  organ.  In  children  the  abdomen  may  reach  an 
enormous  size  and  the  veins  are  proni'nent  and  distended.  On  bimanual 
])alpation  the  tumor  is  felt  to  occupy  the  lumbar  region  and  can  usually 
be  lifted  slightly  from  its  bed;  in  some  cases  it  is  very  movable,  even  when 
large;  in  others  it  is  fixed,  firm,  and  solid.  The  respiratory  movements 
have  but  slight  influence  upon  it.  Eapidly  growing  renal  tumors  are  soft, 
and  on  palpation  may  give  a  sense  of  fluctuation.  A  point  of  considerable 
importance  is  the  fact  that  the  colon  crosses  the  tumor,  and  can  usually  be 
detected  without  difficulty. 

Diagnosis. — In  children  very  large  abdominal  tumors  are  either  renal 
or  retroperitoneal.  The  retroperitoneal  sarcoma  (Lobstein's  cancer)  is  more 
central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  only  toward  the 
end,  a  differential  diagnosis  may  be  impossible;  but  as  a  rule  the  sarcoma 
is  less  movable.  It  is  to  be  remembered  that  these  tumors  may  invade  the 
kidney.  On  the  left  side  an  enlarged  spleen  is  readily  distinguished,  as 
the  edge  is  very  distinct  and  the  notch  or  notches  well  marked;  it  descends 
during  respiration,  and  the  colon  lies  behind,  not  in  front  of  it.  On  the 
56 


8U8 


DISEASES  OP  TUE  KIDNEYS. 


right  side  growths  of  the  liver  are  occasionally  confounded  with  renal 
tumors;  but  such  instances  are  rare,  and  there  can  usually  be  detected  a 
zone  of  resonance  between  the  upper  margin  of  the  renal  tumor  and  the 
ribs.  Late  in  the  disease,  however,  this  is  not  possible,  for  the  renal  tumor 
is  in  close  union  with  the  liver. 

A  malignant  growth  in  a  movable  kidney  may  be  very  deceptive  and 
may  simulate  cancer  of  the  ovary  or  myoma  of  the  uterus.  The  great  mo- 
bility  upward  of  the  renal  growth  and  the  negative  result  of  examination 
of  the  pelvic  viscera  are  the  reliable  points. 

Medicinal  treatment  is  of  no  avail.  When  the  growth  is  small  and  the 
patient  in  good  condition  removal  of  the  organ  may  be  undertaken,  but  the 
percentage  of  cases  of  recovery  is  very  small,  only  5.4  per  cent  (G.  Walker). 


/ 


XIII.    CYSTIC    DISEASE    OF   THE    KIDNEY. 

The  following  varieties  of  cysts  are  met  with: 

(1)  The  small  cysts,  already  described  in  connection  with  the  chronic 
nephritis,  which  result  from  dilatation  of  obstructed  tubules  or  of  Bow- 
man's capsules.  There  are  cases  very  difficult  to  classify,  in  which  the 
kidneys  are  greatly  enlarged,  and  very  cystic  in  middle-aged  or  elderly 
persons,  and  yet  not  so  large  as  in  the  congenital  form. 

(2)  Solitary  cysts,  ranging  in  size  from  a  marble  to  an  orange,  or  even 
larger,  are  occasionally  found  in  kidneys  which  present  no  other  clianges. 
In  exceptional  cases,  they  may  form  tumors  of  considerable  size.  Newman 
operated  on  one  which  contained  25  ounces  of  blood.  They,  too,  in  all 
probability,  result  from  obstruction. 

(3)  The  congenital  cystic  kidneys.  In  this  remarkable  condition  the 
kidneys  are  represented  by  a  conglomeration  of  cysts,  varying  in  size  from 
a  pea  to  a  marble.  The  organs  are  greatly  enlarged,  and  together  may 
weigh  G  or  more  pounds.  In  the  foetus  they  may  attain  a  size  sufficient 
to  impede  labor.  Little  or  no  renal  tissue  may  be  noticeable,  although  in 
microscopical  sections  it  is  seen  that  a  considerable  amount  remains  in 
the  interspaces.  The  cysts  contain  a  clear  or  turbid  fluid,  sometimes  red- 
dish brown  or  even  blackish  in  color,  and  may  be  of  a  colloidal  consistence. 
Albumin,  blood  crystals,  cholesterin,  with  triple  phosphates  and  fat  drops 
are  found  in  the  contents.  Urea  and  uric  acid  are  rarely  present.  The 
cysts  are  lined  by  a  flattened  epithelium.  It  is  not  yet  accurately  known 
how  these  cysts  originate.  That  it  is  a  defect  in  development  rather  than 
a  pathological  change  is  suggested  by  the  fact  that  in  the  embryo  it  is  often 
associated  with  other  anomalies,  particularly  imperforate  anus.  Both  Shat- 
tock  and  Bland  Sutton,  who  have  studied  the  question  carefully,  believe 
that  the  anomaly  of  development  is  in  the  failure  of  complete  difi'erentia- 
tion  of  the  Wolffian  bodies,  which  are,  as  it  were,  mixed  with  the  kidney:^ 
and  give  rise  to  the  cysts.  Though  the  condition  is  congenital,  yet  from 
the  history  of  certain  cases  it  is  evident  that  the  organs  must  increase  enor- 
mously in  size.  In  a  patient  of  Dr.  Alfred  King's,  of  Portland,  Me.,  a 
man  aged  fifty-four,  the  abdomen  presented  nothing  abnormal  on  careful 


CYSTIC  DISEASE  OP  THE  KIDNEY. 


899 


with  renal 

detected  a 

or  and  the 

■enal  tumor 

jeptive  and 
5  great  mo- 
xamination 

all  and  the 
en,  but  the 
i.  Walker). 


he  chronic 

)r  of  Bow- 

which  the 

or  elderly 

;e,  or  even 

ir  changes. 

Newman 

too,  in  all 

dition  the 

size  from 

ether  may 

sufficient 

though  in 

emains  in 

times  red- 

)nsistence. 

fat  drops 

lent.     The 

ly  known 

thor  than 

it  is  often 

oth  Shat- 

y,  believe 

ifferentia- 

e  kidneys 

yet  from 

?ase  enor- 

:1,  Me.,  a 

n  careful 


examination  tliree  years  before  liis  death,  but  three  months  prior  to  this 
ilate  there  were  large  bilateral  tumors  in  the  renal  regions,  which  were 
readily  diagnosed  as  cystic  kidneys.     The  organs  weighed  4  pounds  each. 

In  a  large  majority  of  the  cases  death  occurs,  either  in  uleru  or  shortly 
after  birth;  but  instances  are  met  with  at  all  ages  up  to  fifty  or  sixty,  and 
1  see  no  reason  to  suppose  that  these  are  not  instances  of  persistence  of  the 
congenital  form. 

In  the  adult  the  tumors  may  be  felt  in  the  lumbar  region  as  large 
rounded  masses. 

The  symptoms  are  those  of  chronic  interstitial  nephritis.  Many  of  the 
cases  have  ])resented  no  indications  whatever  until  a  sudden  attack  of 
uraemia;  others  have  died  of  heart-failure.  A  rare  termination,  as  in  a  case 
at  the  University  Hospital,  Philadelphia,  is  the  rupture  of  one  of  the 
cysts  and  the  production  of  a  perinephritic  abscess.  The  cardio-vascular 
changes  induced  are  similar  to  those  of  interstitial  nephritis.  The  left 
ventricle  is  hypertrophied  and  the  arterial  tension  is  greatly  increased. 
The  condition  is  compatible  with  excellent  health.  Ilivmaturia  may  occur. 
The  dangers  are  those  associated  with  chronic  Bright's  disease.  It  is  im- 
])ortant  to  remember  that  the  conglomerate  cystic  kidney  is  almost  in- 
variably bilateral.  One  kidney  may  be  somewhat  larger  and  more  cystic 
than  the  other. 

The  diagnosis  can  sometimes  be  made.  Great  enlargement  of  both 
organs,  with  hypertrophy  of  the  left  heart  and  increased  arterial  tension, 
would  suggest  the  condition. 

Operative  interference  is  not  justifiable.  I  know  of  an  instance  in 
which  one  kidney  was  removed  and  the  patient  died  within  twenty-four 
liours. 

(4)  Occasionally  the  kidneys  and  liver  present  numerous  small  cysts 
scattered  through  the  substance.  The  spleen  and  the  thyroid  also  may 
be  involved,  and  there  may  be  congenital  maH'iirmation  of  the  heart.  The 
cysts  in  the  kidney  are  small,  and  neither  so  numerous  nor  so  thickly  set 
as  in  the  conglomerate  form,  though  in  these  cases  the  condition  is  prob- 
iiljly  the  result  of  some  congenital  defect.  There  are  cases,  however,  in 
which  the  kidneys  are  very  large.  It  is  more  common  in  the  lower  ani- 
mals than  in  man.  I  have  seen  several  instances  of  it  in  the  hog;  in  one 
case  the  liver  weighed  40  pounds,  and  was  converted  into  a  mass  of  simple 
cysts.  The  kidneys  were  less  involved.  Charles  Kennedy  *  states  that  he 
has  found  references  to  12  cases  of  combined  cystic  disease  of  the  liver  and 
kidneys. 

The  echinococcus  cysts  have  been  described  under  the  section  on  para- 
sites. Paranephric  cysts  (external  to  the  capsule)  are  rare;  they  may  reacli 
a  large  size. 

*  Laboratory  Reports  of  the  Royal  College  of  Physicians,  Edinburgh,  vol.  iii. 


900 


DISEASES  OF  THE  KIDNEYS. 


/ 


XIV.     PERINEPHRIC    ABSCESS. 

Su|)i)iinitiou  ill  the  connective  tissue  about  the  kidney  may  follow  (1) 
blows  Jind  injuries;  {2}  the  extension  of  inilaniination  from  the  pelvis  of 
the  kidney,  the  kidney  itself,  or  the  ureters;  (3)  perforation  of  the  bowel, 
most  ecjjunionly  tlie  a[)pendix,  in  some  instances  the  colon;  (4)  extension 
of  sujipu ration  from  the  spine,  as  in  caries,  or  from  the  pleura,  as  iu  em- 
pyema; (.■))  as  a  se(iuel  of  the  fevers,  particularly  in  children. 

Post  mortem  the  kidney  is  surrounded  by  ])us,  ])artieularly  at  the  pos- 
terior ])art,  thou^di  the  pus  may  lie  altogether  in  front,  between  the  kidney 
and  the  i)eritonieum.  Usually  the  abscess  cavity  is  extensive.  The  ])us 
is  often  offensive  and  may  have  a  distinctly  faecal  odor  from  contact  with 
the  large  bowel.  It  may  burrow  in  various  directions  and  Inirst  into  the 
])]eura  and  be  discharged  through  the  lungs.  A  more  frequent  direction  is 
down  the  j)soas  muscle,  when  it  ap])ears  in  the  groin,  or  it  may  pass  along 
the  iliaeus  fascia  and  appear  at  Poupart's  ligament.  It  may  perforate  the 
bowel  or  rupture  into  the  peritoniuum;  sometimes  it  penetrates  the  bladder 
or  vagina. 

Post  mortem  we  occasionally  find  a  condition  of  chronic  perinephritis 
in  which  the  fatty  capsule  of  the  kidney  is  extremely  firm,  with  numerous 
bands  of  fibrous  tissue,  and  is  stripped  oif  from  the  proper  capsule  with  tlic 
greatest  difficulty.     Such  a  condition  probably  produces  no  symptoms. 

Symptoms. — There  may  be  intense  pain,  aggravated  by  pressure,  in 
the  lumbar  region.  In  other  instances,  the  onset  is  insidious,  without  pain 
in  the  renal  region;  on  examination  signs  of  deep-seated  suppuration  may  be 
detected.  On  the  affected  side  there  is  usually  pain,  which  may  be  referred 
to  the  neighborhood  of  the  hip-joint  or  to  the  joint  itself,  or  radiate  down 
the  thigh  and  be  associated  with  retraction  of  the  testis.  The  patient  lies 
with  the  thigh  flexed,  so  as  to  relax  the  psoas  muscle,  and  in  walking  throws, 
as  far  as  possible,  the  weight  on  the  opposite  leg.  The  patient  keeps  the 
spine  immobile,  assumes  a  stooping  posture  in  walking,  and  has  great  diffi- 
culty in  voluntarily  addncting  the  thigh  (Gibney). 

There  may  be  pus  in  the  urine  if  the  disease  has  extended  from  the 
pelvis  or  the  kidney,  but  in  other  forms  the  urine  is  clear.  When  pus  has 
formed  there  are  usually  chills  with  irregular  fever  and  sweats.  On  ex- 
amination, deep-seated  induration  is  felt  between  the  last  rib  and  the  crest 
of  the  ilium.  Bimanual  palpation  may  reveal  a  distinct  tumor  mass. 
(Edema  or  puffiness  of  the  skin  is  frequently  present. 

The  diagnosis  is  usually  easy;  when  doubt  exists  the  aspirator  needle 
should  be  used.  We  cannot  always  differentiate  the  primary  forms  from 
those  due  to  perforation  of  the  kidney  or  of  the  bowel.  This,  however,  makes 
but  little  difference,  for  the  treatment  is  identical.  It  is  usually  possible  by 
the  history  and  examination  to  exclude  diseases  of  the  vertebra.  In  children 
hip-joint  disease  may  be  suspected,  but  the  pain  is  higher,  and  there  is  no 
fulness  or  tenderness  over  tlie  hip-joint  itself. 

The  treatment  is  clear — early,  free,  and  permanent  drainage. 


follow  (1) 
u  pelvis  ul' 

the  bowel, 
)  extension 
,  as  iu  ciii- 


at  the  pos- 
tiie  kidney 
The  pus 
mtact  witli 
3t  into  the 
lirection  is 
pass  alon<,' 
rforate  the 
he  bladder 

irinephritis 
.  numerous 
le  with  the 
ptoms. 
iressure,  in 
thout  pain 
ion  may  he 
)e  referred 
liate  down 
latient  lies 
ng  throws, 
keeps  the 
Treat  diffi- 

from  the 

n  pus  has 

.     On  ex- 

the  crest 

inor   mass. 

or  needle 
rms  from 
er,  makes 
ossible  by 
1  children 
lere  is  no 


SECTION   X. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


I.    GENEEAL  INTRODUCTION. 

T\  diseases  of  the  nervous  system  it  is  of  the  greatest  importance  to 
know  accurately  the  position  of  the  morl)id  })rocess,  and  here,  even  more 
than  in  the  other  departments  of  medicine,  a  thorough  knowledge  of  anat- 
omy and  ])hysi()logy  is  essential.  For  full  details  the  student  is  referred  to 
the  text-books  on  tlie  subject,  as  it  is  not  possible  to  do  more  than  touch  on 
the  subject  in  this  place. 

Eecent  studies  have  modified  our  conceptions  of  the  fundamental  struc- 
ture of  the  nervous  system.  At  present  we  think  of  it  as  a  combination 
of  an  immense  number  of  units,  called  neurones,  all  having  an  essentially 
similar  structure.  Each  neurone  is  composed  of  a  cell  body,  the  protoplasmic 
processes  or  dendrites,  and  the  axis-cylinder  process  or  axone.  The  nutri- 
tion of  the  neurone  depends  in  large  part  upon  the  condition  of  the  cell 
body,  and  this  in  turn  in  all  probability  upon  the  activity  of  the  nucleus. 
If  the  cell  is  injured  in  any  manner  the  ])rocesscs  degenerate,  or  if  the  i)ro- 
cesses  are  separated  from  the  cell  they  degenerate.  Whether  or  not  the 
neurones  are  organically  connected  with  one  another  is  still  in  dispute.  The 
weight  of  evidence  is  in  favor  of  complete  anatomical  and  relative  physio- 
logical independence.  The  terminals  of  the  axone  of  one  neurone  are  re- 
lated to  the  dendrites  and  cell  bodies  of  other  neurones  by  contact  (Ramon 
y  Cajal)  or  by  concrescence  (Held).  Tt  is  generally  admitted,  however,  that 
occasional  coarse  anastomoses  exist  between  neighboring  dendrites  (accord- 
ing to  Dogiel),  especially  in  the  retina.  The  studies  of  Ajnithy  sp(>ak  in 
favor  of  a  general  interconnection  by  means  of  neurofiljrils  and  proto]ilasmic 
bridges.  In  general,  it  may  be  stated  that  the  dendrites  or  proto])lasmic 
processes  conduct  impulses  toward  the  cell  body  (cellulipetal  conduction), 
and  the  axis-cylinder  process  conducts  them  away  from  the  cell  (cellulifugal 
conduction).  The  axis-cylinder  process  after  leaving  the  cell  gives  ofp  at 
varying  intervals  lateral  branches  called  collaterals,  which  run  at  right 
angles  to  the  process.  The  collaterals  and  finally  the  axis-cylinder  ])rocess 
itself  at  their  terminations  split  up  into  many  fine  fibres,  forming  the  end- 
brushes.    These,  known  as  arborizations,  surround  the  body  of  one  or  more 

flOl 


902 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


of  tlio  many  other  ct'lls,  or  interlace  with  their  protophismic  j)rocos8cs.  The 
cell  l)o(li('.s  of  the  iiciiroiies  are  coUected  more  (»r  h'ss  closely  tot^i^ther  in 
the  ^M'ay  matter  oi"  tiie  brain  and  spinal  cord  and  in  the  ^^anglia  of  the  i)eri|)li- 
eral  lu'rves.  Their  processes,  especially  the  axis-cylindi'r  processes,  run  for 
the  most  part  in  the  white  tracts  of  the  brain  and  spinal  cord  and  in  the 
l)eriplieral  nerves.  In  this  way  the  ditl'erent  parts  of  tlu;  ci'nlral  nervous 
system  are  broii<,dit  into  relation  with  each  other  and  with  the  rest  of  the 
body.  In  many  eases  the  connections  are  extremely  complicated  and  have 
only  just  begun  to  be  unravelled,  but,  fortunately  for  the  clinician,  the 
nervous  mechanism  i\\Hm  which  motion  depends  is  tlie  best  understood 
and  is  the  simplest. 

A  voluntary  motor  imi)ulse  starting  from  the  brain  cortex  must  [)as> 
through  at  least  two  neurones  before  it  can  reach  the  muscles,  and  we 
therefore  speak  of  the  motor  tract  as  being  composed  of  two  segments — 
an  upper  and  a  lower.  'J'he  neurones  of  tlie  lower  segnu'ut  have  the  cell 
bodies  and  their  ])roto))lasmic  ])rocesses  in  the  diiferent  levels  of  the  ventral 
horns  of  the  spinal  cord  and  in  the  motor  nuclei  of  the  cerebral  nerves. 
The  axis-cylinder  ])rocesscs  of  the  lower  motor  neurones  leave  the  spinal 
cord  in  the  ventral  roots  and  run  in  the  ])eri|)heral  nerves,  to  bo  distril)- 
uted  to  all  the  muscles  of  the  body,  where  they  end  in  arborizations  in  the 
motor  end  plates.  "^I'liese  neurones  are  direct — that  is,  their  cell  bodies, 
their  processes,  and  the  muscles  in  which  they  end  are  all  on  the  same  side 
of  the  body.* 

The  neurones  of  the  U])per  motor  segment  have  their  cell  bodies  and 
proto])lasmic  i)rocesses  in  the  cortex  of  the  l)rain  about  the  fissure  of  Ro- 
lando. Their  axis-cylinder  ])rocesses  run  in  the  white  matter  of  the  brain 
through  the  internal  capsule  and  the  cerebral  peduncles  into  the  ])ons. 
medulla,  and  cord,  ending  in  arborizations  around  the  protoplasmic  ]no- 
cesses  and  cell  bodies  of  the  lower  motor  neurones.  The  uii]ier  segment  is. 
in  the  main,  a  crossed  tract — that  is  to  say,  the  neurones  which  compose  it 
have  their  proto])lasmic  processes  and  cell  bodies  on  one  side  of  the  body, 
whereas  their  axis-cylinder  processes  cross  the  middle  line,  to  end  about  cell 
bodies  of  the  lower  motor  neurones  on  the  opposite  side  of  the  body.  A 
certain  number  of  the  axones  of  the  pyramidal  tract,  however,  run  to  the 
lower  motor  neurones  of  the  same  side. 

Motor  impulses  starting  in  the  left  sfde  of  the  brain  cause  contractions 
of  muscles  on  the  right  side  of  the  body,  and  those  from  the  right  side  of 
the  brain  in  muscles  of  the  left  side  of  tlie  body.  Leaving  out  of  considera- 
tion the  exceptions  which  have  been  mentioned,  it  may  be  stated  as  a  gen- 
eral rule  that  the  motor  path  is  crossed,  and  that  the  crossing  takes  place 
in  the  upper  segment  (Figs.  1  and  2).  Every  muscular  movement,  even  the 
simplest,  requires  the  acti>ity  of  many  neurones.  In  the  production  of 
each  movement  special  neurones  are  brought  into  play  in  a  definite 
combination,  and  whenever  these  neurones  act  in  this  combination  that 
specific  movement  is  the  result.    In  other  words,  all  the  movements  of  the 

*  Tho  root  fibros  of  the  norviis  troohloaris  and  a  portion  of  the  root  fibres  of  the 
nervus  oculoinotorius  are  well-known  exceptions  to  this  rule. 


GENERAL   INTUODUCTION. 


903 


togc'tlior  ill 
tlio  pcriph- 
'cs,  run  for 
and  in  the 
I'iil  nervous 
rest  of  till' 
J  and  luivt" 
nician,  tiic 
undorstood 

I  mist  pasH 
;s,  and  \vi' 
egments — 
vo  the  CT'II 
;he  ventral 
ral  nerves, 
the  spiiiiil 
be  distri li- 
ons in  the 
3ll  bodies, 
same  side 

odies  and 
re  of  ]{<). 
the  lira  in 
the  ])ons, 
niic  ])ro- 
f^mient  is. 
)inpose  it 
;he  body, 
bout  cell 
)ody.  A 
n  to  the 

traetions 
t  side  of 
)nsidera- 
s  a  iren- 
:es  plaoe 
?ven  th(> 
ption  of 
definite 
on  that 
s  of  the 


body  arc  represented  in  the  eentral  nervous  system  by  combinations  of 
neurones — that  is,  they  are  localized.  Muscular  movements  are  localized  in 
every  part  of  the  motor  ]mth,  and  in  eases  of  disease  of  the  nervous  system 
a  study  of  the  motor  defect  often  eiuibles  one  to  fix  upon  the  site  of  the 
process,  and  it  would  be  hard  to  overesti- 
mate'the  importance  of  a  thorough  knowl- 
edge of  such  localization. 

The  axis-cylinder  processes  of  the  lower 
motor  neurones  run  in  the  peripheral  nerves. 
I'lach  nerve  contains  processes  which  are 
supplied  to  definite  muscles,  and  we  have 
in  this  way  a  jieripheral  localization.  (See 
sections  on  Diseases  of  the  C'erebrai  and 
Spinal  Nerves.) 

The  axis-cylinder  processes  which  run  in 
the  peripheral  nerves  leave  the  central  nerv- 
ous system  from  its  ventral  aspect.  The 
ventral  roots  of  the  spinal  cord  are  from 
iiliove  down,  collected  into  small  groujis, 
which,  after  joining  with  the  dorsal  roots 
of  the  same  level  of  the  cord,  leave  the  spinal 
<'amil  between  the  vertebne  as  the  s[iinal 
nerves.  That  part  of  the  cord  from  which 
the  roots  forming  a  single  spinal  nerve  arise 
is  called  a  segment,  and  corresjionds  to  the 
nerve  which  arises  from  it  and  not  to  the 
vertebra  to  which  it  nuiy  be  opposite.  The 
axis-cylinder  processes  which  go  to  make  up 
any  one  ])eripheral  nerve  do  not  neces- 
sarily arise  from  the  same  segment  of  the 
spinal  cord;  in  fact,  most  peripheral  nerves 
contain  processes  from  several  often  quite  widely  se])arated  segments,  and 
so  it  hajipens  that  the  movements  are  rejiresented  in  the  spinal  cord  in  a 
different  manner — that  is,  there  is  s])inal  localization,  or,  better,  lower  level 
localization,  since  it  also  includes  the  motor  nuclei  of  the  cerebral  nerves. 

Our  knowledge  of  the  localization  of  the  muscular  movements  in  the 
gray  matter  of  the  lower  motor  segment  is  far  from  complete,  but  enough 
is  known  to  aid  materially  in  determining  the  site  of  a  s])inal  lesion.  A 
number  of  tables  have  been  ]n'e]iared  by  different  observers  to  represent 
our  ])resent  knowledge  of  this  subject.  They  differ  from  each  other  in 
minor  details,  but  agree  in  the  main.  The  following  is  the  talde  prepared 
by  Starr,  in  which  the  names  of  the  muscles  are  given  whose  movements 
are  represented  in  each  of  the  sjiinal  segments.  Movements,  not  muscles, 
are  localized  in  the  central  nervous  system,  a  point  carefully  to  be  borne  in 
mind  by  the  student. 


Fio.  1. — Diagram  of  motor  path, 
showing  the  crossing  of  the 
path,  which  talies  place  in 
the  upper  segment.  (Van  Ge- 
huchten.  colored.) 


es  of  the 


9U4 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


\,  T.  a 


^ 


PVc.  2. — Diagram  of  motor  path  from  right  brain.  The  upper  segment  is  black,  the  lower 
red.  The  nnclci  of  the  motor  cerebral  nerves  are  shown  on  the  left  side :  on  the  right 
side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1  would  cause  upper 
segment  paralysis  in  the  arm  of  the  opposite  side — cerebral  monoplegia ;  at  2,  upper 
segment  paralysis  of  the  whole  opposite  side  of  the  body — hemiplegia ;  at  3,  upper 
segment  paralysis  of  the  opposite  face,  arm,  and  leg,  and  lower  segment  paralysis 
of  the  eye  muscles  on  the  same  side — crossed  paralysis ;  at  4,  upper  segment  paraly- 
sis of  opposite  arm  and  leg,  and  lower  segment  paralysis  of  the  face  and  the  external 
rectus  on  the  same  side — crossed  paralysis;  at  5,  upper  segment  paralysis  of  all  mus- 
cles below  lesion,  and  lower  segment  paralysis  of  muscles  represented  at  level  of 
lesion — spinal  paraplegia;  at  6,  lower  segment  paralysis  of  muscles  localized  at  seat 
of  lesion — anterior  poliomyelitis.     (Van  Gehuchten,  modified.) 


OENERATi  INTIinnrCTION.  905 

Locniiintion  of  the  Functions  of  the  SrymtntH  of  the  Spinnl  Cord, 


the  lower 
the  right 

use  upper 

t  2,  upper 

3,  upper 

paralysis 

it  paraly- 
external 
all  mus- 
level  of 

(1  at  seat 


Heombnt. 

Mt'KLU. 

RtrLBX. 

Bbmmtion. 

II  1111(1 

Stfriio-mastoiil. 

11}  pochnndnuni  ((). 

IJaik  of  head  to  ver- 

HI ('. 

Trapezius. 

Sudden    inspirutioa   pro- 

tex. 

Scaleiii  and  nci  k. 

duced  by  sudden  press- 

Neck. 

Diiiphragni. 

ure    betieath   ttiu  luwur 
liorder  of  ribs. 

IV  c. 

Diaplira^ni. 

Pupil.    4th    to   7th   cer- 

Neck. 

Deltoid. 

vical. 

Upper  shoulder. 

Miceps. 

Dilatation   of    tho   pupil 

Outer  arm. 

('oraeo-hrnchialis. 

produced   by  irritation 

Supinator  lon^^us. 

of  neck. 

iihoinltoid. 

Supra-  and  itifra-.spinatus. 

vc. 

Deltoid. 

Scapular. 

Back  of  shoulder  and 

Biceps. 

-Ithcervicaltolst  thoracic. 

arm. 

Coraeo-brachialis. 

Irritation  of  skin  over  the 

Outer    side    of    arm 

Krachialis  anticus. 

scapula   ]iroduces   con- 

and  forearm,  front 

Supinator  longiis. 

traction  of  tho  scapular 

and  back. 

Supinator  brevis. 

muscles. 

Uhoniboid. 

Supinator  longus. 

Teres  minor. 

Tapping    its    tendon    in 
wrist   produces  flexion 

i'ectoralis  (clavicfular  part). 

Serratua  niagnus. 

of  forearm. 

VI  c. 

Biceps. 

Triceps. 

Outer  side    of    fore- 

Brachialis anticus. 

nth  to  (5th  cervical. 

arm,      front      and 

Pectoralis  (clavicular  part). 

Tapping     elbow    tendon 

back. 

Serratus  niagnus. 

produces    ext<Mision   of 

Outer  half  of  hand. 

Triceps. 

forearm. 

Extensors    of    wrist     and 

Posterior  wrist. 

fingers. 

0th  to  8th  cervical. 

Pronators. 

Tapping  tendons  causes 
extension  of  hand. 

VII  c. 

Triceps  (long  head). 

Anterior  wrist. 

Inner  side  and  back 

Extensors    of     wrist     and 

7th  to  8th  cervical. 

of    arm    and    fore- 

fingers. 

Tapping  anterior  tendons 

arm. 

Pronators  of  wrist. 

causes  flexion  of  wrist. 

Radial    half    of    tho 

Flexors  of  wrist. 

Palmar.     7th  cervical  to 

hand. 

Subscapular. 

1st  thoracic. 

Pectoralis  (costal  part). 

Stroking     palm     causes 

Latissinius  dorsi. 

closure  of  fingers. 

Teres  major. 

VIII  c. 

Plexors  of  wrist  and   fin- 

Forearm  and    hand, 

gers. 

inner  half. 

Intrinsic  muscles  of  hand. 

IT. 

Extensors  of  thumb. 

Forearm,  inner  half. 

Intrinsic  hand  muscles. 

Ulnar  distribution  to 

Thenar     and     hypothcnar 

hand. 

eminences. 

Tito 

Muscles  of  back  and  abdo- 

Epigastric.   4th    to    7th 

Skin    of    chest    and 

XII  T. 

men. 

thoracic. 

abdomen   in   bands 

Erectores  spinre. 

Tickling    mammary    re- 

running       around 

gions  causes  retraction 

and  downward,  cor- 

of epigastrium. 

responding   to  spi- 

Abdominal.    7th  to  11th 

nal  nerves. 

thoracic. 

Upper  gluteal  region. 

Stroking  side  of  abdomen 

causes      retraction     of 

bellv. 

«()«•) 


DISKAHKS  OF  Till-:   NKUVOUS  MYSTKM. 


HlUMBMT. 


Hi. 


II    h. 


Ill    li. 


IV  L 


VL. 


I  t.)  II  S. 


into 
vs. 


Mt'WLM. 


Iliri-pHOUH. 

SiirloriuM. 

MuNfloH  of  Hli(ioini>n. 


Ilio-psoii.H.     SiirtDriiis. 
Flexors  of  kiicu  (UiMiiiik). 
l^uiKliici'iis  furnoris. 


(^imdrici'iis  fmiioris. 
liiiuT  I'otiilorH  of  llii^h. 
Abductors  of  tliigli. 


Alidiiclors  of  llii;,'li. 
A<ldiictors  of  tlii^jli. 
Flexors  of  kiico  (Ferricr). 
Til>iiilis  iinliuut). 


Oiitwiu'd  rotators  of  thi^h. 
Flexors  of  kiieo  (Fcrrior). 
Flexors  of  iiiikle. 
i']xtensor8  of  toes. 


i'Mcxors  of  ankle. 

lioiit,'  (lexor  of  toca. 

i'eromi'i. 

Intrinsic'  iniiscli'S  of  foot. 


UKri.ikX. 


Perineal  muscles. 


Croinasterlc.      1st   to  ad 

liunliiir. 
Strokin{{      inner      Ihi^di 

eiiuses      retraction      uf 

scrotum. 

INitcilar  tendon. 
'I'appin^    tendon    (;huhus 
extension  of  leff. 


<i  luteal.  4th  to  Qth  lum- 
bar. 

Strokinjf  buttock  causes 
dimpling;  in  fold  of 
l)Uttock. 


HKNaATIOM. 


Plantar. 

Tickling  solo  of  foot 
causes  flexion  of  toes 
and  retraction  of  leg. 

Foot     reflex.      Achilles 

tendon. 
Overextension      of     foot 

causes     rapid     flexion ; 

ankle-clonus. 
Bladder  and  rectal  centres. 


Skin  over  groin  and 
front  of  scrotum. 


Outer  side  of  thigli 


Front  and  inner  side 
of  thigh. 


Inner   side   of    tliigli 

and  leg  to  aid<le. 
Inner  side  of  foot. 


Back  of  thigh,  1>ih  k 
of  leg,  anil  (Milcr 
j)art  of  foot. 


Hack  of  thigh. 
Leg   and  fool,  oute 
side. 


Skin  over  sacrum. 

Anus. 

I'erimt'um.    Genital- 


Tlic  !il)()Vo  liihlo  refers  only  to  localization  in  the  .«j)inal  cord.  The 
manner  in  which  movements  arc  ro|)re.sente(l  in  the  pons  and  medulla  is 
al)out  as  follows.  This  tahlo  is  constructed  from  ahove  downward  in  refer- 
once  to  the  motor  nuclei  of  the  cranial  nerves: 


Nuclei. 
III. 


IV. 


'  Sphincter.     Ciliary  muscles. 
Levator  palpebr.ii  superioris.     Rectus  internus  (in  convergence). 
Hectns  superior.     Rectus  inferior. 
01ili(iuus  inferior. 
Obliquus  superior. 
(Ul>per  facial  group.) 


y  <  (Associated  movement  of  levator  palpebrtu.) 
■  /  Muscles  of  lower  jaw. 


C  Rectus  extcrnus.     Rectus 
VI.  <       inter,  of  opposite  side 
[^     in  lateral  movements. 


VII. — Facial  muscles. 


XII. 


(Lower  facial  group). 
Muscles  of  tongue. 


IX.  f  Muscles  of  pharynx. 
X.  ■{  Muscles  of  (I'sophagus. 
XL 


■I  Muscles  of  (I'sophagus 
[  Muscles  of  larynx. 


GKNKllAL   INTKODI'CTION. 


u<>r 


nuation. 


)f  BcTotlim. 


Cerebral  Motor  Localization. — 'I'lir  crll  iMxIits  df  iho  iip|)or  motor  lum- 

roii'.'s  lilt'  I'niiiiil  ill  llic  hniiii  cortex  alioiit  tlir  lissiirc  of  Kolaiiilo,  iiixl  it  i.s  in 
tliiri  region  that  wo  find  tho  inovt'iiiciitH  of  tlio  body  ngaiii  ruprcst'iitcd. 


(la  of  thigh. 


n\  inner  flidn 
h. 


<Ie  of    tliigti 
:  to  (inklc. 

If  of  foot. 


tlii{,'h,  liiick 
(iiid    oiitiT 
foot. 


Iiiiil. 
foot,   outer 


Buuruni. 
1.    Geiiilals. 


Td.  Tli<. 
L'dulla  is 
in  rd'or- 


tll)ebra!.) 


I  '^ 

f  s 

o  i 

c  S 

°  a. 

o  « 

It!  * 


3  5 


-3 

3 


■3 
3 


m 


x>   s 


S     V 


i)   a 

-      D 

-3 


'T3  ' 

C  '- 

a  -s 

^  s 

■t-l  J^ 

0)  ^-- 


N      s 
t^     O) 

•1-1    22 

s  t 

2  = 

tC    0) 


2  4' 

O  CJ 

«  o 

-^  a 


'/.  a 

S  3 

C  O 

'::  J 

'/J  .s 

c  « 

Si  :S 

^  3 

o  J 

01 

e}  o 

3  "3 

o  o 

-J  '2 


.2   P 
fe,.2 

•t-t    uS 


''^6»^«^' 


The  clinical  studios  of  Trugldinfis  Jackson,  and  the  cxj)orimcnts  of  Ilitzij; 
and  Fritsch,  and  of  Fcrrier,  laid  the  foundation  for  the  prcat  mass  of 
most  excellent  work  which  has  been  done  uj-oii  this  subject.    We  owe  much 


V 


9U8 


DISEASES  OF  THE  >  EllVOUS  SYSTEM. 


''Hi 


to  Victor  Ilorslcy  and  his  associates  I'or  tlicir  carel'iil  work  in  this  direc- 
tion, and  tiio  I'oUowin^  description  is  hased  hirgely  iii)on  their  writings,  and 
t'spucially  upon  tlie  paper  of  lieevor  and  llorsloy,  in  which  they  give  tlie 
results  of  tiieir  experimental  work  on  the  orang-outang.  Clinical  observa- 
tion and  electrical  stimulation  oi'  the  brain  cortex  during  operations  on 
human  beings  have  coniirnied  the  results  oi'  experiments  upon  animals. 

The  motor  area  comprises  the  anterior  central  convolution,  and  to  a  less 
extent  the  posterior  central  convolution,  the  hinder  part  of  the  three  frontal 

convolutions  and  the  paracentral  lobule. 
In  the  orang-outang  and  man  not  every 
l)art  .')f  this  region  is  excitable  by  elec- 
trical stimulation.  The  movements  are 
(juite  sharjily  localized,  and  there  are  in- 
excitable  arjas  between  the  areas  of  re[)re- 
sentation  of  the  larger  divisions  of  the 
body.  The  diagram  (Fig.  3)  shows  the 
centres  as  given  by  Beevor  and  Horsley. 
Certain  landmarks  are  important.  The 
genu  of  the  fissure  of  Eolando,  which 
when  ])rosent  in  num  is  found  at  a  point 
about  midway  or  even  higher  between  the 
u])per  margin  of  the  hemisph-jre  and  the 
fissure  of  Sylvius,  marks  the  boundary  be- 
tween the  area  of  representation  of  the 
arm  from  that  of  the  face.  The  level  of 
the  superior  frontal  sulcus  indicates  the 
division  of  the  leg  from  the  arm  area. 
From  above  down  the  areas  of  representa- 
tion occur  in  this  order:  leg,  arm,  face. 
Those  of  the  leg  and  arm  occui)y  the 
npper  half  jf  the  convolution,  and  that 
for  the  face  is  spread  out  over  the  lower 
half.  The  diagram  indicates  the  localiza- 
tion of  the  movements  of  the  different 
parts  of  the  extremities. 

The  centres  for  the  trunk  are,  accord- 
ing to  Schiifer,  situated  in  the  marginal  gyrus  just  within  the  longitudinal 
fissure  in  the  paracentral  lobule.  In  man  the  motor  speech  centre  is  local- 
ized in  the  posterior  part  of  the  left  inferior  frontal  c^.  evolution. 

The  axis-cylinder  processes  of  the  upper  motor  neurones  after  leaving 
the  gray  matter  of  the  motor  cortex  pass  into  the  white  matter  of  the  brain 
and  form  part  of  the  corona  radiata.  They  converge  and  pass  between 
the  basal  ganglia  in  the  internal  capsule.  Here  the  motoi  axis-cylinders- 
are  collected  into  a  compact  bundle — the  pyramidal  tract — occupying  the 
knee  and  anterior  tAvo  thirds  of  the  posterior  limb  of  the  internal  capsule. 
The  order  in  which  the  movements  of  the  opposite  side  of  the  body  are 
represented  here  is  given  in  Fig.  4. 

After  passing  through  the  internal  capsule  the  fibres  of  the  pyramidal 


OPTK 
'•■(iAP, 


Fio.  4, — Diagram  of  motor  and  sen- 
sory representation  in  the  inter- 
nal capsule.  NL.,  Lenticular 
nucleus.  NC,  Caudate  nucleus. 
TIIO.,  Optic  thalamus.  The 
motor  paths  are  red  and  black, 
the  sensory  are  blue. 


Ill 

Ml 

ai 

(•l[ 

oil 

ill 

ni 

(l(h 

fJ 

eil 

tl 

oi 

tl 


tliis  direc- 
itings,  and 
■y  give  the 
ill  observH- 
rations  on 
ninials. 
id  to  a  less 
reo  frontal 
ral  lobule. 

not  every 
e  by  elec- 
nients   are 
;re  are  in- 
s  of  repre- 
ns  of  the 
shows  the 
1  Horsley. 
int.     The 
lo,   whieh 
it  a  point 
tween  the 
e  and  tJie 
ndary  bc- 
)n  of  the 
e  level  of 
cates  the 

rm  area. 

)resenta- 
rm,  face. 

iipy   the 
and  that 

le  lower 

localiza- 

different 

aceord- 
;itudinal 
is  local- 
leaving 
le  brain 
jetween 
vlinders 
ing  Die 
capsule, 
ody  are 

ramidal 


GENERAL   INTRODUCTION. 


909 


Fig.  5. — Diagram  of  motor  ami  sensory  paths  in  Crura. 


tract  leave  the  hemisphere  by  the  erus,  in  which  they  occupy  about  the 
middle  three  fifths  (Fig.  5).  The  movements  of  the  tongue  and  lips  are 
represented  nearest  the  middle  line. 

As  soon  as  the  tract  enters  the  cms,  some  of  its  axis-cylinder  processes 
leave  it  and  cross  the 
middle  line  to  end  in 
arl)orizati()ns  about  the 
ganglion  cells  in  the  nu- 
cleus of  the  third  nerve 
on  the  opposite  side;  and 
in  this  way,  as  the  py- 
ramidal tract  ])asses 
down,  it.  gives  off  at  dif- 
ferent levels  fibres  whicn 
end  in  the  nuclei  of  all 
the  motor  cerebral  nerves 
on  the  opposite  side  of 
the  body.  Some  fibres, 
however,  go  to  the  nu- 
clei of  the  same  side 
(Iloche).  From  the  crus,  the  pyramidal  tract  runs  through  the  pons  and 
forms  in  the  medulla  oblongata  the  ])yramid,  which  gives  its  name  to  the 
tract.  At  the  lower  part  of  the  medulla,  after  the  fibres  going  to  the  cere- 
bral nerves  have  crossed 
the  middle  line,  a  large 
proj)ortion  of  the  remain- 
ing fil)res  cross,  decussat- 
ing with  those  from  the 
op])osite  pyramid,  and 
pass  into  the  opposite  side 
of  the  s])inal  cord,  form- 
ing the  crossed  pyramidal 
tract  of  the  lateral  col- 
umn (fasciculus  cerebro- 
spinalis  lateralis)  (Fig.  (!, 
1).  The  smaller  numl)er 
of  fibres  which  do  not  at 
this  time  cross,  desct.;J 
in  the  ventral  column 
of  the  same  side,  form- 
ing the  direct  pyramidal 
tract,  or  Tiirck's  column 
(lasciculus  cerebrospinalis 
ventralis)  (Fig.  6,  2). 
At  every  level  of  the 
spinal  cord  axis-cylinder  processes  leave  the  crossed  pyramidal  tract  to  enter 
the  ventral  horns  and  end  about  the  cell  bodies  of  the  lower  motor  neurones. 
The  tract  diminishes  in  size  from  above  dov/nward.    The  fibres  of  the  direct 


Fig.  6.— Diagram  of  cross-section  of  spinal  cord,  show- 
ing motor,  red,  and  sensory,  blue  paths.  1,  Lateral 
pyramidal  tract.  2,  Ventral  pyramidal  tract.  3, 
Dorsal  columns.  4,  Direct  cerebellar  tract.  5, 
Ventro-lateral  ground  bundles.  6,  Ventro-lateral 
•"nding  tract  of  Gowers.    (Van  Gehuchten,  col- 


ih 


yio 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


C  VIII 


YiQ.  7. — Diagram  of  skin  areas  corresponding  to  the  different  spinal  segments. 
(Combined  from  Head's  diagrams.) 


GENERAL  INTRODUCTION. 


911 


C  VI- 


CVIII    - 


evil 


evil 


Fm.  8.— Diagram  of  skin  areas  corresponding  to  the  different  spinal  segments. 
(Combined  from  Head's  diagrams.) 


«12 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


y^ 


pyramidnl  tract  cross  at  difVcrt'iit  levels  in  the  ventral  white  commissure, 
and  also,  it  is  believed,  end  about  cells  in  the  ventral  horns  on  the  opposite 
side  of  the  cord.  This  tract  usually  ends  about  the  middle  of  the  thoracic 
region  of  the  cord. 

The  path  for  sensory  conduction  is  more  complicated  than  the  motor 
path,  and  in  its  simplest  form  is  composed  of  at  least  three  sets  of  neurones, 
one  above  the  other.  The  cell  bodies  of  the  lowest  neurones  are  in  the 
ganglia,  on  the  dorsal  roots  of  the  spinal  nerves,  and  the  ganglia  of 
the  sensory  cerebral  nerves.  These  ganglion  cells  have  a  special  form, 
having  ai)[)arently  but  a  single  i)rocess,  which,  soon  after  leaving  the  cell, 
divides  in  a  T-shaped  manner,  one  portion  running  into  the  central  nerv- 
ous system  and  the  other  to  the  periphery  of  the  body.  Embryological 
and  com])ar'itive  anatomical  studies  have  made  it  probable  that  the  periph- 
eral sensory  fibre,  the  process  which  conducts  toward  the  cell,  represents 
the  protoplasmic  processes,  while  that  which  conducts  away  from  the  cell 
is  the  axis-cylinder  process.  In  the  peripheral  sensory  nerves  we  have,  then, 
the  dendrites  of  the  lower  sensory  neurones.  These  start  in  the  periphery 
of  the  body  from  their  various  specialized  end  organs.  The  axis-cylinder 
processes  leave  the  ganglia  and  enter  the  spinal  cord  by  the  dorsal  roots  of 
the  spinal  nerves.  After  entering  the  cord  each  axis-cylinder  process  di- 
vides into  an  ascending  and  a  descen  ling  branch,  which  run  in  the  dorsal 
fasciculi.  The  descending  branch  runs  but  a  short  distance,  and  ends  in 
the  gray  matter  of  the  same  side  of  the  cord.  It  gives  off  a  number  of 
-collaterals,  which  also  end  in  the  gray  matter.  The  ascending  branch  may 
■end  in  the  gray  matter  soon  after  entering,  or  it  may  run  in  the  dorsal  fas- 
ciculi as  far  as  the  medulla,  and  end  in  the  nuclei  of  these.  In  any  case  it 
does  not  cross  the  middle  line.    The  lower  sensory  neurone  is  direct. 

The  cells  about  which  the  axis-cylinder  processes  and  their  collaterals 
of  the  lower  sensory  neurone  end  are  of  various  kinds.  They  are  known 
as  sensory  neurones  of  the  second  order.  In  the  first  place,  some  of  them 
end  about  the  cell  bodies  c?  the  lower  motor  neurones,  forming  the  path 
for  reflexes.  They  also  end  about  cells  whose  axis-cylinder  processes  cross 
the  middle  line  and  run  to  the  opposite  side  of  the  brain.  In  the  spinal 
■cord  these  cells  are  found  in  the  different  parts  of  the  gray  matter,  and  their 
axis-cylinder  processes  run  in  the  opposite  ventro-lateral  ascending  tract 
of  Gowers  (Fig.  6,  6)  and  in  the  ground  bundles  (fasciculus  lateralis  pro- 
prius  and  fasciculus  ventralis  proprius).  ' 

In  the  medulla  the  nuclei  of  the  dorsal  fasciculi  (nucleus  fasciculi  gra- 
cilis (Golli)  and  nucleus  fasciculi  cuneati  (Burdachi))  contain  for  the  most 
part  cells  of  this  character.  Their  axis-cylinder  processes,  after  crossing, 
run  toward  the  brain  in  the  medial  lemniscus  or  bundle  of  the  fillet;  certain 
of  the  longitudinal  bundles  in  the  formatio  reticularis  also  represent  sensory 
paths  from  the  spinal  cord  and  medulla  toward  higher  centres.  The  fibres 
of  the  medial  lemniscus  or  fillet  do  not,  however,  run  directly  to  the  cere- 
bral cortex.  They  end  about  colls  in  the  ventro-lateral  portion  of  the  optic 
thalamus,  and  the  tract  is  continued  on  by  way  of  another  set  of  neurones, 
which  send  processes  to  end  in  the  cortex  of  the  central  convolutions  and 
the  parietal  lobe.     This  is  the  most  direct  path  of  sensory  conduction. 


ill 
tf 

it 
'11 


GENKRAL  INTRODUCTION. 


913 


commissure, 
tlie  opposite 
the  thoracic 

1  the  motor 
j1"  neurones, 
I  are  in  the 

ganglia  of 
)ocial  form, 
ng  the  cell, 
3ntral  nerv- 
ihryological 
the  periph- 
,  represents 
3m  the  cell 
liave,  then, 
e  periphery 
xis-cylinder 
sal  roots  of 
process  di- 

the  dorsal 
ud  ends  in 
numher  of 
ranch  may 
dorsal  fas- 
any  case  it 
ct. 

collaterals 
ire  known 
e  of  them 

the  path 
isses  cross 
the  spinal 

and  their 

ing  tract 
rails  pro- 

iculi  gra- 
the  mo.-;( 
crossing. 
;  certain 
t  sensory 
'he  fibivs 
the  cere- 
the  optic 
leuroncs. 
ions  nnd 
duction. 


hut  hy  no  means  the  only  one.  The  peripheral  sensory  neurones  may 
also  end  ahout  cells  in  the  cord  whose  axones  run  hut  a  short  (iistance 
toward  the  bvain  before  ending  again  in  the  gray  matter,  and  tiie  patii,  if 
l)ath  it  can  ))e  called,  is  made  uj)  of  a  scries  of  these  superimposed  lU'uroiies. 
The  gray  nuitter  of  the  cord  itself  is  also  believed  to  olfer  paths  of  sensory 
conduction.  All  these  paths  reach  the  tegmentum  and  optic  thalamus,  and 
from  thence  are  distributed  to  the  cortex  along  with  the  other  sensory  paths. 
There  may  also  be  paths  of  sensory  conduction  through  the  cerebellum  by 
way  of  the  direct  cerebellar  tract  and  (iowers'  bundle.  From  this  short 
summary  it  is  evident  that  the  possible  paths  of  sensory  comluction  arc 
many,  and  that  our  knowledge  of  them  is  as  yet  very  indefinite;  for  liis 
reason  disturbances  in  sensation  do  not  give  us  as  much  help  in  nuiking 
a  local  diagnosis  as  do  those  of  motion.  Certain  facts  are  important  to  keep 
in  mind.  The  ditferent  peripheral  nerves  contain  sensory  fibres  from  defi- 
nite areas  of  the  skin,  and  upon  this  depends  the  peripheral  sensory  repre- 
sentation.    (See  section  on  Diseases  of  the  Spinal  Nerves.) 

The  sensory  areas  of  the  skin  are  re])resented  in  the  s|)inal  cord  in  an 
entirely  different  manner  from  the  peripheral  representation,  just  as  is  the 
case  in  regard  to  motion.  The  surface  of  the  body  has  been  mapped  out 
into  areas  which  are  meant  to  correspond  to  the  different  dorsal  roots  or 
spinal  segments.  In  Starr's  table  the  third  column  indicates  his  belief. 
11  is  more  recent  division  of  the  sensory  areas  on  the  limbs  is  pictured  in 
the  American  Journal  of  the  Medical  Sciences,  June,  1895.  Figs.  7  and  8 
embody  the  result  of  Head's  work.  They  are  also  the  areas  in  which  the 
referred  pain  and  cutaneous  tenderness  in  visceral  diseases  make  their  ap- 
pearance. The  cutaneous  sensory  im])ressions  are  in  man  conducted  toward 
the  brain,  probably  on  the  opposite  side  of  the  cord — that  is,  the  path  crosses 
to  the  opposite  side  soon  after  entering  the  cord.  Muscular  sense,  on  the 
other  hand,  is  conducted  on  the  same  side  of  the  cord  in  the  fasciculi  of 
Goll,  to  cross  above  by  means  of  the  axones  of  sensory  neurones  of  the  second 
order  in  the  medulla. 

The  localization  of  sensory  impressions  in  the  cortex  of  the  brain  is  not 
definitely  determined,  but  in  a  general  way  it  corresponds  to  the  motor  repre- 
sentation. Sensation  seems,  however,  to  be  more  widely  represented  than 
motion,  and  to  occupy  most  of  the  parietal  lobe  as  well  as  the  central  con- 
volutions. 

The  paths  for  the  conduction  of  the  stimuli  which  underlie  the  special 
senses  are  given  in  the  section  iipon  the  cerebral  nerves,  and  it  is  only  neces- 
sary here  to  refer  to  what  is  known  of  the  cortical  representation  of  these 
senses. 

Visual  impressions  are  localized  in  the  occipital  lohes.  The  primary 
visual  centre  is  on  the  mesial  surface  in  the  cuneus,  especially  about  the' 
calcarine  fissure,  and  here  are  represented  the  opposite  half-visual  fields. 
Some  authors  believe  that  there  is  another  higher  centre  on  the  outer  sur- 
face of  the  occipital  lobe,  in  which  the  vision  of  the  opposite  eye  is  chiefly 
represented.  However  this  may  be,  most  authors  hold  that  the  angular 
gyrus  of  th  left  hemisphere  is  a  part  of  the  brain  in  which  are  stored  the 
memories  i.i.  the  meaning  of  letters,  words,  figures,  and  indeed  of  all  seen 
57 


914 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


objoc'tn.  This  is  designated  in  the  visual  si)coch  centre  on  the  diagram 
(Kig.  I{).     b'lecliHig  and  Monokow  do  not  admit  this. 

Audilory  impressions  are  localized  for  tlu!  most  part  in  the  first  tem- 
poral convolution  and  the  transverse  temporal  gyri,  and  it  is  in  this  region 
in  the  left  liemisphere  that  the  memories  of  the  meanings  of  heard  words 
and  sounds  are  stored.  Musical  memories  are  localized  somewhat  in  front 
of  those  for  words  (Fig.  -'O-  '^I'l'i^'  cortical  centres  for  smell  include  a  i>urt  of 
the  base  of  the  frontal  lobe,  the  uncus,  and  perhaj)S  the  gyrus  hii)poeampi. 
The  centres  for  taste  are  .supposed  to  be  situated  near  those  for  smell,  but 
we  possess  as  yet  no  definite  information  about  them. 

Topical  Diagnosis. — The  successful  diagnosis  of  the  position  of 
a  lesion  in  the  nervous  system  depeiuls  U})on  a  careful  and  exhaustive 
examiiudion  into  all  the  symptoms  that  are  present,  and  then  endeavoring 
with  the  hell)  "^  anatomy  and  jjhysiology  to  determine  the  place,  a  disturb- 
ance at  which  might  produce  these  symi)tom8. 

The  abnormalities  of  motion  are  usually  the  most  important  localizing 
sym[)tonis,  both  on  account  of  the  ease  with  which  they  can  be  demon- 
strated, and  also  because  of  the  comparative  accuracy  of  our  knowledge  of 
the  motor  path. 

Lesions  in  any  part  of  the  motor  path  cause  disturbances  of  motion.  If 
destructive,  the  function  of  the  part  is  al)oli.shed,  and  as  the  result  there 
is  paralysis.  If,  on  the  other  hand,  the  lesion  is  an  irritative  one,  the 
structures  are  thrown  into  abnormal  activity,  which  produces  abnormal 
muscular  cotiiraction.  The  character  of  the  i)aralysis  or  of  the  abnornud 
muscular  contraction  varies  with  lesions  of  the  upjjcr  and  lower  motor  seg- 
ment, the  variations  depending,  first,  upon  the  anatomical  position  of  the 
two  segments;  and,  secondly,  upon  the  symptoms  which  are  the  result  of 
secondary  degeneration  in  each  of  the  segments. 

(a)  Lesions  of  the  Lower  or  Spino-muscular  Segment. — Destructive 
Ijcsions. — It  has  been  stated  above  that  the  nutrition  of  all  parts  of  a  neu- 
rone depends  upon  their  connection  with  its  healthy  cell  body;  and  if  the 
•cell  body  be  injured,  its  processes  undergo  degeneration,  or  if  a  portion 
of  a  process  be  separated  from  the  cell  body,  that  part  degenerates  along 
its  whole  length.  This  so-called  secondary  degeneration  plays  a  very  impor- 
tant role  in  the  symptomatology. 

In  the  lower  motor  segment  the  degeneration  not  only  affects  the  axis- 
cylinder  processes  which  run  in  the  peripheral  nerves,  but  also  the  muscle 
fibres  in  which  the  axis-cylinder  processes  end.  The  degeneration  of  the 
nerves  and  muscles  is  made  evident,  first,  by  the  muscles  becoming  smaller 
and  flabby,  and,  secondly,  by  change  in  their  reaction  to  electrical  stimula- 
tion. The  degenerated  nerve  gives  no  response  to  either  the  galvanic  or 
the  faradic  current,  and  the  mnscle  does  not  respond  to  faradic  stimula- 
tion, but  reacts  in  a  characteristic  manner  to  the  galvanic  current.  The 
contraction,  instead  of  being  sharp,  quick,  lightning-like,  as  in  that  of  a 
normal  muscle,  is  slow  and  lazy,  and  is  often  produced  by  a  weaker  current, 
and  the  anode-closing  contraction  may  be  greater  than  the  cathode-closing 
contraction.  This  is  the  reaction  of  degeneration,  but  it  is  not  always  pres- 
ent in  the  classical  form.    The  essential  feature  is  the  slow,  lazy  contrac- 


GENERAL  INTRODUCTION. 


915 


;he  d 


lagrain 


c  first  tom- 
this  region 
loard  words 
lilt  in  front 
ill'  fi  part  of 
lippofiimpi. 
:  smell,  but 

position   of 

oxliaiistivo 

ndeavoriiiff 

,  a  disturb- 

t  localizing 
be  demon- 
owledge  of 

notion.    If 

"suit  there 

e  one,  the 

abnormal 

abnormal 

notor  seg- 

on  of  the 

result  of 

hstriic/ire 
of  a  neu- 
nd  if  tlio 
I  portion 
tos  along 
•y  impor- 

tho  axis- 
musclo 

n  of  the 
smaller 

stimula- 

vanic  or 

stimula- 

t.     The 

lat  of  a 

current. 

-closing 

ys  prcs- 

3ontrac- 


tion  of  the  muscle  to  the  galvanic  current,  and  when  this  is  present  the 
muscle  is  diigencrated. 

The  myotatic  irritability,  or  muscle  rcHex,  and  the  muscle  tonus  de- 
pend upon  the  mlegrily  of  the  reflex  arc,  of  which  the  lower  motor  s(!g- 
inent  is  the  eil'erent  lind),  and  in  a  paralysis  due  to  lesion  of  this  segment 
the  muscle  reflexes  (tendon  reflexes)  are  abolished  and  there  is  a  diminished 
muscular  tension. 

Jjower  scgnu'nt  ))aralyses  have  for  their  characteristics  degenerative 
atrophy  with  the  reaction  of  degeneration  in  the  affected  muscles,  loss  of 
their  reflex  excitability,  and  a  diminished  muscular  tension.  These  are 
the  general  characteristics,  but  the  anatomical  relations  of  this  segment 
also  give  certain  peculiarities  in  the  distribution  of  the  paralyses  which 
help  to  distinguish  them  from  those  which  follow  lesions  of  the  upper  seg- 
ment, and  which  also  aid  in  determining  the  site  of  the  lesion  in  the  lower 
segnu'nt  itself.  The  cell  bodies  of  this  segment  are  distributed  in  groups, 
from  tlu!  level  of  the  ])eduncleK  of  the  brain  throughout  the  whole  extent 
of  the  s[)iiuil  cord  to  its  termination  opposite  the  second  lumbar  vertebra, 
and  their  axis-cylinder  processes  run  in  the  jjcripheral  nerves  to  every  mus- 
cle in  the  body;  so  that  the  component  ])arts  are  more  or  less  wi(h'ly  sepa- 
rated from  each  other,  and  a  local  lesion  causes  paralysis  of  oidy  a  few 
muscles  or  groups  of  muscles,  ami  not  of  a  whole  section  of  the  body,  as 
is  the  case  where  lesions  affect  the  up])er  segment.  The  muscles  which 
are  paralyzed  indicate  whether  the  disease  is  in  the  ])eripheral  nerves  or 
spinal  cord;  for,  as  we  have  seen  above,  the  muscles  are  represented  differ- 
ently in  the  ])eripheral  nerves  and  in  the  spinal  cord.  Sensory  sym])tomft, 
which  may  accompany  the  ])aralysis,  are  often  of  great  assistance  in  making 
a  local  diagnosis.  Thus,  in  a  paralysis  with  the  characteristics  of  a  lesion 
of  the  lower  motor  segment,  if  the  paralyzed  muscles  are  all  sup])licd  by 
<me  nerve,  and  the  anaesthetic  area  of  the  skin  is  supplied  by  that  nerve, 
it  is  evident  that  the  lesion  must  be  in  the  nerve  itself.  On  the  other  hand, 
if  the  muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but  are  repre- 
sented close  together  in  the  spinal  cord,  and  the  angesthetic  area  corresponds 
to  that  section  of  the  cord  (see  table),  it  is  equally  clear  that  the  lesion  must 
be  in  the  cord  itself  or  in  its  nerve  roots. 

Irritative  Lesions  of  the  Lower  Motor  Segment. — Lesions  of  this  seg- 
ment cause  comparatively  few  symptoms  of  irritation,  and  our  knowledge 
on  the  point  is  neither  extensive  nor  accurate.  The  fd)rillary  contractions 
which  are  so  common  in  muscles  undergoing  degeneration  arc  ])robably 
due  to  stimulation  of  the  cell  bodies  in  their  slow  degeneration,  as  in  ])ro- 
gressive  muscular  atrophy,  or  to  irritation  of  the  axis-cylinder  ])rocesses 
in  the  peripheral  nerves,  as  in  neuritis.  Lesions  which  affect  the  motor 
roots  as  they  leave  the  central  nervous  system  may  cause  s])asmodic  con- 
tractions in  the  muscles  sup]ilicd  by  them.  Certain  convulsive  paroxysms, 
of  which  laryngismus  stridulus  is  a  type,  and  to  which  the  spasms  of  tetany 
also  belong,  are  believed  to  be  due  to  abnormal  activity  in  the  lower  motor 
centres.  These  are  the  "lowest  level  fits"  of  llughlings  Jackson.  Cer- 
tain poisons,  as  strychnia  and  that  of  tetanus,  act  particularly  upon  these 
centres. 


910 


DISEASKS  OF  Tim  NERVOUS  SYSTEM. 


/ 


The  principle  disoasos  in  which  the  lower  motor  sc^^rncnt  may  be  in- 
volved arc:  all  diHcascs  involving  the  peripheral  nerves,  eerehral  and  Hj)inal 
meningitis,  injuries,  Ineniorrhages  and  tnniors  of  the  mednlla  and  cord  or 
their  niend)ranes,  lesions  of  the  gray  matter  of  the  segment,  anterior  polio- 
myelitis, progressive  musenlar  atrophy,  hulhar  paralysis,  oi)hthulmoplegia, 
syringo-myelitt,  etc. 

{//)  Lesions  of  the  Upper  Motor  Segment. — Dcsfniciivc  kfiions  cause,  as 
in  the  lower  motor  segnu'nt,  paralysis,  and  her((  again  the  secondary  degen- 
eration which  follows  tlie  lesion  gives  to  the  paralysis  its  distinctive  char- 
acteristics, in  this  case  the  paralysis  is  accompanied  hy  u  spastic  condi- 
tion, shown  in  an  exaggeration  of  muscle  reflex  and  an  increase  in  the  ten- 
sion of  the  muscle.  It  is  not  accurately  known  how  the  degeneration  of 
the  i)yramidal  lihres  causes  this  excess  of  the  muscle  rellex.  The  usual  ex- 
])lanation  is,  that  under  nornuil  circumstances  the  upper  motor  centres 
are  constantly  exerting  a  restraining  inlluence  upon  the  activity  of  the 
lower  centres,  and  that  when  the  inlluence  ceases  to  act,  on  account  of  dis- 
ease of  the  jjyramidal  fihres,  the  latter  take  on  increased  activity,  which  is 
made  manifest  hy  an  exaggeration  of  the  muscle  rellex. 

"We  have  seen  that  the  neurones  composing  each  segment  of  the  motor 
path  are  to  he  considered  as  nutritional  units,  and  therefore  the  secondary 
degeneration  in  the  u])per  segment  stops  at  the  beginning  of  the  lower. 
For  this  reason  the  muscles  ])aralyzed  from  lesions  in  the  upper  segment  do 
not  undergo  degenerative  atrophy,  nor  do  they  show  any  marked  change 
in  their  electrical  reactions. 

The  se])arate  i)arts  of  tlie  upper  motor  segment  lie  much  more  closely 
together  than  do  those  of  the  lower  segment,  and  therefore  a  small  lesion 
may  cause  paralysis  in  many  muscles.  This  is  more  particularly  true  in 
the  internal  capsule,  where  all  the  axis-cylinder  processes  of  this  segment 
are  collected  into  a  compact  bundle — the  pyramidal  tract.  A  lesion  in 
this  region  usually  causes  paralysis  of  all  the  muscles  on  the  opposite  side 
of  the  body — that  is,  hemi])legia.  The  pyramidal  tract  continues  in  a  com- 
pact bundle,  giving  olf  fibres  to  the  motor  nuclei  at  different  levels;  a 
lesion  anywhere  in  its  course  is  ^ollowed  by  paralysis  of  all  the  muscles 
whose  nuclei  are  situated  below  the  lesion.  When  the  disease  is  above  the 
decussation,  the  paralysis  is  on  the  o])posite  side  of  the  body;  when  below, 
the  paralyzed  muscles  are  on  the  same  side  as  the  lesion.  Above  the  in- 
ternal capsule  the  path  is  somewhat  more  separated,  and  in  the  cortex  the 
centres  for  the  movements  of  the  different  sections  of  the  body  are  com- 
paratively far  apart,  and  a  sharply  localized  lesion  in  this  region  may  cause 
a  more  limited  paralysis,  affecting  a  limb  or  a  segment  of  a  limb — the  cere- 
bral monojdegias;  but  even  here  the  paralysis  is  not  confined  to  an  indi- 
vidual muscle  or  group  of  muscles,  as  is  commonly  the  case  in  lower  seg- 
ment paralysis  (see  Fig.  2  and  explanation). 

To  sum  up,  the  paralyses  due  to  lesions  of  the  upper  motor  segment 
are  widespread,  often  hemiplegic;  the  paralyzed  muscles  are  spastic  (the 
tendon  reflexes  exaggerated),  they  do  not  undergo  degenerative  atrophy, 
and  they  do  not  present  the  degenerative  reaction  to  electrical  stimulation. 

There  is  an  exception  to  the  above  statement — that  is,  in  the  paralyses 


OENKIlATi  INTRODUCTION. 


917 


may  be  in- 
iiiul  Hpinal 
11(1  cord  or 
crior  polio- 
iiluiojilcgia, 

«.s"  causp,  as 
lary  de^ron- 
ctivc  char- 
«tic'  oondi- 
iu  the  teii- 
icratiou  of 
'  usual  ex- 
or  centres 
ity  of  the 
Hit  of  dis- 
,  which  is 

the  motor 
secondary 
the  lower, 
'ginent  do 
id  change 

re  close ly 
lall  lesion 
y  true  in 
segment 
esion  in 
f)site  side 
n  a  corn- 
levels;  a 

muscles 
bove  the 
n  below, 

the  in- 
rtex  the 
re  coni- 
^y  cause 
he  cere- 
ui  indi- 
ver  seg- 

egment 
ic  (the 
ffophy, 
ilation. 
iralyses 


which  follow  n  complete  transverse  lesion  of  the  spinal  cord.  Here  the 
iinilis  arc  oi"  course  (•omplclcly  paraly/etl,  but  instead  of  being  spastic  tlicy 
are  llaccid  and  tiie  (!('(■[)  rellexcs  are  absent.  There  is,  however,  no  markitl 
atrophy  in  the  nniscies,  and  tiiey  ri'act  normally  to  electricity.  There  is 
no  satisfactory  explanation  of  why  the  rellexcs  should  be  aiiolished  under 
these  conditions. 

Irritative  Lesions  of  the  Upper  Motor  Segment.— Our  knowledge  of 

such  lesions  is  couiincd  for  tlie  nujst  part  to  those  acting  on  tlie  motor  cor- 
tex. The  abnornud  muscular  contractions  residting  from  lesions  so  situ- 
ated have  as  their  type  the  localized  convulsive  seizures  classed  under  Jack- 
sonian  or  cortical  epilepsy,  whicii  are  characterized  by  the  convulsion  l)egin- 
iiing  in  a  single  muscle  or  group  of  muscles  and  involving  other  muscles 
in  a  delinite  order,  depending  upon  the  ])osition  of  their  repn-sentation  in 
the  cortex.  For  instance,  such  a  convulsion,  beginning  in  the  muscles  of 
the  face,  next  involves  those  of  the  arm  and  hand,  and  then  the  leg.  The 
convulsion  is  usually  accompanied  by  sensory  phenomena  and  followed  by 
a  weakness  of  the  muscles  involved. 

A  majority  of  lesions  of  the  motor  cortex  ""e  both  destructive  and  irri- 
tative— i.  e.,  they  destroy  the  nerve  cells  of  ^  rtain  centre,  and  either  in 
their  growth  or  by  their  i)rescnce  throw  into  abnormal  activity  those  of  the 
surrounding  centres. 

The  upi)er  motor  segment  is  involved  in  nearly  all  the  diseases  of 
the  brain  and  sjjinal  cord,  especially  in  injuries,  tumors,  abscesses,  and 
luvmorrhages;  transverse  lesions  of  the  cord;  syringomyelia,  ]>rogres- 
sive  muscular  atro])hy,  bulbar  paralysis,  etc.  One  lesion  often  involves 
both  the  upper  and  the  lower  motor  segments,  and  we  have  paralysis  in 
the  diiferent  parts  of  the  body,  with  the  characteristics  of  each.  Such 
a  combination  enables  us  in  many  cases  to  make  an  accurate  local  diag- 
nosis. 

Lesions  in  the  optic  path  and  in  the  different  speech  centres  also  give 
localizing  symptoms,  which  should  be  always  looked  for. 

(c)  Lesions  of  the  Sensory  Path. — ITere  again  the  le-<ion  may  be  either 
irritative  or  destructive.  Irritaiive  lesions  cause  abnormal  subjective  sen- 
sory impressions — paresthesia,  formication,  a  sense  of  cold  or  constriction, 
and  pain  of  every  grade  of  intensity.  The  character  of  the  sensory  symp- 
toms gives  very  little  indication  as  to  the  position  of  the  irritating  process. 
Intense  pain  is,  as  a  rule,  a  symptom  of  a  lesion  in  the  peripheral  sensory 
neurones,  but  it  may  be  caused  by  a  disease  of  the  sensory  path  within  the 
central  nervous  system. 

The  exact  distribution  of  symptoms  gives  us  more  accurate  data,  for  if 
they  are  confined  to  the  distribution  of  a  peripheral  nerve  or  of  a  spinal 
segment  the  indication  is  plain.  If  one  side  of  the  body  is  more  or  less 
completely  affected,  we  must  think  of  a  lesion  somewhere  within  the 
brain,  etc. 

Destructive  Lesions. — A  complete  destruction  of  the  sensory  paths  from 
any  part  of  the  body  would  of  course  deprive  that  part  of  sensation  in  all 
its  qnalities.  This  occurs  most  frequently  from  injury  to  the  peripheral 
sensory  Tieurones  within  the  peripheral  nerves,  and  the  area  of  anesthesia 


inH 


msKASKH  or  TIIR  NKIlVOrs  SYSTKM. 


(I<>|i('n()s  iipnii  till'  iitTV*'  injiin'tl.     ( 'iiin|ilrtt'  tniiiMvci'Hi'  IcHion  of  llu>  coril 
ci.UKi'H  cniiipli'lr  iintrstlicHiii  lirlow  ()ii<  iiijiin'. 

I'liiliitrnil  li'sidiis  of  tlic  cunl.  iii«'<liilhi,  (IiuhmI  |iiirl  oT  (he  |i<tnH,  ii'^^ 
iiK'iiliiiii,  lliiiliiniiis,  itilt'iiiiil  iii|isiil('.  iiikI  ('iii'Ii>\  niiisf  tlistiirliiiiin's  uf  hciimu 
tliin  oil   llic  u|i|M»>il('  ^kIc  til"  llic  IuhIv;    licit'  il^'illll   llic  cvlciil   til"  llir  dcici  I 
iiKU'i'  lli.'iii  Its  cliiinu  tcr  licljis  us  to  (IrltTiiiiiit'  tlic  |iosilioii  ol'  tlic  It'sioii. 
Ilt'iiiimiirstlicsia  involvinj,'  I  lie  luce  iis  well  iis  llir  rest  ol'  lln'  liody  can  oiilv 
orciir  iilioxc  llic  |iiii(»'  \\  liiTi'  llic  sciisury   [iiitliH   I'roiii   the  lil'lli    nerve   liitve 
(loosed   the  iiiKldie  line  on   tlieii'  wiiy   to  llie  cortex.      'I'liis  is  in   the  ii|(|M't' 
part  v\'  the  pons.      l'"ioiii  this  point   to  where  lln'V  leiivc  the  inleniiil  cup 
side  the  sensory  paths  are  in  fairly  close  relation,  and  are  at  times  involved 
in   a    very   small    lesion.     Ahovi'   the    inlernal    capsule   the   paths   diverge 
t|uicl\ly.  and  for  this  reason  only  an  extensive  lesion  can  involve  them  all, 
and  in  lesions  of  this  part  we  arc  more  apt  to  have  the  sclisory  disliiiluinces 
contined  to  one  or  the  othi'r  se<,Miients  of  the  liody.      llnilateral   lesions  of 
the  pons,  medulla,  and  cord  usually  cause  sensiu'y  distiirhances  on  the  same 
siiit'  of  the  hody.  as  well  as  those  on  the  opposite  siile.      'I'liese  an-  due  to 
tlu'  involvement  td'  the  sensory  paths  as  they  eiiler  the  central  nervous  sys 
lem  at  or  a  little  helow  the  site  of  the  lesion  and  hefore  the  axoncs  of  the 
sensory  neiirtuies  of  the  second  order  have  crossed  the  middle  line.     'The 
ari'a  of  disturhed  sensation   is  limited  to  the  distriluilion   of  one  or  more 
spinal  sefinients  and  often  indicates  accurately  the  piisition  and  exieni   of 
the  diseased  process.     As  a  rule,  destructive  lesions  td'  the  central  nervous 
system  i\o  not  involve  all  the  paths  o\'  sensory  conduction,  and  the  loss  of 
stMisation   is  not   complete.     It    is  often  asloiiishinjj   lu)W    very   sli;,dii  the 
sens(try  disturhanees  are  which  result  frcun  an  extensive  lesion  of  the  nerv- 
ous system.     Sensation  may  he  diminished  in  all  of  its  (pialities,  or,  what  is 
mori'  common,  certain  (pialilics  may  lu'  all'ccted   while  others  are  normal. 
These  cases  of  dissociation  (d'  sensatioJi.  or  so-called  elective  sensory  paraly- 
sis, have  heeii  much  studied  of  late.     Tlius  the  sen.se  of  pain  and  tempera- 
ture may  he  lost  while  that  of  touch  remains  normal,  as  is  often  the  case  in 
diseases  o(  the  spinal  cord,  or  there  may  he  simply  a  loss  of  the  inuseiilar 
sense  and  of  the  storeo<;nostic  sense  (tlio  coinplcv  sensory  impression  which 
enables  one  \o  rei'ojinize  an  object  placed  in  the  hand),  as  occurs  frecinently 
from  lesions  o(  the  cortex.     Occasionally  pain  sensation  persists  with  loss 
o{'  tactile  and   Ihermii'   sensations.      .Mmost    every   other   conibinatioii    has 
been  described.    It  is  tho  distribution  moro  than  tho  clianu'tcr  of  the  sensory 
liefoet  that  is  of  importance,  and  t»ftt>n  the  (listribuiiou  u^ivoa  but  uncertain 
indit'ation  td'  the  position  of  the  lesion.     Tlu'  combination  of  tlie  sensory 
defect  with  dilTerent   forms  of  jiaralysis  gives  the  most  certain  diagnosti*; 
siiins.     The  student  is  referred  to  tho  sections  on  tlu'  individual  parts  of 
tho  nervous  svstom  for  a  moro  detailed  consideration  of  the  subject. 


I'  |I<»IM,  \v^ 
I'CS   III'  H<>llM|| 

r  iik'  (I('IV(  I 

llic    ll'sillll. 

ily   CUM   niilv 

llflVf    IlilM' 

I  (lie  ii|i|)t'i- 
ilt'niiil  ni|»- 
n'H  involved 
(liH  divcrm' 
'«'  llii'in  all, 
li>*liirlinii(('s 

I     It'sidllH    tlf 

III  lilt'  Hiiinc 
IMC  line  lu 

H'l'VOllS  HVK- 
tmcH  (if   llir 

liri.'.     Thr 
lie  or  iiioi'c 

I    I'Xicill     (if 

III   nt'i'voiis 

lilt'  loss  ul" 

sli^^ht    I  he 

till'  iicrv- 

i)i\  what  is 

I'l'  normal. 

•IT  paraiy- 

1  i('in|)('ra- 

lic  ('as(>  in 

innsciilar 

ion  which 

i('<iu('n(ly 

wi(h  loss 

iition   has 

0  sensory 

incortain 

t'  sensory 

iiif^Miostid 

parts  of 


INTIKUMMTION.  \)\\) 


11.     S  VST  KM    DISKASI'X 
I.    INTRODUCTION. 

There  are  eerliiiii  iliseaHes  ol'  the  nervoiiH  Hysjeni  which  arc  confincil, 
if  iiol  altHoliilcly,  Hiill  ill  ^I'ciil  pari,  lo  ileiiiiile  tnich  (cutnliiniil  iniih  cf 
iiciiroiics)  which  Htilmcrve  like  fiiiiclioiis.  'I'liese  t rails  are  called  kjih- 
hnis,  and  a  disease  whi<'h  is  eonlined  lo  one  of  theiii  is  a  sifslnn  iliMi'iisr, 
If  more  Ihiiti  one  Hysleni  is  involved,  the  proeesM  is  ealled  a  eoinhiiicd  systeMi 
(iiscase.  .Iiisl  what  diseases  should  he  classed  under  these  names  has  )^riveii 
use  lo  milch  discussion  hut  to  very  lillle  a^^recmeid.  We  eaiinol  speak 
|i(isilively ;  our  knowled^'e  is  as  yet  nol  siillicieiilly  accurate,  eillier  in  re^^Mird 
III  the  exact  limits  (d'  the  systems  themselves,  or  to  (he  nature  ntid  exlenl 
(if  the  niorhid  process  in  the  several  diseiHcs.  In  the  classification  whit  h 
liiis  heeii  adopted  ill  this  edition  the  endeavor  has  heeu  to  miike  the  arran;.'e- 
iiicnt  as  simple  as  possihie,  and,  while  it  is  hase(|  upon  what  is  helieved  to 
lie  the  best  rounded  views  of  the  systems  and  their  diseaseH,  there  has  hceti 
no  attempt  to  carry  the  classilicalion  to  its  lo^'ieal  eoneliision,  nor  have  the 
liiiiils  of  the  theory  hi-en  always  rcspecte(|. 

In  ^fciieral  it  may  he  said  thai  I  he  neivous  system  i-<  composed  of  '  ,v(» 
fireal  systems  of  neurones,  I  he  all'ereiil  or  sensory  system  iiiid  the  eir<'reiit 
(ir  motor  system,  and  the  connections  hetween  them.  (See  (Jeiienil  In  co- 
(luetion.) 

lioeomolor  ataxia  is  a  diseasi'  eonlined  to  the  allerent  system,  an'  pro- 
j^ressive  muscular  atrophy  is  one  of  the  elVereiit  system.  I{e|)re-<enliii;f  typ- 
ical Hystem  diseases  as  we  now  understand  them,  they  have  heen  taken  as 
the  hasis  of  the  ehisi  [lication.  Several  theories  have  heen  advanced  to  ex- 
pliiiii  why  a  disease  shmild  he  limited  to  a  dednite  system  of  neiirone-i.  Oni! 
view  is  hased  upon  the  idea  that  in  certain  individuals  one  or  the  olli(;r  of 
these  systems  has  an  innate  tendency  t<»  inider^o  (le;^'eiieratioii;  another  as- 
sumes that  neurones  with  a  similar  fuiiclion  have  a  sitnihr  chemical  con- 
struction (which  dill'ers  from  that  of  neurones  with  a  diirereiit  function), 
and  this  is  taken  to  explain  why  a  poison  circulating'  in  the  hlood  Klimihl 
show  a  selective  action  for  a  single  fiiiictioiial  system  of  iieiirones. 

In  the  all'enMit  tract  locomotor  ataxia  stands  alone  a-;  a  syKt(;m  disease. 
Ill  the  eU'erent  tract  proi,M'esKiv(!  (e(!ntral)  muscular  atrophy  is  the  chief 
representative,  as  in  it  the  whole  motor  path  is  more  or  le.-s  involved.  The- 
oretically, primary  lat<'ral  sclerosis  is  a  disease  confiiutd  to  tin;  up|)or  se^'- 
iiient  of  the  eU'erent  tract,  while  anterior  polioniyolitis  inv(jlves  the  lower 
se^jment  of  the  tract. 

In  eoiineetion  with  progressive  (central)  inii-;ciilar  atropliy,  the  other 
foniis  of  muscular  atrophy  are  considered  as  a  matter  of  convenience.  In 
other  instances,  too,  diseases  are  arraiii;ed  in  positions  to  which  they  ini<rht 
not  be  entitled,  had  a  rigid  classification  of  sy.steni  disuuses  boon  maintained. 


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Hiotographic 

Sciences 
Corporation 


33  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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920 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


II.   DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM. 

Locomotor  Ataxia 
( Tabes  Dorsalis  ;  Posterior  Spinal  Sclerosis). 

Definition. — An  alTection  charaetorizcd  clinically  by  incoorclination, 
sensory  and  troi)hic  disturbances,  and  involvement  of  the  special  senses, 
particularly  the  eyes.  Anatomically  there  arc  found  degeneration  of  the 
posterior  roots  and  of  the  dorsal  columns  of  the  cord;  sometimes  the  spinal 
ganglia  and  pei'ipheral  ncn'cs  are  aU'ected.  Foci  of  degeneration  in  the 
basal  ganglia  and  degenerative  changes  in  the  cortex  cerebri  have  been 
described. 

Etiology. — It  is  a  widespread  disease,  more  frequent  in  cities  than  in 
the  country.  The  relative  proportion  may  be  judged  from  tlic  fact  that 
of  8S)i2  cases  in  the  neurological  dispensary  of  the  Johns  Hopkins  Hos- 
pital there  were  89  cases  of  locomotor  ataxia  (II.  M.  Thomas).  Males  are 
attacked  more  frequently  than  females,  the  proportion  being  at  least  10  to 
1.  Mitchell  has  called  attention  to  the  fact  that  it  is  a  rare  disease  in 
the  negro.  It  is  a  disease  of  adult  life,  a  majority  of  the  cases  occurring 
between  the  thirtieth  and  fortieth  years.  Occasionally  cases  are  seen  in 
young  men.  The  form  of  ataxia  which  occurs  in  children  is  a  different  dis- 
ease. Of  special  causes  syphilis  is  the  most  important.  According  to  the 
figures  of  Erb,  Fournier,  and  Gowers.  in  from  50  to  75  per  cent  of  all  cases 
there  is  a  history  of  this  disease.  Erb's  recent  figures  are  most  striking; 
of  300  cases  of  tabes  in  private  practice  89  per  cent  had  had  syphilis.  Moe- 
bius  goes  so  far  as  to  say,  "  The  longer  I  reflect  upon  it,  the  more  firmly  I 
believe  that  tabes  never  originates  without  syphilis." 

Excessive  fatigue,  overexertion,  injury,  exposure  to  cold  and  wet,  and 
sexual  excesses  are  all  assigned  as  causes.  There  are  instances  in  which 
the  disease  has  closely  followed  severe  exposure.  James  Stewart  has  noted 
that  the  Ottawa  lumbermen,  who  live  a  very  hard  life  in  the  camps  during 
the  winter  months,  are  frequently  the  subjects  of  locomotor  ataxia.  Trauma 
has  been  noted  in  a  few  cases.  Alcoholic  excess  does  not  seem  to  predis- 
pose to  the  disease.  Among  patients  in  the  better  classes  of  life  I  do  not 
remember  one  in  which  there  had  been  a  previous  history  of  prolonged 
drunkenness.  There  are  now  a  good  many  cases  on  record  of  the  existence 
of  the  disease  in  both  husband  and  wife. 

Morbid  Anatomy  and  Patholoffy. — Our  conception  of  tabes 
dorsalis  has  undergone  radical  alteration,  and  the  studies  of  Leyden,  Red- 
lich,  Marie,  and  others  have  shown  that  it  can  no  longer  be  regarded  as  a 
primary  sclerosis  of  the  dorsal  columns.  These,  it  will  be  remembered,  are 
made  up.  in  great  part,  of  the  axis-cylinder  processes  of  the  spinal  ganglia, 
and  they,  with  their  branches,  represent  in  the  cord  the  paths  of  sensory 
conduction.  The  peripheral  sensory  nerves  represent  the  protoplasmic 
processes  of  the  spinal  ganglia,  which  important  structures  are  the  trophic 
centres  both  for  the  sensory  nerves  as  well  as  for  the  axis-cylinder  processes 
which  make  up  the  dorsal  columns  of  the  cord.     Marie  calls  attention  also 


ySTEM. 


rdir.ation, 
ial  senses. 
on  of  tho 
the  spinal 
on  in  the 
lave  heen 

3S  than  in 

fact  that 

kins  Hos- 

]\lales  are 

east  10  to 

disease  in 

occurring 

e  seen  in 

'orent  dis- 

ng  to  tlie 

f  all  cases 

striking; 

is.     Moe- 

3  firrnly  I 

wet,  and 

in  which 

lias  noted 

js  during 

Trauma 

0  predis- 

1  do  not 
jrolonged 
existence 

of  tabes 
len,  Red- 
rded  as  a 
)ered,  are 
ganglia, 
f  sensory 
oplasmic 
e  trophic 
processes 
ition  also 


DISEASES  OF  THE  AFFERENT  OR  SRNSORY  SYSTEM. 


021 


lo  the  possibility  of  the  existence  of  ])oripheral  or  terminal  ganglion  cells 
w  liich  are  found  in  diil'erent  organs — cells  IVoni  w  liiili  ((rtaiii  of  the  sensory 
Jii)res  are  derived  which  go  to  form  the  dorsal  nerve-roots.  According  to 
I  lie  ueneral  laws  of  nerve  physiology,  already  nientioiKMl,  lesions  of  the  nerve 
pmglia  would  be  i'oiIi:wed  by  degeneration  of  the  dorsal  rool-iibres  and  of 
I  heir  continuation  in  th?  cord,  and  this  is  practically  what  the  recent  theory 
(if  tal)es  involves.  The  changes  in  the  dorsal  coluiuns  are  merely  a  se- 
(jiicnce,  and  not  the  primary  disease.  The  libres  of  the  dorsal  root  are  di- 
\  uled  into  three  sets: 

(1)  The  short  fibres,  which  pass  almost  directly  into  the  dorsal  cornu 
after  entering  the  cord. 

(2)  Fibres  of  moderate  length,  which  run  upward  in  the  cord;  some 
of  them  enter  the  dorsal  horn  at  its  middle  part,  while  others  pass  into 
Clarke's  column.  The  libres  yf  this  group  run  in  the  fasciculus  cuneatus 
of  Burdach. 

(;j)  iV  group  of  long  fibres,  which  are  derived  chiefly  from  the  roots  of 
the  Cauda  eipiina,  and  which  pass  the  whole  length  of  the  cord  to  enter 
certain  nuclei  in  the  medulla.  Tiiey  form  the  fascicidus  gracilis  of 
(loll. 

'J'he  initial  cord  lesion  in  tabes  is  found  in  the  dorsal  root-zone  and 
iu  the  zone  or  tract  of  J^issauer,  a  narrow  portion  situated  between  the 
margin  of  the  cord  and  the  apex  of  the  ])osterior  horn.  In  the  fasciculus 
of  lUirdach  the  sclerosis  is  in  almost  direct  proportion  to  the  duration  of  the 
disease,  slight  at  first  and  centrally  placed,  and  becoming  widespread  as 
the  disease  advances.  The  fasciculus  of  GoU  is  alfected  slightly  in  the  early 
stages,  but  in  the  advanced  s  :age  there  is  extensive  M-lerosis.  ^larie  cor- 
relates the  sclerosis  of  these  dilTerent  })arts  with  the  diil'erent  groups  of 
nt'rve-fibres  of  the  dorsal  root,  the  dorsal  root-zone  and  the  zone  of  Lis- 
sauer  degenerating  from  the  involvement  of  the  short  fibres;  the  sclerosis 
of  the  fasciculi  of  Burdach  and  the  disaj^pearance  of  the  network  of  the 
ncrve-filjres  in  the  column  of  Clarke  l)eing  due  to  the  degeneration  of  the 
second  grou]),  the  fibres  of  nu)derate  length;  while  the  sclerosis  of  the  fas- 
ciculi of  Goll  is  caused  by  the  degeneration  of  the  third  group,  namely,  the 
long  fibres.  lie  suggests  also  that  groups  of  fibres  in  the  dilTcreut  (hu'sal 
roots  are  not  sinudtaneously  aff'-cted,  and  the  lesions  may  be  in  an  ad- 
vanced stage  in  one  region  and  but  slight  in  the  other.  "  The  lesions  of  the 
spinal  cord  in  fahes  occur  hi/  scfpncnfs,  each  dorsal  root  bringing  into  the 
dorsal  column  a  fresh  contingent  of  degenerated  fibres." 

According  to  this  interesting  hypothesis  the  lesions  of  the  ganglia  of 
the  dorsal  roots  are  res])onsil)le,  in  ])art  at  least,  for  the  peripheral  neuritis, 
since  in  degeneration  of  the  spinal  ganglia  and  consequent  loss  of  trophic 
iiilluonce  there  would  necessarily  be  degeneration  in  the  peripheral  nerve- 
trunks.  Possibly,  too,  Marie  suggests,  the  degeneration  of  the  peripheral 
ganglion  cells  may  liavo  a  good  deal  to  do  with  the  neuritis  of  tabes. 

Obersteiner  ami   liedlich,  while  agreeinu-  that  the  degeiu'ration  of  the 

dorsal  columns  of  the  cord  is  dependent  upon  a  disease  in  the  dorsal  roots, 

believe,  at  least  for  most  cases,  that  tlie  change  in  the  latter  is  secondary  to 

a  chronic  inflammation  of  the  pia  mater,  which,  by  making  pressure  on  the 

58 


922 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


/ 


--(!; 


dorsal  root-fibres  just  where  they  are  poor  in  myeliiie,  causes  them  to  de- 
generate. 

The  spinal  ganglia  have  been  found  diseased  in  certain  cases,  but  in 
ntlicr  cases  no  cliange  whatever  could  be  detected,  even  by  the  aid  of  the 
most  delicate  technicpie,  and  Marie  acknowledges  tliat  there  is  very  littU' 
anatomical  proof  for  his  theory  that  it  is  these  structures  that  are  primarily 
all'ected  in  tal)es. 

Trepinski  has  divided  the  dorsal  fasciculi  into  dilTcrent  systems  accord- 
ing to  the  time  of  the  development  of  their  myeline,  and  has  endeavored 
to  show  that  the  sclerosis  in  tabes  follows  these  -ystems. 

Symptoms. — These  are  best  considered  under  three  stages — the  in- 
cij)ient  stage,  the  ataxic  stage,  and  the  paralytic  stage. 

The  Incipient  Stage. — This  is  sometimes  called  the  preataxic  stage. 
The  manner  in  which  tabes  makes  its  onset  differs  very  widely  in  the  dif- 
ferent cases,  and  mistakes  in  diagnosis  are  often  made  early  in  the  disease. 
The  following  are  the  most  characteristic  initial  symptoms: 

Pains,  usually  of  a  sharp  stabbing  character;  hence  the  term  lightning 
pains.  They  last  for  only  a  second  or  two  and  are  most  common  in  the  legs. 
They  may  be  associated  with  a  hot  burning  feeling.  Occasionally  herpes 
may  develop  at  the  site  of  the  pain.  They  may  occur  at  irregular  intervals, 
and  are  more  })rone  to  follow  excesses  or  to  come  on  when  health  is  im- 
paired. The  gastric  crises  and  other  crises  may  occur  in  the  disease. 
Para}sthesia  may  also  be  among  the  first  symptoms.  Xumbness  of  the  feet, 
tingling,  etc.,  and  at  times  a  sense  of  constriction  about  the  body. 

Ocular  Symptoms. — (a)  Optic  atrophy.  This  occurs  in  about  10  per  cent 
of  the  cases,  and  is  often  an  early  and  even  the  first  symptom.  There  is 
a  gradual  loss  of  vision,  which  in  a  large  majority  of  cases  leads  to  total 
blindness,  (h)  Ptosis,  which  may  be  double  or  single,  (c)  Paralysis  of  the 
external  muscles  of  the  eye.  This  may  be  of  a  single  muscle  or  occasion- 
ally of  all  of  the  muscles  of  the  eye.  The  paralysis  is  often  transient,  the 
patient  merely  complaining  that  he  saw  double  for  a  certain  period,  (d) 
Argyll  Eobertson  pupil,  in  which  there  is  loss  of  the  iris  reflex  to  light 
but  contraction  during  accommodation.  The  pupils  are  very  small — spinal 
myosis. 

Bladder  Symptoms. — The  first  warning  of  the  disease  which  the  patient 
has  may  be  a  certain  difficulty  in  emptying  the  bladder.  Incontinence  of 
urine  occurs  only  at  a  later  stage  of  the  disease.  Decrease  in  sexual  desire 
and  power  may  also  be  an  early  symptom. 

Trophic  Disturhances. — These  usually  occur  later  in  the  disease,  but  at 
times  they  are  very  early  symptoms  and  it  is  not  very  infrequent  to  have 
one's  attention  called  to  tli^  trouble  by  the  presence  of  a  perforating  ulcer 
or  of  a  characteristic  Charcot's  joint. 

Loss  of  the  Knee-jerl: — This  early  and  most  important  symptom  may 
occiir  years  before  the  development  of  ataxia.  Even  alone  it  is  of  great  mo- 
ment, since  it  is  very  rare  to  meet  with  individuals  in  whom  the  knee-jerk 
is  normally  absent.  The  combination  of  loss  of  the  knee-kick  with  one 
or  more  of  the  sym])toms  mentioned  above,  especially  with  the  lightning 
pains  and  ptosis  or  Argyll  Eobertson  pupil,  is  practically  diagnostic.     The 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM. 


923 


licm  to  tlo- 

sos,  but  in 
aid  of  the 
vcrv  little 

•e  primarily 

2ms  accord - 
endeavored 

;es — the  in- 

taxic   stage. 

in  the  dif- 

the  disease. 

m  lightning 
in  the  legs. 
lally  herpes 
ar  intervals, 
oalth  is  im- 
the  disease, 
of  the  feet, 

10  per  cent 
I.  There  is 
ads  to  total 
alysis  of  the 
or  occasion- 
ansient,  the 
period.  ((/) 
lex  to  light 
uall — spinal 

tlie  patient 
)ntinence  of 
exual  desire 

;ease,  but  at 
ent  to  have 
rating  ulcer 

mptom  may 
of  great  mo- 
le  knee-jerk 
?k  with  one 
le  lightning 
lostic.     The 


1 
i 


knee-jerk  is  not  lost  su.'denly,  jjut  gradually  decreases,  often  disappearing 
in  one  leg  before  the  other. 

These  are  the  most  connnon  symptoms  of  the  initial  stage  of  tabes  and 
mav  persist  for  years  without  the  development  of  incoiirdination.  The  pa- 
tient may  look  well  and  feel  well,  and  be  troubled  only  by  occasional 
attacks  of  lightning  pains  or  of  one  of  the  other  subjective  syin])t()nis. 
^loebius  goes  so  far  as  to  state  that  the  typical  Argyll  liobcrtson  pui)il 
means  either  tabes  or  general  paralysis,  and  that  i)aralysis  of  the  external 
muscles  of  the  eye  develoj)ing  in  adults  are  of  almost  e(iual  im[)()rtance.  es- 
liecially  if  they  develop  painlessly. 

The  time  between  the  syi)hilitie  infection  and  the  occitrrence  of  the 
first  symptoms  of  locomotor  ataxia  varies  within  wide  limits.  About  one 
half  the  cases  occur  between  the  sixth  and  fifteenth  year,  but  many  begin 
even  later  than  this. 

The  disease  may  never  progress  ])eyond  this  stage,  and  when  optic 
atrophy  develojjs  early  and  leads  to  blindness,  ataxia  rarely,  if  ever,  super- 
venes. There  is  a  sort  of  antagonism  between  the  ocular  symptoms  and 
the  progress  of  the  ataxia.  Charcot  laid  considerable  stress  upon  this,  and 
both  Dejerine  and  Spiller  have  since  emphasized  the  point. 

Ataxic  Stage. — Motor  Si/mptoms. — The  ataxia  is  believed  to  be  due  to 
a  disturbance  or  loss  of  the  afferent  impulses  from  the  muscles,  and  a  dis- 
turbance of  the  muscle  sense  itself  can  usually  be  demonstrated.  It  de- 
velops gradually.  One  of  the  first  indications  to  the  i)atient  is  inal)ility 
to  get  about  readily  in  the  dark  or  to  maintain  his  equilibriuui  when  wash- 
ing his  face  with  the  eyes  shut.  When  the  patient  stands  with  the  feet 
together  and  tne  eyes  closed,  he  sways  and  has  difficulty  in  maintaining 
his  position,  and  he  may  be  quite  unable  to  stand  on  one  leg.  Tliis  is 
known  as  Romberg's  symptom,  lie  does  not  start  oif  promptly  at  the  word 
of  command.  On  turning  quickly  he  is  apt  to  fall.  He  descends  stairs 
with  more  difficulty  than  he  ascends  them.  Gradually  the  characteristic 
ataxic  gait  develops.  The  patient,  as  a  rule,  walks  with  a  stick,  the  eyes 
are  directed  tc  the  ground,  the  body  is  thrown  forward,  and  the  legs  are 
wide  apart.  In  walking,  the  leg  is  thrown  out  violently,  the  foot  is  raised 
too  high  and  is  brought  down  in  a  stamping  manner  with  the  heel  first,  or 
the  whole  sole  comes  in  contact  with  the  ground.  Ultinuitely  the  patient 
may  be  unable  to  walk  without  the  assistance  of  two  canes.  This  gait  is 
very  characteristic,  and  unlike  that  seen  in  any  other  disease.  The  inco- 
ordination is  not  only  in  walking,  but  in  the  performance  of  other  move- 
ments. If  the  patient  is  asked,  when  in  the  recundjent  posture,  to  touch 
the  knee  wiih  one  foot,  the  irregularity  in  the  movement  is  very  evident. 
Incoordination  of  the  arms  is  less  common,  but  usually  develops  in  some 
grade.  It  may  in  rare  instances  exist  before  the  incoordination  of  the  legs. 
It  may  be  tested  by  asking  the  patinnt  to  close  his  eyes  and  to  touch  the  tip 
of  the  nose  or  the  tip  of  the  ear  with  the  finger,  or  with  the  arms  thrust  out 
to  bring  the  tips  of  the  fingers  together.  '^I'lu  incoordination  may  early  be 
noticed  by  a  difficulty  which  the  patient  exi)eriences  in  buttoning  his  collar 
or  in  performing  one  of  the  ordinary  routine  acts  of  dressing. 

One  of  the  most  striking  features  of  the  disease  is  that  with  marked 


934 


DISEASES  OE  THE  NERVOUS  SYSTEM. 


incoordination  llicrc  is  no  loss  of  imisciilar  power.  Tlic  <frip  ol,'  the  hands 
nuiy  be  stronjf  and  Jirni,  llic  })o\vt'r  ol'  lliu  lL'<fs,  tested  by  tryinj^  to  Ilex  them, 
may  be  iiiiinipaircd,  and  their  niiti'ition.  except  toward  the  (lose,  may  he 
uiiall'eeted. 

'i'here  is  a  remarkable  mnscnlar  relaxation  whieh  enables  the  joints  to 
l)e  phieed  in  positions  of  ]iy])erextensi()n  and  liy|)erl]exion.  It  <^ives  some- 
times a  marked  backward  curve  to  the  ie^^s.  Friiid'Cel,  who  calls  the  condi- 
tion hypotonia,  says  it  may  he  an  early  symptom. 

Snisari/  Si/ni/iliniis. — The  li^htnin;^'  pains  may  j)ersist.  They  vary 
greatly  in  ditl'ereiit  cases.  Some  p"tiei\1s  are  rendered  miserable  by  the 
fre(Hient  occurrence  of  the  attacks;  others  escape  alto;^t!ier.  In  addition, 
oomuKUi  symptoms  are  tin<,dint;\  ])ius  and  needles,  particularly  in  the  fi'ct. 
and  areas  of  liypera'sthesia  or  of  ana'sthesia.  The  patient  may  complain  of 
a  chanji'e  in  the  sensation  in  the  soles  of  the  feel,  as  if  cotton  was  inter- 
])osed  between  the  tloor  and  the  skin.  Sensory  disturbances  occur  le>.. 
frecpuMitiy  in  the  hands.  Objective"  si'nsory  dist  url)ances  can  usually  be 
diMuonstrated,  and  indeed  almost  every  variety  of  sensory  distui'bance  has 
been  described.  They  have  been  carefully  studied  in  this  country  by  Knap|) 
and  by  Patrick,  and  in  I']uro|)e  l)y  many  observers.  Uands  about  the  chest 
of  a  moderate  j^n'ade  of  ana'sthesia  are  not  uncounnon;  they  are  apt  to 
follow  the  (listril)ution  of  spinal  se!j;uu'  its.  The  most  marked  distui'hances 
are  usually  foumi  on  the  le;i;s.  IJetardation  of  the  sense  of  pain  is  common, 
and  a  pin-prick  on  the  foot  is  first  felt  as  a  simple  tactile  im[)ression.  and 
the  sense  of  pain  is  not  ])erceived  for  a  nccond  or  two  or  may  be  delayed  for 
iis  nnicli  as  ten  seconds.  The  pain  felt  may  ])ersist.  A  curious  piienomenon 
is  the  loss  of  the  power  of  localizin,if  the  pain,  j-'or  instance,  if  tlie  patient 
is  ])ricked  on  one  limb  he  may  say  that  be  feels  it  on  the  other  (alloclieiria), 
01'  a  pin-prick  on  the  foot  may  be  felt  on  liolh  feet.  The  muscular  sense 
whith  is  usually  all'ected  early,  becomes  unich  im|)aired  and  the  ])atient 
no  lonji'cr  recoirnizes  the  ]iosition  in  which  his  limbs  are  i)laced.  This  may 
be  ])resent  in  the  ])re-ataxic  stage. 

licflc.vcs. — As  mentioned,  the  loss  of  Ih^'  knee-jerk  is  one  of  the  earliest 
symptoms  of  the  disease.  Occasionally  a  case  is  found  in  which  it  is  re- 
tained. The  skin  relU'xes  may  at  first  be  increased,  but  latf  are  usually 
involved  with  the  dee])  rellexes. 

Spenal  Senses. — The  eye  syni])toms  noted  above  may  be  present,  but, 
as  mentioned,  ataxia  is  rare  with  atrophy  of  the  oi)tic  nerve. 

Deafness  may  (b'velop,  due  to  lesion  of  the  auditory  nerve.  There  may 
also  be  attacks  of  vertigo.     Olfactory  syni])toius  are  rare. 

Msrrral  Sijinploms. — Among  the  most  remarkable  sensory  disturbances 
are  the  tabetic  crises,  severe  paroxysms  of  pain  referred  to  various  viscera; 
thus  laryngeal,  gastric,  ncphric,  rectal,  urethral,  and  clitoral  crises  have 
been  described.  The  most  common  are  the  gastric  and  laryngeal.  In  the 
former  there  are  intense  ])ains  in  the  stomach,  vomiting,  and  a  secretion 
of  hyperacid  gastric  juice.  The  attack  may  last  for  several  days  or  even 
longer.  There  may  be  severe  pain  without  any  vomiting.  The  attacks  are 
of  variable  intensity  and  usually  reipiire  morphia.  Paroxysms  of  rectal 
pain  and  tenesmus  are  described.     They  have  not  been  common  in  my 


DISEASES   OF  THE  AFFERENT  oH  SENSORY  SYSTE^f. 


925 


'  the  hiuids 

)  IIOX   tllL'Ill, 


sc 


may 


10  joints  to 

i'ivc's  souit;- 

tlie  coudi- 


I  hey  vary 
Idu   by    tile 

I  addition, 

II  the  IVct, 
)iHj)laiii  of 
was  iiitcT- 

OCCUr     ll'S:; 

usually  be 
■bailee  bas 
by  Kna|)|) 

liie  (-best 
ire  apt  to 
■iturl)anccs 
i  eoininoii, 
ssion.  and 
I'laycd  J'oc 
pnonioiioii 
It'  patient 

)eheiria), 
liar  sense 
e  patient 
Ills  may 

e  earliest 

it  is  re- 

B  usually 

ont,  but, 

lore  may 

iirbanees 

viscera; 

ses  have 

In  th(> 

secretion 

or  even 

acks  are 

)f  rectal 

in  niv 


(XperieiU'C.  Jiaryn^cal  crisi's  also  are  rave.  Tlu're  may  be  true  spasm 
with  dyspnu-a  and  noisy  iiis})iration.  In  one  instance  at  least  the  patient 
has  died  in  tlie  attack. 

J'lie  spbiiicteis  are  i're(|uently  involved.  Marly  in  the  disease  then?  may 
1)0  a  retardation  or  hesitancy  in  making''  water,  l^ater  there  is  retention, 
and  cystitis  may  occur.  I'nless  jireat  care  is  taken  the  inllammation  may 
extend  to  tlu;  kidneys.  Constipation  is  extri'inely  common.  Late  in  the 
disease  the  sphincter  ani  is  weakened.  The  sexual  power  is  usually  lost  in 
the  ataxic  stage. 

Tnijihic  (  li(iiit/('s. — Skin  rashes  may  develo])  in  the  course  of  the  li<,dit- 
iimg  pains,  such  as  lier])es,  cedeiiia,  or  local  sweating;'.  Alteration  in  the 
nails  may  occur.  A  perforating  ulcer  may  develop  on  the  foot,  usually 
heiu'atli  the  great  toe.  A  i)erforating  buccal  ulcer  has  also  been  described. 
Onychia  may  ])rove  very  trouI)les()me. 

The  arthropathies  or  joint  lesions  atl'ect  chiefly  the  knees.  'J'hey  are 
iiiKluestionably  associated  witli  the  disease  itself,  and  are  not  necessarily  a 
result  of  trauma.  The  ct)iidition,  known  as  Charcot's  joint,  is  anatomic- 
ally similar  to  that  of  chronic  arthritis  deformans.  The  elfusiou  may  be 
rapid  and  there  may  be  great  disintegration  ai.d  destruction  of  the  carti- 
lages and  hones,  leading  to  dislocation  and  deformity.  Suppuration  may 
occur.  Spontaneous  fractures  may  occur.  Among  other  trophic  disturb- 
aiucs  may  be  mentioned  atropiiy  of  the  muscles,  wliicii  is  usually  a  late 
manifestation,  hut  may  be  localized  and  associatetl  with  neuritis.  Jn  any 
very  large  collection  of  cases  many  instances  of  atrophy  are  found,  due  cither 
to  involvement  of  the  ventral  horns  or  to  peripheral  neuritis. 

Cerebral  iSijiiiploiits. — Hemiplegia  may  (k'Vt'lop  at  any  stage  of  the  dis- 
ease, more  commonly  when  it  is  well  advanced.  It  may  be  due  to  luemor- 
rhagic  softening  in  coiise(|iience  of  disease  of  the  vessels  or  to  jirogressivo 
cortical  changes.  Jlemiaiuesthesia  is  sometimes  present.  Very  rarely  the 
lienii])legia  is  due  to  coarse  syjjhilitic  disease. 

Dementia  paralytica  fre(|iiently  exists  with  talx's,  and  it  may  be  ex- 
tremely dillicult  to  determine  which  has  been  the  primary  all'ection;  indeed, 
some  authors  believe  tlu.t  these  two  diseases  are  sim|)ly  dilfereiit  localizations 
of  the  same  morbid  ])r()cess.  In  a  majority  of  the  cases  the  symptoms  of 
locomotor  ataxia  have  i)recedcd  those  of  general  paresis.  In  other  instances 
melancholia,  dementia,  or  ])aranoia  develo]). 

{(■)  Paralytic  Stage. — After  jjcsisting  for  an  indefinite  number  of  years 
i1k'  ])atieiit  gradually  loses  the  power  of  walking  and  becomes  bedridden 
or  paralyzed.  In  this  condition  he  is  very  likely  to  be  carried  olf  by  some 
intercurrent  affection,  such  as  pyelo-nephritis,  pneumonia,  or  tuberculosis. 

Tlie  Course  of  the  Disease. — A  ])atient  may  remain  in  the  ])re-ataxic 
staiic  for  an  indefinite  period;  and  the  loss  of  knee-jerk  and  the  gray 
atrophy  of  the  o])tic  nerves  may  be  the  sole  indication  of  the  true  nature 
of  the  disease.  In  such  cases  incoordination  rarely  develops.  In  a  ma- 
jority of  cases  the  ])rogress  is  slow,  and  after  six  or  eight  years,  sometimes 
less,  the  ataxia  is  well  develo])ed.  The  symptoms  may  vary  a  good  deal; 
thus  the  i«ains,  which  may  have  been  excessive  at  lirst,  often  lessen.  Tlio 
disease  may  remain  stationary  for  years;  then  exacerbations  occur  and  it 


92G 


DISEASES  OP  THE  NEKVOUS  SYSTEM. 


makes  rnpid  |ir()<,'r('ss.  Oconsioimlly  tlic  process  sccnis  to  be  arrested.  Tlurc 
are  instance's  of  wliat  may  la'  called  acute  ataxia,  in  wli  ch,  within  a 
year  or  even  less,  the  incoilrdination  is  marked,  and  the  [laralytie  staj^e 
may  develoji  within  a  few  months.  The  disease  itself  rarely  causes  death, 
and  after  hecomin^r  bedridden  the  patient  may  live  for  fifteen  or  twenty 
years. 

Diagnosis. — In  the  initial  static  the  combination  of  li«ilitning  pains 
and  the  absence  of  knee-jerk  is  distinctive.  The  association  of  progressive 
atrojjhy  (jf  the  ojitic  nerves  with  loss  of  knee-jerk  is  also  characteristic. 
The  early  ocular  palsies  are  of  the  greatest  importance.  A  scpiint,  ptosis, 
or  the  Argyll  IJobt'rtson  jjupil  may  be  the  lirst  symi)toni,  and  may  exist 
vith  the  loss  only  of  the  knee-jerk.  Loss  of  the  knee-jerk  alone,  however, 
does  occasionally  occur  in  healthy  individuals.  A  history  of  preceding 
syphilis  lends  added  weight  to  the  symptoms,  and  its  presence  or  absence 
may  be  of  the  utmost  importance  in  determining  the  diagnosis.  If  the 
possibility  of  syi)hilitic  infection  can  be  excluded,  a  circumstance  but  too 
rarely  met  with,  only  the  most  unecpiivocal  combination  of  symptoms  can 
justify  the  diagnosis  of  locomotor  ataxia. 

The  diseases  most  likely  to  be  confounded  with  locomotor  ataxia  are: 
(1)  Peripheral  NcurHis. — The  steppage  gait  of  arsenical,  alcoholic,  or  dia- 
betic paralysis  is  quite  iiidike  that  of  locomotor  a+"ixia.  In  these  forms 
there  is  a  i)aralysis  of  the  feet  and  the  leg  is  lifted  high  in  order  that  the 
toes  may  clear  the  floor.  The  use  of  the  word  tabes  in  this  connection 
should  no  longer  be  continued.  In  the  rare  cases  in  Avhich  the  muscle 
sense  nerves  are  particularly  affected  and  in  which  there  is  true  ataxia,  the 
absence  of  the  lightning  pains  and  eye  symptoms  and  the  history  will  suffice 
in  the  majority  of  eases  to  make  the  diagnosis  clear.  In  diphtheritic  paraly- 
sis the  early  loss  of  the  knee-jerk  and  the  associated  eye  symptoms  may  sug- 
gest tabes,  but  the  history,  the  existence  of  paralysis  of  the  throat,  and 
the  abi-encc  of  ])ains  render  a  diagnosis  easy. 

('^)  Ataxic  Paraph(jia. — Marked  incoordination  with  spastic  paralysis 
is  characteristic  of  the  condition  wliich  Gowers  has  termed  ataxic  paraplegia. 
In  a  majority  of  the  cases  this  alTection  is  distinguished  also  by  the  ab- 
sence of  ])ains  and  of  eye  symptoms. 

(3)  Cerebral  Disease. — In  diseases  of  the  brain  involving  the  afferent 
tracts  ataxia  is  at  times  a  proniinent  symptom.  It  is  usually  unilateral  or 
limited  to  one  limb;  this,  with  the  history  and  the  associated  symptoms, 
excludes  tabes. 

(4)  Cerehellar  Disease. — The  cerebellar  incoordination  has  only  a  super- 
ficial resemblance  to  that  of  locomotor  ataxia,  and  is  more  a  disturbance 
of  erpiilibrium  than  a  true  ataxia;  the  knee-jerk  is  usually  present,  there 
are  no  lightning  pains,  no  sensory  disturbances;  while,  on  the  other  hand, 
there  are  headache,  optic  neuritis,  and  vomiting. 

(5)  Some  acute  affections  involving  the  dorsal  columns  of  the  cord  may 
be  followed  by  incoordination  and  resemble  tabes  very  closely.  In  a  case 
under  my  care,  the  gait  was  characteristic  and  Romberg's  symptom  was 
present.  The  knee-jerk,  however,  was  retained  and  there  were  no  ocular 
symptoms.    The  condition  had  developed  within  three  or  four  months,  and 


DISKASRS  OP  TRR  AFFERENT  OR  SENSORY  SYSTEM. 


927 


'tod.  Tlur.. 
',  witliiii  ii 
a  lytic  x{i\'^i> 
iiisi's  (K'iidi, 
1  or  twenty 

tiling  pains 

progrossivL' 

aracteristic". 

lint,  ptosiji, 

may  exist 
e,  howevL'i-, 

preceding- 
or  absence 
is.  If  tlie 
lee  but  too 
iptoms  can 

ataxia  are: 
lie,  or  dia- 
lose  forms 
'r  that  the 
connection 
he  muscle 
itaxia,  the 
.vill  sufBce 
tic  paraly- 
niay  sug- 
iroat,  and 

paralysis 
araplegia. 
y  the  ab- 

;  afTerent 
Uiteral  or 
rmptoms, 

a  supcr- 
turbance 
lit,  there 
er  hand, 

ord  may 
n  a  case 
torn  was 
0  ocular 
ths,  and 


tlicre  was  a  wcU-iiiarkcd  history  of  syphilis.  I'nder  lar<;e  dosos  of  iodide 
of  i)otassiuni  the  ataxia  and  other  syni])tonis  completely  disapjjeared. 

(0)  Oencral  I'airsis. — In  some  cases  tiiis  olTers  a  serious  dillieulty.  In 
the  iirst  place,  in  general  })aresis,  tabetic  sym[»toms  often  develop;  on  the 
other  '".iiul,  tliere  are  cases  of  locomotor  ataxia  in  which,  toward  the  <'nd, 
there  aie  sym[)toms  of  general  })arcsis.  Cases  of  unusually  acute  ataxia 
with  mental  symptoms  belong,  as  a  rule,  to  the  former  disease.  The  (pies- 
tion  will  be  considered  uiuler  general  paresis. 

(7)  Visceral  crises  and  neuralgic  sym|)toms  may  lead  to  error,  and  in 
middle-aged  men  with  severe,  recurring  attacks  of  gastralgia  it  is  always 
well  to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  exam- 
ination of  the  eyes  and  of  the  knee-jerk. 

Prognosis. — Complete  recovery  cannot  be  ex])ected,  but  arrest  of  the 
l)rocess  is  not  unconunon  and  a  nuirked  amelioration  of  the  symi)toms  is 
frequent.  Optic-nerve  atrophy,  one  of  the  nu)st  serious  events  in  the  dis- 
ease, has  this  hoj)eful  aspect — that  incoordination  rarely  follows  and  the 
])rogress  may  be  arrested.  The  optic  atrophy  itself  is  occasionally  checked. 
On  the  whole,  the  prognosis  in  tabes  is  bad.  The  experience  of  such  men 
as  Weir  Mitchell,  Charcot,  and  Gowers  is  distinctly  opposed  to  the  belief 
that  locomotor  ataxia  is  ever  completely  cured.*  No  such  instance  has 
come  under  my  personal  observation. 

Treatment. — To  arrest  the  progress  and  to  relieve,  if  possible,  the 
symptoms  are  the  objects  which  the  practitioner  should  have  in  view.  A 
quiet,  well-regulated  method  of  life  is  essential.  It  is  not  well,  as  a  rule, 
for  a  patient  to  give  up  his  occupation  so  long  as  he  is  able  to  keep  about 
and  perform  ordinary  work.  I  know  tabetics  who  have  for  years  conducted 
large  businesses,  and  there  have  been  several  notable  instances  in  our  i)ro- 
fession  of  men  who  have  risen  to  distincti<  x  in  spite  of  the  existence  of  this 
disease.  Excesses  of  all  sorts,  more  i)articularly  in  hacclio  et  venere,  should 
be  carefully  avoided.     A  man  in  the  pre-ataxic  stage  should  not  marry. 

Care  should  be  taken  in  the  diet,  particularly  if  gastric  crises  have  oc- 
curred. To  secure  arrest  of  the  disease  many  remedies  have  been  em- 
l)loyed.  Although  syphilis  plays  such  an  important  rule  in  the  etiology, 
it  is  universally  acknowledged  that  neither  mercury  nor  the  iodide  of  po- 
tassium have  as  a  rule  the  slightest  influence  over  the  tabetic  lesions.  To 
this  there  is  but  one  excei)tion — when  the  syphilis  is  comi)aratively  recent; 
when  the  symptoms  develoj)  within  two  years  of  the  jjrimary  infection, 
there  is  then  a  possibility  of  arrest  by  mercury  and  iodide  of  potassium. 
However,  they  do  not  always  relieve.  In  two  cases  of  very  rapidly  pro- 
gressing tabes  following  sy])hilis  this  medication  was  of  no  avail.  Of  reme- 
dies which  may  be  tried  and  are  believed  by  some  writers  to  retard  the  pro- 
gress, the  following  are  recommended:  Arsenic  in  full  doses,  nitrate  of 
silver  in  quarter-grain  doses.  Calabar  bean,  ergot,  and  the  preijarations 
of  gold. 

The  treatment  by  suspension  introduced  a  few  years  ago  has  already 
been  practically  abandoned.     Good  effects  certainly  have  followed  in  a  few 

*  For  a  study  of  reputed  cures,  see  L.  C.  Gray,  N.  Y.  Medical  Journal,  November,  1889. 


028 


DISKASES  OF  THE  NERVOUS  SYSTEM. 


i 

I 


CUS08,  but  it  wns  imrcasoiialil''  from  tliu  outset,  oithcr  on  tlu'nipt'utic  or 
sc'iciitilic  <ii'(>uii(ls,  to  hope  tliai  l)y  such  a  iiicasurc  [tcnnaiu'nt  cliaiij^X'S  cuuld 
be  induci'd  in  tlic  patliolojiical  t'oiiditioii.  Tlic  hi'iiciits  were  due  ui  gri'at 
]mrt  to  su«,f<i;L'stion  aud  to  ])syebi('al  t'lroftti.  Jii  any  case  it  must  bo  used 
with  cauti(tii. 

l-'or  tlic  pains,  conipK'tc  rest  in  bed,  as  advised  l)_v  Weir  Mit(iu'll,  and 
eouider-ii'ritalidii  to  tlie  sjiine  (eillier  blisters  or  the  thermo-eautery)  may 
bo  empjoyeij.  'I'lu'  severe  spells  wliieh  eomo  on  particularly  after  excesses 
of  any  kind  are  often  promptly  relieved  liy  a  hot  bath  oi'  by  a  Turkish  Ijatii. 
A  pr(»lon<;('d  course  of  nitrate  of  isilver  seems  in  some  cases  to  allay  the 
])ains  and  lessen  the  liability  to  the  attacks.  1  have  nevi'r  seen  ill  olb'cts 
from  its  i\>:v  in  spinal  sclerosis.  Antipyrin  and  antifebrin  may  be  en\- 
j)l()yod,  and  occasionally  do  ^ood,  but  Ibcii'  analgesic  ])o\vers  in  this  disease 
bavo  been  fiieatly  overrated.  Cannabis  indica  is  sometimes  useful.  In 
the  severe  paroxysms  of  pain  bypodernncs  of  morphia  or  of  cocaine  must 
be  used.  'i"he  use  of  nu)i'[)hia  should  be  post])oned  as  long  as  ])ossible. 
Klectricity  is  of  very  little  I)enelit.  I-'or  the  severe  attacks  of  gastralgia, 
morphia  is  also  required.  The  laryngeal  crises  are  rarely  dangerous. 
An  a|tplication  of  cocaine  may  bo  made  during  the  s[)asm,  or  a  few  whill's 
of  chloroform  may  be  given,  or  nitrite  of  amyl.  In  all  cases  of  tabes  with 
increased  arterial  tension  the  [)i()longed  use  of  nitroglycerin,  given  in  in- 
creasing doses  until  the  j)hysiological  eU'eet  is  produced,  is  of  grea.  service 
in  allaying  the  neuralgic  pains  and  diminishing  the  Imiuency  of  the  crises. 
Its  aise  must  ))e  guarded  when  there  is  aortic  insulliciency.  The  s|)ecial 
indication  is  increased  tension.  The  blatlder  symptoms  demand  constant 
caro.  When  the  organ  cannot  be  i)erfectly  em[)tied  the  catheter  should  be 
used,  and  the  ])aticnt  may  be  taught  its  use  and  how  to  keep  it  thoroughly 
sterilized. 

I'Yiinkcl's  nu'tliod  of  re-education  often  heli)S  the  patient  to  regain  to  a 
considerable  extent  the  control  of  the  voluntary  movements  which  he  has 
lost.  By  this  method  the  patient  is  first  taught,  by  repeated  systematic 
efforts,  to  ])erform  sim])le  movements;  from  this  he  goes  to  more  and  more 
complex  nu)vements.  The  treatment  should  l)e  directed  and  supervised  by 
a  trained  teacber,  as  tbe  result  depends  upon  the  skill  of  the  teacher  quite 
as  much  as  upon  the  perseverance  of  the  patient. 


III.     DISEASES    OF   THE    EFFERENT    OR    MOTOR    TRACT. 

A.    OF  THE   WHOLE  TRACT. 
1.  Progressive  (Central)  Muscular  Atrophy 

(Poliomyelitis  Anterior  Chronica ;  Amyotrophic  Lateral  Sclerosis;  Progressive  Bulbar 

Paralysis), 

Definition. — A  disease  cliaracteriz.^d  by  a  chronic  degeneration  of  the 
motor  tract.  The  whole  tract  is  usually  involved,  but  at  times  the  degen- 
eration is  limited  to  the  lower  segments.  Associated  with  it  is  a  progressive 
atrophy  of  the  muscles,  combined  with  more  or  less  spastic  rigidity. 


riiiiciilic  or 
iiigcs  c'uitid 
ic!  ill  givat 
1st  Iji;  u«t'(l 

tdu'll,  and 
lien)   iiijiy 
cr  c'xt'i'sst's 
rkisli  hntli. 
•  allay  llio 
.  ill  olfocts 
iiy  hv  ciii- 
liis  disease 
isel'ul.     J II 
•aiiio  Jiiiist 
s  ])()ssi])l('. 
Kiistralgiu, 
lani^'crous. 
I'cw  whin's 
tabes  with 
ten   ill   iii- 
■av  st'i'vioc 
the  crises, 
ht'  special 
coiisiaiit 
should  l)(; 
lurou^hly 

.yaiii  to  a 
h  he  has 
ystemalic 
nid  more 
rvised  by 
her  quite 


RACT. 


'e  Bulbar 


u  of  the 

degen- 

Igressive 


DISKASKS  OF  THE  EFKKIIKNT  Oil   MOTOR  TRACT. 


920 


Three  aireetiniis,  as  a  rule  dcserilied  apart,  l)e|oiig  together  ill  this 
category:  ('/)  Progressive  iiiiiseular  atrophy  of  spinal  origin;  {!>)  ainyo- 
lri>|)hic  lateral  Hclorosis;  and  (r)  progressive  bulbar  paralysis.  A  slow 
atr()|)luc  change  in  the  motor  neurones  is  the  amitoinical  basis,  and  the  dis- 
ease is  one  of  the  whole  motor  path,  involving,  in  many  eases,  the  cortical, 
lailhar,  and  8[)inal  centres.  There  may  be  simple  muscular  atrophy  willi 
little  or  no  spasm,  or  progressive  wasting  with  marked  spasm  and  great 
increase  in  the  relieves.  In  others,  there  are  added  symptoms  of  involve- 
iiieiit  of  the  motor  nuclei  in  the  medulla — a  glosso-labio-laryngeal  paralysis; 
while  in  others,  again,  with  atrophy  (especially  of  the  arms),  a  spastic  con- 
dition of  the  legs  and  bulbar  plieiiometia,  tremors  develop  and  signs  of  cor- 
tical lesion.     These  various  stages  may  be  traced  in  llie  same  case. 

J''or  convenience,  bulbar  |)aralysis  will  be  considered  separately,  and  T 
>liall  here  take  up  tog<'ther  jir<i(/irssin'  iiitisnihir  (tlm/ilii/  and  (niii/nlnijiliic 
laleral  sclcnisis. 

The  disease  is  known  as  the  Aran-Duchenne  type  of  progressive  muscular 
atro])liy  and  as  Cruvcilhier's  palsy,  after  the  French  physicians  who  early  de- 
scribed it.  iicvy  and  LocklKirt  Clarke  first  demonstrated  that  the  cells  of  the 
ventral  lutriis  of  the  spinal  (ord  we:e  diseased.  Charcot  se[)arated  two  types 
— one  with  simple  wasting  of  thv  iiiuscles,  due,  be  believed,  to  degeneration 
confined  to  the  ventral  horns  (and  to  this  he  resti'icted  the  name  progressive 
muscular  atro|»liy — type,  Aran-Duchenne);  the  other,  in  whi>!.  thore  was 
spastic  paralysis  ol"  the  muscles  followed  by  atrophy.  As  the  aiialomieal 
basis  Tor  this  he  assumed  a  primai'y  degeneraliou  of  the  pyramidal  tracts 
and  a  secondary  atropip-  of  the  ventral  horns.  To  this  he  gave  the  name 
of  ainyotro])hic  latei-fl  sclerosis.  There  is  but  little  evidc  iice,  however,  to 
show  that  any  such  sliarj)  distinction  can  be  made  between  these  two  dis- 
eases, and  Leyden  aiid  Ciowers  regard  them  as  identical. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  is  more  f!'e(|iieiit 
in  males  than  in  females.  It  aU'ects  adults,  di'veloping  after  the  thirtieth 
year,  though  occasionally  younger  persons  are  attacked.  A  large  majori*" 
of  all  cases  of  progressive  muscular  atrophy  under  twenty-five  years  of 
belong  to  the  dystrophies.  Cold,  wet,  exposure,  fright,  and  mental  won.es 
are  mentioned  as  possible  causes.  Erb  has  lately  called  attention  to  cer- 
tain cases  following  injury.  Hereditary  influences  are  present  in  certain 
cases.  The  rare  form  which  occurs  in  infancy  usually  affects  several  mem- 
bers of  the  same  family.  Hereditary  and  family  intlueiices,  however,  play 
but  a  small  part  in  the  etiology  of  this  disease,  and  in  this  it  is  in  contrast 
to  progressive  neural  muscular  atrophy  and  the  dystrophics.  Yet,  in  the 
I'^arr  family,  which  I  recorded  some  years  ago,  in  which  thirteen  members 
were  afl'ccted  in  two  generations,  with  the  exce])tion  of  two,  the  cases  oc- 
curred or  proved  fatal  above  the  age  of  forty,  and  the  late  onset  speaks 
rather  for  a  central  affection.  The  spastic  form  may  develoj)  late  in  life — 
after  seventy — as  a  senile  change. 

Morbid  Anatomy. — The  essential  anatomical  change  is  a  slow  de- 
generation of  the  motor  ])ath,  involving  ])articularly  the  lower  motor  neu- 
rones. The  up))er  neurones  are  also  involved,  either  first,  simultaneously, 
or  at  a  later  period.     Associated  with  the  degeneration  in  the  cells  of  the 


030 


DISEASES  OF  TTIE  NERVOUS  SYSTEM. 


vontnil  linrns  tlioro  is  n  (Ic^'ciicrntivo  ntropliy  <il'  iho  iinisclc'S.  Tlio  fuUowiii;^' 
art'  the  iiiiiiorliiiit  aiiatoiiiical  cliaii^ics:  {n)  Tlu'  ^'ray  matter  oi  the  cdiiI 
shows  the  most  markt.'d  alteration.  Tlie  large  ganglion  colls  of  the  ventral 
horns  are  atrophied,  or,  in  places,  have  entirely  disappeared,  the  neuroglia 
is  increased,  and  tlio  mcdidlatcd  (litres  are  much  decreased,  ^'lie  fibres  of 
the  ventral  ncrvc-roots  passing  through  the  white  matter  are  wasteil.  (/») 
The  ventral  roots  outside  of  the  cord  are  also  atrophied,  (c)  The  muscle-, 
which  are  ad'eeted  show  degenerative  atrophy,  and  the  inter-muscular 
hranches  of  the  motor  nerve  are  degenerated.  (</)  The  degeneration  of  tlir 
gray  matter  is  rarely  contincd  to  the  cord,  hut  extends  to  the  iiu'dulla.  wheic 
the  nuclei  of  the  motor  eereln'al  nerves  are  found  extensively  wasted,  (f) 
Jn  a  majority  of  all  the  cases  there  is  sclerosis  in  the  ventro-lateral  wliilt! 
tract?,  the  lateral  pyramidal  tracts  particularly  are  diseased,  hut  the  degener- 
ation is  not  confined  to  these  tracts,  and  extends  into  the  ventro-lateral 
ground  bundles.  The  dirtct  cerebellar  and  the  ventro-lateral  asccndini; 
tracts  are  spared.  'JMie  degeneration  in  the  pyramidal  tracts  extends  toward 
the  brain  to  different  levels,  and  in  several  cases  has  been  traced  to  the 
motor  cortex,  the  cells  of  vhicli  have  been  found  degenerated.  Tn  the 
medulla  the  medial  longitudinal  fasciculus  has  1)een  found  diseased. 
(/')  Jn  those  cases  in  Avhich  no  sclerosis  has  been  fouiul  in  the  jtyramidal 
tracts  there  has  been  a  sclerosis  of  the  ventro-lateral  ground  bundle  (short 
tracts). 

Symptoms. — Irregular  ])ains  may  jjrecede  the  onset  of  the  wasting, 
and  cases  may  be  ti'eatod  for  ciironic  rheumatism.  The  hands  are  usually 
first  alfected,  and  there  is  difliculty  in  performing  delicate  manipulations. 
The  muscles  of  the  ball  of  the  thumb  waste  early,  then  the  interossei  and 
luud)ricales,  leaving  marked  depressions  between  the  metacari)al  hones. 
l'ltinu\tcly  the  contraction  of  the  flexor  and  extensor  mu.scles  and  the  ex- 
treme atroi)hy  of  the  thumb  muscles,  the  interossei,  and  lumbricales  pro- 
duces the  claw-band — main  en  griffe  of  Duchenne.  The  flexors  or  the  fore- 
arm are  usually  involved  before  the  extensors.  In  the  shoulder-girdle  the 
deltoid  is  first  alTected;  it  may  waste  even  before  the  other  muscles  of  the 
upper  extremity.  The  trunk  muscles  arc  gradually  attacked;  the  upper 
part  of  the  trapezius  long  remains  unaffected.  Owing  to  the  feebleness  of 
the  muscles  which  support  it,  the  head  tends  to  fall  forward.  The  platysma 
myoides  is  unafTected  and  often  hy])ertrophies.  The  arms  and  the  trunk 
muscles  may  be  much  atrophied  before  the  legs  are  attacked.  The  face 
nmscles  are  attacked  late.  Ultimately  the  intercostal  and  abdominal  mus- 
cdes  may  be  involved,  the  wasting  }>roceeds  to  an  extreme  grade,  and  the 
])aticnt  may  be  actually  ''  skin  and  bone,"  and,  as  "  living  skeletons,"  the 
cases  are  not  uncommon  in  "  museums  "  and  "  side-shows."  Deformities 
and  contn;ctures  result,  and  lordosis  is  almost  always  present.  A  curious 
twitching  of  the  muscles  (fibrillation)  is  a  common  symptom,  and  may  occur 
in  muscles  which  are  not  yet  attacked.  It  is  a  most  important  symptom, 
but  is  not,  as  was  formerly  supposed,  a  characteristic  feature  of  the  disease. 
The  irritability  of  the  muscles  is  increased.  Sensation  is  unimpaired,  but 
the  patient  may  complain  of  numbness  and  coldness  of  the  alfected  limbs. 
The  galvanic  and  faradic  irritability  of  the  muscles  progressively  dimin- 


DISEASPW  OP  TflF)  EFFERENT  OR  MOTOR  TRACT. 


931 


lio  followiii  ' 

Ol    tllO    Colli 

'  the  ventral 
Ik'  iii'uroKli;, 

'lie  lil)rt',s  III' 
wastc'il.  (//) 
riie  inusc'lrs 

tT-IllUSClllill' 
iltidll  ol'  thr 

iullii.  wIr'iv 
wasted.  ((■) 
itt'i-al  whi.c 
Ik.'  <le<,a'iu'r- 
'iitro-latcTiil 
1  asceiuliii;; 
-■nils  toward 

UXhI    to    tilt' 

•1.     In  tlio 

1    (liseasc'(l. 

pyramidal 

ndle  (sliort 

10  wastinir, 

are  usually 

lipulation.'^. 

LTos.sc'i  and 

I'al    bone.s. 

nd  the  ex- 

icales  pro- 

'  the  forc- 

,nrdle  the 

los  of  the 

the   upper 

!)lenes.s  of 

|>laty.<ina 

the  trunk 

The  face 

inal  mus- 

',  and  the 

ons/'  the 

forniities 

'\  curious 

nay  occur 

Bymptom, 

e  disease. 

ired,  but 

ed  limbs. 

y  dimin- 


ishes and  may  become  extinct,  the  galvanic  persisting  lor  ihe  longer  time. 
In  cases  ol'  rapid  wasting  anil  i)aralysis  there  may  l)e  the  reaction  of  degen- 
eration. The  excital)ility  of  tlie  nerve-trunks  may  i)ersist  after  the  nuus- 
( les  have  ceased  to  respond.  Tiie  loss  of  [tower  is  usually  proportionate  to 
I  lie  wasting. 

The  foregoing  description  applies  to  the  grou[)  of  cases  in  which  the 
atrophy  and  paralysis  are  llaccid — atonic,  as  (lowers  calls  it.  In  other  cases, 
those  which  Charcot  describes  as  .imyotrophic  lateral  sclerosis,  spastic  paraly- 
sis precedes  the  wasting.  This  tonic  atrojthy  lin..  involves  the  arms  and 
llicii  the  legs.  The  rellexcs  are  g'rcatly  increased.  It  is  one  of  the  rare  con- 
ditions in  which  a  jaw  clonus  nuiy  be  obtained.  The  most  tyi)ical  coiulition 
of  spastic  paraph'gia  may  be  ])roduced.  On  starting  to  walk,  the  [tatient 
x'cms  glued  to  the  ground  and  makes  inelTectual  attempts  to  lift  the  toes; 
then  four  or  live  short,  (|iiick  steps  are  taken  on  the  toes  with  the  hody 
thrown  forward;  and  finally  he  starts  olf,  sometiines  with  great  rapidity. 
Some  of  the  j)atients  can  walk  up  and  down  stairs  better  than  on  the  level. 
The  wasting  is  never  so  extreme  as  in  the  !i tonic  form,  and  the  loss  of 
power  may  be  out  of  proportion  to  it.  The  spiiincters  are  unalfeeted. 
Sexual  power  miy  be  .lost  early.  Cases  are  met  with  which  corres[)ond  ac- 
curately to  the  clinical  picture  given  by  Charcot  of  amyotrot)hic  lateral 
sclerosis.  These  are  not  very  common,  ami  it  is  much  more  usual  to  h wo 
a  combination  of  the  two  tyi)es.  A  flaccid  atrophic  paralysis  with  increased 
reflexes  is  often  met  with.  These  diU'ercnces  dejteiul  upon  the  relative  ex- 
tent of  the  involvement  of  the  upper  and  lower  motor  segments  and  the 
time  of  the  involvement  of  each. 

As  the  degeneration  extends  upward  an  im|)ortant  changi  takes  jdaco 
from  the  development  of  bulbar  symptoms,  which  may,  however,  precede 
the  s})inal  manifestations.  The  lips,  tongue,  face,  i)harynx,  and  larynx 
may  be  involved.  The  lips  may  be  affected  and  articulation  impaired  for 
years  before  serious  symptoms  occv  In  the  final  stage  there  may  be 
tremor,  the  memory  fails,  and  a  condition  of  dementia  may  develop. 

Gowers  gives  the  following  useful  classification  of  the  varieties  of  this 
affection:  (1)  Atonic  atrophy,  becoming  extreme;  (2)  muscular  weakness 
with  spasm,  but  without  wasting  or  with  only  slight  wasting;  and  (13)  atonic 
atro])hy,  rarely  extreme  in  degree,  with  exaggeration  of  the  reflexes.  These 
conditions  may  "coexist  in  every  degree  and  combination — between  uni- 
versal atonic  atrophy  on  the  one  hand  and  universal  sjjastic  paralysis  with- 
out wasting  on  the  other." 

Diagnosis. — Progressive  (central)  muscular  atroidiy  begins,  as  a  rule, 
in  adult  life,  without  hereditary  or  family  influences  (the  early  infantile 
form  being  an  exception),  and  usually  affects  first  the  muscles  of  the  thumb, 
and  gradually  involves  the  interossei  and  lumltricales.  Fibrillary  contrac- 
tions are  common,  electrical  changes  occur,  and  the  deep  refle.:es  are  usu- 
ally increased.  These  characteristics  are  usually  sullficient  to  distinguish 
it  from  the  other  forms  of  muscular  wasting. 

In  syringo-myelia  the  symptoms  may  be  very  similar  to  those  in  the 
spastic  form  of  muscular  atropiiy.  The  sensory  disturbances  in  the  former 
•disease  make,  as  a  rule,  the  diagnosis  clear,  but  when  those  are  absent  or 


932 


DISKASI<:S  OP  THE  NERVOUS  SYSTEM. 


l)ut  litilo  ik'volopccl  it  iiiay  be  very  (liiTiciilt  or  even  iiiii)()ssil)lo  to  distinguisli 
lliu  discuses. 

Treatment.— 'JMic  disease  is  iiu*ural)le.  I  have  never  seen  tlie  slight- 
est benefit  from  drugs  or  ele(,'tricity.  Tlie  downward  progress  is  slow  but 
certain,  though  in  a  few  cases  a  temporary  arrest  may  take  place.  With  a 
history  of  syphilis,  iiierciiry  and  iochde  of  potassium  may  be  tried,  and 
Ciowers  reconiiiieiuls  courses  of  arsenic  and  the  hypodermic  injection  of 
eiryclinine.  IVobably  the  most  useful  means  is  systematic  massage,  partic- 
ularly in  tlie  spastic  cases. 


.  \ 
/ 


Bulbar  I'arali/sis  (Cllosso-ldltio-hirijiKjral  Parnhjiiis). 

M''hen  tlie  disease  ad'ects  the  motor  nuclei  of  the  medulla  first  or  early, 
it  is  called  bulbar  paralysis,  but  it  has  practically  no  independent  existence, 
as  the  spinal  cord  is  sooner  or  later  involved. 

Symptoms. — 'i'he  disease  usually  begins  with  slight  defect  in  the 
speech,  and  the  ])atient  has  diiliculty  in  pronouncing  the  dentals  and  Un- 
guals. 'Vhv  |)aralysis  starts  in  the  tongiu',  and  tlu!  su])erior  lingual  muscle 
gradually  becomes  atro])liied,  and  iinally  the  mucous  membrane  is  thrown 
into  transverse  folds.  Jn  the  ])rocess  ot!  wasting  the  fibrillary  tremors  are 
seen.  Owing  to  the  loss  of  power  in  the  tongue,  the  food  is  with  diiliculty 
])uslied  back  into  the  ])harynx.  'I'he  saliva  also  nuiy  be  increased,  and  is  apt 
to  accumulate  in  the  mouth.  When  the  lips  Ix'come  involved  the  ])atient 
can  lU'ither  whistle  nor  pronounce  the  labial  consonants.  The  mouth  looks 
large,  the  lips  are  ])roniinent,  and  there  is  constant  drooling.  The  food 
is  niasticati'd  with  diiliculty.  Swallowing  becomes  dillicult,  owing  i)artly 
to  the  regurgitation  into  the  nostrils,  ])artly  to  the  involvement  of  the 
])haryngeal  muscles.  The  muscles  ot  the  vocal  cords  waste  and  the  voice 
becomes  feeble,  but  the  laryngeal  paralysis  is  rarely  so  extreme  as  that  ol" 
the  lips  and  tongue. 

The  course  of  the  disease  is  slow  but  progressive.  Death  often  results 
from  an  as|)iration  pneumonia,  sometimes  from  choking,  more  rarely  from 
involvement  of  the  resi)iratory  centres.  The  mind  usually  remains  clear. 
The  patient  nuiy  become  emotional.  In  a  majority  of  the  cases  the  dis- 
ease is  only  part  of  a  progressive  atrophy,  either  simple  or  associated  with 
a  s])astic  condition.  In  the  latter  stage  of  amyotrophic  lateral  sclerosis 
the  bulbar  lesions  may  i)aralyze  the  lips  long  before  the  pharynx  or  larynx 
becomes  affected. 

The  (lirif/nosis  of  the  disease  is  readily  made,  either  in  the  acute  or 
chronic  form.  The  involvement  of  the  lips  and  tongue  is  usually  well 
marked,  while  that  of  the  palate  may  be  long  deferred.  A  coiulition  has 
been  described,  however,  which  may  closely  simulate  ludbar  paralysis. 
This  is  the  so-called  pseud o-hnJbar  form  or  bulbar  palsy  of  cerebral  origin. 
Bilateral  disease  of  the  motor  cortex  in  the  lower  part  of  the  ascending 
frontal  convolution,  or  about  the  knee  of  the  internal  ca])sule,  may  cause 
])aralysis  of  the  li))s  and  tongue  and  })harynx,  which  closely  simulates  a 
lesion  of  the  medulla.  Sometimes  the  sym])toms  apjiear  on  one  side,  but 
in  many  instances  they  develop  suddenly  on  both  sides.     A  bilateral  le- 


DISEASES  OF  THE  EFFERENT  OR  MOTOR  TRACT. 


933 


distinguisli 

(lie  s]i<:li(- 
is  sl(jvv  but 
•0.     With  a 

tried,  and 
iijc'C'don  of 
11^%  partic- 


st  or  oiij'ly, 
t  oxistunco, 

ect  in  llio 

Is  and  liii- 

ual  muscle 

is  thrown 

rcniors  arc 

1  diiliculty 

and  is  apt 

lie  patient 

outh  looks 

The  food 

ig  partly 

It  of  the 

the  voice 

3  that  of 

n  results 
■ely  from 
iis  clear, 
the  dis- 
ted  with 
sclerosis 
>v  larynx 

acute  or 
lly  well 
tion  has 
a  ra  lysis. 
orii,n'n. 
ieendin','- 
ly  cause 
ulates  a  • 
ide,  but 
era]  le- 


sion has  usually  been  found,  but  in  several  instancs  the  disease  was  uni- 
lateral. 

The  so-called  aciilc  bulbar  paruh/si.s  may  bo  due  to  (a)  ha'iuorrha^dc  or 
(■iid)olic  softeninj^  in  the  pons  and  medulla;  {h)  acute  inllanimatory  softening, 
iiualoji'ous  to  polio-myelitis,  occiirrintj;  occasionally  as  a  post-i'cbrile  all'i'ction. 
it  usually  conu'S  on  very  sudiK'uly,  hence  the  term  apoplectiform,  'i'ho 
.-vmptoms  in  this  form  may  correspond  closely  to  those  of  an  advanced  case 
(if  chroiuc  i)ulbar  ])aralysis.  The  sudden  onset  and  the  associated  symptoms 
make  the  dia<,niosis  easy.  In  these  acute  cases  there  may  !)e  loss  of  power 
m  one  arm,  or  henui)le<iia,  sometimes  allcrnate  hemiplegia,  with  paralysis 
on  one  side  of  the  face  and  loss  of  power  on  the  other  side  of  the  body. 

2.  TiuxiUKSsrvK  Nkth-m.  ^[usculau  ATHoriiv. 

This  form,  known  also  as  the  ])eroneal  type,  or  by  the  names  of  tlu-  men 
who  have  described  it  most  accurately  of  latc^namely,  Charcot,  Marie,  and 
Tooth — occurs  either  as  a  hei'cditary  or  as  a  family  alfection.  It  usually 
lieiiiiis  in  early  childhood,  alTectin<;'  first  the  muscles  of  the  feel  and  the 
|ieroneal  <irou|);  as  a  result  of  the  weakeiun<j  of  these  muscles,  clid)-fo()t, 
eillier  pes  ('(piinus  or  pes  ecpiino-varus  occurs.  In  rare  instances  the  dis- 
ease may  be<^in  in  the  hands,  but  the  upper  lind>s,  as  a  rule,  are  not  alfectcd 
for  some  years  after  the  leiis  an;  attacked,  and  the  trouble;  then  be;^ins  in 
the  small  muscles  of  the  hands.  Scmsory  dislui'bances  are  freepicntly  |)resent 
and  form  important  dia<;nostic  features.  Fibrillary  contractions  and  twitch- 
iu<;s  also  occur.  The  electrical  reactions  are  altered;  there  is  either  a  loss  or 
a  very  jrreat  decrease  of  the  excitability,  \  Inch  can  be  demonstrated  not 
only  in  the  atrophic  muscles,  but  also  in  muscles  and  nerves  which  are  ap- 
parently normal. 

This  form  of  muscular  ati'o])hy  seems  to  stand  between  the  cenlral  form 
and  the  muscidar  dystrophies.  ()ccurrin<?  in  famili(>s  and  bei^inniny  in 
early  life,  it  rescnd)les  the  latter,  but  it  is  more  like  the  foi'uu'r  in  that 
librillary  contractions  and  muscular  twitchin<;s  are  common,  that  the  small 
muscles  of  the  hand  are  apt  to  be  involved,  and  that  electrical  chau.i>X's  are 
present.  In  the  prominence  of  sensory  sym])t()nis  it  dilTers  fi'om  l)oth.  In 
cases  of  actpured  double  club-foot  this  disease  should  be  suspected. 

3.  Tiih:  ]\Its('iT,M{  T)vsTi{()i'Tiii;s 
{Dystrophia  rnuscuUirii^  proyrcusiva,  Krh). 

Definition. — ^luscular  wastiu<r,  with  or  wilhout  an  initial  hypertro- 
|thy,  bc<iinning  in  various  <iroups  of  muscles,  usually  ])ro<j;ressive  in  char- 
acter, and  dependent  on  y)rimary  chanjics  in  the  muscles  themselves.  A 
marked  hereditary  disposition  is  met  with  in  the  disease. 

Etiology. — No  etiolojrical  factors  of  any  moment  are  known  other 
than  heredity.  The  inlluence  may  show  itself  by  triic  heredity — the  dis- 
ease occurring  in  two  or  more  generations — or  several  mend)ers  of  the  same 
generation  may  be  affected,  showing  a  family  tendency.  INlauy  memhers 
of  the  same  family  may  he  attacked  through  several  generations.     Males, 


934 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


as  a  rule,  are  more  fro(iiicntly  afrcctcd  tlian  females.  T'  e  diseas  is  usually 
transmitted  through  the  mother,  though  slie  may  not  herself  be  all'ected 
As  many  as  20  or  30  eases  have  been  described  in  five  generations.  In  Erb'.- 
cases  44  per  cent  showed  no  heredity.  The  disease  usually  sets  in  before 
puberty,  but  may  be  as  late  as  the  twentieth  or  twenty-fifth  year,  or  in  sonu' 
instances  oven  later. 

Symptoms. — The  first  symptom  noticed  is,  as  a  rule,  clumsiness  in 
the  movements  of  the  child,  and  on  examination  certain  muscles  or  grouji.- 
of  muscles  seem  to  be  enlarged,  particularly  those  of  the  calves.  The 
extensors  of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoid,  triceps 
and  infraspinatus,  are  the  next  most  frequently  involved,  and  may  stand 
out  with  great  prominence.  The  muscles  of  the  neck,  face,  and  forearm 
rarely  suffer.  So-"-  cimes  only  a  portion  of  a  muscle  is  involved.  "With  thi;- 
hyi)crtro])hy  of  some  muscles  there  is  wasting  of  others,  particularly  the 
lower  portion  of  the  pectorals  and  the  latissimus  dorsi.  The  attitude  when 
standing  is  very  characteristic.  The  legs  are  far  apart,  the  shoulders  thrown 
back,  the  spine  is  greatly  curved,  and  the  abdomen  protrudes.  The  gait  is 
waddling  and  awkward.  In  getting  up  from  the  floor  the  position  assumed, 
so  well  known  now  through  Gowers'  figures,  is  pathognomonic.  The  ]ia- 
tient  first  turns  over  in  the  all-fours  position  and  raises  the  trunk  with 
his  arms;  the  hands  are  then  moved  along  the  ground  until  the  knees  are 
reached;  then  with  one  hand  upon  a  knee  he  lifts  himself  up,  grasps  the 
other  knee,  and  gradually  pushes  himself  into  the  erect  posture,  as  it  has 
been  expressed,  by  climbing  up  his  legs.  The  striking  contrast  between  the 
feebleness  of  the  child  and  the  powerful-looking  pseudo-hypertrophic  mus- 
cles is  very  characteristic.  The  enlarged  muscles  may,  however,  be  rela- 
tively very  strong. 

The  course  of  the  disease  is  slow,  but  progressive.  Wasting  proceeds 
and  finally  all  traces  of  the  enlarged  condition  of  the  muscles  disappear. 
At  this  late  period  distortions  and  contractions  are  common. 

The  muscles  of  the  shoulder-girdle  are  nearly  always  affected  early  in 
the  disease,  causing  a  symptom  upon  which  Erb  lays  great  stress.  "With 
the  hands  under  the  arms,  when  one  endeavors  to  lift  the  patient,  the 
shoulders  are  raised  to  the  level  of  the  ears,  and  one  gets  the  impression 
as  though  the  child  were  slipping  through.  These  "  loose  shoulders  "  are 
very  characteristic.  The  abnormal  mobility  of  the  shoulder-blades  gives 
them  a  winged  appearance,  and  makes  the  arms  seem  much  longer  than 
usual  when  they  are  stretched  out. 

The  patients  comi)lain  of  no  sensory  symptoms.  The  atrophic  mus- 
cles do  not  show  the  reaction  of  degeneration  except  in  extremely  rare  in- 
stances. 

Clinical  Forms. — A  number  of  different  types  have  been  described, 
depending  upon  the  age  at  the  onset,  the  muscles  first  affected,  the  occur- 
rence of  hypertro])hy,  the  prominence  of  heredity,  etc.  But  Erb  has  shown 
that  there  is  no  sharp  division  between  these  different  forms,  and  classes 
them  all  under  the  name  of  dystropJiia  miisrularis  progressiva.  For  con- 
venience of  descri])tion  he  subdivides  the  disease  into  two  large  groups: 

I.  Those  cases  which  occur  in  childhood. 


all 


ell 


tH 


i  is  usually 
)e  alt'ectcd 
.    InErbV 
i  in  befoii 
or  in  some 

msiness  in 
I  or  gr()Uji> 
Ivcs.  Til.. 
dd,  tricep.- 
may  stand 
id  forearm 
With  tliis 
lularly  the 
tude  when 
ers  throw  11 
rhe  gait  is 
1  assumed. 

The  pa- 
runk  with 
knees  are 
grasps  the 
,  as  it  has 
!t\veen  the 
pliic  nuis- 

be  rela- 

proceeds 
disappear. 

early  in 

s.     With 

lent,  the 

npression 

ers  "  are 

es  gives 
ger  than 

lie  mus- 
rare  in- 
escribed, 
le  occur- 
is  shown 
d  classes 
.^^or  con- 
ips: 


DISEASES  OP  THE  EFFERENT  OR  MOTOR  TRACT. 


935 


IL  The  cases  occurring  in  yoiitli  and  adult  life. 

The  first  division  is  subdivided  into  (1)  the  hypertrophic  and  (2)  the 
atrophic  form. 

Under  the  hypertrophic  form,  which  is  the  pseudo-hypertrophic  mns- 
lular  paralysis  of  authors,  he  thinks  it  is  useful  to  distinguish  between 
the  cases  in  which  (a)  the  enlarged  muscles  have  undergone  lijioniatosis — 
i.  e.,  i»seudo-hypertrophy — from  those  (h)  in  which  there  is  a  real  hyper- 
troi»hy. 

The  atroi)hic  form  also  includes  two  siiljclasscs:  (a)  Those  cases  in 
which  the  muscles  of  the  face  are  involved  early;  this  corresponds  to  the 
infantile  forin  of  Duchenne — the  Landouzy-Dejerine  type,  (l))  Those  cases 
in  which  the  face  is  not  involved. 

I.  Dystrophia  niusndaris  pro'  -"ssiva  infantum. 

1.  IIypertroj)hic  form. 

(a)  With  pseudo-hypertrophy. 

(b)  With  real  hypertrophy. 

2.  Atrophic  form. 

(a)  With  primary  involvement  of  the  face  (infantile  form  of 
Duchenne). 

(b)  Without  involvement  of  the  face. 

II,  Dystrophia  muscularis  progressiva  juvenum  vel  adultorum  (Erb's 
juvenile  form). 

Morbid  Anatomy. — According  to  Erb,  the  disease  consists  in  a 
change  in  the  muscles  themselves.  At  first  the  muscle-fibres  hypertrophy, 
and  become  round;  the  nuclei  increase,  and  the  muscle-fibres  may  become 
fissured.  At  the  same  time  there  is  a  slight  increase  in  the  connective  tissue. 
Sooner  or  later  the  muscle-fibres  begin  to  atrophy,  and  the  nuclei  become 
greatly  increased.  Vacuoles  and  fissures  appear,  and  the  fibres  finally  be- 
come completely  atrophic,  the  connective  tissue  becoming  markedly  in- 
creased. Fat  may  be  deposited  in  the  connective  tissue  to  such  an  extent  as 
to  cause  hypertrophic  lipomatosis — pseudo-hypertrophy.  The  dilferent 
stages  of  these  changes  may  be  found  in  a  single  muscle  at  the  same  time. 

The  nervous  system  has  very  generally  been  found  to  be  without 
demonstrable  lesions,  but  in  certain  cases  changes  in  the  cells  of  the  ventral 
horn  have  been  described. 

Diagnosis. — The  muscular  dystrophies  can  usually  be  readily  distin- 
guished from  the  other  forms  of  muscular  atrophy. 

(fl)  In  the  cerebral  atrophy  loss  of  power  usually  precedes  the  atrophy, 
which  is  either  of  a  monoplegic  or  hemiplegic  type. 

{h)  From  progressive  (central)  muscular  atrophy  the  distinctions  are 
clearly  marked.  This  form  begins  in  the  small  muscles  of  the  hand,  a  situ- 
ation rarely  if  ever,  affected  by  the  dystro])hies,  which  involve  first  those 
of  the  calves,  the  trunk,  the  face,  or  the  shoulder-girdle.  In  the  central 
atrophy  the  reaction  of  degeneration  is  present  and  fibrillary  twitchings 
occur  in  both  the  atrophied  and  non-atrophied  muscles.  In  many  cases,  in 
addition  to  the  wasting  in  the  arms,  there  is  a  spastic  condition  in  the  legs 
and  increase  in  the  reflexes.  The  central  atrophies  come  on  late  in  life; 
the  dystrophies  develop,  as  a  rule,  early.    In  the  progressive  muscular  dys- 


936 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


.  \ 
/ 


tropliios  liorcdity  plays  an  important  role,  whicli  in  the  central  form  is  quite 
siihf^idiary.  In  llic  rare  ea.ses  of  early  infantile  spinal  muscular  atrophy 
occinring  in  families  the  sym])toms  are  so  characteristic  of  a  central  disea.s(' 
that  the  (liaj,niosis  presents  no  dillieulty. 

(r)  In  the  neuritic  muscular  atrophies,  whether  due  to  lead  or  to  trauma, 
the  <i;eneral  characters  and  the  mode  of  ojiset  are  distinctive.  ]n  the  eases 
of  mulliple  neuritis  seen  for  the  first  tijue  at  a  jjeriod  when  the  wasting  is 
marl\('d  tliei'i'  is  often  dillieulty,  hut  the  ahsence  (,ii  family  history  and  the 
distrihutioii  iire  important  features.  Moreover,  the  paralysis  is  out  of  ))ro- 
])ortion  to  the  atrophy.  Sensory  sym])toms  nuiy  he  ])resent,  and  in  the  cases 
in  which  the  legs  iire  chiefly  involved  there  is  usually  the  dcppiuja  gait  so 
charactei'istic  of  peripheral  Jieuritis. 

{d)  I'rogressive  lu'iiral  muscular  atrophy.  Here  heredity  is  also  a  factor, 
iind  the  disease  usually  hegins  in  early  life,  but  the  distriljiition  of  atrophy 
and  paralysis,  which  in  tiiis  all'ection  is  at  first  confined  to  the  i)eriphei'y 
of  the  extremities,  hel[)S  to  distinguish  it  from  the  dystrophies;  while  the 
occurrence  of  sensory  sym|)toins,  fibrillaiy  contractions,  and  the  marked 
decrease  in  the  electrical  e.xcitahility  usually  make  the  distinction  clear. 

The  outlook  in  the  ])riniary  muscular  dystro])liies  is  had.  The  wasting 
])rogresses  uniforndy,  uninlluenced  by  treatment.  Krb  holds  that  l)y  elec- 
tricity and  massage  the  progress  is  i ccasionally  arrested.  The  general  health 
should  he  carefully  looked  afi  -r,  moderate  exercise  allowed,  frictions  with 
oil  a])|)lied  to  the  muscles,  and  hen  the  ])atient  hecomcs  bedfast,  as  is  in- 
evitable sooner  or  later,  care  sli>  Id  he  taken  to  prevent  contractures  in 
awkwai'd  positions. 

The  three  forms  of  ])rogressive  muscular  wasting — progressive  (central) 
muscular  atrophy,  ])r()gressive  neural  muscular  atroph^',  and  the  muscular 
dystrophies — have  been  considered  as  distinct  diseast  ,  ..nt  certain  recent 
writings  make  it  ])rohahle  that  the  distinction  may  not  be  so  sharp  as  we 
believe.  Certain  cases  occur  which  seem  not  to  belong  to  any  one  of  thi' 
forms  hut  to  stand  between  them.  The  changes  in  the  nniscles  which  were 
thought  to  be  characteristic  cf  Mie  dystro])hies  have  been  found  in  the 
other  forms.  The  central  form  occurs  as  a  family  disease  in  infancy,  and 
the  nervous  system  has  been  found  diseased  in  the  dystro])hies. 

The  whole  (piestion  is  in  a  chaotic  state,  and  it  is  at  present  better  to 
keep  to  the  old  divisions.  Even  if  it  sliould  turn  out  to  be  true,  as  Striimpell 
suggests,  that  all  the  forms  depend  upon  a  congenital  tendency  of  the 
motor  system  to  degenerate,  they  reiiresent  well-defined  clinical  ty]ies,  into 
Avhich  the  cases  can,  as  a  rule,  be  grouped  without  dilTiculty,  while  corre- 
sponding to  each  there  is  a  fairly  well-determined  anatomical  basis. 


R.    SYSTP:>r   DISEASES   OF  THE  UPPER  IMOTOR  SEGMENT. 


The  (piestion  of  an  uncomplicated  primary  degeneration  of  the  upper 
motor  neurones  has  not  been  decided.  Cases  with  a  clinical  picture  corre- 
sponding to  this  lesion  are  not  uncommon,  and  they  may  persist  for  a  long 
time  without  change.  T"^nfortunately  the  cases  which  have  come  to  autopsy 
have  shown  various  conditions.    In  only  two  or  three  has  the  disease  been 


DISKASES  OP  THE  EFFERENT  OR   MOTOR  TRACT. 


1)37 


)rin  IS  ((II ik' 
lur  iitrojdiy 
itrul  dii>i.'a.sc 

:  to  traumii, 
In  the  cusi'.s 
J  wasting  is 
3ry  and  the 
out  of  ))r()- 
iii  the  cases 
ni(/e  gait  so 

so  a  factor, 
of  atropliy 
i  pcriidici')- 
;  while  tlic 
lie  marked 
n  clear, 
lie  M'asting 
at  by  elec- 
leral  health 
•tions  with 
•t,  as  is  iii- 
Mctures  in 

e  (central) 
!  niuscular 
ain  recent 
larp  as  we 
)ne  of  the 
'hich  were 
nd  in  the 
nicy,  and 

])etter  in 
StriiiiipcH 
:\y  of  tlie 
\'l)es,  into 

ile  corrc- 
is. 


T. 

he  upper 
ire  corre- 
or  a  long 
)  autopsy 
'ase  been 


so  nearly  couCuhmI  to  the  pyramidal  tract  thai  they  can  be  used  as  an  argu- 
ment for  the  indeiK-ndeiice  ol'  tiiis  condition.  Tiu'  cases  of  AliuiiowsUi, 
Di'cschl'eld,  aiul  Siriinipeli  are  not  absolutely  conclusive,  as  they  are  m)t 
ijiiite  pure,  although  they  go  far  to  prove  that  a  degeneration  in  the  pyraiii- 
nlal  tract  may  be  unconii)licated,  at  least  for  a  long  time.  M'he  .sinie 
may  be  said  for  the  group  of  cases  described  l»y  Bernhardt  and  Sti'iimpell 
under  the  name  hereditary  sjiastic  s|)inal  i)aralysis,  in  wliich  the  extensive 
systemic  degeneration  of  the  ]jyramidal  tracts  is  cond)ined  with  slight  de- 
•icneration  in  other  tracts  of  the  cord. 

1.  Spastic  Pa I{.\ lysis  or  Adi'i.ts 
(TdhcH  dartsaUs  ttpiuvnodiqite ;  J'riiiuiri/  Ldtcral  Sclerosis). 

Definition. — A  gradual  loss  of  power  with  s[)asin  of  the  muscles  of  the 
liody,  the  lower  cxtrt'initit'S  being  lirst  and  most  alfected,  unaccompanied 
hy  muscular  atrophy,  sensory  disturbance,  or  other  symptoms.  The  patho- 
logical anatomy  is  nmleternuned,  but  a  systemic  degeneration  of  the  pyram- 
idal tracts  is  assumed. 

Symptoms. — The  general  sj/mphims  of  s])as(ic  ])arn]degia  in  adults  are 
very  distinctive.  The  patient  complains  of  feeling  tired,  of  stiffness  in  the 
legs,  and  jierhaps  of  ))ains  of  a  dull  aching  character  in  the  back  or  in  tho 
calves.  There  may  be  no  defhdte  loss  of  power,  even  when  the  spastic  con- 
dition is  well  established.  In  other  instances  there  is  definite  weakness.  The 
stiffness  is  felt  most  in  the  morning.  In  a  well-develo|)e(l  case  the  gait  is 
most  characteristic.  The  legs  are  moved  stillly  and  with  hesitation,  the 
toes  drag  and  catch  against  the  ground,  and,  in  extreme  cases,  when  the 
ball  of  the  foot  rests  upon  the  ground  a  distinct  clonus  develops.  The 
legs  are  kejjf  close  together,  the  knees  touch,  and  in  certain  cases  the  ad- 
ductor spasm  may  cause  cross-legged  progression.  On  examination,  the  legs 
may  at  first  ai)pear  tolerably  su])])le,  perha])s  flexed  and  extended  readily. 
In  other  cases  the  rigidity  is  nuirked,  ])articularly  when  the  limbs  arc  ex- 
tended. The  spasm  of  the  adductors  of  the  thigh  may  be  so  extreme  that 
the  legs  are  separated  with  the  greatest  difliculty.  In  cases  of  this  extreme 
rigidity  the  ])atient  usually  loses  the  ])owcr  of  walking.  The  nutrition  is 
well  maintained,  the  muscles  may  be  hypertro])hied.  The  reflexes  are 
greatly  increased.  The  slightest  tmich  u])on  the  patellar  tendon  ])roduce9 
an  active  knee-jerk.  The  rectus  clonus  and  the  ankle  clonus  are  easily  ob- 
tained. In  some  instances  the  slightest  touch  may  throw  the  legs  into  vio- 
lent clonic  spasm,  the  condition  to  which  lirown-Seipiard  gave  the  name  of 
spinal  e])ilepsy.  The  sn])erficial  reflexes  are  also  increased.  The  arms  may 
be  unaffected  for  y^ars,  but  occasionally  they  become  weak  and  stiff  at  the 
same  time  as  the  ^  ■'!.  This  was  the  case  in  a  colored  boy  who  was  in  my 
wards  for  several  years.  He  ])resented  a  degree  of  general  spastic  rigidity 
that  I  have  never  seen  equalled.  The  disease  had  begun  after  puberty, 
develo])ed  gradually,  and  remained  cpiite  stationary  for  more  than  a  year 
before  he  left  the  wards.    There  were  nr    )ther  symptoms. 

The  course  of  the  disease  is  progressively  downward.  Years  may  elapse 
before  the  patient  is  bedridden.  Involvement  of  the  sphincters,  as  a  rule, 
50 


938 


DISEASES  OF  THE  NERVOUS  SYl>TEM. 


is  Ititi';  oc'cnsionally,  liowcvor,  it  is  early.  The  sens  )ry  symptoms  rarely 
pro^MX'ss,  and  the  patients  may  retain  their  general  nutrition  and  enjoy  ex- 
cellent health.     Oeidar  symptoms  are  rare. 

I'he  (lidi/nosis,  so  i'ar  as  the  clinical  picture  is  concerned,  is  readily  made, 
but  it  is  often  very  diilicult  to  determine  accurately  the  nature  oi'  the  under- 
lying i)athologieal  condition.  A  history  of  sy})liilis  is  i)resent  in  many  ol' 
the  cases.  Cases  wliieh  have  run  u  fairly  tyi)ieal  clinical  course  upon  com- 
ing to  autopsy  have  Ix'cn  found  to  have  been  due  to  very  dill'erent  condi- 
tions— transverse  myelitis,  multiple  sclerosis,  cerebral  tumor,  etc.  General 
paralysis  of  the  insane  may  begin  with  symptoms  of  si)astic  paraplegia,  and 
Westphal  believed  that  it  was  oidy  in  relation  to  this  disease  that  a  jjrimary 
sclerosis  of  the  i)yramidal  tracts  ever  occurred.  In  any  case  the  diagnosis 
of  ))rimary  systemic  di'goneration  of  the  ])yraniidal  tract  is,  to  say  the  least, 
douljtful. 


/ 


i 


2.  Spastic  Paralysis  of  Ixfaxts — Spastic  Diplegia — Birth  Palsies 

{Paraplegia  cerebraJia  spastica  {Heine);  Little's  Disease). 

In  this  condition  there  is  a  paralysis  with  spasm  of  all  extremities,  dating 
from  or  shortly  succeeding  birth,  more  rarely  following  the  fevers  or  an 
attack  of  convulsions.  The  legs  are  usually  nmre  involved  than  the  arms; 
there  is  no  wasting,  no  disturbance  of  sensation.  The  reflexes  are  increased. 
The  mental  condition  is  usually  much  disturbed.  The  ])atients  aie  often 
imbeciles  or  idiots,  helpless  in  mind  and  body.  Ataxic  and  athetoid  move- 
ments of  the  most  exaggerated  kind  may  occur. 

While  a  limited  luunber  only  of  cases  of  infantile  hemiplegia  are  con- 
genital, on  the  other  hand,  in  si)astic  diplegia  and  paraplegia  a  large  pro- 
portion of  the  cases  results  from  injury  at  ])irth.  The  arms  may  be  so 
slightly  affected  as  to  nudce  it  difficult  to  determine  whether  it  is  a  case  of 
diplegia  or  para])legia.  The  disease  usually  dates  from  birth,  and  a  ma- 
jority of  the  children  are  born  in  first  labors  or  are  forceps  cases,  and  are 
at  birth  as])hyxiated  blue  babies.  Eoss  suggests  that  in  feet  presentations 
there  may  l)e  laceration  or  tearing  of  the  cerebro-si)inal  membranes.  Pre- 
mature birth  is  also  given  as  a  cause. 

Morbid  Anatomy. — The  birth  jialsies  which  ultimately  induce  the 
spastic  dijjlegias  or  paraplegias  are  most  frequently  the  result  of  meningeal 
hivmorrhage.  The  importance  of  this  condition  has  hccn  shown  by  the 
studies  of  Litzmann  and  Sarah  J.  ]\rcXutt.  The  bleeding  may  come  from 
the  veins,  or,  as  in  one  case  which  I  saw  with  Hirst,  from  the  longitudinal 
sinus.  The  ha^norrhage  has  in  many  cases  becu  vhickest  over  the  motor 
areas,  and  it  seems  ])rol)able  that  the  sclerosis  found  in  these  cases  may  re- 
sult from  compression  by  the  blood-clot.  In  other  instances  the  condit'on 
may  be  due  to  a  footal  meningo-encephalitis.  In  16  autopsies  collected  in 
the  literature,  in  which  the  patients  died  at  ages  varying  from  tw^o  to  thirty, 
the  anatomical  condition  was  either  a  diffuse  atrophy,  which  w^as  most  com- 
mon, or  ])orcnce]ihalus.  From  the  fact  that  certain  of  the  cases  are  born 
prematurely,  before  the  pyramidal  tracts  are  developed,  it  has  been  as- 
sumed by  some  that  a  non-development  of  these  tracts  is  the  cause  of  the 


)ioms  rarc'l}' 
1(1  enjoy  ex- 

wulily  madi', 
1'  tliu  under- 
ill  many  ol' 
i  ni)()n  coni- 
LTent  coiidi- 
te.  General 
aplegia,  and 
It  a  primary 
le  diagnosis 
ly  the  leasts 


rii  Palsies 


itics,  dating- 
L'vers  or  an 
1  the  arms; 
0  increased, 
s  aie  often 
itoid  niove- 

ia  are  con- 
large  j)ro- 
niay  be  so 
s  a  case  of 
md  a  ma- 
s,  and  are 
sentations 
nes.     I're- 

nduce  the 
meningeal 
n  by  the 
onie  from 
gitudinal 
he  motor 
s  may  re- 
eondit'on 
lected  in 
to  thirty, 
lost  corn- 
are  born 
been  as- 
se  of  the 


DISEASES  OF  THE  EFFERENT  OR  MOTOR  TRACT. 


939 


(lit>ease.  This  hyi)othonia  has  been  urged  by  Marie,  who  limits  the  name 
s[»astic  jjaraplegia  to  that  group  of  the  infantile  eases  in  whieh  there  is  no 
evidence  of  involvement  of  the  brain — intellectual  disturbances,  epilepsy, 
etc.,  and  it  is  in  tiu'se  cases  that  he  believes  the  jiyramidal  tract  has  re- 
mained undeveloped. 

Symptoms. — At  first  nothing  abnormal  may  lie  noticed  about  tlio 
child.  Jn  some  instances  there  have  been  early  and  frequent  convulsions; 
then  at  the  age  when  the  child  should  begin  to  walk  it  is  noticed  that  the 
liml)S  are  not  used  readily,  and  on  e.vamination  a  stilfness  nf  the  legs  and 
arms  is  found.  Even  at  the  age  of  two  the  child  may  not  be  able  to  sit 
lip,  and  often  the  head  is  not  well  sujjported  by  the  ueck  muscles.  The 
rigidity,  as  a  rule,  is  more  marked  in  the  legs,  and  there  is  adductor  spasm. 
When  su|)])orted  on  the  feet,  the  child  either  rests  on  its  toes  and  the  inner 
surface  of  the  feet,  with  the  knees  close  together,  or  the  legs  may  be  crossed. 
The  stiiTness  of  the  upper  limbs  varies.  It  may  be  scarcely  noticeable  or 
the  rigidity  may  be  as  marked  as  in  the  legs.  When  the  spastic  condition 
affects  the  arms  as  well  as  the  legs,  we  speak  of  the  condition  as  diplegia; 
when  the  legs  alone  are  involved,  as  i)araplegia.  There  seems  to  be  no  suf- 
iicient  reason  for  considering  them  separately.  Constant  irregular  move- 
ments of  the  arms  are  not  inicommon.  The  child  has  great  dilliculty  in 
gias})ing  an  object.  The  spasm  and  weakness  may  be  more  evident  on  one 
side  than  the  other.  'J'he  mental  condition  is,  as  a  rule,  defective  and  con- 
vulsive seizures  are  common. 

Associated  with  the  s])ustic  ])aralysis  are  two  allied  conditions  of  con- 
siderable interest,  charactei  zed  by  spasm  and  disordered  movements.  A 
child  with  si)astic  diplegia  may  ])resent,  in  an  unusual  degree,  irregular 
movements  of  the  muscles.  In  attemj)ting  to  grasp  an  object  the  fingers 
may  be  thrown  out  in  a  stilf,  spasmodic,  irregular  manner,  or  there  may  be 
constant  irregular  movements  of  tlie  shoulders,  arms,  and  hands,  with 
slight  incoordination  of  the  head.  Cases  of  this  descri})tion  have  been  de- 
scribed as  chorea  spaslica,  and  they  may  be  difficult  to  se})arate  from  mul- 
tiple sclerosis  and  from  Friedreich's  ataxia. 

A  still  more  remarkable  condition  is  that  of  hUalcral  athetosis,  in  which 
there  is  a  combination  of  S])asm  more  or  less  marked  with  the  most  extraor- 
dinary bizarre  movements  of  the  muscles.  The  condition,  as  a  rule,  dates 
from  infancy.  The  ])atient  may  not  be  able  to  walk.  The  head  is  turned 
from  side  to  side;  there  are  continual  irregular  movements  of  the  face  mus- 
cles, and  the  mouth  is  drawn  and  greatly  distorted.  The  extremities  are 
more  or  less  rigid,  particularly  in  extension.  On  the  slightest  attempt  to 
move,  often  s])ontaneously,  there  arc  extraordinary  movements  of  the  arms 
and  legs,  ■|)articularly  of  the  arms,  somewhat  like  though  much  m  re  exag- 
gerated than  athetosis.  The  patients  are  often  unalde  to  help  tiiemselves 
on  account  of  these  movements.  The  reflexes  are  increased.  The  mental 
condition  is  variable.  The  ]iatient  may  l)e  idiotic,  but  in  3  of  the  0  cases 
which  I  have  seen  the  patients  were  intelligent.  Massalongo,  who  has  care- 
fully studied  this  condition,  describes  3  cases  in  one  family.  I  have  col- 
lected 53  cases  from  the  literature,  33  of  which  occurred  in  males  and  20 
in  females. 


940 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


3.  lIiniKDiiAitv  Si'Asric  l'.\i{Ai'i-i;(iiA 
{IleredUary  Spaalic  Spinal  J'aralijfiin ;  Font ili/  form  uf  Spastic  Spinal  Paralynin). 

j\Iiicli  iiitcicsl  liMs  Ix'cii  iiroiiscd  in  this  tv|i(',  ciiscs  ol'  wliicli  have  bct'ii 
(Ic'scrihi'd  \>y  (ivv,  Striiiii|icll,  Hciiihiiidl,  l.atiiiicr,  Mcwniark,  Krh,  Tooth, 
Siiclis,  ami  olluTs.  i\|t|)iii('ntly  wc  liave  to  distiii^iiish  in  this  I'oi'in  two 
gronps  of  cases,  in  one  the  iliseasu  devolops  in  infancy  or  chihihood,  and 
the,'  cases  liave  all  the  cliai'actei's  of  a  iKiraplcf/ia  i<ji<islic(i  rcrchralis.  Jn  these 
cases,  however,  the  syni|itonis  pointiiiff  to  disease  of  the  l)rain,  mental  dis- 
tiirhances,  epilepsy,  etc.,  may  bo  entirely  \vantin<;',  and  it  wa.s  in  relation  to 
them  that  Mrli  made  the  sii<i';,festion  that  ])oss!l)ly  too  much  stress  had  been 
laid  upon  the  cerebral  disease,  lie  thought  that  a  systemic  (le<ieneration 
of  the  lower  part  of  the  pyramidal  tract  accounted  I'or  the  symptoms.  The 
eases  of  amaurotic  family  idiocy  described  by  Sachs,  Peterson,  llirsch,  and 
others  do  not  belong  hei'e,  although  in  them  there  is  also  a  sclerosis  of  the 
pyramidal  tract. 

In  the  other  grouj)  of  cases,  described  by  Uernhardt  and  Striimpell,  the 
disease  develops  later,  usually  between  twenty  and  thirty.  The  progress 
is  very  slow,  extending  over  many  years.  At  first  there  is  no  ])aralysis,  only 
a  spastic  condition  of  the  legs.  The  arms  are  atl'ccted  later.  Toward  the 
end  there  may  be  a  true  paralysis,  sensation  may  be  aU'ected,  and  the  bladder 
may  be  slightly  involved.  ]n  a  fatal  case  of  Striim])eirs  there  was  an  ex- 
.tensive  degeneration  of  the  pyramidal  tract  and  slight  disease  of  the  col- 
umns of  (ioll  and  of  the  direct  cerebellar  tract. 

Amaiirolic  Faiiiihj  Jdiori/. — A  remarkable  form  of  iiifantile  paralysis 
has  been  descri1)ed  by  Sachs,  Peterson,  and  llirsch.  The  symptoms  as  sum- 
marized l)y  Sachs  are:  1.  Psychic  disturbances  that  a])])ear  in  early  life 
\(first  or  second  year)  and  ])rogress  to  total  idiocy.  2.  Paresis,  and  ulti- 
mately com])lete  ])aralysis  of  the  extremities,  Avliich  may  be  either  llaccid 
or  s])astic.  15.  Increased,  decreased,  or  normal  tendon  reflexes.  4.  Partial, 
followed  by  total,  blindness  (macular  changes,  with  subsequent  atrophy  of 
the  optic  nei've).  ').  ^Marasmus  and  death,  usually  before  the  second 
year.  (>.  ])istinct  familial  typo.  Occasional  symptoms  are  nystagmus, 
strabismus,  hyperacusis,  or  im])airment  of  hearing.  The  ])athological 
changes  are  jn-imitive  type  of  the  cerebral  convolutions,  macrogyria,  de- 
generative changes  in  the  large  i)yramidal  cells,  absence  of  the  tangential 
fibres,  and  decrease  of  the  fibres  of  the  white  matter.  The  blood-vessels 
are  normal.  There  is  also  degeneration  of  the  ])yramidal  columns  of  the 
cord.  Of  ^7  cases  collected  by  Sachs,  17  occurred  in  six  families;  all  in 
Jews. 

4.  Kru's  Syi'iiilttic  Spixal  Paralysis. 

Va-])  has  described  a  symptom  group  under  tlie  term  sy])hilitic  spinal 
paralysis,  to  which  much  attention  has  been  given.  The  ])oints  u]ion  which 
he  lays  stress  are  a  very  gradual  onset  with  a  develo])ment  finally  of  the 
features  of  a  spastic  paresis:  the  tendon  reflex<>s  are  greatly  increased,  but 
the  muscular  rigidity  is  slight  in  comparison  with  the  exaggerated  deep 
reflexes.    There  is  rarely  much  pain,  and  the  sensory  disturbances  are  trivial. 


DISEASES  OF  THE  EPFEIIENT  OH  MOTOR  TRACT. 


941 


ParahjHitt). 

Imvu  \)w\\ 
iv\),  Tooth, 
s  form  l\\(i 
(lliood,  and 
<.  Jn  tlic'.-c 
inoiitiil  (lis- 

rt'liition  to 
J.s  liad  1)0011 
'^•(Micration 
toiiis.  Tlic 
lirsch,  and 
rosis  oi'  the 

iiiii|)i'll,  tho 
10  ])ro<jros,s 
a  lysis,  only 
roward  tho 
Iho  hladdor 
was  an  o.\- 
of  the  eol- 

e  paralysis 
ms  as  sum- 
early  life 
and  ulti- 
hor  ilaoeid 
4.  Partial, 
itrophy  of 
he  second 
lystagmus, 
xtholof^ical 
),uyi'ia,  de- 
tail <i;ential 
ood-vessols 
nns  of  the 
ios;  all  in 


l)iit  there  may  ho  jiara'sthosia  and  the  <iirdlo  sensation,  'riic  hladdor  and 
rectum  are  usually  involved,  and  I  here  is  sexual  I'niluro  or  ini|»oleiico.  And, 
liistly,  improvemont  is  not  infreiiueiit.  .'.  majofity  of  iiistanoos  of  spastic 
|innilysis  of  adults  not  the  result  (d'  slow  comitression  of  the  cord  are  asso- 
ciated with  syphilis  and  helong  to  this  ^'nuip. 

I'lrh  thought  the  lesion  to  he  a  special  form  of  trMiisvciNc  myelitis,  l)ut 
pc!'lia[)s  it  sliouki  he  classed  with  the  system  tliseases,  iiuder  the  name  toxic 
silastic  sjtinul  paralysis. 

5.  SiccoxDAiiY  Spastic  I'ahalysis. 

FoUowiu",''  any  lesion  of  the  pyramidal  tract  we  may  have  spasiie  paraly- 
sis; thus,  in  a  transverse  lesion  of  the  cord,  whether  the  result  of  slow  com- 
pression (as  in  caries),  chronic  myelitis,  the  pressure  of  tumor,  chronic 
menin^'o-myelitis,  or  multiple  sclerosis,  defeneration  takes  place  in  the 
pyramidal  tracts,  lielow  the  ])oint  of  disease.  'I'he  le^'s  soon  heeoine  stilt'  and 
riffid,  and  tiie  retlexes  increase.  iJastian  has  shown  that  in  compression  para- 
plejiia  if  the  transverse  lesion  is  complete,  the  liiiihs  may  he  llaccid,  willuuit 
increase  in  the  retlexes — pitra/ih'i/ic  flasipic  of  the  French.  The  condition 
(if  the  jjatieiit  in  these  secondary  forms  varies  very  much.  In  chronic  mye- 
litis or  in  multiple  sclerosis  he  may  he  ahle  to  walk  ai)out,  hut  with  a  char- 
acteristic spastic  gait.  In  the  compression  myelitis,  in  fracture,  or  in  caries, 
there  may  he  complete  loss  of  power  with  rigidity. 

It  may  he  dillicult  or  even  impossihlc  to  distinguish  thv-e  cases  from 
those  of  ])riniary  spastic  ])aralysis.  Ji'eliancc  is  to  he  placed  upon  the  asso- 
ciated symjjtoms;  when  these  are  ahsent  no  definite  diagnosis  as  to  the  cause 
of  the  spastic  paralysis  can  he  given. 

().    HYSTKlUrAL    Sl'ASTlC    JVv  ItAl'LKG  [A, 

There  is  no  spinal-cord  disease  which  may  he  so  accurately  mimicked  as 
sjiastic  paraplegia.  In  the  hysterical  form  there  is  wasting,  the  sensory 
symptoms  are  not  marked,  the  loss  of  power  is  not  complete,  and  there  is  not 
that  extensor  spasm  so  characteristic  of  organic  disease.  The  reflexes  arc, 
as  a  rule,  increased.  The  knee-jerk  is  i)rescnt.  and  there  may  he  a  well- 
developed  ankle  clonus,  (iowers  calls  attention  to  the  fact  that  it  is  usually 
a  spurious  clonus,  "  due  to  a  half-voluntary  contraction  in  the  calf  muscles." 
A  true  clonus  does  occur,  however,  and  there  may  he  the  greatest  difficulty 
in  determining  whether  or  not  the  case  is  one  of  hysterical  paraplegia.  The 
hysterical  contracture  will  he  considered  later. 


itic  spinal 
]ion  which 
illy  of  tlie 
•eased,  but 
ated  deep 
are  trivial, 


C.    SYSTEM  DISEASES  OF  TIIE  LOWER  MOTOR  SEGMENT. 

1.  Chronic  Axtekior  Pot.io-myelitis 

{Progressive  Mnscnlnr  Atrophy — Aran-Duchinne). 

This  disease  has  heen  considered  as  one  of  the  types  making  up  the 
progressive  (central)  muscular  atroi)liies.  In  certain  rare  cases  the  process 
is  confined  to  the  lower  motor  segments.     They,  however,  differ  so  little 


MI3 


DISKASKS  (>K  THK  N'KUVOUH  SYSTKM. 


cliiiiciilly  frmn  iiiaiiy  <il'  llic  cnscs  in  which  Ihc  pynmiithil  IracU  nro  iii- 
vnlvcil  ihtit  il  scciiis  hcltcr  (o  iiiiikc  no  shiiip  (lisliiiclioii  hclwccn  Ihcrii. 
'VUo  Hiiiiic  niiiv  III'  said  of  chi'dnii'  hiilhnr  |tiniil\>»ih' 

v'.    Ol'liril  M.MOI'I.IXII  \. 

This  disease  is  at  times  (hie  to  a  ehronic?  (h'^'eiu'ration  (tf  the  luulei  of 
the  motor  nerves  oi'  the  eyeluills.  and  so  is  a  system  disease  of  (lie  lower 
motor  se;;nient.  It  is  treated  of  in  eonneetioii  with  the  otiier  oeidar  palsies 
for  th«'  >al\e  of  simplicity  and  because  all  ophlhalmojilej^ias  are  not  duo  to 
nuclear  disease. 


;{.  AciTi:  Antkkiou  I'oi.io-myki.itih 

(Atrophic  Spinal  I'untlysis;  Infantile  I'aralyniii). 

This  diseasi'  was  fornu-rly  hclieved  to  he  due  to  an  acute  intlammation 
«d"  the  tells  of  the  ventral  horns,  depending'  upon  a  selective  action  of  the 
poison  for  these  cells,  and  would  on  this  thetwy  have  properly  been  classed 
as  a  system  disease  of  llu'  lower  motor  neuroui'S.  Later  ohservalions  indi- 
cate tliat  the  distribution  of  the  inllanunation  depends  upon  the  blood  sup- 
ply, and  possibly  that  a  throndiotii'  or  an  eudxdic  process  itiay  act  as  the 
excitinj:  tause  of  the  intlaiuination.  ,Iust  why  this  process  should  always 
ai  t  throujrh  the  arteries  supplyinj;  the  ventral  horns  has  not  been  explaiiu'd. 
In  any  case  the  disease  apjiears  to  be  a  focal  inllanuuation,  and  not  a  system 
diseasi"  in  the  sense  that  the  term  is  used  in  this  work. 

Cliniially,  the  symptoms  are  conlined  to  the  nmtor  system,  and  for  this 
reason  it  is  idusidereil  heri'  and  not  with  the  local  lesions  of  the  spinal  cord, 
when'  (Uir  present  views  of  its  pathology  would  place  it. 

Definition. — An  atlVction  occurrinji:  most  conunonly  within  the  first 
thri'i'  yt'ars  of  life,  characterized  by  fever,  loss  of  powi'r  in  certain  muscles, 
and  rapid  atrophy. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  has  been  at- 
tributed to  loid.  to  the  irritation  from  dentition,  or  to  overexertion.  Since 
the  days  (d'  Mephiboshcth,  parents  have  bi'cn  inclined  to  attribute  this  form 
of  ]>aralysis  to  the  carelessness  of  nurses  in  lettinj;  the  children  fall,  but  very 
iMrely  is  the  disease  induced  by  traumatism,  and  in  ])erhaps  a  nuijority  of 
the  cases  the  child  is  attacked  while  in  full  health.  As  Sinkler  has  pointed 
out.  the  cases  are  mo-e  connnon  in  the  warm  months.  JJoys  are  more 
liable  to  be  atVected  than  girls,  ."^evcral  instances  of  the  occurreiue  of 
numerous  cases  to<:ether  in  epidemic  form  have  been  described,  iledin  re- 
]iorts  from  Stockholm  an  epidemic  in  which  from  the  9th  of  August  to  the 
■?od  of  September  "^M)  lases  came  under  observation.  In  two  instances  two 
children  in  the  sanu'  family  were  attacked  within  a  fow^  days. 

The  nuist  remarkable  epidemic  is  that  which  occurred  in  the  vicinity 
of  Rutland.  Vt..  and  which  has  been  recorded  by  Cavcrly  (New  York  Med- 
ical Record.  1804.  ii).  One  hundred  and  nineteen  cases  occurred  during 
the  summer  of  lS9-i;  85  were  under  six  years  of  age;  18  died. 


■ 


IHSKASKS  OK  TIIK   KKI-'KHKNT  oil  MOToU  TItACT. 


\)U] 


U  aro  ill- 
ecu  thrill. 


I'  niiclt'i  <>l' 

I  he  Ittwcr 

uliir  i>iilsits 

IKtl   (llU!   to 


itlailUIUltini) 
ctidii  dl'  thr 

Ix'l'Il    clilSSlMl 

,ali(»iis  iiiili- 
V  lilood  siip- 
y  net  iis  tlu' 
loiild  nlwiiys 

Ml   ('Xl)l!lilU'»l. 

not  ti  systoiii 

hikI  r<»r  tliin 
spinal  cord, 

liii  till'  lirst 
iiiii  muscli't-', 

us  Ikh'm  at- 
•tion.  Since 
,tc  this  form 
'all,  but  very 
majority  of 
has  pointed 
ivs  are  more 
ccurreiiie  of 
^ledin  re- 
iiiiust  to  the 
nstances  two 

the  vicinity 
,v'  York  ^led- 
urreJ  during 


Althmi;;h  iiiosl  rri'(|iii'iil  in  rhildrcii,  it  dcv<'|o|iH  occaHioiially  in  yoiiii;; 
luhiltH,  or  even  in  niiddle-a;,M'<l  persoiiH. 

Morbid  Anatomy. — Tiic  dineahe  is  oflem'sl  seen  in  «illi(r  the  cer- 
vical or  liimhar  ciihir;^ciiicnls.  In  very  early  ciises,  hiicli  as  lli(tse  de- 
scrilied  hy  J)avid  |)i'iiiiiiiiniid  and  Cliarlewdnd  'riniier,  the  lesion  has  heeii 
that  of  an  acute  lia>iiiorrha^M(.  niyclitis  with  defeneration  and  rapid  de- 
-Irnctioii  (d'  the  larfj;c  j^an^lion  (ells.  The  condition  may  he  strictly  con- 
lined  to  the  ventral  coriiiia;  in  Home  insliiiices  there  is  sli^dit  iiieninp>al 
involveiiienl.  Tlie  investi;;ali(»iis  id'  (loldscheider,  Sieinerlinj,',  and  others 
have  denmnslraled  the  ailerial  ori^iin  of  the  disease,  which  is  localized 
in  the  parts  supplied  hy  the  ventral  nictlian  hranch  of  the  ventral  Hpiiial 
aiiery.  Occasionally  the  chan;<es  arc  found  in  the  rc;,don  (tf  di.^lrihiition 
«\'  the  ventral  radicular  arteiies.  Marie  thinks  that  the  initial  process  is 
endiolisni  or  thromhosis  (d"  the  arteries  of  the  ventral  Imrns,  the  result 
of  an  acute  infection.  In  cases  in  which  the  examination  is  not  made 
lor  some  nionllis  or  years  the  chan^'es  ar(!  very  characteristic.  The  ven- 
tral cornii  in  the  alVccleil  rc^fion  is  ^'really  atrophied  and  the  lar;^e  motor 
rells  are  either  entirely  ahseiit  or  only  a  few  remain.  The  aU'ected  half  of 
Jhe  cord  may  he  coiisiderahly  smaller  than  the  other.  The  veiitro-lateral 
column  may  show  slijiht  sch'rotie  clian;;es,  chielly  in  the  pyramidal  tia(t. 
Th''  correspond iiij,'  ventral  nerve  rool.s  are  atropliii<l,  and  the  muscles  are 
wasted  and  j^radually  undergo  a  fatty  aiul  sclerotic  chan<:e. 

Symptoms. — In  a  majority  <d'  the  cases,  after  sli;.dit  indisposition 
and  feverishness,  tlu;  child  is  noticed  to  have  lost  the  um'  of  one  limh. 
Convulsions  at  the  outset  arc  rare,  not  constant  as  in  the  acute  cerehral 
palsies  of  children.  I''ever  is  usually  present,  the  t<'mperatiire  risinj^  to 
101°,  sometimes  to  10)5°.  I'ain  is  often  complained  of  in  the  early  sta^res. 
This  may  he  localized  in  the  hack  or  hetwcen  the  shoulders;  any  ])ressure 
<iu  the  paralyzeil  limhs  may  he  jiainful,  causing,'  the  patient  to  cry  out  when 
lie  is  movc<l  in  hed.  'JMie  paralysis  is  ahriipt  in  its  onset  and,  as  a  rule, 
is  not  pro^n'cssive,  hut  reaches  its  maximum  in  a  very  short  timc!,  even 
within  twenty-four  hours,  it  is  rarely  ^Generalized.  The  suddenness  of 
4)iiset  is  remarkahle  and  su^'fiests  a  primary  aU'ection  of  tin;  hlocd-vessels, 
a  view  which  the  lia'inorrha<ii(;  character  of  the  early  lesion  su|)ports.  The 
distrihution  of  the  paralysis  is  very  variahh'.  Its  irrej;ularity  and  lack  of 
symmetry  is  (|uite  characteristic  of  the  disease.  One  or  hotli  arms  may  he 
aU'ected,  one  arm  and  one  lej;,  or  hoth  le^zs;  or  it  may  he  a  crossed  paraly.«is, 
the  ri^dit  leji;  and  the  left  arm.  In  the  upper  extremities  the  paralysis  is 
rarely  compleie  and  ^n'oups  of  muscles  may  he  alTected.  .\s  Remak  has 
pointed  out,  there  is  an  upper-arm  and  a  lower-arm  type  of  palsy.  '^I'he  del- 
toid, the  hiceps,  hrachialis  anticus,  and  supinator  loiijius  may  Ije  aU'ected 
in  the  former,  and  in  the  latter  the  extensors  or  llexor.s  of  the  finfrers  and 
Mrists.  This  distrihution  is  due  to  the  fact  that  muscles  acting  functionally 
together  are  represented  near  each  other  in  the  sjiinal  coid. 

In  the  legs  the  tibialis  anticus  and  extensor  grou|)s  of  muscles  are  more 
affected  than  the  hamstrings  and  glutei.  The  muscles  of  the  face  are 
very  rarely,  the  sphincters  hardly  ever  involved.  While  the  rule  is  for 
the  paralysis  to  he  abrupt  and  sudden,  there  are  cases  in  which  it  comes 


044 


IHSKASKS  OF  TllK   NKIIVOUS  SVSTKM. 


(HI  slowly  lunl  (iikis  from  three  to  live  diiVH  for  its  (levelo|)iii('iit.  \i  lirsL 
tlie  aU'eeted  liiiili  looks  natural,  ami  as  cliildreii  lielweeii  two  ami  tlircr 
are  usually  fat,  very  liltK'  chan^'e  may  lie  iiotieed  for  some  time;  hut  the 
atrophy  proeeeds  rapidly,  and  the  liiid)  heeomes  llaecid  ami  I'eels  soft  ainl 
ilahhy.  I'sually  as  early  as  the  end  of  the  iirst  week  the  reaetion  of  de- 
feneration is  present.  The  nerves  are  found  to  have  lost  their  irritahility. 
'The  niuseli's  do  not  react  to  the  induced  curri'iit,  hut  to  the  con.>ianl  eur- 
I'ent  they  respond  hy  a  slujrfiish  contraction,  usuidly  to  a  wt'akc*  curreni 
than  is  normal.  'The  paralysis  remains  stationary  for  a  tinu',  and  iIhii 
there  is  j«raduid  im|»rovem"'nt.  Coinpleti'  recovery  is  ran',  and.  when  tlie 
anatomii'al  condition  is  consideri'd,  is  scarcely  to  he  I'Xpected.  'I'lie  lar^c 
motor  cells  of  the  cornua,  when  thoroughly  disintegrated,  cannot  hi'  re- 
stored. In  loo  niany  cases  the  improvement  is  (»nly  slif^ht  and  permaneiil 
paralysis  remains  in  certain  grou|>s.  Sensation  is  unalVected;  the  skin  i 
llexi'S  are  ahseiit,  and  the  deep  rellcxes  in  the  all'eeted  muscles  are  usu- 
ally lost. 

When  the  paralysis  persists  the  wastin<f  is  extreme,  the  •riowth  of  the 
hones  of  the  all'eeted  liiid)  is  arrested,  or  at  any  rate  retarded,  and  the 
joints  may  he  vi'ry  relaxi'd;  as,  for  it,-tance,  when  the  deltoid  is  all'eeted, 
tho  head  of  the  humerus  is  no  lonjjci  kept  in  contact  with  the  j;lenoid 
cavity.  In  tho  later  staj^es  very  serious  deformities  are  produced  hy  the 
contracture  of  the  muscles. 

Diagnosis. — The  condition  is  *)nly  too  evident  in  tho  majority  of 
cases.  There  is  a  tlaccid,  Ilahhy  paralysis  of  one  or  more  liinhs  which  has 
sot  in  ahruptly.  Tho  iiqild  nastinj.',  the  lax  state  of  tho  muscles,  tin 
electrical  reactions,  and  tho  ahscnee  of  rellexes  distin»>iiisli  it  frt)m  the 
corohral  ])alsies.  In  multiple  neuritis,  u  rare  disease  in  childhood,  the 
])aralysis  is  hilaterally  symmetrical,  all'ects  tho  musi'les  at  the  periphery  of 
tho  limhs,  and  is  comhined  with  sensory  symptoms.  The  ])seiido-]>arosis 
of  rii'kets  is  a  condition  to  ho  carefully  distin<iuislu(l.  In  this  tho  loss  of 
l)ower  is  in  the  lej-s,  rapid  atrophy  is  not  present,  certain  movoinents  are 
po  sihlo  hut  painful.  'J'ho  jroneral  hypera'sthesiu  of  tho  skin,  tho  charac- 
teristic chanji:es  in  the  hoiu's,  aiul  tho  dilfuse  sweats  are  present.  Disease 
of  the  h'p  or  kiu'o  nuiy  i)roduco  a  pseudo-paralysis  which  can  with  care  he 
readily  distin<:uished. 

Prognosis. — The  outlook  in  any  case  for  complete  recovery  is  bad. 
'I'he  natural  course  of  the  disease  must  he  home  in  mitul;  the  sudden  onset, 
the  rapid  l)ut  not  pro<rressive  loss  of  power,  a  stationary  period,  then  nuirked 
improvement  in  certain  muscle  f;rou])s,  and  limUly  in  many  cases  contrac- 
tures ami  deformities.  There  is  no  other  disease  in  which  tho  physician 
is  so  often  subject  to  unjust  criticism,  and  the  friends  should  bo  told  at  tlu' 
outset  that  in  the  severe  and  extensive  ])aralysis  com])leto  recovery  should 
not  ho  expected.  The  best  to  be  ho])ed  for  is  a  gracbial  restoration  of  power 
in  certain  muscle  groups.  In  estimating  the  probable  grade  of  permanent 
paralysis,  tho  eloetrical  examination  is  of  great  value. 

Treatment. — The  treatment  of  acute  infantile  paralysis  has  a  bright 
and  a  dark  side.  In  a  case  of  any  extent  complete  recovery  cannot  be  ex- 
pected; on  the  other  hand,  it  is  remarkable  how  much  improvement  may 


t.     At  HihL 

lUIll  (llt'CC 
ic;  l)llt  tile 
'Is  Koll,  lllld 
tiull    tlf    llc- 

irriliil)ilily. 
iistiiiit  ciir- 
<("•  currciii 
,  lllld  tlii'ii 
.  when  the 

'I'llC     llll'f,'!' 

iiiiil    1m'   rc- 

|M'|'llllllU'lll 
III'    ."-Ixill    1 

's  arc  iisii- 
wtli  of  tlic 

I,    Mini     tile 

is  M !]■(•{•( I'd, 
lie  ^k'Hoid 
■I'd   In-   the 

liijority  of 
wliicli  has 
isc'Ics,   llic 

from  tlu' 
hood,  the 
i'i|»hc'ry  of 
ido-))aresis 
he  Joss  of 
incuts  arc 
10  charuc- 
Diseaso 

li  care  bo 

y  is  bad. 
Ion  onset, 
n  marked 
>  contrac- 
l)Iiysician 
)ld"at  the 
y  shoidd 
of  power 
ermancnt 

a  bright 
ot  be  ex- 
icnt  may 


DISKASKS  OF  TFIH    KKKKURNT  <»U    Mo'l'olt   TIJ ACT. 


945 


linally  take  |ila(-e  in  a  limb  wliich  \h  at  lirst  coiii|dcl'  y  llaccid  and  licl|i|«>((rt, 
'I'lie  followin;^  ti'eatiiiciit  niav  be  |iui>.ncil:  If  .seen  in  llic  febrile  ^la^^e,  u 
brisk  la.Mitive  and  a  fever  mixture  may  be  ;^iveii.  'llic  child  should  be  in 
bed  and  the  alVeeted  limb  or  limbs  wrapiicd  in  cotton.  As  in  the  <:reat 
majority  (d"  eases  the  daniimf  is  already  done  when  the  |ibysiciaii  is  callcfl 
and  the  disease  mak(-s  no  further  iiro^M'ess,  ihe  a|i|)licatioii  of  blistcis  ami 
other  forms  u[  coiintcr-irritalioii  to  the  back  is  irrational  and  only  crnel  to 
Ihe  child 

Till'  ■  encral  niitrilioii  should  be  carefully  mainlaincd  b_v  fcediii;,'  tin; 
child  well,  .iiid  takiii;,'  it  out  of  doors  every  day.  A«  soon  as  the  <  hild  can 
bear  fri.lioii  the  alfected  part  should  be  carcfnily  nibbed;  at  liist  once  ii 
day,  snbsctiiieiitly  morning  and  I'veiiing.  Any  inlclligciit  mot  her  can  bo 
laiiglit  systematically  to  nib,  knead,  and  pinch  the  muscles,  using  either 
(lie  bare  hand  or,  belter  still,  sweet  oil  or  cod-liver  oil.  This  is  Worth  all  tlio 
oilier  niea«nres  advised  in  the  disease,  and  should  be  systematically  prae- 
li>e(l  for  months,  or  even,  if  ncccssMiT.  a  year  or  more.  Klectricity  has  a 
much  more  limited  use,  and  cannot  be  compared  with  massage  in  maiii- 
laining  the  nutrition  of  the  muscles.  The  faradic  current  should  be  applied 
|((  those  mnsclcrt  which  respond.  The  essence  ui  the  treatment  is  in  main- 
laiiiiiig  the  niiliilion  of  the  iiiiis(dcs,  so  thai  in  the  gradual  im|)roveiiient 
which  takes  place  in  parts,  at  least,  of  the  all'ccted  segments  of  the  c^rd 
the  motor  impulses  may  have  to  deal  with  wcll-ncurished,  iiol  atrophied 
muscle  libres. 

Of  medicines,  in  the  early  stage  ergot  and  lu'lladoiina  have  been  warmly 
recommended,  but  it  is  unlikely  that  they  iiavo  the  slightest  inihiencu. 
Later  in  the  disease  strychnia  may  be  used  with  advantage  in  one  or  tw(j 
minim  doses  of  the  licpiur  strychnia',  whicli,  if  it  has  nu  ulher  elfect,  is  a 
useful  tonic. 

The  most  distressing  eases  are  those  which  conu  under  the  notice  of 
the  physician  six,  eight,  or  twelve  months  after  the  onset  (d'  the  paralysis, 
when  one  leg  or  one  arm  or  both  h'gs  are  llaccid  and  have  little  or  no 
motion.  Can  nothing  be  done?  A  careful  electrical  test  should  bi-  mado 
to  ascertain  which  muscles  respond.  This  may  not  be  apparent  at  lirst, 
and  several  applications  may  be  necessary  before  any  contractility  is  no- 
ticed. With  a  few  lessons  an  intelligent  mother  Ciip.  lie  taught  to  use  tlio 
electricity  as  well  as  to  apply  the  massage.  Jf  in  a  lase  in  which  the  paraly- 
sis has  lasted  for  six  or  eight  months  no  observable  improvement  takes  place 
ill  the  next  six  months  with  thorough  and  systematic  treatment,  little  or  ikj 
hope  can  be  entertained  of  further  chanire. 

Jn  the  hiter  stage  care  should  be  taken  to  prevent  the  ilcformilics  '• 
suiting  from  the  contractions,  tireat  benelit  results  from  a  carefully  a|)- 
plicd  ajiparatus.  The  tendon  transplantation  introduced  by  (ioldthwaito 
seems  to  be  a  distinct  advantage  in  many  cnt^H.  Eulenberg  has  recently 
reported  a  case  tl8!)(S)  in  which  the  pes  erpiinus  was  marked;  he  was  able 
to  afford  notable  relief  by  ti'ndon  implantation.  JIalf  of  the  tendo- 
Achilles  and  a  part  of  the  tendon  of  the  soleus  were  implanted  upon  tlie 
tendons  of  the  ])eroneus  longus  ct  brevis,  the  remaining  half  of  the  tendo- 
Aehilles  being  divided.     The  transference  of  the  functions  from  the  flexors 


940 


DLSR.VSES  OP  THE  NERVOUS  SYSTEM. 


to  the  pronators  was  satisfactorily  accomplished,  and  the  results  were  sur- 
l)risingly  benellcial. 


/ 


4.    AcUTIi   AND   SUIJACUTE   PoLIO-MYELITIS    I\    AdULTS. 

An  acute  i)olio-myelitis  in  adults,  the  exact  counterpart  of  the  disease 
in  children,  is  recognized,  iv  majority,  however,  of  the  cases  described 
under  this  heading  have  been  multiple  neuritis;  but  the  suddenness  ol' 
onset,  the  rapid  wasting,  and  the  nuirked  reaction  of  degeneration  are 
thought  by  some  to  be  distinguishing  features.  Multiple  neuritis  may. 
however,  set  in  with  rapidity;  there  may  be  great  wasting  and  the  react iun 
of  degeneration  is  sometimes  present.  The  time  element  alone  may  deter- 
mine the  true  nature.  Recovery  in  a  case  of  extensive  multiple  paralysis 
from  polio-myelitis  will  certainly  be  with  loss  of  power  in  certain  groujjs 
of  muscles;  whereas,  in  multiple  neuritis  the  recovery,  while  slow,  may  be 
perfect. 

The  subacute  form,  the  parulysie  yenerale  spinalc  arlerieiire  suhai(ju'c 
of  Duchenne,  is  in  all  i)roUability  a  peripheral  palsy.  The  paralysis  usually 
l)egins  in  the  legs  with  atrophy  of  the  muscles,  ther  the  arms  are  involved, 
but  not  the  face.     Sensation  is,  as  a  rule,  not  involved. 


5.  Acute  Ascexdixg  (Landry's)  Paralysis. 

Definition. — An  advancing  paralysis,  beginning  in  the  legs,  rapidly 
extending  to  the  trunk  and  arms,  and  finally,  in  nuuiy  cases,  involving  the 
muscles  of  respiration.  It  j)resents  a  renuirkable  similarity  in  its  symp- 
toms to  certain  cases  of  polyneuritis,  with  which  it  is  now  grouped  by 
many  writers. 

Etiology  and  Pathology. — This  disease  occurs  most  commonly  in 
males  between  tiie  twentieth  and  thirtieth  years.  It  has  sometimes  fol- 
lowed the  specific  fevers.  An  elaborate  study  of  93  cases  collected  from 
the  literature  Ims  been  made  by  James  Eoss,  who  concludes  that  in  etiol- 
ogy, sym])toms,  course,  and  termination  it  conforms  to  a  peripheral  neu- 
ritis. Neuwerk  and  Barth  have  reached  a  similar  conclusion.  In  theii- 
case  an  interstitial  neuritis  was  found  in  the  nerve  roots,  but  the  peripheral 
nerves  were  normal.  Spiller  found  in  a  rai)idly  fatal  case  destructive 
changes  in  the  jjeriphcral  nerves  and  corresi)onding  alterations  in  the  cell 
bodies  of  the  ventral  horns.  He  suggests  that  the  toxic  agent  acts  on  the 
lower  motor  neurones  as  a  whole,  and  that  possibly  the  reason  why  no  lesions 
were  found  in  some  of  the  cases  is  that  the  more  delicate  histological  meth- 
ods were  not  used.  We  may  regard  the  disc  se,  then,  as  an  acute  poisoning 
of  the  lower  motor  neurones. 

Symptoms. — Weakness  of  the  legs,  gradually  progressing,  often  with 
toleral)le  rapidity,  is  the  iirst  symptom.  In  some  cases  within  a  few  hours 
the  ])aralysis  of  the  legs  becomes  complete.  The  muscles  of  the  trunk  are 
next  atTected,  and  within  a  few  days,  or  even  less  in  more  acute  cases,  the 
arms  are  also  involved.  The  neck  muscles  are  next  attacked,  and  finally 
the  muscles  of  respiration,  deglutition,  and  articulation.     The  reflexes  are 


s  wore  sur- 


s. 

the  diseasi' 
s  described 
klennc'ss  ul' 
enitioii  arc 
uritis  may. 
;he  react  iu  11 

may  deter- 
le  paralysis 
tain  grouj)s 
ow,  may  be 

re  suhaiijxi'c 
ysis  usually 
re  involved, 


egs,  rapidly 
volving  the 
1  its  symp- 
grouped  by 

mmonly  iu 

letimes  fol- 

ected  from 

at  in  etiol- 

jhcral  ueu- 

In  their 

peripheral 

destructive 

in  the  cell 

iicts  on  the 

y  no  lesions 

gical  meth- 

e  poisoning 

often  with 
I  few  hours 
trunk  are 
cases,  the 
and  finally 
reflexes  are 


COMiilNKD  SYSTEM  DTSKASES. 


047 


lost,  but  the  muscles  neither  waste  nor  siiow  electrical  changes.  'V\w  sen- 
sory sym])tonis  are  variable;  in  some  cases  tingling,  numbness,  and  liy[)t'r- 
u'sthesia  have  been  present.  In  the  nu)re  characteristic  cases  sensation  is 
intact  and  the  sphincters  are  uninvolved.  J']nlargement  of  the  spleen  has 
been  noticed  in  several  cases.  The  conrse  ot  the  disease  is  variable.  It 
may  {)rove  fatal  in  less  than  two  days.  Other  cases  persist  for  a  week  <>r 
for  two  weeks.  \\\  some  instances  recovery  has  occurretl,  but  in  a  large  pro- 
portion of  the  cases  the  disease  is  fatal. 

The  dio'judsis  is  dilliciilt,  particularly  from  certain  forms  of  multiple 
neuritis,  and  if  we  include  in  Landry's  paralysis  the  cases  in  which  sensa- 
tion is  invobetl,  distinction  between  the  two  aU'ections  is  imi)()ssible.  We 
ai)i)arently  have  to  recognize  the  existence  of  a  rapidly  advancing  motor 
paralysis  witbout  involvement  of  the  sphincters,  without  wasting  or  elec- 
trical changes  in  the  muscles,  without  trojjbic  lesions,  and  without  fever — 
features  sullicient  to  distinguish  it  from  either  the  acute  central  myelitis 
or  the  polio-myelitis  anterior.  It  is  doubtful,  however,  whether  these 
characters  always  sulHce  to  enable  us  to  differentiate  the  cases  of  multiple 
neuritis. 

G.  Asthenic  (IUlhah)  Takalysis 
(Myasthenia  gravis  psendo-paralylica  ;  Eih-Cioldflam''s  Symptom-coviple.)), 

During  the  last  few  years  much  attention  has  been  given  to  this  re- 
markable affection,  of  which  a  number  of  cases  have  been  reported.  The 
chief  characteristics  are  the  rapidity  with  which  the  muscles  become  ex- 
hausted, the  great  variability  of  the  symjitoms  from  day  to  day,  the  occur- 
rence of  remissions  and  relapses,  the  sudden  attacks  of  paralysis  of  respira- 
tion and  deglutition,  and  the  absence  of  muscular  atroi)hy,  the  reaction  of 
degeneration  and  sensory  symptoms.  The  onset  is  usually  acute  or  subacute, 
•chiefly  in  young  persons.  The  external  eye  muscles,  the  muscles  of  mastica- 
tion, the  facial  muscles,  the  muscles  of  deglutition,  and  certain  spinal  mus- 
<'les  may  be  cpiickly  involved.  Any  repeated  ell'orts  with  the  aU'ected  mus'^'les 
causes  them  to  become  com})letely  exhausted  and  })aralyzed  for  tbe  time 
lieing.  They  recover  their  power  after  a  rest.  In  certain  cases  there  is  a 
true  paresis,  which  persists.  After  re])cated  stimulation  by  electricity  the 
muscles  may  become  exhausted  and  cease  to  respond  (myasthenic  reaction, 
(iolly).  The  affection  may  ])r()ve  fatal,  and  as  no  well-defined  anatomical 
lesions  have  been  discovered,  a  dynamic  change  in  the  lower  motor  neurones 
has  been  assumed  to  explain  th.e  condition. 


IV.    COMBINED    SYSTEM    DISEASES. 

"When  the  disease  is  not  confined  within  the  limits  of  either  the  afferent 
or  efferent  systems,  but  affects  both,  it  is  known  as  a  roiiihiiicd  si/sInn  disease. 
Some  authors  contend  that  the  diseases  usually  classed  under  this  head  are 
not  really  system  diseases,  but  are  diffuse  processes.  This  is  the  view  taken 
by  Leyden  and  Goldscheider,  who  limit  the  term  system  disease  to  loco- 
motor ataxia  and  progressive  muscular  atrophy. 


948 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


/ 


In  certain  cases  ui'  locomotor  ataxia  which  have  run  a  fairly  ty[)ical 
course  there  may  be  found  after  death,  besides  the  aiuitonucal  picture  corre- 
sponding,' to  this  disease,  a  moderate  degeneration  of  tlie  |)yranudal  tracts 
and  of  the  ventral  horns.  In  i)r()gressive  muscular  atro])iiy,  on  the  other 
luind,  there  may  be  degeneration  in  the  dorsal  column.  During  life  these 
secondary  involvements  of  other  systems,  as  tiiey  may  l)e  termed,  niiiy  or 
may  not  be  accom[)anied  by  demonstrable  symptoms,  and  when  such  do 
occur  they  make  their  ajipearance  late  in  the  disease. 

There  is  another  group  of  cases  in  which  from  the  very  first  the  symp- 
toms point  to  an  involvement  of  lioth  the  all'erent  and  efferent  systems,  and 
it  is  to  these  that  the  term  })rimary  combined  system  disease  is  usually 
limited. 

1.  Ataxic  Pakaplkoia. 

This  name  is  applied  by  Gowers  to  a  disease  characterized  clinically  by 
a  combination  of  ataxia  and  spastic  para])legia,  and  anatonucally  by  in- 
volvement of  the  dorsal  and  lateral  columns. 

The  disease  is  most  common  in  nuddle-aged  males,  Exposure  to  cold 
and  traumatism  have  been  occasional  antecedents.  In  striking  contrast  to 
ordinary  tabes  a  history  of  syphilis  is  rarely  to  be  obtained. 

The  anatomical  features  are  a  sclerosis  of  the  dorsal  columns,  which 
is  not  more  marked  in  the  hunbar  region  and  not  specially  localized  in 
the  root  zone  of  the  cnneate  fasciculi.  The  involvement  of  the  lateral  col- 
umns is  diffuse,  not  always  lindted  to  the  pyramidal  tracts,  and  there  may 
be  an  annular  sclerosis,  ^iarie  Ijclieves  that  in  many  cases  the  distribution 
of  the  sclerosis  is  due  to  the  arterhl  sup])ly  and  not  to  a  triie  systemic  de- 
generation, the  vessels  involved  being  branches  of  the  dorsal  s|)inal  artery. 

The  symptoms  are  well  defined.  The  patient  complains  of  a  tired  feel- 
ing in  the  legs,  not  often  of  actual  pain.  The  sensory  symi)toms  of  true 
tabes  are  absent.  An  unsteadiness  in  the  gait  gradually  develops  with 
progressive  weakness.  The  reflexes  are  increased  from  the  outset,  and 
there  may  be  well-developed  ankle  clonus.  Rigidity  of  the  legs  slowly  comes 
on,  but  it  is  rarely  so  marked  as  in  the  uncomi)licated  cases  of  lateral 
sclerosis.  From  the  start  incoordination  is  a  well-characterized  feature, 
and  the  difhculty  of  walking  in  the  dark  or  swaying  when  the  eyes  are 
closed  may,  as  in  true  tabes,  be  the  first  symptjm  to  attract  attention. 
In  walking  the  ])atient  uses  a  stick,  keeps  the  eyes  fixed  on  the  ground, 
the  legs  far  apart,  but  the  stamping  gait,  with  elevation  and  sudden  descent 
of  the  feet,  is  not  often  seen.  The  incoordination  may  extend  to  the  arms. 
Sensory  symptoms  are  rare,  but  Gowers  calls  attention  to  a  dull,  aching 
pain  in  the  sacral  region.  The  sphincters  usually  become  involved.  Eye 
sym])toms  are  rare.  I^ate  in  the  disease  mental  symptoms  may  develop, 
similar  to  those  of  general  paresis. 

In  well-marked  cases  the  diaqnosis  is  easy.  The  combination  of  marked 
incoordination  Avith  retention  of  the  reflexes  and  more  or  less  spasm  are 
characteristic  features.  The  absence  of  ocular  and  sensory  symptoms  is 
an  important  point. 


COMHINKD  SYSTEM  DISHASKS. 


949 


•ly  typical 
tiiro  curiv- 
idal  tracts 
tlic  other 
lii'e  these 
d,  may  or 
Q  such  do 

the  (^ynip- 

steius,  and 

is  usually 


inically  by 
,lly  by  in- 

ire  to  cold 
ioutrast  to 

ms,  which 
realized  in 
lateral  col- 
there  may 
istribution 
stemic  dc- 
nal  artery, 
tired  feel- 
ns  of  true 
lops  with 
itset,   and 
wly  comes 
of  lateral 
feature, 
eyes  are 
attention, 
e  ground, 
n  descent 
the  arms. 
I,  aching 
ved.     Eye 
develop, 

Df  marked 
pasm  are 
ciptoms  is. 


2.  PlUMAIiY    CoMIUN'Kn    ScLKROSlS    (PrTXAM). 

In  addition  to  the  alaxic  para|)h'gia  just  mentioned,  here  may  be  con- 
sidered certain  cases  which  are  characterized  anatoniically  by  a  relatively 
chronic  sck'rosis  oi'  the  (U)rsal  cohinms,  of  the  lateral  colunins,  chielly 
the  ])yramidal  tract,  and  also  of  the  cerehellar  tract.  With  these  are 
usually  associated  more  acute  changes  in  adjoining  areas,  cither  dilTuse  or 
systemic,  some  grade  of  degeneration  in  the  gray  matter,  and  involve- 
ment of  the  nerve  roots.  This  form  has  been  studied  hy  .).  .1.  Put- 
nam and  Dana.  The  cases  are  usually  in  wonuMi — 7  out  of  1!)  collected 
hy  Dana;  the  ages,  from  forty-five  to  sixty-four.  The  disease  runs 
a  rather  rapid  course.  Neuropathic  iidu-ritance  is  ])resent  in  some  in- 
stances. ''  :  \iim  thinks  that  ])ossil)ly  hotli  lead  and  arsenic  ])lay  a  part 
in  the  eti' 

The  sijmi/tonis  are  both  sensory  and  motor.  The  onset  is  usually  with 
numbness  in  the  extremities,  ])rogressive  loss  of  strength,  and  emaciation. 
Paraplegia  gradually  develo})S,  before  which  there  have  been,  as  a  rule, 
spastic  symptoms  with  exaggerated  knee-jerk.  The  arms  are  atfected  less 
ilian  the  legs.  Mental  symptoms  suggestive  of  dementia  paralytica  may  de- 
velop toward  the  close. 

The  diiKjnosis  of  this  mixed  sclerosis  rcfets  upon  the  combination  of 
sensory  and  motor  symjttoms  witli  the  presence  t)f  exaggerated  n'flexes. 
As  stated,  the  sensory  features  consist  chielly  of  [)ara'sthesia,  and  there 
may  be  dilliculty  in  distinguishing  the  cojulition  from  multiple  neuritis. 
The  frequency  of  the  disease  in  more  or  less  enfeebled  or  ana,'mic  women 
])ast  middle  life  is  also  an  important  1  jature. 

3.  Hereditary  Ataxia  (Friedreich's  Ala.ria). 

In  18G1  Friedreich  reported  0  cases  of  a  form  of  hereditary  ataxia,  and 
the  affection  has  usually  gone  Ijy  his  name.  Unfortunately,  paranri/oclomis 
inuJtipJe.r  is  also  called  Friedreicli's  disease;  so  it  is  best,  if  his  name  is  used 
in  connection  with  this  ail'ection,  to  term  it  Friedreich's  ataxia.  It  is  a  very 
ditferent  disease  in  nuuiy  respects  from  ordinary  tabes.  It  may  or  may  not 
be  hereditary.  It  is  really  a  family  disease,  several  l)rothers  and  sisters 
being,  as  a  rule,  affected.  The  1  Hi  cases  analyzed  liy  (Jriilith  occurred  in 
Tl  unrelated  families.  In  his  series  inheritance  of  the  disease  itself  occurred 
in  only  33  cases.  Various  influences  in  the  parents  have  been  noted;  alco- 
holism in  only  7  cases.  8y])hilis  has  rarely  been  ])resent.  Of  the  113  cases, 
(SG  were  males  and  57  females.  The  disease  sets  in  early  in  life,  and  in  (irif- 
fith's  series  15  occurred  l)efore  the  age  of  two  years,  39  before  the  sixth 
year,  45  between  the  sixth  and  tenth  years,  20  between  the  eleventh  and 
fifteenth  years,  18  between  the  sixteenth  and  twentieth  years,  and  5  be- 
tween the  twentieth  and  twenty-fifth  years. 

The  morhid  anafoviij  shows  an  extensive  sclerosis  of  tlie  dorsal  and 
lateral  columns  of  the  s])inal  cord.  The  ])<'ri])hery,  and  the  cerebellar  tracts 
are  usually  involved.  The  observations  of  Dejerinc  and  Letullc  are  of  spe- 
<!:il  interest,  since  they  seem  to  indicate  that  the  change  in  this  disease  is 


I 


950 


disease:.s  OB"  the  nervous  system. 


a  neurngliar  (cctoilornial)  sclerosis,  difTeriii^'  entirely  from  the  ordinary 
spinal  sclerosis.  According  to  this  view,  Friedreich's  disease  is  a  gliosis  of 
tlie  dorsal  columns  duo  to  developmental  errors;  but  the  question  is  still 
unsettled. 

Symptoms. — The  ataxia  differs  somewhat  from  the  ordinary  form. 
The  incoordination  begins  in  the  legs,  but  the  gait  is  peculiar.  It  is  sway- 
ing, irregular,  and  more  like  that  of  a  drunken  man.  There  is  not  the  char- 
acteristic stamping  gait  of  the  true  tabes.  Romberg's  symptom  nuiy  or 
may  not  be  present.  The  ataxia  of  the  arms  occurs  early  and  is  very 
marked;  the  movements  are  almost  choreiform,  irregular,  and  somewhat 
swaying.  In  making  any  voluntary  movement  the  action  is  overdone,  the 
])rehension  is  claw-like,  and  the  lingers  may  be  spread  or  overextended 
just  before  grasping  an  object.  The  hand  frequently  nu)ves  about  an  object 
for  a  moment  and  then  suddenly  pounces  njwn  it.  There  are  irregular, 
swaying  movements,  some  of  which  are  choreiform,  of  the  head  and  shoul- 
ders. There  is  present  in  many  cases  what  is  known  as  static  ataxia,  that  is 
to  say,  ataxia  of  quiet  action.  It  occurs  when  the  body  is  held  erect  or  when 
a  limb  is  extended — irregular,  oscillating  movements  of  the  head  and  body 
or  of  the  extended  limb. 

Sensory  .symptoms  are  not  usually  present.  The  deep  reflexes  are  lost 
early  in  the  disease,  and,  next  to  the  ataxia,  this  is  the  most  constant  and 
important  symptom  (Striimpell).  The  skin  reflexes  are  usually  normal, 
and  the  pu})illary  reflex  to  light  is  practically  never  affected. 

Nystagmus  is  a  characteristic  symptom.  Atrophy  of  the  optic  nerve 
rarely  occurs.  A  striking  feature  is  early  deformity  of  the  feet.  There 
is  talipes  eqninus,  and  the  patient  Avalks  on  the  outer  edge  of  the  feet. 
The  big  toe  is  flexed  dorsally  on  the  first  phalanx.  Lateral  curvature  of 
the  spine  is  very  common. 

Tro])hic  lesions  are  rare.  As  the  disease  advances  paralysis  conies  on 
and  may  ultimately  be  complete.     Some  of  the  patients  never  walk. 

Disturbance  of  speech  is  common.  It  is  usually  slow  and  scanning; 
the  expression  is  often  dull;  the  mental  power  is,  as  a  rule,  maintained,  but 
late  in  the  disease  becomes  impaired. 

The  diagnosis  of  the  disease  is  not  difficult  when  several  members  of 
a  family  are  affected.  The  onset  in  childhood,  the  curious  form  of  inco- 
ordination, the  loss  of  knee-kicks,  the  early  talipes  equinus,  the  posi- 
tion of  the  great  toe,  the  scoliosis,  the  nystagmu.?,  and  scanning  speech  make 
up  an  unmistakable  ])icture.  The  disease  is  often  confounded  with  chorea, 
with  the  ordinary  form  of  which  it  has  nothing  in  common.  With  hered- 
itary chorea  it  has  certain  similarities,  but  usually  this  disease  does  not  set 
in  until  after  the  thirtieth  year. 

The  affection  lasts  for  many  years  and  is  incurable.  Care  should  be 
taken  to  prevent  contractures. 

Cerebellar  Type. — There  is  a  form  of  hereditary  ataxia,  described  by 
^larie  as  cerehellar  hcredo-ataxia,  which  starts  later  in  life,  after  the  age  of 
twenty,  with  disability  in  the  legs,  but  the  gait  is  less  ataxic  than  "  groggy."' 
The  knee-jerks  are  retained,  and  a  spastic  condition  of  the  legs  ultimately 
develops.    There  is  no  scoliosis,  nor  does  clul>foot  develop.    Sanger  Brown's 


2  ordinary 
I  gliosis  of 
ion  is  still 

lary  form. 
Jt  is  sway- 
t  the  char- 
Ill  may  or 
od  is  very 

somewhat 
■rdone,  the 
erextended 
t  an  ohjcct 

irregular, 
and  shoiil- 
xia,  that  is 
ct  or  when 
I  and  body 

cs  are  lost 
iistant  and 
ly  normal, 

ptic  nerve 
it.  There 
the  feet, 
rvatiire  of 

conies  on 
alk. 

scanning; 
ained,  but 

eml)crs  of 
[1  of  inco- 
the  po:;i- 
^cch  make 
1  chorea, 
th  hered- 
es  not  set 

should  be 

?ribed  by 
he  age  of 

groggy." 
iltimately 

Brown's 


AFFECTIONS  OF  THE  MKNIXGES. 


951 


cases,  25  in  one  family,  and  J.  II.  Xeff's,  13,  appear  to  belong  to  this  type. 
The  cerebellum  has  been  found  atrophied  in  2  cases. 

4.  PiiooiiKssivE  Ixti:rstiti.m,  IIvi'khtkopiiic  Neuritis  of  Infants. 

Under  this  imposing  title  Dejerine  and  Sottas  described  a  rare  and  inter- 
esting alfection.  It  is  a  family  disease,  and  begins  in  early  life.  The  sym[)- 
tnms  are  those  typical  of  locomotor  ataxia,  to  which  is  added  progressive 
muscular  atrophy,  with  involvement  of  the  face  and  a  hypertroi)i)y  and 
liiirdening  of  the  peripheral  nerves.  As  the  name  indicates,  it  is  an  inter- 
stitial hyi)crtrophic  neuritis  with  secondary  involvement  of  the  dorsal  col- 
umns of  the  cord.  This  disease  has  been  associated  with  ])rogressive  iiciir;il 
muscular  atroi)hy,  but  Dejerine  has  shown  that  it  is  quite  distinct. 

5.  Toxic  Combined  Sclerosis. 

Certain  poisons  cause  changes  in  the  lateral  and  dorsal  columns  of  the 
cord  that  resemble  those  of  the  cdinltiiu  1  system  diseases.  They  have  been 
demonstrated  in  pellagra  and  in  ergotism,  and  have  already  been  descril)ed. 
In  pernicious  ana'inia  and  many  chronic  wasting  disease  these  scleroses 
occur,  and  are  believed  to  be  due  to  the  action  of  poisons  produced  within 
the  system. 


Hi.    DIFFUSE  DISEASES   OF  THE  NEEYOUS   SYSTEM. 

I.   AFFECTIONS   OF   THE    MENINGES. 

Diseases  of  the  Dura  Mater  {Pachymeninrjilis). 

Pachymeningitis  Externa. — Cerebral . — Ilivmorrhage  often  occurs  as  a 
result  of  fracture.  Inflammation  of  the  external  layer  of  the  dura  is  rare. 
Caries  of  the  bone,  cither  extension  from  middle-ear  disease  or  due  to 
syphilis,  is  the  principal  cause.  In  the  sy])hilitic  cases  there  may  be  a 
great  thickening  of  the  inner  table  and  a  large  collection  of  pus  between 
the  dura  and  the  bone. 

Occasionally  the  pus  is  infiltrated  between  the  two  layers  of  the  dura 
mater  or  may  extend  through  and  cause  a  dura-arachnitis. 

The  symptoms  of  external  pachymeningitis  are  indefinite.  In  the  syi>h- 
ilitic  cases  there  may  be  a  small  si  lus  communicating  with  the  exterior. 
Compression  symptoms  may  occur  with  or  without  paralysis. 

Spinal. — An  acute  form  may  occur  in  syphilitic  affections  of  the  bones, 
in  tumors,  and  in  aneurism.  The  symptoms  are  those  of  a  compression  of 
the  cord.  A  chronic  form  is  much  more  common,  and  is  a  constant  accom- 
paniment of  tuberculous  caries  of  the  spine.  The  internal  surface  of  the 
dura  may  be  smooth,  Miiile  the  external  is  rough  and  covered  with  caseous 
masses.  The  entire  dura  may  be  surrounded  or  the  process  may  be  con- 
fined to  the  ventral  surface. 


952 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


Pachymeningitis  Interna. — This  occurs  in  three  forms:  (1)  Pseudo- 
iricml)niii(iiis,  {'^)  piiriilciit,  iind  (;})  liu'iiiorrliiifjic.  'i'hc  first  two  are  un- 
im  *ii!!t.  rsciido-iiK'Hibranous  iiillaiiunation  ol'  tlic  lining  lucnihrane  of 
th'  I  is  not  usually  recognized,  but  a  most  characteristie  example  ot  ii 

canu  idcr  my  ohsiTvation  as  a  seconchiry  process  in  juieumonia.  I'uruleni 
jiMcliymcningitis  may  i'oUow  an  injury,  but  is  more  commonly  the  result 
ol'  extension  Jrom  iidlammation  of  the  pia.  It  is  remarkable  how  rarely  pus 
is  found  between  the  dura  and  arachnoid  membranes. 


ir.K.MoiMiiiAGic  1'.\ciivmi:nin(htis  {Ifa'iiialonia  af  lite  Durn  Mulcr). 

Cerebral  Form. — IMiis  remarkable  condition,  first  described  by  A'irchow, 
is  very  rare  in  general  medical  practice.  i)ui'ing  ten  years  no  instance  of  it 
came  under  my  observation  at  the  ^Montreal  General  Iiosi)ital.  On  the  other 
hand,  in  the  ])ost-morteni  room  of  the  I'hiladelphia  llosjjital,  which  received 
material  from  a  large  almshouse  and  asylum,  the  cases  were  not  nncommou, 
antl  within  three  months  1  saw  four  characteristic  exam])les,  three  of  which 
came  from  the  medical  wards.  The  frequency  of  the  condition  in  asylum 
work  may  be  gathered  from  the  fact  that  in  1,185  ])ost  mortems  at  the  (!ov- 
ernnu'nt  iiospital  for  the  Insane,  Washington,  to  .Tune  30,  1S!)7,  there  were 
1!)7  cases  with  "a  true  neo-mend)rane  of  internal  pachymeningitis"  (lUack- 
burn).  Of  these  cases,  45  were  chronic  denumtia,  37  were  general  ])aresis, 
30  senile  dementia,  1^8  chronic  nuinia,  28  chronic  melancholia,  'i'i  chronic 
epilei)tic  insanity,  6  acute  mania,  and  1  case  imbecility.  Forty-two  of  the 
cases  were  in  persons  over  seventy  years  of  age. 

It  has  also  been  found  in  profound  auivmia  and  other  diseases  of  the 
blood  and  of  the  blood-vessels,  and  is  said  to  have  followed  certain  of  the 
acute  fevers.  Ilerter  has  called  attention  to  the  not  infrequent  occurrence 
of  the  lesion  in  badly  nourished,  cachectic  children. 

The  morbid  anatomy  is  interesting.  Virchow's  view  that  the  delicate 
vascular  nuMubrane  ])recedes  the  luvmorrhage  is  nndoid)tedly  correct.  Prac- 
tically we  see  one  of  three  conditions  in  these  cases:  {a)  Subdural  vascular 
niend)ranes,  often  of  extreme  delicacy,  formed  by  the  penetration  of  I)lood- 
vessels  and  granulation  tissue  into  an  inflammatory  exudate  (so-called  "  or- 
ganization "'  of  an  intlammatory  exudate);  (/•)  sim])le  subdural  luemor- 
rluige;  {r)  a  cond)ination  of  the  two,  vascular  mend)rane  and  blood-clot. 
Certainly  the  vascular  membrane  may  exist  without  a  trace  of  hoomorrhage 
— sim])ly  a  fd)rous  sheet  of  varying  thickness,  permeated  with  large  vessels, 
which  may  form  beautiful  arborescent  tufts.  On  the  other  hand,  there 
are  instances  in  which  the  subdural  haemorrhage  is  found  alone,  but  it  is 
possible  that  in  some  of  these  at  least  the  haemorrhage  may  have  destroyed 
all  trace  of  the  vascular  membrane.  In  some  cases  a  series  of  laminated 
clots  are  found,  forming  a  layer  from  3  to  5  mm.  in  thickness.  Cysts  may 
occur  within  this  membrane.  The  source  of  the  hosmorrhage  is  probably  the 
dural  vessels.  TTuguenin  and  others  hold  that  the  bleeding  conies  from  the 
A'^essels  of  the  ])ia  mater,  hut  certainly  in  the  early  stage  of  the  condition 
there  is  no  evidence  of  this;  on  the  other  hand,  the  highly  vascular  sub- 
dural membrane  may  be  seen  covered  with  the  thinnest  possible  sheeting 


^1)  .l'.suudo- 
Lwo  are  un- 
loiiibniiit'  of 
cainplf  ol'  ii 
I.  riu'ulfiit 
y  tlio  result 
w  rarely  pus 


Malcr). 

)y  A'irchow, 
islance  of  it 
)ii  tlio  other 
it'll  received 
iinct)iiiiii()ii. 
'ce  ol'  wliieli 

I  in  iisyliiiu 
at  the  («()v- 
,  iliere  wore 
tis"  (lUaek- 
eral  ])arosis, 

22  ehronie 
'-two  of  tile 

'asos  of  tlio 
tain  of  the 
occurreiico 

lie  dolieato 
ect.  Prac- 
al  vascular 

II  of  blood- 
called  "  or- 
al  liiiMiior- 

)lood-cl()t. 
iriiiorrlia.u'e 
rge  vessel ?:. 
and,  there 
c,  hut  it  is 
?  destroyed 

laminated 

Cysts  may 
■ohahly  the 
from  the 
(  condition 
jcular  suh- 

e  sheetim: 


AFFECTIONS  OP  THE   MKXINOES. 


053 


of  clot,  which  has  evidently  come  from  the  dura.  The  tsuhdiiral  lui'iiior- 
rhage  is  usually  associated  with  atrophy  of  the  convolutions,  and  it  is  held 
lliat  this  is  one  reason  wliy  it  is  so  common  in  the  insane,  es[)eciaily  in  de- 
mentia paralytica  and  dementia  senilis;  Init  there  must  he  sc»me  other 
factor  than  atrophy,  or  we  should  meet  with  it  in  phthisis  and  various 
caehectic  conditions  in  which  the  cerebral  wasting  is  as  common  and  almost 
as  marked  as  in  cases  of  insanity. 

The  symptoms  are  indeHnite,  or  there  may  be  none  at  all,  especially 
Mlien  the  luemorrhages  are  small  or  have  occurred  very  gradually,  and  the 
diagnosis  cannot  be  made  with  certainty.  Headache  has  been  a  prominent 
sym])tom  in  some  cases,  and  when  the  condition  exists  on  one  side  there 
may  he  hemiplegia.  The  most  helpful  symi)toms  for  diagnosis,  indicating 
that  the  luemorrliage  in  an  apoplectic  attack  is  meningeal,  are  (1)  those 
referable  to  increased  intracerebral  pressure  (slowing  and  irregularity  of 
the  pulse,  vomiting,  coma,  contracted  pupils  reacting  to  light  slowly  or  not 
at  all)  and  (2)  paresis  and  paralysis,  gradually  increasing  in  extent,  accom- 
jianied  by  symptoms  which  jKiint  to  a  cortical  origin.  lOxtensive  bilateral 
disease  may,  however,  exist  without  any  symptoms  whatever. 

Spinal  Form. — The  spinal  pachymcniiu/itis  interna,  described  by  (.'har- 
cot  and  JofTroy,  involves  chi'Ily  the  cervical  region  {P.  ccrvicalis  hi/prr- 
iropliica).  The  interspace  b  tween  the  cord  and  the  dura  is  occupied  by  a 
firm,  concentrically  arranged,  fibrinous  growth,  which  is  seen  to  have  de- 
veloped within,  not  outside  of,  the  dura  mater.  It  is  a  condition  ana- 
tomically identical  with  the  luemorrhagic  ptichymeningitis  interna  of  the 
brain.  The  cord  is  usually  compressed;  the  central  canal  may  be  dilated — 
hydromyelus — and  there  are  secondary  degenerations.  The  nerve  roots  are 
involved  in  the  growth  and  are  damaged  and  compressed.  The  extent  is 
variable.  It  may  be  limited  to  one  segment,  but  more  commonly  involves 
a  considerable  portion  of  the  cervical  enlargement.  The  disease  is  chronic, 
and  in  some  cases  presents  a  characteristic  group  of  sym[)toms.  There 
are  intense  neuralgic  pains  in  the  course  of  the  nerves  whose  roots  are 
involved.  They  are  chiefly  in  the  arms  and  in  the  cervical  region,  and 
vary  greatly  in  intensity.  There  may  be  hypera^sthesia  with  numbness  and 
tingling;  atrophic  changes  may  develop,  and  there  may  be  areas  of  anaes- 
thesia. Gradually  motor  disturbances  appear;  the  arms  become  weak  and 
the  muscles  atrophied,  particularly  in  certain  groups,  as  the  flexors  of  the 
hand.  The  extensors,  on  the  other  hand,  remain  intact,  so  that  the  con- 
dition of  claw-hand  is  gradually  produced.  The  grade  of  the  atrophy  de- 
pends much  upon  the  extent  of  involvement  of  the  cervical  nerve  roots, 
and  in  many  cases  the  atrophy  of  the  muscles  of  the  shoulders  and  arms 
becomes  extreme.  The  condition  is  one  of  cervical  paraplegia,  with  con- 
tractures, flexion  of  the  wrist,  and  typical  main  en  (jrijfe.  Usually  before 
the  arms  are  greatly  atrophied  there  are  the  symptoms  of  what  the  French 
writers  term  the  second  stage — namely,  involvement  of  the  lower  extremi- 
ties and  the  gradual  production  of  a  spastic  paraplegia,  which  may  develop 
several  months  after  the  onset  of  the  disease,  and  is  due  to  secondary  cimnges 
in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  perhaps,  two  or  more  years. 
60 


I 


p 


954 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


t-i 


^5 


I 


In  11  few  instances,  in  wliicli  symptoms  pointed  definitely  to  this  condition, 
recovery  liiis  taken  place.  'J'lie  disease  is  to  We  distini^uislied  from  amyn- 
tiopliic  lateral  sclerosis,  syrin^fomyelia,  and  tumors.  From  the  ih•^^t  it  is 
separated  l>y  the  marked  severity  of  the  initial  [)ains  in  the  neck  and  arms; 
from  the  se(!ond  l)y  the  ahsenee  of  the  sensory  chanj^es  characteristic  of 
syrinjromyelia.  From  certain  tumors  it  is  very  diMicult  to  distinguish; 
in  fact,  the  lihrinous  layers  form  a  tumor  around  the  cord. 

The  condition  known  as  hwmatoma  of  the  dura  mater  may  occur  at  any 
part  of  the  cord,  or,  in  its  slow,  progressive  form — pachymeningitis  hivm- 
orrhagica  interna — may  ho  limited  to  the  cervical  region  and  j)roduee  tiie 
symptoms  just  mentioned.  Jt  is  sometimes  extensive,  and  may  coexist  with 
a  similar  condition  of  the  cerehral  dura.  Cysts  may  occur  tilled  with  ha'm- 
orrhagic  contents. 

DrsEASES  OF  THE  PiA  Mater  {Acute  Cerebrospinal  Leptomeningilis). 

Etiology. — Under  cerehro-spinal  fever  and  tuherculosis  the  two  most 
important  forms  of  meningitis  have  heen  described.  Other  conditions  with 
which  meningitis  is  associated  are:  (1)  The  acute  ferers,  more  particulaily 
pneumonia,  erysipelas,  and  septiciemia;  less  freiiuently  small-pox,  typhoid 
fever,  scarlet  fever,  measles,  etc.  (2)  Injury  or  disease  of  Ihe  hones  of  the 
skull.  In  this  group  by  far  the  most  frequent  cause  is  necrosis  of  the  petrous 
])ortion  of  the  temj)oral  bone  in  chronic  otitis.  (3)  Extension  from,  discasf 
of  lilt'  n(.sp.  Meningitis  has  followed  perforation  of  the  skull  in  sounding  the 
frontal  sinuses,  suj)purative  disease  of  these  sinuses,  and  necroses  of  tlu; 
cribriform  ])late.  As  mentioned  under  eerebro-spinal  fever,  the  iniection 
is  thought  to  be  possible  through  the  nose.  (4)  As  a  terminal  infection  in 
chronic  nephritis,  arterio-sclerosis,  heart-disease,  gout,  and  the  wasting 
diseases  of  children.  Bacteriologically,  we  nuiy  recognize  four  great  groups 
of  meningitides — the  form  due  to  the  meningococcus  (dijjlococus  intracellu- 
laris),  the  ])neumococcus  meningitis,  the  form  due  to  the  tubercle  bacillus, 
and  the  streptococcus  meningitis.  The  gonococcus,  the  typhoid  bacillus, 
the  colon  bacillus,  and  sta])hylococci  also  cause  meningitis,  but  a  great  ma- 
jority of  all  tiie  cases  are  due  to  the  four  first-mentioned  micro-organisms. 
I  have  already  spoken  of  the  pneumococcus  meningitis,  which  not  only 
occurs  in  connection  with  pneumonia,  but  as  an  independent  infection.  A 
nuijfU'itv  of  all  the  cases  of  so-called  sporadic  meningitis  are  probably  caused 
by 'it. 

The  streptococcus  meningitis  is  the  usual  form  in  the  cases  due  to 
trauma,  to  otitis  media,  and  in  septic  processes.  In  ulcerative  endocarditis 
it  is  not  uncommon;  it  occurred  in  25  of  809  collected  cases. 

The  terminal  meningitides  are  caused  by  the  streptococci,  sometimes 
by  staphylococci. 

Morbid  Anatomy. — The  basal  or  cortical  meninges  may  be  chiefly 
attacked.  The  degree  of  involvement  of  the  spinal  meninges  varies.  In 
the  form  associated  with  pneumonia  and  ulcerative  endocarditis  the  disease 
is  bilateral  and  usually  limited  to  the  cortex.  In  extension  from  disease  of 
the  ear  it  is  often  unilateral  and  may  be  accompanied  with  abscess  or  with 


APFRf'TTONS  OP  TRE  MENINOES. 


on  5 


lis  condition, 
from  um}n- 

Iio  fli'Ht  it  is 

;k  and  arms; 

ruc'toristic  of 
distinguiyli; 

orcMir  at.  any 
ingitis  Inviii- 
prodncx'  tiic 
coexist  with 
1  with  hcem- 


eningilis). 

lie  two  most 
ditions  with 
})articnlaiiy 
lox,  typlioid 
banes  of  Ihi' 
'  the  pel  rolls 
^rom  discasf 
ounding  the 
OSes  of  tlie 
le  iuiection 
infection  in 
he   wastinij 
reat  groups 
;  intraoellii- 
lo  hacilhis, 
id  hacillus, 
I  great  nia- 
-organigms. 
not  only 
'eetion.     A 
ibly  cauf^cd 

ses  due  to 
idocarditis 

sometimes 

be  chiefly 
varies.  In 
lie  disease 
disease  of 
ss  or  with 


thromltosis  of  the  Hinuses.  In  the  non-tuhercidous  fftrm  in  children,  in  the 
ineningitiH  of  chronic  liright's  diMcatie,  and  in  cachectic  conditions  the  huso 
is  usually  involved.  In  tlie  cases  secondary  to  pnenmonia  the  elVusion  he- 
neath  the  arachnoid  may  he  very  thick  am!  |>uridcnl,  completely  hiding 
the  convolutions.  The  ventricles  also  may  he  involved,  though  in  these 
simple  forms  they  rarely  present  the  distention  and  softening  which  is  so 
frecpient  in  the  tuberculous  meningitis.  For  a  more  detailed  description 
the  student  is  referred  to  the  sections  on  cerebro-spimd  fever  and  tubercu- 
lous meningitis. 

Symptoms. — 'The  clinical  features  of  meningitis  have  already  been 
described  at  length  in  the  diseases  just  referred  to,  and  I  shall  here  give  a 
general  summary.  1  have  already,  on  several  occasions,  called  attention  to 
the  fact  that  cortical  meningitis  is  not  to  be  recognized  by  any  sym|)toms 
or  set  of  symptoms  from  a  condition  which  may  be  produced  by  the  poison 
of  many  of  the  specific  fevers.  In  the  cases  of  so-called  cerebral  pneumonia, 
unless  the  base  is  involved  and  the  nerves  affected,  the  disease  is  unre(U)g- 
uizable,  since  identical  symi)toms  may  be  ])ro(luced  by  intense  engorgement 
of  the  meninges.  Jn  typhoid  fever,  in  which  meningitis  is  very  rare,  tue 
twitchings,  s])asnis,  and  retractions  of  the  neck  are  almost  invariably  as- 
sociated with  cerebro-spinal  congestion,  not  with  meningitis.  Actual  men- 
ingitis does,  however,  occur  in  typhoid  fever,  and,  as  Ohlmacher's  cases 
show,  the  ty|)hoid  bacilli  may  be  present  in  the  exudate. 

A  knowledge  of  the  etiology  gives  a  very  im])ortant  clew.  Thus,  in 
middle-ear  disease  the  development  of  high  fever,  delirium,  vomiting,  con- 
vulsions, and  retraction  of  the  head  and  neck  would  be  extremely  suggestive 
of  meningitis  or  abscess.  Headache,  which  may  be  severe  and  continuous, 
is  the  most  common  symptom.  While  the  patient  remains  conscious  this  is 
usually  the  chief  complaint,  and  even  when  semicomatose  he  may  continue 
to  groan  and  to  place  his  hand  on  his  head.  In  the  fevers,  particularly 
in  pneumonia,  there  may  be  no  complaint  of  headache.  Delirium  is  fre- 
quently early,  and  is  most  marked  when  the  fever  is  high.  Convulsions 
are  less  common  in  simple  than  in  tuberculous  meningitis.  They  were 
not  present  in  a  single  instance  in  the  cases  which  I  have  seen  in  pneu- 
monia, ulcerative  endocarditis,  or  septicaemia.  In  the  simple  meningitis 
of  children  they  may  occur.  E])ilei)tiform  attacks  which  come  and  go  are 
highly  characteristic  of  direct  irritation  of  the  cortex.  Kigidity  and  spasm 
or  twitchings  of  the  muscles  are  more  common.  Stiffness  and  retraction  of 
the  muscles  of  the  neck  are  important  sym])toms;  but  they  are  by  no  means 
constant,  and  are  most  frequent  when  the  inflammation  is  extensive  on  the 
meninges  of  the  cervical  cord.  There  may  be  trismus,  gritting  of  the  teeth, 
or  spastic  contraction  of  the  abdominal  muscles.  Vomiting  is  a  common 
symptom  in  the  early  stages,  particularly  in  basilar  meningitis.  Constipa- 
tion is  usually  present.  In  the  late  stages  the  urine  and  fa>ces  may  be 
passed  involuntarily.  Optic  neuritis  is  rare  in  the  meningitis  of  the  cortex, 
but  is  not  uncommon  when  the  base  is  involved.  Leube  lays  stress  on  the 
hyperaesthesia  of  the  skin  and  muscles,  especially  of  the  muscles  of  the  neck 
and  calves. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  base.    Stra- 


950 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


hiHtmis  or  ptosis  mny  occtir.  The  fnciiil  norvo  may  bo  involved,  pnxVicinj^ 
Hiiglit  paralysis,  or  tliiTt'  may  l»e  damage  to  tiie  lil'tli  nerve,  producing  an- 
ii'stliesia  and,  ii'  the  (Ja^aerian  ganglion  is  alVected,  trophic  changes  in  the 
cornea.  'I'he  jUipils  arc  at  first  eoiilraeted,  Huhsecpiently  dilated,  and  per- 
ha|)8  iinecjnal.  The  rellexes  in  the  extremities  arc  often  accentuated  at  the 
heginning  of  the  disease;  later  they  are  diminishe(l  or  entirely  abolished. 
Herpes  is  common,  particularly  in  the  epidemic  form. 

Fever  is  present,  moderate  in  grade,  rarely  rising  abovi'  lo;{".  In  the 
non-tuberculous  leptomeningitis  of  dei)ilitated  children  and  in  Hright's 
disease  there  may  be  little  or  no  fever.  The  pulse  may  be  increased  in  fre- 
qvney  at  lirst,  though  this  is  unusual.  Oiie  of  the  striking  features  of  the 
(1  sease  is  the  slowness  of  the  pulse  in  relation  to  the  tcm|)erature,  even  in 
the  early  stages.  Subse(iuently  it  mny  be  irregular  and  still  slower.  The 
very  rapid  emaciation  which  often  occurs  is  doubtless  to  be  rt'ferred  to 
a  disturbance  of  the  cerebral  inllui'nce  upon  metabolism.  The  spinal  men- 
inges are  so  often  alfected  simultaneously  that  lund)ar  ])uncture  is  exceed- 
ingly valuable  for  diagnosis.  Not  oidy  does  this  freipiently  prove  indis- 
putably the  existence  of  an  acute  meningitis,  l)ut  the  bneteriologieal  ex- 
amination may  decide  as  to  the  etiological  factor,  and  thus  yield  a  nmre 
rational  basis  for  treatment. 

Treatment. — There  are  no  remedies  which  in  any  way  control  the 
course  of  acute  meningitis.  An  ice-bag  should  be  applied  to  the  head  and, 
if  the  subject  is  young  and  full-blooded,  general  or  local  de))letion  may  be 
practised.  Absolute  rest  and  (piiet  should  be  enjoined.  "When  disease  of 
the  ear  is  jiresent,  a  surgeon  slioidd  be  early  called  in  consultation,  and  if 
there  are  symptoms  of  meningo-enccphalitis  which  can  in  any  way  be  local- 
ized trejthining  should  be  practised.  An  occasional  saline  ])urge  will  do 
more  to  relieve  the  congestion  than  blisters  and  local  de|)letion.  I  have 
no  ])clief  whatever  in  the  eflficacy  of  counter-irritation  to  the  back  of  the 
neck,  and  to  ai)ply  a  blister  to  a  ])atient  sufTering  with  agonizing  headiiche 
in  meningitis  is  needlessly  to  add  to  ihe  sufTering.  If  counter-irritation  is 
•deemed  essential,  the  thernio-cautery,  lightly  applied,  is  more  satisfactory. 
Large  doses  of  the  perchloridc  of  iron,  iodide  of  potassium,  and  mercury 
are  recommended  by  some  authors. 

The  application  of  an  ice-cap,  attention  to  the  bowels  and  stomach,  and 
keeping  the  fever  within  moderate  limits  by  sponging,  are  the  necessary 
measures  in  a  disease  recognized  as  almost  invariably  fatal,  and  in  which 
the  cases  of  recovery  are  extremely  doubtful.  Quincke's  lumbar  puncture 
(see  page  107)  has  ])een  used  as  a  therapeutic  measure  with  success  by  Fiir- 
bringcr;  fiO  cc.  of  cloudy  fluid  were  removed,  in  which  tubercle  bacilli  were 
found.  The  headache  and  other  cerebral  symptoms  disappeared,  and  the 
•patient,  a  man  of  twenty,  recovered.  Wallis  Ord  and  Waterhouse  report  a 
case  of  recovery,  in  a  child  of  five  years,  after  trephining  and  drainage. 


SCLEROSES  OF  THK    UliAIN. 


957 


L    |)r()(l'R'ill|r 

Dclucing  nn- 
ill<,'c.s  ill  the 
'<l,  and  |)('r- 
latcd  at  till' 
y  ubolisht'd. 

'3°.  In  Ihc 
in  Hright's 
ixuvd  in  I'ro- 
turos  of  the 
ire,  even  in 
owcr.  The 
rcrcrrcd  to 
'pinal  nion- 
3  is  oxci'cd- 
>rovo  indis- 
>l()^n('al  ox- 
old  a  more 

r'onlrol  the 
!  Iiead  and, 
ion  may  bo 
disease  of 
ion,  and  if 
ly  ho  local- 
Ko  will  do 
1.  I  have 
ack  of  the 
;:  hoadacho 
•ritation  is 
ilisl'aotory. 
d  mercury 

mach,  and 
necessary 
in  which 
puncture 

's  by  Fiir- 

icilli  were 
and  the 

e  report  a 

ainage. 


rusTKUiou  AIiiNiNorris  of  Infants  {Xon-lukirulouii  Leylomminijitis 

Inftiiitnin). 

This  form  lias  liccn  specially  stjulicd  l»y  (ice  and  iJarluw,  and  has 
boon  callcMl  occlusive  meningitis,  (loo  ciiilod  it  (rrrittil  njiislhittonos  of  in- 
lanls,  from  the  most  prominent  foaluro  of  llu;  disoiise.  A  careful  study 
has  boon  nuido  of  11  cases  by  .1.  W.  Carr.  In  all  casea  there  was  well- 
marked  distention  of  the  lateral  and  third  vcnfricli'S,  goiu'raily  of  the  fourth 
also,  with  '*  olfusion  of  lymph,  thickening  of  the  pia-araclinoid,  and  mal- 
ting of  the  parts  over  the  posterior  and  central  area  of  the  base  of  the  brain 
from  the  lower  end  of  the  nuHlulla  to  the  optic  commissure."  The  <lis- 
oase  is  most  common  in  infants  under  one  year.  In  only  ;{  cases  a  few 
Hakes  of  lym|)h  wore  found,  and  lU'ithor  the  choroid  ])lcxuscs  nor  the  cpou- 
doma  showed  naked-eye  appearaiurs  of  inllammation.  Head  retraction 
a]»penred  early  and  was  persistent  throughout,  being  absent  in  only  one 
case.  It  is  usually  much  more  nuirked  than  in  tuberculous  meningitis.  At 
a  com))arativcly  early  stage,  even  weeks  before  death,  the  infants  pass  into 
stupor  or  coiui)lete  coma.  This  form  is  sometimes  met  with  in  older  chil- 
dren. 

Chronic.  Lrplomcnivfjitis. — This  is  rarely  seen  apart  from  syphilis  or 
tuberculosis,  in  which  the  meningitis  is  associated  with  the  growth  of  the 
granuloniata  in  the  nuMiinges  and  about  the  vessels.  '^Pho  symptoms  in  such 
ciises  are  exlreiiu'ly  variable,  depending  enlirely  upon  the  situation  of  the 
growth.  They  may  closely  resemble  those  of  tximor  and  be  associated  with 
localized  convulsions.  The  c])idemic  meningitis  may  run  a  very  chronic 
course.  The  le]»tomeuingitis  infantiim  may  be  clironic.  In  the  cases  re- 
jtorted  by  (Joe  and  liarlow  the  duration  in  some  instances  extended  even  to 
a  year  and  a  half.  Quincke's  nicniii(/iUs  serosa  is  considered  with  hydro- 
cei»halus. 

II,    SCLEROSES   OF   THE    BRAIN. 

G-eneral  Hemarks. — The  connective  tissue  of  the  central  nervous 
system  is  of  two  kinds — one,  the  neuroglia,  s])ccial  and  peculiar,  derived 
from  the  ectoderm,  with  distinct  morphological  and  chemical  characters; 
the  otlier,  in  the  meninges  and  accompanying  the  blood-vessels,  derived 
from  the  mesoderm,  identical  with  the  ordinary  collagenous  fibrous  tissue 
of  th'!  body.  Both  play  important  parts  in  indurative  processes  in  the 
brain  and  cord.  A  convenient  division  of  the  cerehro-spinal  scleroses  is  into 
degenerative,  inflammatory,  and  developmental  forms. 

The  defjeiieratire  scleroses  comprise  the  largest  and  most  im])ortant  sub- 
division, in  which  provisionally  the  following  groups  may  be  made:  (a) 
The  common  secondary  degeneration  which  follows  when  nerve-fibres  are 
cut  off  from  their  trophic  centres  (the  severance  of  portions  of  neurones 
from  the  main  portions  containing  the  nuclei);  (h)  toxic  forms,  among  which 
may  be  i)laccd  the  scleroses  from  lead  and  ergot,  and,  most  important  of  all, 
the  sclerosis  of  the  dorsal  columns,  due  in  such  a  large  proportion  of  cases 
to  the  virus  of  syphilis.     Other  unknown  toxic  agents  may  possibly  induce 


DISKASKS  OF  THK  NKIIVOUS  SVSTKM. 


<lt'j,'('iu'ni(inii  (if  tlic  ncrvr-Cihrrs  in  (•crlaiii  tniclH.  Tlu'  syslciiiic  |(ii(liH  in 
tlu'  ciinl  tliilVr  ii|)|i)ir('iillv  in  liirir  Hiisct'ittiltilit)'  and  the  (IoihuI  i;olunins 
uppcur  nuiHt  inonc  to  under;;;))  this  cliango;  (r)  lin*  sclci-oHis  us.Hut'iatiMl 
with  change  in  the-  Hniallor  arlci'ii'H  ami  capillaries,  which  in  met  with  uh  a 
Kenih>  process  in  the  convoliitioiiH.  In  all  prohahility  some  of  the  forms  of 
insnlar  8clentsis  arc  due  to  primary  alterationH  in  the  lilood-vessels;  hut 
it  Ih  not  }el  Hcttled  whether  the  lesion  in  theHc  cuses  is  a  primary  degen- 
eration of  the  nerve  cells  ami  lilires  to  which  the  scdcroHirt  i8  Hceomlary,  or 
wild  her  the  essential  fact(»r  is  an  alteration  in  nutrition  cans(3(l  by  lesions 
of  the  capillaries  and  snudler  arteries. 

'I'he  iiifliiiiiniiihirij  scleroses  endirace  a  less  important  and  iesH  extenKivo 
group,  comprising  secondary  forms  which  develop  in  conse(|uenee  of  irri- 
tative inllammation  ahout  tumors,  foreign  bodies,  luemorrhages,  and  ahscess. 
Histologically  these  are  chielly  nusodcrmic  (vascular)  scleroses,  which  arise 
I'ntm  the  conni'divc  tissue  about  the  blood-vessels.  I'ossibly  a  similar 
change  may  follow  the  primary,  ucute  encephalitis,  which  Striimpell  holds 
is  the  initial  lesion  in  the  cortical  sclerosis  which  is  so  commonly  i\)uiul 
}iost  morl  m  in  infantile  hemiplegia. 

'IMie  tlerelopnienldl  sclercses  are  believed  to  l)e  of  a  purely  lu'iirogliar 
character,  and  embrace  the  lU'w  growth  about  the  central  canal  lU  syringo- 
myelia and,  according  to  recent  French  writers,  the  sclerosis  of  the  dor- 
sal columns  in  Friedreich's  ataxia.  It  is  stated  that  histologically  this 
form  is  dill'i  rent  from  the  ordimiry  variety.  It  nuiy  be,  too,  that  the  diU'use 
cortical  sclcrosi.s  met  with  as  a  congenital  condition  without  thickening 
of  the  iiu'ningcs  belongs  to  this  type.  It  is  not  improbable  that  many 
forms  of  scleroses  are  of  a  mixed  character,  in  which  both  the  ectodermic 
glia  and  niosodermic  connective  tissue  are  involved. 

Anatomically  we  meet  with  the  following  varieties: 

(1)  Miliary  sclerosis  is  a  term  which  has  been  ap|)lied  to  several  diirer- 
ent  conditions.  Gowers  mentions  a  case  in  which  there  were  grayish-red 
spots  at  the  jnnction  of  the  white  and  gray  matters,  and  in  which  the  neu- 
roglia was  increased.  '^Phere  is  also  a  condition  in  which,  on  the  surface 
of  the  convolutions,  there  arc  oinall  nodular  projections,  varying  from  a 
half  to  five  or  more  millimetres  in  diameter.  Single  nodules  of  this  sort 
are  not  uncommon;  sometimes  they  are  abundant.  So  fur  as  is  known  no 
symptoms  are  produced  by  them. 

(2)  DifTuse  sclerosis,  which  may  involve  an  entire  liemisphere,  or  a 
single  lobe,  in  which  case  the  term  sclerose  lubaire  has  heen  applied  to  it 
by  the  French.  It  is  not  an  important  condition  in  general  medical  prac- 
tice, but  occurs  most  frequently  in  idiots  and  ind^eciles.  In  extensive  cor- 
tical sclerosis  of  one  hemisphere  the  ventricle  is  usually  (lilated.*  The 
symptoms  of  this  condition  depend  upon  the  region  afTeeted.  There  may 
be  a  considerable  extent  of  sclerosis  without  symptoms  or  witliout  much 
mental  impairment.  In  a  majority  of  cases  there  is  hemiplegia  or  diplegia 
with  imbecility  or  idiocy. 


*  In  my  monopfraph  on  Ceretiral  Palsies  of  Cliijdren  I  liavo  piven  a  description  of  tlio 
distribution  of  the  sclerosis  in  ten  specimens  in  ttic  museum  at  the  Elwyn  Institution. 


io  putliM  ill 
111  coluiiiiiH 

assdi'iati'd 
t  with  tiH  a 
u'  roniis  dl" 
r't'Hsi'ls;  but 
iniy  (li'gfii- 
•iiiiilary,  ur 

by  Ifsiiiiis 

H  cxtciiKivi' 
let'  of  ini- 
11(1  abdci'ss. 
vliic'h  arise 
a  ^;illlilal' 
i|i('ll  lioid.-i 
inly  round 

Tic'iiro^iior 
II  .syriiit,'u- 
l'  llic  dor- 
t-aily  this 
die  difhiso 
liickoiiiii;; 
lilt  many 
t;todc'rniic 


ral  difTor- 
jiyi-sli-rc'd 
tlio  neu- 
e  surface 
f  from  a 
this  sort 
nown  no 

■re,  or  a 
i('(I  to  it 
cal  prac- 
sivo  cor- 
L*  The 
lore  may 
it  much 
diplegia 


HCLKIIOSKS  OF  TIIK   MliAIN. 


060 


ion  of  tlio 
:ution. 


(li)  Tuberous  Sclerosis.  -  III  tliis  remarkabU'  form,  whiili  Im  aUo  known 
as  hypcrlrophic  HcU'roHin,  then-  arc  on  tiic  convolutions  areas,  projcctinj^ 
licyond  the  surfaces,  of  an  opa(pie  white  I'olor  and  excci'din^dy  linn.  The 
i-clcrosis  may  not  disliirl)  Ihe  symnictiy  (d'  the  convoliilioii,  but  siiu'dy  caiiHc 
a  ^'reat  enlargement,  increase  in  the  density,  and  a  cban;,a'  in  the  eidor. 

These  three  forms  are  not  cd"  much  practical  iiiterewt  except  in  asylum 
and  inslitiilion  work.  The  hist  variety  forms  a  wcll-charaeterized  diseaHO 
of  cunsiderirble  importance,  namely: 

(I)  1nhi'i..\u  SciJWioHis  (Sch'rose  en  phqups). 

Definition. — A  chronic  alfcclion  of  the  brain  and  cord,  characteri/ed 
bv  localized  areas  i:i  which  Ihe  nerve  elements  an'  more  (U-  less  replaced  by 
conncetive  tissue,  'i'his  may  occur  in  the  brain  or  cord  a'one,  more  com- 
monly in  both. 

Etiolog^y. — This  is  obscure.  Kahler,  Marie,  and  others  assign  great 
importance  to  the  infectious  diseases,  particularly  scarlet  fever.  It  is 
found  most  commonly  in  young  persons,  and  eases  are  not  uncoiuinon  in 
children,  in  whom  I'ritchard  states  that  more  than  >)()  eases  have  been  re- 
ported. Sachs  has  recently  reviewed  the  whole  subject  (.Jour,  of  Xcrv.  and 
Mental  Diseases.  1S!»S). 

Morbid  Anatomy. — The  scl  ntic  nrons  are  widely  distributed 
through  the  brain  and  eord,  and  eases  limited  to  either  part  alone  are  almost 
unknown.  The  grayish-red  areas  are  scattered  inditrerently  through  the 
white  and  gray  matter  (Iv  W.  Taylor).  The  paiches  are  most  abundant 
in  the  neighborhood  of  the  ventricles,  and  in  the  pons,  cerebclluiii,  basal 
ganglia,  and  the  medulla.  The  cord  may  be  only  slightly  involved  or 
there  may  be  irregular  areas  in  diU'erent  regi(Uis.  The  cervical  region  is 
most  often  the  seat  of  nodules.  The  nerve-roots  and  Ihe  branches  of  the 
Cauda  ecpiina  are  often  attacki'd.  Histologically  in  the  sclerosed  patches 
tJii're  is  very  marked  proliferation  of  the  neuroglia,  the  fibri's  of  which  are 
denser  and  firmer.  The  gradual  growth  destroys  the  medulla  of  the  nerves, 
but  the  axis  cylinders  ])ersist  in  a  remarkable  way.  There  is  as  a  conse- 
(pience  relatively  little  secondary  degeneration  of  nerve  tracts. 

Symptoms. — The  onset  is  slow  and  the  disease  is  chronic.  Feeble- 
ness of  the  legs  with  irregular  pains  and  stilTness  are  among  the  early 
symptoms.  Indeed,  the  clinical  picture  may  be  that  of  spastic  paraplegia 
with  great  increase  in  the  reflexes.  The  following  are  the  most  im|)ortant 
fi'atures: 

(r;)  Vo1i({(wnl  Tremor  (>r  So-rnlird  luteiilinn  Tremor. — There  is  no  paraly- 
sis of  the  arms,  but  on  attempting  to  pick  up  an  olijei  t  there  is  trembling 
or  rapid  oscillation.  A  patient  may  bo  unable  to  lift  even  a  glass  of  water 
to  the  mouth.  The  tremor  may  he  marked  in  the  logs  and  in  the  head, 
whiv  ii  shakes  as  he  walks.  When  the  patient  is  recumbent  the  muscles  may 
be  perfectly  quiet.  On  attempting  to  raise  the  liead  from  the  pillow, 
trembling  at  once  comes  on.  {h)  Scanning  Speech. — The  words  are  pro- 
nounced slowly  and  separately,  or  the  individual  syllables  may  he  accentu- 
ated.    This  staccato  or  syllabic  utterance  is  a  common  feature,     (c)  Nys- 


900 


DISEASES  OP  THE  NERVOUS  SVSTEM. 


.  \ 
/ 


layniKs,  a  ra|)id  oscillatory  iiiovcnioiit  of  both  eyes,  constitutes  an  important 
syniptoMi. 

Sensation  is  unairected  in  a  majority  of  the  cases.  Optic  atrophy  some- 
times occurs,  hut  iu)t  so  fre(iucntly  as  in  tabes.  The  sphincters,  as  a  rule, 
are  unad'ccted  until  the  last  sta<i;es.  Mental  debility  is  not  uncommon. 
Henuukable  remissions  occur  in  the  course  of  the  disease,  in  which  for  a 
time  all  the  symptoms  may  imi)rove.  Vertigo  is'  connnon,  and  there  may 
be  sudden  attacks  of  coma,  such  as  occur  in  general  paresis. 

The  symjjtoms,  on  the  whole,  are  extraordinarily  variable,  corresponding 
to  tb     very  irregular  distribution  of  the  nodules. 

Tue  <//(///«(«('«  in  \vell-n\arke(l  cases  is  easy.  Volitional  tremor,  scan- 
ning speech,  and  nystagmus  form  a  characteristic  sym|)tom-group.  With 
this  there  is  usually  nunc  or  less  spastic  weakness  of  the  legs.  Paralysis 
agitans,  certain  cases  of  general  i)aresis,  and  occasionally  hysteria  may 
simulate  the  disease  very  closely.  If  the  case  is  not  seen  ur.til  near  the 
end  the  diagnosis  may  be  im})ossible.  Buzzard  holds  that  of  all  organic 
diseases  of  the  nervous  system  disseminated  sclerosis  in  its  early  stages  is 
that  which  is  most  conunonly  mistaken  for  hysteria.  The  points  to  be 
relied  upon  in  the  diU'erentiation  are,  in  order  of  importance,  the  nystag- 
mus, the  bladder  disturbances,  and  the  volitional  tremor.  The  tremor  in 
hysteria  is  not  volitional. 

Much  more  puzzling,  however,  are  the  instances  of  pseudo-scUrose  en 
plaqvrs,  which  have  been  described  by  West})hal.  French  writers  regard 
them  as  instances  of  hysterical  tremor.  In  children  the  condition  may 
"with  dilFiculty  be  separated  from  Friedreich's  ataxMa. 

The  profjnosis  is  unfavorable.  Ultimately,  the  patient,  if  not  carried 
ofT  by  sonu.'  intercurrent  alfection,  becomes  bedridden. 

Treatment. — No  known  treatuient  has  any  influence  on  Lhc  progress 
of  sclerosis  of  the  brain.  Neither  the  iodides  nor  mercury  have  the  slight- 
est elTect,  but  a  prolonged  course  of  nitrate  of  silver  may  be  tried,  and  ar- 
senic is  recommended. 


ill.    CHRONIC    DIFFUSE    MENINGO-ENCEPHALITIS 

{Dementia  Paralytica ;  General  Paresis). 

Definition. — A  chronic,  progressive  meningo-encephalitis  associated 
with  ])sychical  and  motor  disturbances,  finally  leading  to  dementia  and 
])ari;  lysis. 

Etiology. — IMales  are  affected  much  more  frequently  than  females. 
It  occurs  chiefly  between  the  ages  of  thirty  and  fifty-five.  Heredity  is  a 
factor  in  only  a  few  instances.  An  overwhelming  majority  of  the  cases  are 
in  married  people.  Statistics  show  that  it  is  more  common  in  the  lower 
classes  of  society,  but  in  this  country  in  general  medical  practice  the  dis- 
ease is  certainly  more  common  in  the  well-to-do  classes.  An  important 
predisposing  cause  is  "  a  life  absorbed  in  ambitious  ])r()jects  with  all  its 
strongest  mental  efforts,  its  long-sustained  anxieties,  deferred  hopes,  and 
straining  expectation  "  (Mickle).     The  habits  of  life  so  frequently  seen  in 


n  important 

rophy  somc- 
s,  as  a  rulo, 
uncommon, 
wliifl.  for  a 
1  there  may 


rrespondin 


einor,  souti- 
oup.  Witli 
.  I'araly.sis 
V'steria  may 
:il  near  tlu- 
all  opfijanit' 
ly  stages  is 
oints  to  bo 
the  nysta<^- 
2  tremor  in 

^-sclerose  en 
ters  regard 
ditiou  may 

not  carried 

le  progress 
the  slig'it- 
xl,  and  ar- 


ITIS 


associated 
entia  and 

females, 
edity  is  a 
I  cases  are 
the  lower 
c  the  dis- 
mportant 
th  all  its 
Dpes,  and 
y  seen  in 


CHRONIC  DIFFUSE  MENINGO-ENCEPHALITIS. 


061 


active  business  men  in  our  largo  cities,  and  well  cxprcs^sed  by  the  phrase 
'*  burning  the  candle  at  both  ends,"  strongly  i)redispose  to  the  disease. 
'JMie  important  individual  factor  is  sy|)hilis,  which  is  an  antecedent  in 
from  TO  to  DO  i)er  cent  of  all  cases.  To  this  disease  dementia  i)aralytica 
and  tabes  dorsalis  are  so  closely  related  that  Fournier  describes  them 
under  the  heading  Lcs  Affections  Parasi/phililiques.  J  lis  recent  work,  with 
this  title,  is  full  of  interesting  details  gleaned  from  an  enornujus  experi- 
ence, lie  snggests  that  these  two  disorders  nuiy  be  not  merely  diverse  ex- 
])rcssions  of  one  and  the  same  morbid  entity,  but  that  they  possibly  may 
be  one  and  the  same  disease. 

Morbid  Anatomy. — The  essential  histological  changes  in  the  cere- 
bral cortex  are  thus  summarized  by  Bovan  Lewis:  (1)  A  stage  of  inflam- 
matory change  in  the  tunica  adventitia  of  the  arteries  with  excessive  nu- 
clear proliferation,  profound  changes  in  the  vascular  channels,  and  trophic 
changes  induced  in  the  tissues  around. 

{'i)  A  stage  of  extraordinary  development  of  the  lymph-connective  sys- 
tem of  the  brain,  with  a  parallel  degeneration  and  disai)})earance  of  nerve 
elements  and  the  axis  cylinders  of  which  they  are  denuded. 

(3)  A  stage  of  general  fibrillation  with  shrinking  and  extreme  atrophy 
of  the  parts  involved. 

The  macroscopical  changes  are:  Increase  in  the  cerebro-spinal  fluid, 
codoma  of  the  pia,  and  thickening  and  opacity  of  the  meninges,  which  are 
adherent  in  places  and  tear  the  cortex  on  removal.  The  dura  is  sometinus 
thickened,  and  ])achymoningitis  "ha'morrhagica  interna  may  be  present. 

The  convolutions  are  atrophied,  usually  in  a  marked  degree,  and  in 
consequence  the  brain  looks  small.  '^I'his  is  particularly  noticeable  in  the 
frontal  and  ])arietal  regions.  Flochsig  suggests,  from  his  own  experience 
and  that  of  Tuczek,  that  the  different  types  met  with  are  dependent  upon 
the  localization  of  the  malady  in  given  cases,  predominantly  in  the  anterior 
or  in  the  ])osterior  ''  association  centre."  On  section  the  brain  cuts  with 
firmness.  In  extreme  cases  the  gray  matter  may  be  ob.scurcly  outlined. 
The  grade  of  sclerosis  varies  much  in  different  cases.  The  white  matter 
may  be  firmer  in  consistence,  but  it  does  not  show  such  important  changes. 
The  ventricles  are  dilated  and  the  opendyma  is  extremely  granular.  In 
addition,  there  arc  frequently  areas  of  softening  or  luemorrhage  associated 
with  chronic  arterio-sclerosis. 

The  degenerative  changes  are  not  limited  to  the  cortex,  but  also  invade 
subcortical  regions  and  the  spinal  cord.  In  the  spinal  cord  changes  are  al- 
most constantly  found,  usually  sclerosis  of  the  dorsal  fasciculi,  either  alone 
or,  more  commonly,  with  involvement  of  the  lateral. 

Symptoms. — (o)  Prodrr.mal  Stof/c. — This  is  of  variable  duration,  and 
is  characterized  by  a  general  mental  state  which  finds  exj)ression  in  syinp- 
toms  trivial  in  themselves  but  important  in  connection  with  others.  Irri- 
tability, inattention  to  business  amounting  sometimes  to  indifference  or 
apathy,  and  sometimes  a  chamje  in  cliaracter  marked  by  acts,  which  may 
astonish  the  friends  and  relatives,  may  be  the  first  indications.  There  may 
be  unaccountable  fatigue  after  moderate  ])hysical  or  mental  exertion.  In- 
stead of  apathy  or  indiU'crence  there  may  be  an  extraordinary  degree  of 


962 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


.  \ 
/ 


physical  and  mental  restlessness.  The  patient  is  continually  i)lanning  and 
Kcheniing,  or  may  launcii  into  extravagances  and  speculation  of  the  wildest 
character.  A  common  feature  at  this  period  is  the  display  of  an  im- 
bounded  egoism.  Jle  hoasts  of  his  i)ersonal  attainments,  his  property,  his 
position  in  life,  or  of  his  wife  and  children.  Following  these  features  are 
important  indications  of  moral  perversion,  manifested  in  oflences  against 
decency  or  the  law,  many  of  which  acts  have  about  them  a  suspicious 
ell'rontery.  Forget  fulness  is  common,  and  may  be  shown  in  inattention  to 
business  details  and  in  the  minor  courtesies  of  life.  At  this  period  there 
may  be  no  motor  phenomena.  The  onset  of  the  disease  is  usually  insidi- 
ous, although  cases  are  reported  in  which  epileptiform  or  a|)oplectiform 
seizures  were  the  first  symptoms.  Among  the  early  motor  features  are 
tremor  of  the  tongue  and  lips  in  speaking,  slowness  of  speech  and  hesi- 
tancy, iiUMpiality  of  the  pujjils,  and  the  Argyll  Ifohertson  j)ui)il. 

(b)  Second  St(uje. — This  is  characterized  in  brief  by  mental  exaltation 
or  excitement  and  a  progress  in  the  motor  symptoms.  "  The  intensity  of 
the  excitement  is  often  extreme,  acute  maniacal  states  are  frequent;  in- 
ce;<^ant  restlessness,  obstinate  sleeplessness,  noisy,  boisterous  excitement,  and 
blind,  uncalculating  violence  especially  characterize  such  states  "  (Lewis). 
It  is  at  this  stage  that  the  delusion  of  grandeur  becomes  marked  and  the 
l)atient  believes  himself  to  he  possessed  of  countless  millions  or  to  have 
reached  the  most  exalted  s})here  possible  in  profession  or  occupation.  This 
expansive  delirium,  as  it  is  called,  is,  however,  not  characteristic,  as  was 
formerly  sujjposed,  of  i)aralytic  dementia.  Besides,  it  does  not  always  oc- 
cur, but  in  its  stead  there  may  be  marked  melancholia  or  hypochondriasis, 
or,  in  other  instances,  alternate  attacks  of  delirium  and  depressi'm. 

The  facies  has  a  peculiar  stolidity,  and  in  speaking  there  is  marked 
trcmulousness  of  the  lips  and  facial  muscles.  The  tongue  is  also  tremu- 
lous, and  may  be  ])rotruded  with  difficulty.  The  speech  is  slow,  inter- 
rupted, and  blurred.  Writing  becomes  difficult  on  account  of  unsteadi- 
ness of  the  hand.  Letters,  syllables,  and  words  may  be  omitted.  The  sub- 
ject matter  of  the  patient's  letters  gives  valuahle  indications  of  the  mental 
condition.  In  many  instances  the  pupils  are  unequal,  irregular,  sluggish, 
sometimes  large.  Important  symptoms  in  this  stage  are  apoplectiform 
seizures  and  paralysis.  There  may  be  slight  syncopal  attacks  in  which  the 
patient  turns  pale  and  may  fall.  Some  of  these  are  petit  mal.  In  the  true 
apoplectiform  seizure  the  patient  falls  suddenly,  becomes  unconscious,  the 
limbs  are  relaxed,  the  face  is  flushed,  the  breathing  stertorous,  the  tem- 
perature increased,  and  death  nay  occur.  The  epileptic  seizures  are  more 
common  than  the  apoplectiform  and  may  occur  in  the  disease.  A  definite 
aura  is  not  uncommon.  The  attack  usually  begins  on  one  side  and  may  not 
spread.  There  may  be  twitchings  either  in  the  facial  or  brachial  muscles. 
Typical  Jacksonian  epilepsy  may  occur.  In  a  case  which  died  recently 
under  my  care,  these  seizures  were  among  the  early  symptoms  and  the  dis- 
ease was  regarded  as  cerebral  syphilis.  Paralysis,  either  monoplegia  or 
liemiplegic,  may  follow  these  epileptic  seizures,  or  may  come  on  with  great 
suddenness  and  be  transient.  In  this  stage  the  gait  becomes  impaired,  the 
patient  trips  readily,  has  difficulty  in  going  up  or  down  stairs,  and  the  walk 


nl 


III 
I'll 

TIM 

^}\ 

J 

ill 
is| 
pil 
till 


CnRONIC  DIFFUSE  MENINGO-ENCEPIIALITIS. 


9G3 


inning  and 
the  wildest 
ol"  an  un- 
opcrty,  his 
i.'atures  aro 
-OS  against 

susj)icioii.s 
ttcntion  to 
n-iod  there 
illy  insidi- 
ploctiforni 
aturcs  are 

and  hesi- 

oxaltation 
itensity  of 
juent;  in- 
nient,  and 
'  (Lewis). 
1  and  the 
r  to  have 
on.  This 
c,  as  was 
Iways  oc- 
ondriasis, 
)n. 

marked 
10  tromu- 
w,  inter- 
unsteadi- 
The  siib- 
e  mental 
sluggish, 

ctiform 
hich  the 
the  true 
ous,  the 
he  tem- 
ire  more 

definite 
may  not 
muscles, 
recently 
the  dis- 
Icgic  or 
th  great 
red,  the 
he  walk 


may  ho  spastic  or  nccasioiudly  t.abetic.  This  paresis  may  he  progressive. 
The  knee-jerk  is  usually  increased.  Bladder  or  rectal  Mniptonis  gradually 
develop.  The  patient  becomes  heli)less,  bedridden,  and  conii)letely  tle- 
jiiented,  and  unless  care  is  taken  may  suH'er  from  bedsores.  Death  occurs 
from  exhaustion  or  from  some  intercurrent  affection.  The  absence  of  pain 
reaction  on  pressure  upon  the  ulnar  nerve  behind  the  elbow  (Uiernacki's 
symptom)  is  apparently  lujt  of  any  s[)ccial  value.  The  spinal-cord  features 
(if  dementia  j)aralytica  may  come  on  with  or  precede  the  menial  troubles; 
in  80  i)er  cent  of  the  cases  they  follow  them.  There  are  cases  in  which  one 
is  in  doubt  for  a  time  whether  the  sym])toms  indicate  tabes  or  domontiu 
])aralytica,  and  it  is  well  to  bear  in  mind  that  every  feature  of  i)re-ataxic 
tabes  nuiy  exist  in  the  early  stage  of  general  paresis. 

Diagnosis. — The  recognition  of  the  disease  in  the  earliest  stage  is  ex- 
tremely difhcult,  as  it  is  often  impossible  to  decide  that  the  slight  altera- 
tion in  conduct  is  anything  more  than  one  of  the  moods  or  phases  to  which 
most  men  are  at  times  subject.  The  following  description  by  Folsom  is 
an  admirable  presentation  of  the  diagnostic  characters  of  the  early  stage 
of  the  disease:  "  It  should  arouse  susi)icion  if,  for  instance,  a  strong,  healthy 
man,  in  or  near  the  prime  of  life,  distinctly  not  of  the  '  nervous,'  neurotic, 
or  neurasthenic  type,  shows  some  loss  of  interest  in  his  affairs  or  imi)aired 
faculty  of  attending  to  them;  if  he  becomes  varyingly  absent-minded,  heed- 
less, indifferent,  negligent,  apathetic,  inconsiderate,  and,  although  able  to 
follow  his  routine  duties,  his  ability  to  take  up  new  work  is,  no  matter  how 
little,  diminished;  if  he  can  less  well  command  mental  attention  and  con- 
centration, conception,  perception,  reflection,  judgincnt;  if  there  is  an  un- 
wonted lack  of  initiative,  and  if  exertion  causes  unwonted  mental  and 
physical  fatigue;  if  the  emotions  are  intensified  and  easily  cliange,  or  are 
excited  readily  from  trifling  causes;  if  the  sexual  instinct  is  not  reasonably 
controlled;  if  the  finer  feelings  are  even  slightly  blunted;  if  the  person  in 
question  regards  with  a  placid  apathy  his  own  acts  of  indifference  and 
irritability  and  their  consequences,  and  especially  if  at  times  he  sees  himself 
in  his  true  light  and  suddenly  fails  again  to  do  so;  if  any  symptoms  of 
cerebral  vaso-motor  disturbances  are  noticed,  however  vague  or  variable." 

There  are  cases  of  cerebral  syphilis  which  closely  simulate  dementia  para- 
lytica. The  mode  of  onset  is  important,  particularly  since  paralytic  symp- 
toms are  iisually  early  in  syphilis.  The  affection  of  the  speech  and  tongue 
is  not  present.  Epileptic  seizures  are  more  common  and  more  liable  to 
be  cortical  or  Jacksonian  in  character.  The  expansive  delirium  is  rare. 
While  symptoms  of  general  paresis  are  not  common  in  connection  with 
the  development  of  gummata  or  definite  gummatous  meningitis,  there  are, 
on  the  other  hand,  instances  of  paresis  which  follow  syphilitic  infection 
so  closely  that  an  etiological  connection  between  the  two  must  be  acknowl- 
edged. Post  mort'^m  in  such  cases  there  may  be  nothing  more  than  a 
general  arterio-scverosis  and  diffuse  meningo-encephalitis,  which  may  pre- 
sent nothing  distinctive,  but  the  lesions,  nevertheless,  may  be  caused  by 
the  syphilitic  virus.  There  are  certain  forms  of  lead  encephalopathy  which 
resemble  general  paresis,  and,  considering  the  association  of  plumbism  with 
arterio-sclerosis,  it  is  not  unlikely  that  the  anatomical  substratum  of  the 


964 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


.  \ 
/ 


discaso  may  result  from  this  poison.  Tumor  may  sometimes  simulate  pro- 
gressive paresis,  but  in  the  former  the  signs  of  general  inerease  of  the  intra- 
eranial  pressure  (pain  in  the  head,  ehoked  disks,  slowing  of  the  pulse-rate, 
projectile  vomiting)  are  usually  present. 

Prognosis. — The  disease  rarely  ends  in  recovery.  As  a  rule  the  prog- 
ress is  slowly  downward  and  the  case  terminates  in  a  few  years,  although 
it  is  occasionally  prolonged  ten  or  fifteen  years. 

Treatment. — The  only  hope  of  pernuinent  relief  is  in  the  cases  follow- 
ing syphilis,  which  should  be  placed  upon  large  doses  of  .udide  of  potas- 
sium. Careful  nursing  and  the  orderly  life  of  an  asylum  are  the  only 
measures  necessary  in  a  great  majority  of  the  cases.  For  sleeplessness  and 
the  epileptic  seizures  bromides  may  be  used.  Prolonged  remissions,  which 
are  not  uncommon,  are  often  erroneously  attributed  to  the  action  of  reme- 
dies. Active  treatment  in  the  early  stage  by  wet-packs,  cold  to  the  head, 
and  systematic  massage  have  been  followed  by  temporary  improvement. 


ly.   DIFFUSE  AND  FOCAL  DISEASES  OF  THE   SPINAL 

COED. 

I.   TOPICAL   DIAGNOSIS 

We  have  seen  that  a  lesion  involving  a  definite  part  of  the  gray  matter 
of  the  lower  motor  segment  is  accompanied  by  loss  of  the  power  to  per- 
form c(  ttuin  definite  movements.  A  disease,  such  as  anterior  polio-mye- 
litis, which  is  confined  to  the  gray  matter,  gives  as  its  only  symptom  a 
characteristic  lower-segment  paralysis.  The  muscles  paralyzed  reveal  the 
seat  of  the  lesion.  In  many  instances  a  transverse  section  of  the  spinal 
cord  is  involved  to  a  greater  or  less  extent;  if  complete,  there  is  lower-seg- 
ment paralysis  at  the  level  of  the  lesion.  If  the  muscles  so  paralyzed  are 
the  same  on  the  two  sides  of  the  body,  the  lesion  is  strictly  transverse,  for, 
obviously,  if  the  cord  is  involved  higher  on  one  side  than  on  the  other  the 
paralyzed  muscles  will  vary  accordingly.  Besides  the  i)aralysis  due  to  in- 
volvement of  the  lower  segment,  the  muscles  whose  centres  are  below  the 
lesion  may  also  be  jiaralyzed  by  the  involvement  of  the  upper  segment  in 
the  pyramidal  tract,  and  present  all  the  characteristics  of  such  a  paralysis. 
The  degree  of  the  paralysis  depends  upon  the  intensity  of  the  lesion  of  the 
pyramidal  tract,  and  varies  from  a  slight  weakness  in  the  flexion  of  the 
ankle  to  an  absolute  paralysis  of  all  the  muscles  below  the  lesion.  The 
sphincter  muscles  of  the  bladder  and  rectum  are  also  often  paralyzed. 

Sensory  symptoms  are  usually  less  prominent,  but  when  the  spinal  cord 
is  much  diseased  there  is  a  dulling  of  sensation  all  over  the  body  below  the 
lesion.  The  upper  border  of  disturbed  sensation  often  indicates  the  level 
of  the  disease,  especially  when  this  is  in  the  thoracic  region,  where  the  cor- 
responding motor  paralysis  is  not  easy  to  demonstrate.  It  is  to  be  noted 
that  the  anjrsthesia  docs  not  reach  quite  to  the  level  of  the  lesion:  thus 
if  the  fifth  thoracic  segment  be  involved,  the  anaesthesia  will  include  the 


iimilato  pro- 
of the  intra- 
0  pulso-rute, 

lie  the  prog- 
rs,  although 

cases  follow- 
le  of  potas- 
re  the  only 
lessness  and 
iions,  whitli 
on  of  renic- 
o  the  head, 
/enient. 


SPINAL 


?ray  matter 

iVXT  to  per- 

polio-mye- 

5ymptom  a 

reveal  the 

the  spinal 

lower-seg- 
•alyzed  are 
sverse,  for, 

other  the 
due  to  in- 
helow  the 
egment  in 

paralysis, 
iion  of  the 
on  of  the 
lion.  The 
lyzed. 
pinal  cord 
below  the 

the  level 
e  the  cor- 

be  noted 
?ion;  thus 
;clude  the 


TOPICAL  DIAGNOSIS. 


905 


area  supplied  l)y  the  sixth  segment,  but  not  that  supplied  by  the  fifth.  This 
is  due  to  the  overlapping  of  the  areas.  There  is  often  a  narrow  zone  of 
livpera'sthesia  above  the  anivsthetic  region. 

When  the  transverse  lesion  is  e()mi)lete  and  the  lower  part  of  tiie  cord  is 
cut  off  from  all  influence  from  above,  there  is  complete  sensory  and  motor 
paralysis,  and  the  deep  reflexes  instead  of  being  exaggerated  are  lost. 

The  different  reflexes  are  dependent  upon  difl'erL'ut  levels  of  the  cord 
(see  Starr's  table,  p.  !»05),  and  their  absence  or  presence  may  be  imi)ortant 
localizing  symptoms. 

Unilateral  Lesions. — The  motor  symptoms  which  follow  lesions  con- 
(ined  to  one  half  of  the  cross-section  of  the  spinal  cord  follow  the  same 
rules  as  those  given  for  transverse  lesions,  except  that  they  are  conflned  to 
one  side  of  the  body — that  is,  they  are  on  the  same  side  as  the  lesion. 

The  sensory  symptoms  are  peculiar.  On  the  side  corresi)onding  to  the 
disease — the  paralyzed  side — there  is  anaesthesia  corresponding  to  the  seg- 
inent  of  the  cord  involved;  above  this  there  is  a  narrow  zone  of  hypertcs- 
thesia,  but  below  this  there  is  no  diminution  in  the  senses  of  touch,  pain, 
or  temperature;  indeed,  there  is  often  hypcnesthesia.  The  muscular  sense, 
however,  is  impaired.  On  the  side  opposite  to  the  lesion  there  may  be  com- 
})lete  loss  of  the  sense  of  touch,  pain,  and  temperature,  or  it  may  only  in- 
volve one  or  two  of  these,  pain  and  temperature  usually  being  associated. 

The  following  table,  slightly  modified  from  Cowers,  illustrates  the  dis- 
tribution of  these  symptoms  in  a  complete  hemi-lesion  of  the  cord: 

Cord. 

Zone  of  cutaneous  hyperrpstliesia. 
Zone  of  cutaneous  anaesthesia, 
liower    segment    paralysis    with 
atrophy. 

Upper  segment  paralysis. 
Ilyperajstliesia  of  skin. 
Muscular  sense  impaired. 
Keflex   action   first   lessened  and 

then  increased. 
Temperature  raised. 


Muscular  power  normal. 
Loss  of  sensibility  of  skin. 
Muscular  sense  normal. 
Reflex  action  normal. 
Temperature  same  as  that  above 
lesion. 


It  is  only  in  exceptional  cases  that  all  these  features  are  met  with,  for  they 
vary  with  its  extent  and  intensity. 

This  combination  of  symptoms  was  first  recognized  by  Brown-Sequard, 
after  whom  it  has  been  named.  It  may  follow  tumors,  stab-wounds,  frac- 
ture and  caries  of  the  spine,  and  it  is  not  infrequently  associated  with 
syringomyelia  and  ha?morrhages  into  the  cord. 

The  explanation  of  the  disturbance  in  sensation  is  not  satisfactory,  and 
cannot  be  until  our  knowledge  of  the  paths  of  sensory  conduction  is  more 
accurate.  These  cases  have  convinced  most  clinicians  that  in  man  the 
paths  for  touch,  pain,  and  temperature  cross  in  the  middle  line  soon  after 
entering  the  spinal  cord,  and  proceed  toward  the  brain  in  the  opposite 
side,  while  that  for  muscular  sense  remains  in  the  dorsal  columns  of  the 


9G6 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


^^V' 


same  side.  We  Imvo  scon  tliat  anatomy  londs  some  support  to  tliis  viow. 
and  tliis  is  llic  explanation  that  is  usually  given.  Tlu;  expcrinK'nts  on 
animals  liavo  thrown  some  doubt  on  this  view,  especially  those  of  Mott  on 
mordteys,  wliich  seem  to  indicate  that  the  sensory  paths  for  the  most  part 
remain  on  the  same  side  of  the  cord. 


II.    AFFECTIONS    OF   THE    BLOOD-VESSELS. 

1.    CoNOIiSTIOX. 

Apart  from  actual  myelitis,  we  rarely  see  post  mortem  evidences  of  con- 
gestion of  the  spinal  cord,  and  when  we  do,  it  is  usually  limited  either  to  the 
gray  matter  or  to  a  definite  portion  of  the  organ.  There  is  necessarily, 
from  the  j)osture  of  the  body  post  mortem,  a  greater  degree  of  vascularity 
in  the  dorsal  portion  of  the  cord.  The  white  matter  is  rarely  found  con- 
gested, even  when  intlamed;  in  fact,  it  is  remarkable  how  uniformly  pale 
this  portion  of  the  cord  is.  The  gray  matter  often  has  a  reddish-pink  tint, 
but  rarely  a  deep  reddish  hue,  except  when  myelitis  is  present.  If  we  know 
little  anatomically  of  conditions  of  congestion  of  the  cord,  we  know  less 
clinically,  for  there  are  no  features  in  any  way  characteristic  of  it. 


2.    AxiEMIA. 

So,  too,  with  this  state.  There  may  he  extreme  grades  of  anosmia  of  the 
cord  without  symptoms.  In  chlorosis  and  pernicious  anannia  there  are 
rarely  symptoms  pointing  to  the  cord,  and  there  is  no  reason  to  suppose  that 
such  sensations  as  heaviness  in  the  limbs  and  tingling  are  especially  asso- 
ciated with  ana3mia. 

There  are,  however,  some  very  interesting  facts  with  reference  to  the 
profound  anaemia  of  the  cord  which  follows  ligature  of  the  aorta.  In  ex- 
periments made  in  Welch's  laboratory  by  Herter,  it  was  found  tliat  within 
a  few  moments  after  the  application  of  the  ligature  to  the  aorta  paraplegia 
came  on.  Paralysis  of  the  sphincters  developed,  but  less  rapidly.  This 
condition  is  of  interest  in  connection  with  the  occasional  rapid  develop- 
ment of  a  para])legia  after  profuse  htemorrhage,  iisually  from  the  stomach 
or  uterus.  It  may  come  on  at  once  or  at  the  end  of  a  week  or  ten  days, 
and  is  probably  due  to  an  anatomical  change  in  the  nerve  elements  similar 
to  that  produced  in  Herter's  experiments.  The  degeneration  of  the  dorsal 
columns  of  the  cord  in  pernicious  anemia  has  already  been  described. 


3.  Embolism  and  Thrombosis. 

Blocking  of  the  spinal  arteries  by  emboli  rarely  occurs.  It  may  bo  pro- 
duced experimentally,  and  Money  found  that  it  was  associated  with  chorei- 
form movements.  Thrombosis  of  the  smaller  vessels  in  connection  with 
endarteritis  plays  an  important  part  in  many  of  the  acute  and  chronic 
changes  in  the  cord. 


AFFECTIONS  OF  THE  nLOOD- VESSELS. 


907 


to  this  view. 
[K-'riinents  on 
e  ot"  .Mott  (111 
he  luu.st  imit 


LS. 


Mict's  of  con- 
eitlier  to  the 

iieces.sarily, 
f  vascularity 

fouiul  coii- 
ifonuly  palf 
ill-pink  tint, 
If  we  know 
3  know  less 
t. 


C7iiia  of  the 
there  are 
ij'pose  that 
ciallv  asso- 


nce  to  the 
a.  In  ex- 
hat  within 
paraplegia 
dly.  This 
d  develop- 
0  stomacli 
ten  days, 
its  similar 
the  dorsal 
ihed. 


ly  bo  pro- 
th  chorei- 
tion  with 
chronic 


4.  ExDAirnuiiTis. 

It  is  remarkable  how  fre(iuently  in  persons  over  lifty  tiie  arteries  of  the 
si)inal  cord  are  found  sclerotic.  The  following  forms  may  he  met  with: 
(1)  A  nodular  peri-arteritis  or  endarteritis  associated  with  syphilis  and 
sometimes  with  gummata  of  the  meninges;  (2)  an  arteritis  obliterans,  with 
great  thickening  of  the  intima  and  narrowing  of  the  lunu'ii  of  the  vessels, 
involving  chieily  the  medium  and  larger-sized  arteries.  Miliary  aneurisms 
or  aneurisms  of  the  larger  vessels  are  rarely  found  in  the  spinal  cord.  In 
the  classical  work  of  Leyden  but  a  single  instance  of  the  latter  is  mentioned. 

5.    ILUMORItllAGE  INTO  THE  SPINAL  MeMBRANES;   ILeMATORHIIACHIS. 

In  meningeal  apoplexy,  as  it  is  called,  the  blood  may  be  between  the 
dura  mater  and  the  spinal  canal — extra-meningeal  luemorrhage — or  within 
the  dura  mater — intra-meningeal  haunorrhage. 

(a)  Extra-meninin'nl  Jui'morrhaye  occurs  usually  as  a  result  of  trauma. 
The  exudation  may  be  extensive  without  compression  of  the  cord.  The 
blood  comes  from  the  large  plexuses  of  veins  which  may  surround  the  dura. 
The  rupture  of  an  aneurism  into  the  spinal  canal  may  produce  extensive 
and  rapidly  fatal  ha-morrhage. 

(b)  Inira-meningeal  hemorrhage  is  rather  more  common,  but  is  rarely 
extensive  from  causes  acting  directly  on  the  S])inal  meninges  themselves. 
Scattered  IhTUiorrhages  are  not  unfrequent  in  the  acute  infectious  fevers, 
and  I  have  twice,  in  malignant  small-pox,  seen  much  effusion.  Bleeding 
occurs  also  in  death  from  convulsive  disorders,  such  as  epilepsy,  tetanus, 
and  strychnia  ])oisoning.  The  most  extensive  luvmorrhages  occur  in  cases 
in  which  the  blood  comes  from  rupture  ^i  an  aneurism  at  the  base  of  the 
brain,  either  of  the  basilar  or  vertebral  artery.  In  several  cases  of  this  kind 
I  have  found  a  large  amount  of  blood  in  the  spinal  meninges.  In  ventricu- 
lar apoplexy  the  blood  may  pass  from  the  fourth  ventricle  into  the  s])inal 
meninges.  There  is  a  specimen  in  the  medical  museum  of  McGill  College 
of  the  most  extensive  intraventricular  hemorrhage,  in  which  the  blood 
passed  into  the  fourth  ventricle,  and  descended  beneath  the  s])inal  arach- 
noid for  a  considerable  distance.  On  the  other  hand,  lueinorrhage  into 
the  spinal  meninges  may  possibly  ascend  into  the  brain. 

The  symptoms  in  moderate  grades  may  be  slight  and  indefinite.  In 
the  non-traumatic  cases  the  haemorrhage  may  either  come  on  suddenly  or 
after  a  day  or  two  of  uneasy  sensations  along  the  spine.  As  a  rule,  the 
onset  is  abrupt,  with  sharp  pain  in  the  back  and  symptoms  of  irritation  in 
the  course  of  the  nerves.  There  may  be  muscular  spasms,  or  paralysis  may 
come  on  suddenly,  either  in  the  legs  alone  or  both  in  the  legs  and  arms. 
In  some  instances  the  paralysis  develops  more  slowly  and  is  not  complete. 
There  is  no  loss  of  consciousness,  and  there  are  no  signs  of  cerebral  dis- 
turbance. The  clinical  picture  naturally  varies  with  the  site  of  the  h<Tmor- 
rhage.  If  in  the  lumbar  region,  the  legs  alone  are  involved,  the  reflexes  m-iy 
be  abolished,  and  the  action  of  the  bladder  and  rectum  is  impaired.  If  in 
the  thoracic  region,  there  is  more  or  less  complete  paraplegia,  the  reflexes  are 


968 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


usually  rt'taiiu'd,  and  thtM-o  are  signs  of  ilisturbanio  in  the  thoracic  uerves, 
Buch  as  jfinllc  sensations,  jmins,  ant!  sonK'tinics  eruption  of  herpes.  In  the 
cervical  region  the  arms  as  well  as  the  legs  may  he  involved;  there  may 
be  diflicnlly  in  breathing,  still'iiess  of  the  ninscles  of  the  neck,  and  occa- 
sionally pupillary  symptoms. 

The  prognosis  depends  much  upon  the  cause  of  the  hajmorrhago.  Re- 
covery may  take  i)lacc  in  the  traumatic  cases,  and  in  those  associated  with 
the  infectious  diseases. 


C.  n.HMoiMiiiAoi':  INTO  Tiiio  SiTXAL  Coiti)  {II<('mntum!felia). 

Tt  is  nu)re  common  in  males  than  in  females,  and  at  the  middle  period 
of  life.  The  cases  have  followed  either  cold  and  exposure  or  ovcicxertion, 
and,  most  frequently  of  all,  traumatism.  It  is  most  frequent  in  the  lower 
cervical  region,  the  most  connnon  site  lor  dislocation  and  fracture  of  the 
B])ino.  It  occurs  also  in  tetanus  and  convulsions.  I  hemorrhage  into  the 
cord  may  follow  injuries  of  the  si)inal  column,  gun-shot  wouiuls,  etc.,  even 
when  the  cord  itself  has  not  been  touched  (II.  Cushing).  iraMuorrhagc  miy 
be  associated  with  tumors,  with  syringo-myelia,  or  with  myelitis;  it  is  often 
dilHcult  to  determine  whether  the  case  is  one  of  j)rimary  luBtnorrhage  with 
myelitis,  or  myelitis  with  a  secondary  Invmorrhage. 

The  anatomical  condition  is  very  varied.  The  cord  may  l)e  enlarged 
at  the  site  of  the  luvmorrhage,  and  occasionally  the  white  substance  may 
be  lacerated  and  blood  may  escape  beneath  the  meninges.  The  extravasa- 
tion is  chieily  in  the  gray  matter,  and  may  be  limited  or  focal,  or  very 
diffuse,  extending  a  considerable  distance  in  the  cord.  In  a  case  which 
occurred  at  the  Montreal  Cencral  Hospital  under  Wilkins  the  haMuorrhage 
occupied  a  position  opposite  the  region  of  the  fifth  and  sixth  cervical  nerves 
and  on  transverse  section  the  cord  was  occupied  by  a  dark-red  clot  measur- 
ing 13  by  5  mm.,  around  which  the  white  substance  formed  a  thin,  ragged 
wall.  The  clot  could  be  traced  upward  as  far  as  the  second  cervical,  and 
downward  as  far  as  the  fourth  thoracic  segment. 

The  sudden  onset  of  the  symptoms  is  the  most  characteristic  feature 
in  ha^mato"  elia.  The  loss  of  power  necessarily  varies  with  the  locality 
affected.  ^^  in  the  cervical  region,  both  arms  and  legs  may  be  involved; 
but  if  in  the  thoracic  or  lumbar,  there  is  only  paraplegia.  There  is  usually 
loss  of  sensation,  and  at  first  loss  of  reflexes.  Myelitis  frequently  develops 
and  becomes  extensive,  with  fever  and  trophic  changes.  The  condition 
may  rapidly  prove  fatal;  in  other  instances  there  is  gradual  recovery,  often 
with  partial  paralysis. 

The  diagnosis  may  be  made  in  some  instances,  particularly  those  in 
which  the  onset  is  sudden  after  injury,  but  there  is  great  diflRculty  in  dif- 
ferentiating ha>morrhagic  myelitis  from  certain  cases  of  haemorrhage  into 
the  spinal  meninges. 


AFFECTIONS  OF  THK  BLOOD-VESSELS. 


9CS) 


acic  norvct!, 

)c'.s.    In  the 

tlioro  luiiy 

,  und  offu- 

rliii«,'c.     Ito- 
t'iated  with 


lia). 

hllo  pt'riod 
•(-'loxLTtion, 
1  the  lower 

lire  of  tlie 
fe  into  tlie 
,  etc.,  even 
■I'll age  m\y 

it  is  often 
rhage  witli 

e  enlarged 
tance  may 
extravasa- 
.1,  or  very 
ase  which 
Mnorrhage 
cal  nerves 
t  nieasnr- 
n,  ragged 
vieal,  and 

c  featnre 
e  locality 
involved; 
is  usnally 
develops 
condition 
^ry,  often 

those  in 
y  in  dif- 
age  into 


7.  Caisson  DiskahI';  (Diirr's  I'unilysis;  Coinprcssrd  Air  Disrasi'). 

This  renjarl<al)ie  alFectinn,  found  in  divers  and  in  workers  in  (•iii>sons, 
is  characterized  hy  a  paraph-gia,  more  nirely  n  general  palsy,  wiiich  super- 
venes on  returning  from  the  compressed  atmosphere  to  the  surface. 

The  disease  lias  liccii  carcl'ully  studied  hy  the  I'Vench  writers,  l)y  \,oy- 
(len  and  Scliultze  in  (icrmany,  and  in  tiiis  country  particuhirly  l»y  \.  II. 
Smith.  It  has  heen  ma(h'  the  suhject  of  a  special  moiiograiih  hy  Sncll. 
'Die  i)ressure  must  he  more  tlian  that  of  three  atm()S[)heres.  The  sym|)toms 
are  especially  apt  to  come  on  if  the  change  from  the  high  to  the  ordinary 
atmospheri(;  pressure  is  ([uickly  made.  They  may  supervene  inuue(liately 
on  leaving  the  caisson,  or  they  may  be  delayed  for  several  hours.  In  the 
ndldest  form  there  arc  simply  pains  al)out  the  knees  and  in  the  legs,  often 
of  great  severity,  and  occurring  in  })aroxysms.  Abdominal  pain  and  vomit- 
ing are  not  uncommon.  The  legs  may  be  tender  to  the  touch,  and  the 
})atient  nuiy  walk  with  a  stiff  gait.  Dizziness  and  headache  nuiy  accompany 
these  neuralgic  symptoms,  or  may  occur  alone.  More  eommoidy  in  the 
severe  form  there  is  paralysis  both  of  motion  and  sensation,  usually  a  para- 
])legia,  but  it  may  be  general,  involving  the  trunk  ami  arms.  Mon()|)Iegia 
and  henii|»legia  are  rare.  In  the  most  extreme  instances  the  attacks  resem- 
ble apo])lexy;  the  i)atient  rapidly  becomes  conuitose  and  death  occurs  in  a 
few  hours.  In  the  case  of  paraplegia  the  outlook  is  usually  gf^od,  and  the 
paralysis  may  pass  off  in  a  day,  or  may  continue  for  several  weeks  or  even  for 
nu^nths. 

The  explanation  of  this  condition  is  by  no  means  satisfactory.  Several 
careful  autopsies  have  been  made.  In  Leyden's  case  death  occurred  on  the 
fifteenth  day,  and  in  the  thoracic  portion  of  the  cord  there  were  numerous 
foci  of  ha-morrhages  and  signs  of  an  acute  myelitis.  In  Schultze's  case 
death  occurred  in  two  and  a  half  months,  and  a  disseminated  myelitis  was 
found  in  the  thoracic  region.  In  both  cases  there  were  fissures,  and  appear- 
ances as  if  tissue  had  been  lacerated.  In  a  case  examined  on  the  third  day 
(Ziegler's  Beitriige,  185)'^)  this  condition  of  fissnring  and  laceration  was 
found.  It  has  been  suggested  that  the  symptoms  are  due  to  the  liberation 
in  the  spinal  cord  of  1)ubbles  of  nitrogen  which  have  been  absorbed  by  tiie 
blood  under  the  high  ])ressure,  and  the  condition  found  at  the  autopsies 
just  referred  to  is  held  to  favor  this  view. 

A  large  majority  of  the  cases  recover.  The  severe  neuralgic  pains  often 
require  morphia.  Inhalations  of  oxygen  and  the  use  of  compressed  air  have 
been  advised.  When  parajjlegia  develops  the  treatment  is  similar  to  that 
of  other  forms.  In  all  caisson  work  care  should  be  exercised  that  the  time 
in  passing  through  the  lock  from  the  high  to  the  ordinary  pressure  be  suffi- 
ciently prolonged.  Snell  lays  less  stress  on  this  than  on  the  proper  ventila- 
tion of  the  caisson. 


61 


970 


DISKASEH  OF  THE  NERVOUS  SYSTEM. 


III.    COMPRESSION    OF   THE    SPINAL   CORD 

(('omiiri'imion  MyeliliH). 

Definition.  -I iit('rriii)li(»ii  nl"  tlic  riiiiftioiirt  of  the  cord  by  slow  coin- 
])rfssi(iii. 

Etiology. — Curios  ol'  the  spine,  lu'w  growthrt,  uneiirism,  and  puras^ites 
arc  till.'  iiMporlaiit  cauwea  ol'  slow  conipri'ssion.  Caries,  or  I'ott's  disease,  as 
it  is  usually  called,  after  the  surj^feoii  who  first  described  it,  is  in  the  great 
majority  of  iiis(aiie((s  a  tuberculous  ail'ectioii.  In  a  few  cases  it  is  due  to 
syphilis  and  o(;casionally  to  extension  of  disease  from  the  pharynx.  Jt  js 
most  common  in  early  life,  but  may  occur  after  middle  age.  Jt  follows 
trauma  in  a  few  eases.  Compression  occasionally  results  from  aneurism  of 
the  thonuic  aorta  or  the  abdominal  aorta,  in  the  neighborhood  of  the  eadiac 
axis. 

Malignant  growths  frequently  cause  a  compression  paraplegia.  A  retro- 
peritoneal sarcoma  or  the  lyin[)hadenonuitous  growths  of  llodgkin's  disease 
nniy  invade  the  verteljra>.  J\Iore  commonly,  however,  the  involvement  is 
Hecoiidary  to  scirrhus  of  the  l)reast. 

Of  parasites,  the  echinococcus  and  the  cysficorcus  occasionally  occur  in 
th?  si)inal  canal.  For  a  masterly  consideration  of  the  whole  question,  par- 
ticidarly  from  a  surgical  staiulpoint,  Kocher's  monograph  is  all-important 
(Mitt.  a.  d.  (Jrenzgebiet.  der  Chir.  u.  d.  Med.,  ISDC,  Ud.  i). 

Symptoms. — These  may  be  considered  as  they  all'ect  the  bones,  the 
nerves,  and  the  cord. 

(1)  Vertebral. — In  malignant  diseases  and  in  aneurism,  erosion  of  the 
l)odies  may  take  place  without  producing  any  deformity  of  the  spine.  Fatal 
Invmorrhage  may  follow  erosion  of  the  vertebral  artery.  In  caries,  on  the 
other  hand,  it  is  the  rule  to  lind  more  or  less  deformity,  amounting  often 
to  angidar  curvature.  The  compression  is  largely  due  to  the  thickening 
of  the  dura  and  ihe  })rescncc  of  caseous  and  inflammatory  jjroducts  between 
this  membrane  and  the  bone.  The  compression  is  rarely  ])roduce(l  directly 
])y  the  bone.  Pain  is  a  constant  and,  in  the  case  of  aneurism  and  tumor,  an 
agonizing  feature.  In  caries,  the  spinal  ])rocesses  of  the  affected  vertebne 
are  tender  on  pressure,  and  pain  follows  jarring  movements  or  twisting  of 
the  spine.  There  nuiy  be  extensive  tuberculous  disease  without  much  de- 
formity, particularly  in  the  cervical  region. 

(2)  Nerve-root  Symptoms. — These  result  from  compression  of  the  nerve 
roots  as  they  pass  out  between  the  vertebrne.  A  cervico-hraehial  neuralgia 
may  be  an  early  symptom.  It  is  remarkable  how  frequently,  even  in  ex- 
tensive caries,  they  escape  and  the  patient  does  not  complain  of  radiating 
j^ains  in  the  distribution  of  the  nerves  from  the  affected  segment.  Pains 
are  more  common  in  cancer  of  the  spine  secondary  to  that  of  the  breast, 
and  in  such  cases  may  be  agonizing.  There  may  be  acutely  painful  areas — 
the  aiia'sfheaia  dolorofia.  in  regions  of  the  skin  which  are  anaesthetic  to  tac- 
tile and  ])ainful  impressions.  Tro])hic  disturbances  may  occur,  particularly 
herpes.  In  the  cervical  or  lund)ar  regions  pressure  on  the  ventral  roots 
may  give  rise  to  wasting  of  the  muscles  supplied  by  the  affected  nerves. 


I  slow  com- 

kI  pamsitcs 
3  di.sc'usL',  as 
n  the  great 
it  is  diiu  to 
•yiix.     It  is 

It    i'(jll(t\\S 

uu'iirisiii  nl' 
t'  tiic  ca'liae 

I.  A  retro- 
iii's  disL'aso 
jlvoniunt  is 

ly  occur  in 
est  ion,  j)ar- 
l-iniportant 

bones,  the 

<ion  of  the 
ine.  Fatal 
ics,  on  the 
iting  often 
tiiickcning 
ts  I)et\veen 
I'd  directly 

tumor,  an 
1  vertebra' 
wisting  of 

much  de- 

the  nerve 
neuralgia 
vcn  in  ex- 
radiating 
it.     Pains 
he  breast, 
ul  areas — 
tic  to  tac- 
irticularly 
tral  roots 
iierves. 


COMl'IlKSSION  OF  TlIK  SPINAL  CORD. 


071 


(3)  Cord  Symptoms. — {a)  Cervical  liajmi. — Xot  inrre(|UontIy  the  onries 
is  liigii  u|)  between  tiie  axiw  and  the  atlas  or  ix'tween  the  Intlcr  and  the  oc- 
cipital bone.  In  such  instances  a  retropiiaryngeal  al)scess  may  lie  present, 
giving  rise  to  dillicully  in  swallowing.  There  may  be  s|»asm  of  tlu'  cervical 
muscles,  tin.'  head  nuiy  be  fixed,  and  m<»v<'iuents  may  either  he  imposriblo 
or  cnuHU  great  pain.  In  a  case  of  this  kind  in  the  Montr(>al  (ieneral  Hos- 
pital movement  was  liahh;  to  be  followed  by  transient,  instantaneous  paraly- 
sis of  all  four  extremities,  owing  to  com|iression  of  the  cord.  In  one  of 
these  attacks  the  patient  died. 

In  the  lower  cervical  region  there?  may  be  signs  of  interference  with 
the  (;ili()-s|)inal  centre  and  dilatation  of  the  jjupils.  Occasionally  tl'icre  is 
Hushing  of  the  face  and  ear  of  one  side  or  unilateral  sweating.  Deformity 
is  not  HO  common,  but  healing  may  takt'  place  with  the  production  of  a 
callus  of  enormous  l)readth,  with  c()m|>lete  rigidity  of  the  neck. 

{b)  Thoracic  Ueyion. — The  deformity  is  hen;  more  marked  and  pressure 
symptoms  are  nu)re  common.  The  tiine  of  onset  of  the  paralysis  varies 
very  much.  It  may  be  an  early  symptom,  even  before  the  curvature  is 
manifi'st.  More  commonly  it  is  late,  occurring  nuiny  luwuths  after  the  cupvn- 
turc  has  developed.  The  paraplegia  is  slow  in  its  development;  the  patient 
at  first  feels  weak  in  the  legs  or  has  disturbance  of  sensation,  nund)nes8, 
tingling,  pins  and  needles.  The  girdle  sensation  may  be  marked,  or  severe 
pains  in  the  course  of  the;  intercostal  nerves.  Motion  is,  as  a  rule,  more 
(juickly  lost  than  sensation.  liastian's  symptom — abolition  of  the  rellexes — 
is  rarely  met  with  in  compression  from  caries.  I''inally,  there  is  complete 
int(!rrnption  with  the  production  of  paraplegia,  usually  of  the  spastic  type, 
with  exaggeration  of  the  reflexes.  This  may  ])ersist  for  months,  or  even 
for  more  than  a  year,  and  recovery  still  be  possible. 

(c)  Lumbar  Region. — In  the  lower  dorsal  and  lumbar  regions  the  symp- 
toms are  practically  the  same,  but  the  sphincter  centres  are  involved  and 
the  reflexes  are  not  exaggerated. 

Diagnosis. — Caries  is  by  far  the  most  fretpient  cause  of  .slow  com- 
pression of  the  cord,  and  when  there  are  external  signs  the  recognition  is 
easy.  There  are  cases  in  which  the  exudation  in  the  spinal  canal  between 
the  dura  and  the  bone  leads  to  compression  before  there  are  any  signs  of 
caries,  and  if  the  root  symptoms  are  absent  it  may  be  extremely  difficult 
to  arrive  at  a  diagnosis.  Janeway  has  called  attention  to  persistent  lum- 
bago as  a  symptom  of  importance  in  masked  Pott's  disease,  particularly 
after  injury.  Brown-Soquard's  paralysis  is  more  common- in  tumor  aiul  in 
injuries  than  in  caries.  Pressure  on  the  nerve  roots,  too,  is  less  fre(|uent 
in  caries  than  in  malignant  disea.se.  The  cervical  form  of  pachynu'uingitis 
also  produces  a  pressure  paralysis,  the  symptoms  of  which  have  already  been 
detailed.  Pressure  from  secondary  carcinoma  is  naturally  suggested  when 
spinal  sym])toms  follow  within  a  few  years  after  an  operation  for  cancer  of 
the  breast.  In  paraplegia  fcdlowing  tumor  of  the  vertebra  secondary  to 
cancer  of  the  breast,  and  in  the  erosion  of  the  spine  by  retrojieritoneal 
growths,  the  suffering  is  most  intense.  The  condition  has  been  well  termed 
parnplpf/ia  dolorosa.  I  have  seen  2  cases  in  which  the  breast  tumor  had 
not  been  recognized. 


972 


DISEASES  UF  TIIK   NKItVOUS  SYSTEM. 


/ 


Treatment.  —  In  (((inprcssioii  liy  aiicurism  or  tumor  llie  condition  id 
hopeless.  Ill  the  former  tiie  pains  are  ol'teii  not  very  severe,  hut  in  the 
hitter  ii'orpiiia  is  always  necessary.  On  the  other  hand,  (•oinpressi<»n  Ity 
earieH  is  often  siieeessfiilly  relieved  (!ven  after  the  paralysis  has  persisted 
for  a  loiij,'  jieriod.  When  caries  is  reco^nii/.ed  early,  rust  and  support  to 
the  spine  hy  the  various  methods  now  used  hy  sur^'eons  may  do  much  to 
prevent  the  onset  of  paraple^'ia.  When  paralysis  has  develo|)ed,  rest  with 
e.xteiisioii  gives  the  lust  hope  of  ret-overy.  It  is  to  he  reiiiemheretl  that 
restoration  may  occur  after  compression  of  the  cord  lias  lasted  for  many 
months,  or  even  more  than  a  year.  Cases  have  hoen  cured  hy  rest  alone; 
the  extradural  and  iiilliimiiiatory  products  are  ahsorhed  aii<I  the  caries  heals. 
The  most  brilliant  results  in  these  ca.^es  have  heeii  ohtuined  hy  sus|)ensi<in,  a 
method  introduced  hy  J.  K.  Mitchell  in  lH::i(!,  and  pursued  with  remarkable 
eucecss  hy  his  son,  Weir  Mitchell.  Durinjf  my  association  with  the  Inlirmary 
for  Nervous  Diseases  I  had  numerous  opportunities  of  witiiessiii<f  the  really 
remarkable  elTects  of  persistent  suspension,  even  in  apparently  desperate 
and  protracted  ('ases.  .MitcheH's  conclusions  are  that  sus|)eiision  sli(»uld 
he  employed  early  in  Pott's  disease;  that  used  with  care  it  enables  us  slowly 
to  lessen  the  curve;  that  in  the.se  eases  there  nui.t  be,  in  some  form,  a  re- 
placement of  tlu!  crumpled  tissues;  that  unless  there  's  ^reat  loss  of  power 
the  use  of  the  spine-car  or  chair  of  .J.  K.  Mitchell  enables  suspi'iision,  espe- 
cially in  children,  to  be  combined  with  some  e.xercise;  that  no  case  of  I'ott's 
disease  should  be  considered  desperate  without  its  trial;  that  suspension 
has  succeeded  after  failures  of  other  accepted  methods;  that  the  juill  prob- 
ably acts  more  or  less  directly  on  the  cord  itself,  and  that  the  gain  is  not 
explicable  merely  by  obvious  effects  on  the  angular  bone  curve;  that  the 
methods  of  extension  to  be  used  in  carious  cases  may  be  very  varied,  jiro- 
vided  only  we  get  active  extension;  that  the  plan  and  the  length  of  time 
of  extension  must  be  made  to  conform  to  the  needs,  endurance,  and  sensa- 
tion of  th'  '  idual  case.  It  may  be  months  before  there  are  any  signs 
of  inii)''  ...     In  protracted  cases,  after  suspension  has  been  tried  for 

nior'  ixiectoniy  may  be  considered,  and  has  in  some  instances  been 

suc< 

I'Jie  general  treatment  of  caries  is  that  of  tuberculosis — fresh  air,  good 
food,  cod-liver  oil,  and  arsenic.  Counter-irritutiou  in  these  instances  is  of 
doubtful  value. 

Lesions  op  the  Cauda  Equina  and  Conus  Medullaris. 

The  spinal  cord  extends  only  to  the  second  lumbar  Aa'rtebra.  Injury, 
tumors,  and  caries  at  or  below  this  level  involve  not  the  cord  itself,  but  the 
bundle  of  nerves  known  as  the  cauda  equina  and  the  terminal  portion  of 
the  cord,  the  conus  medullaris.  !Much  attention  has  been  given  to  lesions 
of  this  part.  The  whole  sidjject  is  admirably  discussed  in  Thorburn's  work. 
Fractures  and  dislocations  are  common  in  the  lumbo-.sacral  region,  tumors 
not  infrequently  '  volve  tlie  filaments  of  the  cauda  equina,  and  some  of 
the  nerves  may  1,      ntanglod  in  the  cicatrix  of  a  spina  bifida. 

In  a  fracture  or  dislocation  of  the  first  lumbar  vertebra  the  conus  me- 


audition  id 
hut  ill  the 
ir('Srti<m  hy 
s  persists  I 
support  to 
()  nuu'h  ti) 
,  rest  wilh 
hi'ivd   thill 

for  nuuiy 
ri'nt  aloui!; 
iirii'S  heals, 
spciision,  ;i 
rciuarkahlc 
)  Inliriuary 
;  the  really 
'  (k'spenitf 
ion  kI)ouI(I 
s  UH  tilowly 
t'orin,  a  rc- 
H  ol"  power 
iKion,  espe- 
<e  of  Toll's 
suspension 

])ull  proh- 
^txln  is  not 

;  tluit  the 

iried,  ])ro- 
th  of  time 
and  sensa- 

any  sif,nis 
1  tried  for 
mccs  been 

1  air,  good 
ances  is  of 


Rrs. 

I.  Injury, 
]f.  l)nt  the 
portion  of 
to  lesions 
irn's  work. 
)n,  tumors 
d  some  of 

conns  me- 


TUMOUS  OF  TIIK  SIMXMi  (OllD   AND   ITS   MKMHRANRS. 


0T.1 


duljaris  nuiy  he  compressed  witli  the  Ia>t  sacral  nerves  ^iven  oil'  from  it. 
In  a  case  ri-ported  hy  Kircliholf  thi-re  was  laceration  of  the  eonus  with 
(omplcte  |)aralysis  of  the  hhiddcr  and  rectum,  a  case  which  is  held  to  favor 
the  view  that  the  ano-vcsical  cenlri'  in  man  is  siiuaU'd  in  this  re;;ion  of  the 
cord.  'J'here  are  Hoveral  instaneea  on  record  in  which  injury  of  the  eauda 
i*|uimi  has  produced  ,aralysis  of  the  hiaddcr  and  rectum  alone,  sometimes 
with  a  sli<,dit  patch  of  luui'sthesia  in  the  lu-i^ddtorhood  of  the  coccyx  or  the 
pcriua'um.  More  commonly  hraru-hes  of  the  sacral  or  lumbar  nerve  roots 
aie  invidved,  producing  an  irregularly  distrihutcd  motor  and  si'usory  paraly- 
ses in  the  legs.  When  the  lumhar  nerve  roots  from  the  second  to  the  fifth 
are  compressed,  there  is  paralysis  of  the  muscles  of  the  legs,  with  the  ex- 
ception of  the  flexors  (d'  the  auKlcs,  the  pcroUici,  the  long  flexors  of  the 
toes,  and  the  intrinsic  muscles  of  the  feet,  and  loss  of  sensation  in  the  front, 
inner  and  outer  part  of  the  thighs,  the  inner  side  of  the  legs,  and  the  inner 
side  of  the  foot,  'i'he  sacral  roots  may  alone  he  involved.  Thus  in  a  ease 
which  r  have  reported  the  patient  fe'l  from  a  bridge  and  had  paralysis  of 
the  legs  and  of  the  bladder  and  rectum.  When  seen  sixteen  yi'ars  after  the 
injiny,  there  was  slight  weakness,  with  wasting  of  the  left  leg;  there  was 
complete  loss  of  the  function  in  the  ano-vesieal  and  genital  centres,  and 
ana'sthesia  in  a  strip  at  the  buck  part  of  the  thigh  (in  the  distribution  of 
the  snuUl  sciatic),  and  of  the  perina'um,  scrotum,  and  penis.  The  urethra 
was  also  insensitiv«. 

Starr's  table  and  Head's  figures,  given  in  the  general  introduction,  will 
])C  found  useful  in  determining  the  nerve  fibres  and  segments  involved  in 
these  eases  of  inju^-y  of  the  eauda  equina. 


IV.   TUMORS   OF   THE   SPINAL   CORD    AND    ITS 

MEMBRANES. 

New  growths  may  dev^lo])  in  the  cord  or  in  its  membranes,  or  may 
extend  into  them  from  the  spine.  The  first  two  alone  will  be  considered. 
Occasionally  lipoma  and  parasites  occur  in  the  extradural  space.  Within 
the  dura  fibromata,  sarcomata,  and  sy])hilitic  and  tuberculous  growths  are 
most  common.  Tn  the  cord  itself,  and  attached  to  the  pia  nuiter,  the  tu- 
berculons,  sypliilitic,  and  glioimitons  growths  are  most  frecpient.  Of  50 
cases  of  tumor  of  the  spinal  cord  and  its  envelopes,  analyzed  by  IMills  and 
Lloyd,  only  3  were  parasitic.  Of  these.  20  were  some  form  of  nco))lasni,  of 
which  sarcomata  were  most  common,  .5  were  gummatous,  and  4  tubercu- 
lous. ITerter  has  recently  reported  .3  cases  of  solitary  tul)ercle  in  the  cord, 
and  has  analyzed  others  from  the  literature.  Of  24  cases  in  which  the  age 
was  given,  15  occurred  between  the  ages  of  fifteen  and  thirty-five,  and  5 
before  the  fifth  year.  The  tumor  is  most  common  in  the  dorsal  and  lumbar 
regions,  and  is  usually  met  with  in  connection  with  tuberculous  lesions  else- 
where. 

The  anatomical  effects  of  tumor  are  very  varied.  Slow  compression 
is  usually  produced  by  growths  external  to  the  cord,  and  it  is  remarkable 
what  a  high  grade  cf  compression  the  cord  will  bear  without  serious  inter- 


9T4 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


ference  with  its  functions.  In  cases  of  prolonged  interruption  ascending 
and  descending  degenerations  occur.  Tumors  developing  within  the  cord 
may  lead  to  syringo-niyelia.  And,  lastly,  tumors  not  infrequently  excite 
intense  myelitis. 

Symptoms. — These  will  naturally  vary  a  good  deal  with  the  segment 
involved  and  with  the  degree  of  pressure  and  the  extent  of  implication  of 
tlie  nerve  roots. 

Within  the  cord  the  symptoms  are  those  of  a  gradually  progressing 
paraplegia,  which  may  at  first  have  the  picture  of  a  Brown-Sequard  paraly- 
sis. Atrophy  follows  the  involvement  of  the  ventral  cornua,  and  vaso- 
motor disturbances  may  be  marked.  The  rellexes  are  lost  at  the  level  of 
the  lesion,  but  if  this  be  in  the  thoracic  cord,  the  reilexes  are  retained  in  the 
legs.  TIh'  vmptoms  are  apt  to  be  complicated  with  those  of  acute  or  sub- 
acute myemis,  which  nuiy  completely  alter  the  clinical  picture.  Tumors 
of  the  s})inal  mend)ranes  are  characterized  by  the  early  onset  and  persist- 
ence of  the  root  sym])toms,  which  consist  of  radiating  pains,  the  girdle  sen- 
sation, and  hyi)era'sthesia,  or  ana'sthesia  in  various  portions  of  the  trunk. 
There  may  even  be  severe  pain  in  the  ana'sthetic  areas.  Irritation  of  the 
motor  roots  may  cause  spasm  of  the  muscles  supi)lied,  or  wasting  with 
paralysis.  The  para])legia  supervenes  some  time  after  the  occu  rence  of 
the  root  symjjtoms.  In  the  thoracic  region  the  level  of  the  growth  is  usu- 
ally accurately  defined  by  the  level  of  the  pain  and  the  condition  of  the 
reflexes. 

The  diagnosis  of  tumor  within  the  cord  is  sometimes  easy,  the  charac- 
teristic features  being  the  constancy  and  severity  of  the  root  symptoms  at 
the  level  of  the  growth  and  the  progressive  paralysis.  Caries  may  cause 
identical  symptoms,  but  the  radiating  i)ains  are  rarely  so  severe.  Cervical 
meningitis  simulates  tumor  very  closely,  and  in  reality  produces  identical 
eifects,  but  the  very  slow  progress  and  the  bilateral  character  from  the 
■outset  may  be  suflRcient  to  distinguish  it. 

In  chronic  transverse  myelitis  the  symptoms  may,  according  to  Gowers, 
simulate  tumor  very  closely  and  present  radiating  pains,  a  sense  of  con- 
striction, and  progressive  paralysis. 

The  nature  of  the  tumor  can  rarely  be  indicated  with  precision.  With 
a  marked  syphilitic  history  gumma  may  naturally  be  suspected,  and  with 
coexisting  tuberculous  disease  a  solitary  tubercle. 

Treatment. — If  the  possibility  of  syphilitic  infection  is  present  the 
iodide  of  potassium  should  be  giver  in  large  and  increasing  doses.  For 
the  severe  pains  counter-irritation  is  sometimes  beneficial,  particularly  the 
thermo-cautery;  morphia  is,  however,  often  necessary. 

In  a  few  instances  tumors  of  the  cord  or  of  the  membranes  are  amena- 
ble to  surgical  treatment.  The  removal  by  Horsley  of  a  growth  from  the 
spinal  membranes  was  one  of  the  most  brilliant  of  recent  o])erations. 

Ah/iccss  of  the  cord  is  a  rare  lesion,  of  which  only  3  or  4  cases  have  been 
described,  all  metastatic.    It  may  occur  without  meningitis. 


isccnding 

tlie  cord 

:ly  excite 


!  segment 
cation  of 


•ogressing 
•d  paraly- 
ind  vaso- 
e  level  of 
led  in  the 
tc  or  sub- 
Tumors 
d  persist- 
rjrdle  sen- 
he  trunk, 
on  of  the 
ting  with 
I  rence  of 
th  is  usu- 
[on  of  the 

lie  charac- 

iiiptoms  at 

nay  cause 

Cervical 

identical 

'rom  the 

Gowcrs, 
jc  of  con- 


:>n 


Witli 
and  with 

resent  the 
3ses.  For 
ularly  the 

re  amena- 
from  the 

fns. 
lave  been 


SYRINGOMYELIA.  975 


V.    SYRINGOMYELIA. 

Definition. — A  gliomatous  new  formation  about  the  central  canal  of 
llie  spinal  cord,  with  cavity  formation. 

Etiology  and  Morbid  Anatomy. — Syringomyelia  must  l)o  dis- 
tinguished from  dilatation  of  tlie  central  canal — hydromyeliis — slight 
grades  of  which  are  not  very  uncommon  either  as  a  congenital  condition  or 
as  a  result  of  the  ])ressure  of  tumors.  The  cavity  of  syringomyelia  has  a  vari- 
able extent  in  the  cord,  sometimes  running  tiie  entire  length,  but  in  many 
cases  involving  only  the  cervical  and  thoracic  regions  or  a  more  limited  area. 
It  is  usually  in  the  dorsal  ])ortion  of  the  cord  and  may  extend  only  into  o^q 
dorsal  cornu.  The  transverse  section  may  be  oval  or  circidar  or  narrow 
and  fissure-like.  It  varies  at  dilt'erent  levels.  'J'he  condition  is  now  re- 
garded as  a  (jliosis,  a  development  of  embryonal  neurogliar  tissue  in  wliicli 
luemorrhage  or  degeneration  takes  j)lace  with  the  formation  of  cavities. 

Of  190  cases,  133  were  in  men,  57  in  women  (Schlesinger).  A  large 
majority  of  the  cases  begin  before  the  thirtieth  year.  The  disease  has  been 
met  with  in  three  members  of  the  same  family. 

Symptoms. — The  clinical  features  are  extremely  comidex.  In  the 
classical  form  there  arc  irregular  pains,  chiefly  in  the  cervical  region;  mus- 
cular atrophy  develops,  which  may  be  confined  to  the  arms,  or  sometimes 
extends  to  the  legs.  The  reflexes  are  increased  and  a  spastic  condition 
develops  in  the  legs,  ritimately  the  clinical  picture  may  be  that  of  an  amy- 
otrophic lateral  sclerosis.  The  tactile  sensation  is  usually  intact  and  the 
muscular  sense  is  retained,  but  painful  and  thermic  sensations  are  not  recog- 
nized, or  there  may  be  in  rare  instances  complete  ana'sthesia  of  the  skin  and 
of  the  mucous  membranes  (Dejerine).  This  combination  of  loss  of  pain- 
ful and  thermic  sensations  with  paralysis  of  an  amyotrophic  type  is  re- 
garded as  pathognomonic  of  the  disease.  The  s])ecial  senses  are  usually 
intact  and  the  sphincters  uninvolved.  Trophic  troubles  are  not  uncom- 
mon. Owing  to  the  loss  of  the  pain  and  heat  sensations,  the  patients  are 
apt  to  injure  themselves.  Scoliosis  also  may  be  present  in  these  cases. 
The  loss  of  painful  and  thermic  impressions  is  due  to  the  fact  that  these 
pass  to  the  brain  in  the  peri-ependymal  gray  matter,  juirticularly  that  por- 
tion in  the  dorsal  roots,  which  is  almost  constantly  involved  in  syringo- 
myelia. The  tactile  sensation  is  retained  because  the  postero-lateral  column 
is  unf"'^olved. 

Scidesinger,  in  his  recent  monograph  (1895),  recognizes  the  following 
types:  (1)  With  the  classical  features  above  descril)ed,  which  may  begin 
in  the  cervical  Oi  lumbar  regions:  (2)  a  motor  type,  with  the  picture  of 
an  amyotrophic  or  a  spastic  paralysis — the  sensation  may  be  undisturbed 
for  years;  (3)  with  predominant  sensory  features,  simulating  hysterical 
hemiplegia,  or  with  general  pain  and  temperature  anaesthesia;  (4)  with 
pronounced  trophic  distur])ances — to  this  type  belong  the  cases  described 
as  Morvan's  disease,  an  affection  characterized  by  neuralgic  pains,  cuta- 
neous anaesthesia,  and  painless,  destructive  whitlows;  and  (5)  the  tabetic 
type,  either  a  combination  of  the  symptoms  of  tabes  in  the  lower,  and  of 


970 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


syrinponiyolia  in  tlic  upper  extremities,  or  a  pure  taljotic  symptom-coni- 
j»lc'.\,  (hie  to  invasion  by  the  gliosis  of  tlie  dorsal  cohnuns  (Oppenheiui). 
Arthropathies  oecur  in  about  lU  per  cent  of  the  cases. 

In  typical  cases  the  diajjnosis  is  easy.  The  combination  of  an  amyo- 
Irophic  paralysis,  the  j)icture  of  progressive  muscular  atrophy  of  the  Aran- 
Ducheime  type,  with  retention  of  tactile  and  loss  of  thermic  and  painful 
sensation,  is  probably  i)athognomonic  of  the  disease.  Of  aifections  with 
Avhich  it  may  be  confounded,  anti'sthctic  leprosy  is  the  most  important, 
since  the  ana'sthesia  and  the  wasting  nuiy  closely  simulate  it;  but,  as  a 
rule,  in  leprosy  troi)hie  changes  are  more  or  less  marked.  There  is  often 
loss  of  ])halanges  and  there  is  uo  characteristic  dissociation  of  sensory  im- 
pressions. 

VI.   ACUTE    MYELITIS. 


/ 


Etiology. — Acute  myelitis  results  from  many  causes,  and  may  alTect 
the  cord  in  a  limited  or  extended  portion — the  gray  matter  chiefly,  or  the 
gray  and  white  matter  together.  It  is  met  with:  (a)  As  an  independent 
all'ection  following  exposure  to  cold,  or  exertion,  and  leading  to  ra])id  loss 
of  ])ower  with  the  symptoms  of  an  acute  ascending  paralysis,  (h)  As  a 
sequel  of  the  infectious  diseases,  such  as  small-i)ox,  typhus,  and  measles, 
(f)  As  a  result  of  traumatism,  either  fracture  of  the  spino  or  very  severe 
muscular  effort.  Concussion  without  fracture  may  ])rodiice  it,  but  this  is 
rare.  Acute  myelitis,  for  instance,  scarcely  ever  follows  railway  accidents. 
((/)  In  diseases  of  the  bones  of  the  spine,  either  caries  ov  cancer.  This  is  a 
more  common  cause  of  localized  acute  transverse  myelitis  than  of  the  diffuse 
affection,  (c)  In  disease  of  the  cord  itself,  such  as  tumors  and  syphilis; 
in  the  latter,  cither  in  association  with  giimmata,  in  which  case  it  is  usually 
a  late  manifestation;  or  it  may  follow  within  a  year  or  eighteen  months  of 
the  primary  affection. 

Morbid  Anatomy. — In  localized  acute  myelitis  affecting  white  and 
gray  matter,  as  met  with  after  accident  or  an  acute  compression,  the  cord  is 
swollen,  the  ])ia  injected,  the  consistence  greatly  reduced,  and  on  incising 
the  membrane  an  almost  difTluent  fluid  may  escape.  In  less  intense  grades, 
on  section  at  the  affected  area,  the  distinction  between  the  gray  and  white 
matter  is  lost,  or  is  extremely  indistinct.  The  tissue  may  be  injected,  or, 
as  is  often  the  case,  luTmorrhagie.  It  is  particularly  in  these  forms,  due 
to  extension  of  disease  from  Avithout  or  to  acute  compression,  that  we 
find  definite  involvement  of  the  white  matter.  In  other  instances  the 
gray  matter  is  chiefly  affected.  There  may  be  localized  areas  throughout 
the  cord  in  which  the  gray  matter  is  reduced  in  consistence  and  ha>m- 
orrhagic,  the  so-called  red  softening.  There  may  be  definite  cavity  forma- 
tions in  these  foci.  In  some  cases  of  disseminated  or  focal  myelitis  the 
meninges  also  are  involved  and  there  is  a  myelomeningitis.  And,  lastly, 
there  are  instances  in  which,  throughout  a  long  secfion  of  the  cord,  some- 
times through  the  lumbar  and  the  greater  ])art  of  the  thoracic,  or  in  the 
thoracic  and  cervical  regions,  there  is  a  diffuse  myelitis  of  the  gray  sub- 
stance. 


ACUTE  MYELITIS. 


977 


iptom-com- 
ppenhfini). 

r  ati  ainyo- 
t  the  Araii- 
Liul  painful 
L'[ions  with 
important, 
;  but,  as  a 
ire  is  often 
it'usory  im- 


may  affoct 
etly,  or  tlu' 
idopondont 
I  rapid  loss 
(/>)  As  a 
id  measles, 
i'ery  severe 
but  this  is 

accidents. 

This  is  a 
the  diffuse 
-1  syphilis; 

is  nsually 
months  of 

white  and 

he  cord  is 

n  incising 

ise  grades, 

md  white 

ected,  or, 

)rms,  due 

that  we 

HI CCS  the 

rough  out 

lid  ha>m- 

y  forma- 

>litis  the 

],  lastly, 

d,  some- 

)r  in  the 

^rav  sub- 


nistologically  the  nerve  fibres  are  much  swollen  and  irregularly  dis- 
torted, the  axis  cylinders  arc  beaded,  the  myelin  droplets  are  abundant, 
and  the  laminated  bodies  known  as  corpora  amylacea  may  be  seen.  The 
granular  fatty  cells  are  also  numerous  and  there  may  be  leucocytes  and 
red  blood-coriHiscles.  Changes  in  the  blood-vessels  are  striking;  the  smaller 
veins  are  distended  and  may  show  varicosities.  The  perivascular  lymph 
S})aces  contain  numerous  leucocytes,  and  the  smaller  arteries  themselves 
are  frequently  the  seat  of  hyaline  thrombi.  The  ganglion  cells  are  swollen 
and  irregular  in  outline,  the  protoplasm  is  extremely  granular  and  vacuo- 
lated, and  the  nuclei,  though  usually  invisible,  may  show  signs  of  division, 
and  the  processes  of  the  cells  are  not  seen. 

In  cases  which  ])ersist  for  some  time  we  have  an  opportunity  of  seeing 
the  later  stages  of  acute  myelitis.  The  acute,  intlamnuitory,  hypericmic  or 
red  softening  is  succeeded  by  stages  in  which  the  affected  area  becomes 
more  yellow  from  gradual  alteration  of  the  blood-pigment,  and  finally  white 
in  color  from  the  advancing  fatty  degeneration.  In  cases  of  C()m])ression 
myelitis,  a  sclerosis  may  gradually  be  produced  with  the  anatomical  j)icture 
of  a  chronic  diffuse  myelitis. 

Symptoms.— («)  Anite  Central  Myelitis. — Tt  is  this  form  which 
comes  on  spontaneously  after  cold,  or  in  connection  with  syphilis  or  one 
of  the  infectious  diseases,  or  is  seen  in  a  typical  manner  in  the  extension 
from  injuries  or  from  tumor.  The  onset,  though  scarcely  so  abrupt  as  in 
haMuorrhage,  may  be  sudden;  a  person  may  be  attacked  on  the  street  and 
have  difficulty  in  getting  home.  In  some  instances,  the  onset  is  ])receded 
by  pains  in  the  legs  or  back,  or  a  girdle  sensation  is  present.  It  may  be 
marked  by  chills,  occasionally  by  convulsions;  fever  is  usually  present  from 
the  beginning — at  first  slight,  but  siibsequcntly  it  may  become  high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  quickly  as  in  Lan- 
dry's .iScending  paralysis.  The  parai)legia  may  be  complete,  and,  if  the 
myelitis  extends  to  the  cervical  region,  there  may  be  impairment  of  mo- 
tion, and  ultimately  complete  loss  of  power  of  the  uj)per  extremities  as 
well.  The  sensation  is  lost,  but  there  may  at  first  be  hypera\sthesia.  The 
reflexes  in  the  initial  stage  are  increased,  but  in  acute  central  myelitis,  un- 
less limited  in  extent  to  the  thoracic  and  cervical  regions,  the  reflexes  are 
usually  abolished.  The  rectum  and  bladder  are  paralyzed.  Trophic  dis- 
turbances are  nwrked;  the  muscles  waste  rapidly;  tlic  skin  is  ofteia  con- 
gested, and  there  may  be  localized  sweating.  The  temperature  of  the 
affected  limbs  may  be  lowered.  Acute  bed-sores  may  develop  over  the  sacrum 
or  on  the  heels,  and  sometimes  a  multiple  arthritis  is  present.  In  these 
acute  cases  the  general  symptoms  become  greatly  aggravated,  the  pulse 
is  rapid,  the  tongue  becomes  dry;  there  is  delirium,  the  fever  increases,  and 
may  roach  107°  or  108°. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  follows 
in  from  five  to  ten  days.  The  cases  following  the  infectious  diseases,  par- 
ticidarly  the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  diagnosis  of  this  variety  of  acute  myelitis  is  rarely  difficult.  In 
common  Mith  the  acute  ascending  paralysis  of  Landry,  and  with  certain 
cases  of  multiple  neuritis,  it  presents  a  rapid  and  progressive  motor  paraly- 


978 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


sis.  From  the  former  it  is  (listinj^uislied  by  the  more  marked  involvement 
of  sensation,  the  tropliie  disturl)iinees,  the  paralysis  of  bladder  and  rectnni, 
the  Tii]m\  wasting',  the  eleetrical  chanffcs,  and  the  fever.  From  acute  eat-eti 
of  multiple  neuritis  it  nuiy  be  more  diflicult  to  distinguish,  as  the  sensory 
features  in  these  eases  nuiy  be  nuirked,  though  there  is  rarely,  if  ever,  in 
multi[)le  neuritis  complete  ana'sthesia;  the  wasting,  moreover,  is  more  ra])id 
in  myelitis.  The  bladder  and  rectum  are  rarely  involved — though  in  e.\- 
eeptiojuil  cases  they  nuiy  be — and,  most  important  of  all,  the  tro])hic 
changes,  the  develoimient  of  bulla?,  bed-sores,  etc.,  are  not  seen  in  multiple 
neuritis. 

(h)  Acute  Transverse  MycVilis. — The  symi)toms  naturally  differ  with  the 
situation  of  the  lesion. 

(1)  Acute  transverse  myelitis  in  the  thoracic  rcf/ion,  the  most  common 
situation,  ])ro(hu'es  a  very  characteristic  picture.  The  symptoms  of  onset 
are  variable.  There  may  be  initial  pains  or  numbness  and  tingling  in  the 
legs.  The  paralysis  may  set  in  quickly  and  become  complete  within  a 
few  days;  but  more  conmionly  it  is  jireceded  for  a  day  or  two  by  sensa- 
tions of  pain,  heaviness,  and  dragging  in  the  legs  The  paralysis  of  the 
lower  limbs  is  usually  complete,  and  if  at  the  level,  ay,  of  the  sixth  thoracic 
vertebra,  the  abdominal  muscles  are  involved.  Sensation  may  be  partially 
or  com])letely  lost.  At  the  onset  there  may  be  numbness,  tingling,  or  even 
hyperajsthesia  in  the  legs.  At  the  level  of  the  lesion  there  is  often  a  zone 
of  hypera^sthesia,  which  is  discovered  by  passing  a  test-tube  containing  hot 
water  along  the  spine,  when  the  sensation  of  warmth  changes  to  one  of 
actual  ])aiii.  A  girdle  sensation  may  occur  early,  and  when  the  lesion  is  in 
this  situation  it  is  usually  felt  between  the  ensiform  and  umbilical  regions. 
The  retlex  functions  are  variable.  There  may  at  first  be  abolition  of  the 
reflexes;  subsequently,  the  reflexes,  which  pass  through  the  segments  lower 
than  the  one  affected,  may  be  exaggerated  and  the  limbs  may  take  on  a 
condition  of  spastic  rigidity.  It  does  not  always  happen,  however,  that  the 
reflexes  are  increased  in  a  total  transverse  lesion  of  the  cord.  They  may  be 
entirely  lost,  as  first  pointed  out  by  Bastian.  That  this  is  not  due  to  the 
preliminary  shock  is  shown  by  the  fact  that  the  abolition  of  the  reflexes 
may  continue  for  four  or  more  months.  The  trophic  changes  are  not 
marked.  The  muscles  become  extremely  flabby,  but  not  wasted  in  an  ex- 
treme degree;  subsequently  rigidity  develops.  If  the  gray  matter  of  the 
lumbar  cord  is  involved,  the  flaccidity  persists  and  the  wasting  may  be 
considerable.  The  reaction  of  regeneration  is  not  present.  The  tempera- 
ture of  the  paralyzed  limbs  is  variable.  It  may  at  first  rise,  then  fall  and 
become  subnormal.  Lesions  of  the  skin  are  not  uncommon,  and  bed-sores 
are  apt  to  form.  There  is  at  first  retention  of  urine  and  subsequent  incon- 
tinence. If  the  lumbar  centres  are  involved,  there  are  from  the  outset 
vesical  symptoms.  The  urine  is  alkaline  in  reaction  and  may  rapidly  be- 
come ammoniacal.  The  bowels  are  constipated  and  there  is  usually  incon- 
tinence of  the  faces.  Some  writers  attribute  the  cystitis  associated  with 
transverse  myelitis  to  disturbed  trophic  influence. 

The  course  of  complete  transverse  myelitis  depends  a  good  deal  upon 
its  cause.    Death  may  result  from  extension.     Segments  of  the  cord  may 


(1 

d 

n 

r( 

fli 

ti 

ni 

si 


nvolvcmcnt 

liul    R'Ctlllll, 

acute  ca!^c'8 
tlio  sensory 
if  over,  in 
more  ra])i(l 
)ugli  in  ex- 
tlie  troj)liic 
in  multiple 

cr  with  the 

st  common 
ns  of  onset 
:lin<^  in  the 
e  within  a 
3  l)y  sensa- 
lysis  of  the 
til  thoracic 
je  partially 
n<r,  or  even 
I'ten  a  zone 
taining  Jiot 
to  one  of 
lesion  is  in 
nil  regions. 
;ion  of  the 
lents  lower 
take  on  a 
r,  that  the 
ey  may  he 
lue  to  the 
le  reflexes 
s  are  not 
in  an  ex- 
ter  of  the 
g  may  be 
tempera- 
1  fall  and 
bed-sores 
nt  incon- 
lie  outset 
ipidly  be- 
lly incon- 
ited  with 

eal  upon 
cord  may 


TOPICAL  DIAGNOSIS. 


970 


be  comi)letely  and  permanently  destroyed,  in  which  case  there  is  persistent 
jiaraplegia.  'J'he  })yramiilal  libres  below  the  lesion  uiulergo  tiie  secondary 
degeneration,  and  there  is  an  ascending  degeneration  ol  the  dorsal  me- 
dian columns.  If  the  lower  segments  of  the  cord  are  involved  the  legs 
may  remain  ilaccid.  In  some  instances  a  transverse  myelitis  of  the  tiioracic 
region  involves  the  ventral  horns  above  and  l>"low  the  lesion,  i)roducing 
liaccidity  of  the  muscles,  with  wasting,  fibrillar  contractions,  and  the  reac- 
tion of  degeneration,  ^lore  commonly,  however,  in  the  cases  which  last 
many  months  there  is  more  or  less  rigidity  of  the  muscles  with  si)asm  or  per- 
sistent contraction  of  the  flexors  of  the  knee. 

(2)  Transverse  Myelilis  of  the  Cervical  liei/iuii. — If  the  lesion  is  at  the 
level  of  the  sixth  or  seventh  cervical  nerves,  there  is  j)aralysis  of  the  upper 
extremities,  more  or  less  comj)lete,  sometimes  sjjaring  the  muscles  of  the 
shoulder.  (Jradually  there  is  loss  of  sensation.  T'  e  i)aralysis  is  usually 
complete  below  the  point  of  lesion,  but  there  are  rare  instances  in  which  the 
arms  only  are  affected,  the  so-called  cervical  i)arai)legia.  In  addition  to  the 
symptoms  already  mentioned  there  are  several  which  are  more  characteristic 
of  transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of 
vomiting,  hiccough,  and  slow  i)ulse,  which  may  sink  to  20  or  30,  pupillary 
changes — myosis — sometimes  attacks  of  dys[)hagia,  dyspnoea,  or  syncoi)c. 

Treatment  of  Acute  Myelitis. — In  tlie  rapidly  develo])ing  form 
due  either  to  a  diffuse  inflammation  in  the  gray  matter  or  to  transverse 
myelitis,  the  imi)ortant  measures  are:  Scrupulous  cleanliness,  care  and 
watchfulness  in  guarding  against  bed-sores,  the  avoidance  of  cystitis,  either 
by  systematic  catheterization  or,  if  there  is  incontinence,  by  a  carefully 
adjusted  bed  urinal,  or  the  use  of  antiseptic  cotton-wool  repeatedly  changed. 
In  an  acute  onset  in  a  healthy  subject  the  spine  may  be  cupi)ed.  Counter- 
irritation  is  of  doubtful  advantage.  Chapman's  ice-bag  is  sometimes  useful. 
No  drugs  have  the  slightest  influence  upon  an  acute  myelitis,  and  even  in 
subjects  with  well-marked  syi'ulis  neither  mercury  nor  iodide  of  ])()tassium 
is  curative.  Tonic  remedies,  such  as  quinine,  arsenic,  and  strychnia,  may 
be  used  in  the  later  stages.  "When  the  muscles  have  wasted,  massage  is  bene- 
ficial in  maintaining  their  nutrition.  Electricity  should  not  be  used  in  the 
early  stages  of  myelitis.  It  is  of  no  value  in  the  transverse  myelitis  in  the 
thoracic  region  with  retention  of  the  nutrition  in  the  muscles  of  the  leg. 


Y.  DIFFUSE   AND   FOCAL  DISEASES   OF  TIIE  BRAIN. 

I.    TOPICAL   DIAGNOSIS. 

Only  certain  regions  of  the  brain  give  localizing  symptoms.  These 
are  the  cortical  motor  centres,  the  speech  centres,  the  centres  for  the  spe- 
cial senses,  and  the  tracts  which  connect  these  cortical  areas  with  each 
other  and  with  other  parts  of  the  nervous  system. 

The  following  is  a  brief  summary  of  the  effects  of  lesions  from  the 
cortex  to  the  spinal  cord: 


9S0 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


1.  The  Cerebral  Cortex. — (a)  Destructive  lesions  of  tlic  motor  cortex 
(eentnil  ^vn,  lobiilii.s  paraceiitraiis,  posterior  j)ortioiis  of  tlic  tiiree  frontal 
gyri,  especially  of  the  inferior)  cause  .silastic  paralysis  in  liie  niuseles  of  the 
opposite  side  of  the  body.  The  jtanilysis  is  at  iirst  Ihieeid,  Init  eontriuutures 
suhsequently  develoj).  The  extent  of  the  paralysis  depends  upou  tluit  of 
tlie  lesion.  It  is  apt  to  be  limited  to  the  muscles  of  the  face  or  of  an  ex- 
tremity, giving'  rise  to  the  ceri'hral  monojjle^nas  (Fig.  11,  1).  One  group  of 
muscles  may  he  much  more  all'ected  tiwin  others,  especially  in  lesions  of 
tlie  highly  diU'erentiated  area  for  the  npiier  extremity.  It  is  uncommon  to 
find  all  the  muscle  groups  of  an  extremity  equally  involved  in  cortical 
monoplegia.  \'ei'y  rarely  through  small  bilaterally  symmetrical  lesions 
monoplegia  of  the  tongue  nuiy  residt  without  paralysis  of  the  face.  A 
lesion  may  involve  centres  lying  close  tog^'ther  or  overlai)ping  one  another, 
thus  producing  associated  mono])legias — e.  g.,  paralysis  of  the  face  and 
arm,  or  of  the  arm  and  leg,  but  not  of  the  face  and  leg  without  involve- 
ment of  the  arm.  Very  rarely  the  whole  motor  cortex  is  involved,  causing 
l)aralysis  of  the  opposite  side — cortical  hemiplegia.  Usually  in  such  in- 
stances there  is  marked  recovery,  so  that  only  a  monoplegia  persists. 

The  motor  area  corresponds  also,  at  least  in  large  part,  to  the  region 
of  the  cortex  in  which  the  impulses  concerned  in  general  bodily  sensation 
(cutaneous  sensibility,  muscle  sense,  visceral  sensations)  first  arrive  (the 
sonuvsthetic  area).  L'ondjined  with  the  muscular  weakness  there  is  usually 
some  distur])anee  of  sensations,  particularly  of  those  of  the  muscular  sense. 
The  stereognostic  sense  is  very  often  affected.  In  brachial  monoplegia,  for 
exam])le,  a  coin  or  a  knife  when  placed  in  the  hand  of  the  jiaralyzed  liml), 
the  patient's  eyes  being  closed,  is  not  recognized,  owing  to  ina])preciation 
of  the  form  and  consistence  of  the  object,  and  this  even  though  the  slight- 
est tactile  stimulus  api)lied  to  the  fingers  or  surface  of  the  hand  is  felt  and 
may  be  correctly  localized.  The  sense  of  touch,  pain,  and  temprcature  may 
he  lowered,  but  usually  not  markedly  unless  the  superior  and  inferior 
parietal  lobules  are  involved  in  addition  to  the  central  gyri.  I'ara'sthesias 
and  vaso-motor  disturbances  are  common  accompaniments  of  paralyses  of 
cortical  origin. 

(h)  Irritative  lesions  cause  localized  spasms  as  described  above.  The 
most  varied  muscle  grou])s  corresponding  to  particular  movement  forms  may 
be  picked  out.  If  the  irritation  be  sudden  and  severe,  typical  attacks  of 
Jacksonian  epilejjsy  may  occur.  These  convulsions  are  usually  preceded 
and  accom])anied  by  subjective  sensory  impressions.  Tingling  or  pain,  or  a 
sense  of  motion  in  the  part,  is  often  the  si(jnal  symptom  (Seguin),  and  is  of 
great  importance  in  determining  the  seat  of  the  lesion.  Here,  too,  the 
stereognostic  sense  is  frequently  involved. 

Lesions  are  often  both  destructive  and  irritative,  and  we  then  have 
combinations  of  the  symptoms  produced  by  each.  For  instance,  certain 
muscles  may  be  paralyzed,  and  those  represented  near  them  in  the  cortex 
may  be  the  seat  of  localized  convulsions,  or  the  paralyzed  limb  itself  may 
be  at  times  subject  to  convulsive  spasms,  or  muscles  which  have  been  con- 
vulsed may  become  paralyzed.  The  close  observation  of  the  sequence  of 
the  symptoms  in  such  cases  often  makes  it  possible  to  trace  the  progress 


0 

c 
n 
o 

a 

Cl 


t 


TOPICAL  DIAGNOSIS. 


9S1 


otor  cnrti'X 
H'c'u  rrontal 
sclt's  of  the 
ontrac'turc's 
)()ii  that  ol' 
r  oi'  an  ex- 
ic  group  oi' 
I  lesions  ol' 
coiiuiion  to 
in  cortical 
ical  lesions 
e  lace.  A 
ne  anotlicr, 
L'  face  and 
lit  involvc- 
ed,  causing 
u  such  in- 
ists. 

the  region 
^  sensation 
in-rive  (the 
i  is  usually 
;nlar  sense. 
)plegia,  for 
yzed  liml), 
)preciation 
the  slight- 

s  felt  and 

iture  may 
d   inferior 

ra-sthesias 
iralysc6  of 

love.  The 
onns  may 
ittacks  of 
preceded 
lain,  or  a 
and  is  of 
too,  the 

len  have 
e,  certain 
he  cortex 
tself  may 
jeen  con- 
uence  of 
progress 


of  a  lesion  involving  the  motor  corte.x.  In  these  cases  the  most  freipient 
cause  is  a  developing  tumor,  though  sometimes  local  thickenings  of  the 
membranes  of  the  brain,  small  abscesses,  minute  ha'morrluiges,  or  Iragincnts 
of  a  fractured  skull  must  l)e  held  r{;si)onsible. 

In  another  section  lesions  involving  the  centres  for  the  special  senses 
are  considered,  and  we  shall  simply  refer  to  them  here.  The  symptoms 
caused  by  lesions  of  the  speech  centres  will  be  described  under  ai)hasia,  and 
it  Is  only  necessary  to  note  here  the  near  situation  of  the  motor  speech  area 
(Hroca's  centre)  in  the  left  inferior  frontal  convolution  to  the  centres  for 
the  face  and  arm  on  that  side,  and  to  state  that  motor  a[ihasia  is  often 
associated  with  monoplegia  of  the  right  side  of  the  face  and  the  right  arm. 
Accon.j)anying  the  paralysis,  following  a  Jacksonian  iit,  of  the  right  face  or 
arm  there  is  often  a  transient  motor  ai)hasia. 

According  to  Flechsig,  the  sensori-motoi*  centres  are  limited  to  tolerably 
circumscribed  areas  in  the  cortex,  which  differ  from  other  portions  in  that 
they  are  provided  with  ])rojection  fibres  which  connect  them  with  lower 
centres.  The  remaining  areas  of  the  cortex,  amounting,  he  believes,  to 
about  two  thirds  of  the  whole,  are  devoid  of  i)rojection  libres  and  are  con- 
cerned entirely  in  associative  activities.  These  latter  areas,  the  "  association 
centres"  of  Flechsig,  are  three  in  number:  (1)  The  anterior  association 
centre,  including  the  whole  of  the  frontal  lobe  in  front  of  the  sonuesthetic 
area;  (2)  the  middle  association  centre,  corresponding  to  the  cortex  of  tlie 
island  of  Keil;  and  (3)  the  large,  posterior  association  centre,  including  the 
priveuneus,  the  superior  and  inferior  parietal  lobules,  the  supramarginal 
and  angular  gyri,  and  the  whole  of  the  temporal  and  occipital  lobes  except 
the  auditory  and  visual  sensory  areas. 

Flechsig  attributes  the  higher  psychic  functions,  especially  those  con- 
nected with  the  personality  of  the  individual,  to  the  anterior  association 
centres,  while  the  intellectual  activities  which  have  to  do  with  knowledge 
of  the  external  world  he  believes  correspond  to  the  functions  of  the  large 
posterior  association  centre.  Whether  tliese  views  be  true,  and,  if  so,  in  how 
far  they  may  be  applied  practically  in  the  localization  of  diseases,  especially 
of  the  mind,  the  future  has  to  decide. 

2.  Centrum  Semiovale. — Lesions  in  this  part  may  involve  either  projec- 
tion fibres  (motor  or  sensory)  or  association  fibres.  If  involvement  of  the 
motor  path  cause  paralysis,  this  has  the  distribution  of  a  cortical  palsy  when 
the  lesion  is  near  the  cortex,  and  of  a  ])aralysis  due  to  a  lesion  of  the  in- 
ternal capsule  when  it  is  near  that  region.  These  lesions  of  the  motor 
fibres  may  be  associated  with  sym])toms  due  to  interruption  in  the  other 
systems  of  fibres  running  in  the  centrum  semiovale;  there  may  ])e  sensory 
disturbances — hemiana?sthosia  and  hemiano])ia — and  if  the  lesion  is  in  the 
left  hemis[)hcre  one  of  the  different  forms  of  aphasia  nuiy  accompany  the 
paralysis. 

3.  Corpus  Callosum. — This  may  be  congenitally  absent  without  symp- 
toms. An  acute  lesion  involving  a  large  portion  of  the  corpus  callosum 
may,  however,  yield  symptoms  suggestive  of  its  localization  in  this  region. 
In  the  ease  recorded  by  Eeinhard,  in  which  the  situation  of  the  lesion  was 
suspected  ante-mortem,  there  was  disturbance  of  equilibration   (without 


982 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


/ 


•vt  i    '  1 


vertigo)  nnd  of  the  synorgotie  movoincntH  of  both  halves  of  tlie  hody.  The 
autopsy  revealed  a  gliosareonia  whieii  had  dentroyed  the  posterior  three 
fourths  of  the  corijus  eallosuni.  Jn  Jiristowe's  1  eases  there  existed,  as 
syniptniiis  coiiuiioM  to  all,  pain  in  the  head  and  |)artial  or  eoniplete  hemi- 
plegia, with  gradual  extension  of  the  i)aralysis  to  the  opposite  side  of  tiie 
body.  Toward  the  end  of  life  there  was  disturbance  of  speech,  dilFiculty 
in  deglutition,  incontinence  of  urine  and  ftuces  and  dementia.  Here  the 
symptoms  have  in  them  nothing  that  can  be  looked  \\\nn\  as  i)athoguomonii'; 
indeed,  many  of  the  phenomemi  were  doui)tless  dependent  upon  involvement 
of  the  projection  and  association  libres  of  the  centrum  semiovale. 

In  animals  in  which  the  corpus  callosum  has  been  cut  experimentally 
jirogressive  emaciation  has  been  mentioned  as  a  characteristic  phenomenon. 

4.  Internal  Capsule  (Kig.  4).— Through  this  ])ass  within  a  rather 
narrow  area  all,  or  nearly  all,«of  the  i)rojection  fibres  (both  nu)tor  and 
sensory)  which  are  connected  with  the  cerebral  cortex.  It  is  divided  into 
an  anterior  limb,  a  knee,  and  a  posterior  limb,  the  latter  consisting  of  a 
tlialamo-Ienticular  ])<)rtion  (its  anterior  two  thirds)  and  a  retro-lenticular 
])orti()n  (its  posterior  third).  In  considering  the  ell'ects  of  a  given  focal 
lesion  involving  the  fibres  of  the  internal  capsule,  it  is  not  to  be  forgotten 
that  the  relations  of  the  two  limbs  of  the  capsule  to  one  another  and  to  the 
knee  vary  considerably  in  different  horizontal  planes.  Much  of  the  con- 
fusion in  the  bil)liogra])hy  is  de])endcnt  upon  neglect  to  describe  the  hori- 
zontal level  of  the  lesion,  as  well  as  its  situation  in  an  antero-posterior  di- 
rection. The  principal  bundle  passing  through  the  anterior  limb  of  the 
cajjsule  is  that  which  connects  the  frontal  gyri  and  the  medial  bundle  in 
the  ly.se  of  the  ])cduncle  (crus)  with  the  nuclei  of  the  pons.  These  fibres 
are  centrifugal,  and  innervate  chiefly  the  lower  motor  nuclei  governing 
bilaterally  innervated  muscles,  cs]iecially  those  of  the  eyes,  head,  neck,  and 
probably  those  of  the  mouth,  tongue,  and  larynx.  In  lower  horizontal 
planes  these  fibres  are  situated  near  the  knee  of  the  capsule.  It  is  the  region 
of  the  knee  of  the  capsule  which  transmits  especially  the  fibres  passing 
from  the  cerebral  cortex  to  the  nuclei  of  the  facial,  hypoglossal  and  third 
nerves.  The  path  which  snpplics  the  nuclei  governing  the  muscles  used 
in  speech  passes  through  the  knee. 

The  pyramidal  tract  goes  through  the  thalamo-lenticular  portion  of  the 
capsule.  The  motor  fibres  are  arranged  according  to  definite  muscle  groups, 
or  rather  movement  forms,  those  for  the  movements  of  the  arm  being  ante- 
rior to  those  for  the  leg.  The  number  of  fibres  for  a  given  muscle  group 
corresponds  rather  to  the  degree  of  complexity  of  the  movements  than  to 
the  size  of  the  muscles  concerned.  Thus  the  areas  for  the  fingers  and  toes 
are  relatively  large. 

The  fibres  to  the  sonia>sthetic  area  of  the  cortex — that  is,  those  from  the 
ventro-lateral  gronp  of  nuclei  of  the  thalamus  and  the  tegmental  radia- 
tions— carrying  impulses  concerned  in  general  bodily  sensation,  pass  up- 
ward through  the  posterior  part  of  the  thalamo-lenticulnr  portion  of  the 
capsule.  Some  of  these  fibres  pass  through  the  anterior  two  thirds  of  the 
posterior  limb  alongside  of  the  fibres  of  the  pyramidal  tract. 

Through  the  retro-lenticnlar  portion  of  the  posterior  limb,  opposite  the 


post! 
earn 

{<>l»i 
the 

toryl 

sensl 

tril'l 

the 

not 

getlJ 

heuJ 

lesi<l 

ana'! 

lesit 

disc 

evei 

thei 

shoi 

thai 

thai 

if  tl 

ton< 


TOPICAL  DIAGNOSIS. 


083 


ic  body.    The 

Jsti'rior  three 

fo  I'xisted,  as 

iiip'^'tc!  heini- 

t'  side  of  the 

'C'li,  diiriculty 

'1-     Ilpi-e  the 

liognomonio; 

involvement 
le. 

perimentally 
)lieuoineiion. 
i"    a    rather 

motor  and 
livided  into 
sisting  of  a 
'o-lenticiilar 
given  focal 
>e  forgotten 

and  to  the 
3f  the  con- 
e  the  iiori- 
osterior  di- 
mb  of  the 

bundle  in 
liese  fibres 

governing 

neck,  and 
horizontal 
the  region 
-s  passing 
and  third 
'cles  used 

on  of  the 
e  groups, 
ing  ante- 
?le  group 
than  to 
and  toes 

from  the 
il  radia- 
Dass  up- 
of  the 
s  of  the 

•site  the 


posterior  third  of  tiie  lateral  surface  of  tiie  thalamus,  pass  (1)  the  fibres 
carrying  impulses  concerned  in  the  sensations  of  the  opposite  visual  field 
(optic  radiation  from  the  lateral  geniculate  body  to  the  visual  sense  area  in 
the  occipital  cortex);  {"i)  the  librcs  carrying  impulses  coneerned  in  audi- 
tory sensations  (radiation  from  the  medial  geniculate  body  to  tin;  auditory 
sense  area  in  the  cortex  of  the  temporal  lobe);  (.*{)  the  fibres  (probably  cen- 
trifugal) connecting  the  cortex  of  the  temporal  lobe  with  the  nuclei  of 
tiie  pons. 

With  this  preliminary  knowledge  concerning  the  internal  capsule,  it  is 
not  dilhcult  to  understand  the  symi)toms  which  residt  when  it  is  diseased. 

Since  here  all  the  fibres  of  the  ujjper  motor  segment  are  gathered  to- 
gether in  a  compact  bundle,  a  lesion  in  this  region  is  apt  to  cause  ccunplete 
hemiplegia  of  the  op|»nsite  side,  followed  later  by  contractures;  and  if  the 
lesion  involves  ^be  biiuler  portion  of  the  posterior  limb  there  is  also  hemi- 
ana.'sthesia,  including  even  the  special  senses  (Fig.  4).  As  a  rule,  however, 
lesions  of  the  internal  capsule  do  not  involve  the  whole  structure.  The 
disease  usually  alTects  nuiinly  either  the  anterior  or  posterior  portions,  and 
even  in  instances  in  which  at  first  the  symi)toms  point  to  total  involvement, 
there  is  a  disa])pearance  often  of  a  large  part  of  the  ])henomena  after  a 
short  time.  Thus  when  the  pyramidal  tract  is  destroyed  (lesion  of  the 
tbalamo-lenticular  ])ortion  of  the  capsule)  the  arm  may  be  all'ected  nu)re 
than  the  leg,  or  vice  verso.  The  facial  paralysis  is  usually  slight,  though 
if  the  lesion  be  well  forward  in  the  ca])sule  the  i)aralysis  of  the  face  and 
tongue  may  be  marked. 

Ilemiana^sthesia  alone  without  involvement  of  the  motor  fibres,  due  to 
disease  of  the  capsule,  is  rare.  There  is  usually  also  at  least  partial  paraly- 
sis of  the  leg.  When  the  retro-lenticular  portion  of  the  ca])sule  is  destroyed 
the  hemiana\sthesia  is  accompanied  by  hemianopsia,  disturbance  of  hearing, 
and  sometimes  of  smell  and  taste.  The  occurrence  of  bemichorea,  marked 
tremor,  or  hemiathetosis  after  a  cai)sular  hemiplegia  points  to  the  involve- 
ment of  the  thalamus  or  of  the  hy])othalamic  region  in  the  lesion. 

Charcot  and  others  have  described  cases  in  v^'ch  as  a  result  of  disease 
of  the  internal  capsule  there  has  been  paralysis  ox  the  face  and  leg  without 
involvement  of  the  arm.  In  such  instances  the  lesion  is  linear,  extending 
from  the  posterior  ])art  of  the  anterior  limb  of  the  intej^nal  capsule  back 
ward  and  lateralward  to  the  leg  region  in  the  posterior  limb  of  the  capsule, 
the  region  for  the  arm  escaping. 

Capsular  lesions  when  pure  are  not  accompanied  by  aphasic  symptoms, 
alexia,  or  agra])hia.  A  "  subcortical  "  motor  aphasia  may  occur,  if  along 
with  complete  destruction  of  the  anterior  limb  of  the  internal  capsule  on 
one  side  tliere  be  associated  a  lesion  of  the  caudate  nucleus  on  the  opposite 
side  large  enough  to  interfere  with  the  adjacent  fibres  going  to  the  nuclei 
governing  the  muscles  of  si)eecb. 

5.  Crura  (Cerebral  Peduncles). — From  this  level  through  the  pons,  me- 
dulla, and  cord  the  upper  and  lower  motor  segments  are  represented,  the 
first  by  the  fibres  of  the  pyramidal  tracts  and  by  the  fibres  which  go  from 
the  cerebral  cortex  to  the  nuclei  of  the  cerebral  nerves,  the  latter  by  the 
motor  nuclei  and  the  nerve  fibres  arising  from  them.    Lesions  often  affect 


■k 


0S4 


DISEASKH  OF  TIIK  NERVOUS  SYSTEM. 


})()lli  motor  s('j,'ni('ii(s,  nnd  produce  imralyscs  liavini;  tlio  cIiariK'tt'ristics  of 
t'acli.  'I'liiis  a  siiifzli'  lesion  may  involve  the  pyraiiiiilal  tract  and  cause  ii 
spastic  paralysis  on  the  opposite  side  of  the  liody.  and  also  involve  the 
nucleus  or  the  lihres  of  one  of  the  cerehnii  nerves,  and  so  produce  u  lower 
Hc^Mnent  paralysis  on  the  same  side  ns  the  lesion — crossed  paralysis,  in  the 
cms  the  third  and  fourth  cerehral  ru-rves  run  near  the  pyraini<lal  tract,  and 
u  lesion  of  this  re<,Mon  is  apt  to  involve  them  or  their  nuclei,  causiu''  jiartial 
)>ai'alysis  of  the  muscles  of  the  eye  on  the  same  side  as  the  lesions,  cond)ined 
with  a  henMplej,Ma  of  the  opposite  side  (Kig.  10,  3). 

The  o|)tic  tract  also  crosses  the  cms  and  nuiy  bo  involved,  j,dving  hemi- 
anopsia in  the  opjiosite  halves  of  the  visual  fields. 

If  the  Icj^Mucntum  he  the  seat  of  a  lesion  which  does  not  involve  the  haso 
of  the  peduiule  ((U-  pes)  there  nuiy  be  disturbances  of  cutaiu'oiH  and  mus- 
cular sensibility,  ataxia,  disturbances  of  hearing;,  or  oculo-inotor  paralysis. 
An  oculo-motoi-  paralysis  of  one  side,  accompanied  by  a  hemi-ata\ia  of  the 
opijosite  side,  appears  to  be  es|)ecially  characteristic  of  a  tc«;uiental  lesion. 

6.  Corpora  Quadrigemina.— Anatonucal  studies  point  to  the  view  that 
the  superior  collicuhis  (anterior  (iuadrit,'eminal  bo<ly)  represents  the  most 
important  sul)cortical  central  organ  for  the  control  of  the  eye-muscle  nuclei. 
^JMiis  is  sup[torted  t(J  a  certain  extent  hy  clinical  evidence,  though  as  yet 
but  few  cases  have  been  carefully  studied.  Sight  may  he  only  slightly,  if 
at  all,  disturbed  when  the  superior  collicuhis  is  destroyed,  and  color  vision 
may  remain  normal.  The  pupil  is  usually  widened,  and  the  i)upillary  re- 
action, both  to  light  aiul  on  accommodation,  interfi'red  with.  Ap|)arently 
actual  ])aralysis  of  the  eye  muscles  does  not  occur  uidess  the  nucleus  of  the 
third  nerve  ventral  to  the  a(iueduct  be  also  injured. 

The  inferior  collieulus  (posterior  (juadrigeminal  body),  on  the  other 
lumd,  has  been  shown  by  anatomical  study  to  be  an  important  way-station 
in  the  auditory  coiuluct ion-path.  A  large  part  of  the  lateral  lenniiscus 
ends  in  its  nucleus,  and  from  it  enu'rge  medullated  llbres  which  pass  through 
the  l)rachium  quadrigeminuni  inferior  to  the  nu'dial  geniculate  body. 
Thence  a  large  bundle  runs  through  the  retro-lenticular  portion  of  the 
internal  capsule  to  the  auditory  sense  area  in  the  cortex  of  the  temporal 
lobe. 

Weinland  has  collected  19  eases  of  tumors  of  the  corpora  quadrigemina 
from  the  bibliogra])hy;  in  9  of  these  auditory  disturl)ances  were  espe- 
cially noted.  Since  the  central  auditory  ]»ath  of  each  side  receives  im- 
pulses from  both  ears,  lesion  of  the  collicuhis  on  one  side  may  dull  the 
hearing  on  both  sides,  though  the  op])osite  ear  is  usually  the  more  defec- 
tive. Lesion  of  ilie  inferior  collicuhis  may  be  accompanied  by  disturb- 
ance of  mastication,  owing  to  paralysis  of  the  descending  (mesencephalic) 
root  of  the  trigeminus.  The  fourth  nerve  may  also  be  involved.  The 
ataxia  which  sometimes  accompanies  lesions  of  the  cor])ora  (piadrigemina 
is  probably  to  be  referred  to  disturbance  in  conduction  in  the  medial  lem- 
niscus. 

7.  Pons  and  Medulla  Oblongata. — Lesions  involving  the  pyramidal 
tract,  together  with  any  one  of  the  motor  cerebral  nerves  of  this  region, 
cause  crossed  paralysis.     A  lesion  in  the  lower  part  of  the  pons  is  apt  to 


TOPIC. \Ti   DTAONOfllS. 


98B 


(eristics  of 
ml  cauric  a 
iivolvc  the 
ii'e  11  lower 
in.  Jii  till' 
tract,  nnd 
iii^'  partial 
,  combint'd 


^ing  heini- 

.0  the  baso 

and  iniis- 

■  [lanilysis. 

IX la  of  the 

ital  k'Hion. 

\\v\v  that 

the  most 

iclc  nuclei. 

i^h  as  yet 

^ll^htly,  if 

>l(tr  vision 

pillary  ro- 

^pparently 

eus  of  the 

the  other 
ay-statlon 
lemniscus 
's  through 
ite  hody. 
u  of  the 
temporal 

Irlgcmlna 
ere  espe- 
civeg  im- 

dull  the 
)rc  defcc- 

disturb- 
cepliallc) 
ed.  The 
riircmina 
dial  lem- 

•vramidal 
s  region, 
is  apt  to 


cause  a  hnvcr-sogmont  paralysis  of  the  face  oii  I  lie  snnii'  side  (destruction 
of  the  mieleiis  of  the  facial  \u'\\v  or  of  its  root  lilires)  nnd  ii  spastic  paraly- 
sis of  the  arm  and  leg  on  the  opposite  side  (iiijnry  t<i  pyramidal  traet)  (Fig. 
10,  1).  The  ahdiicens,  the  motor  part  of  the  Irigriiiiniis.  nnd  the  liypo- 
glossns  nerves  may  also  he  |)nrnly/('d  in  the  snnie  ninnncr.  W  lien  the  cen- 
tral fihrcs  to  the  nucleus  of  the  hypoglossns  nre  involved  n  peeulinr  form 
of  anni'thria  I'esults.  If  the  nuclens  itself  he  diseased,  swallowing  is  inter- 
fered with. 

W'lu'n  the  sen>ory  llhres  of  the  iiflli  nerve  nre  inlernipled,  together 
with  the  sensory  tract  (the  medial  lemniscus  or  lillet)  for  the  rest  of  the 
hody,  wiiich  has  already  crossed  the  middle  line,  tliei'e  is  a  crossed  sensory 
pnralvsis — i.e.,  disturhed  sensation  in  the  distrihution  of  the  lifth  on  the 
side  of  the  lesion,  and  of  all  the  rest  of  the  hody  on  the  opposite  side. 

A  ]»arnlysis  of  the  external  rectus  muscle  of  one  ey<'  and  of  the  internal 
rectus  of  the  other  eye  (c<)njugati'  paralysis  id'  the  muscles  which  turn  the 
eve  to  one  side),  in  the  absence  of  a  **  forced  position  "  of  the  eyehnlls,  is 
highly  characteristic  of  certain  lesions  (d'  the  pons,  in  such  casts  the  in- 
ti-rnal  rectus  may  still  he  cajiahlc  of  functioning  on  convergence,  (!!•  when 
the  eye  to  which  it  belongs  i.s  tested  independently  of  that  in  which  iIk! 
external  rectus  is  paralyzed.  This  form  of  paralysis  is  found,  as  a  ruli", 
oidy  when  the  nodule  lies  Just  in  front  of  the  ahducens  or  involves  the 
nucleus  itself,  oi-  includes,  bi'sides  the  root  llhres  of  the  ahducens,  that  por- 
tion of  the  forniatio  reticularis  that  lies  between  -them  and  the  fasciculus 
longitudinalis  nu'<lialis  (voji  Monakow).  The  cases  of  conjugate  paralysis 
Just  referred  to  may  be  complicated  by  other  disturbances  of  the  eye-muscle 
nioveiiK'nts,  in  which  case  the  inter|)retation  of  the  symptoms  may  he  ren- 
tlcrcd  dillicult.     The  facial  nerve  is  often  involved  in  these  [laralyses. 

In  lesions  of  the  |)ons  the  patient  often  has  a  tendency  to  fall  toward 
the  side  on  which  the  lesion  is,  prohnbly  on  account  of  im|ilieation  of  the 
nn(hllc  ](eduncle  of  the  cerehcllum  (hrachium  pontis).  Still  more  frc(pient 
is  the  simple  motor  hemi-ataxia  conseipu'iit  upon  lesion  of  the  medial  lem- 
niscus, and  ])erhn[is  of  longitudinal  bundles  in  the  forniatio  ri'ticularis. 
This  is  often  acconii)anied  by  disturbance  of  muscular  and  cutaneous 
sensations.  Only  Avhen  the  lesion  is  very  extensive  are  there  disturh- 
auces  of  hearing  (involvement  of  the  lateral  lemniscus  or  coi'_  iis  trnpi'- 
zoideum). 

The  sym]>t()ms  produci'd  by  involveiiicnt  of  the  dilTereiit  cerebral  nerves 
will  be  considered  in  detail  in  another  set  tioii. 

8.  Cerebellum. — The  functions  of  this  ])art  of  the  brain  are  still  under 
(■(Uisideration.  Luciani,  whose  monograph  is  exhaustive,  regards  it  as  "an 
end  organ,  directly  or  indirec-tly  related  to  certain  jieripheral  sensory  organ> 
nnd  in  direct  eU'erent  relationship  with  certain  ganglia  td'  the  cerebro-spinnl 
nxis,  and  indirectly  with  the  motor  apparatus  in  general.  It  is  functionally 
homogeneous,  each  i)art  exercising  the  functions  of  the  whole,  but  having 
special  relations  to  the  muscles  of  the  corresj)onding  side  of  the  body  " 
(Krauss). 

Lesions  of  the  lateral  l<d)es  affect  the  corresponding  side  of  the  body, 
while  lesions  of  the  middle  lobe  (vermis)  aU'ect  both  sides.  I'artial  removal 
63 


M6 


DISKASKS  OF  TIIK  NKUVOL'S  SYSTKM. 


.  I 
/ 


is  fdlldwcd  liy  triiiisiciil  miisciiliir  \v(  .iliicss;  ('(itnplclc  rciiKtval  Ity  cvlrciiif 
iiicniii'tliiiiiliiiM.  Its  one  iiii|)()i'tMnt  riinctioii  would  a|)|H'iir  lo  bu  tlio  I'n- 
ordiiiiitinii  III'  the  iiiiiscular  iiinvciiicnls. 

Ill  iiioiiki'vs  till'  HVMi|»tniiis  dill'i'i"  imicli  at  dillVri'iit  pcriodri  uftrr  llif 
opciatitiii.  Diiriii;^'  the  lirst  live  oi-  six  days  initatioii  plu'iKHiU'iia  prc-diiiii- 
iiiatt'.  'riicic  is,  accni'diii;;  to  liiiciatii,  astliciiia,  atony,  and  nstasia  of  tlir 
iiiiisilcs  oil  till-  side  td"  tlif  liody  opcrattMl  ii|tnii.  Tin-  aiiiiiial  caiiiiot  staml 
or  walk.     All  tlicsi'  symptoms  may  gradually  disiippnir  in  tlio  course  ul'  a 

I'cw    IllOlltllS. 

\\ .  ( '.  Kraiiss  lias  aiialy/t'd  tlic  lesions  and  symptoms  in  1<><)  cast's  of 
discasi'  (d'  this  part.  'I'lu'  morbid  conditions  wi-rc  as  follows:  Sarcoma  in 
'i'l  cases;  tnlKTcIc  in  '-i'i;  jilioma  in  IH;  abscess  in  10;  tumor  td'  unspecilicd 
tirijiin  in  i;i;  cyst  in  ',;  and  1  case  each  of  softeniii;:,  endothelioma,  cyst 
and  sarcoma.  canciT.  ;,nimma,  libroma,  and  ha'tnorrhaj^'e.  The  left  lobe  was 
nll'i'cted  ;!•.'  times,  the  right  lobe  ;{•.'  times,  and  the  iiiiddK'  lobe  IT  times. 
Thiis  tumor  constituted  by  far  the  most  im|tortant  alVectioii.  There  may  be 
no  syni|itoms  whatever  if  it  is  in  one  hemisphere  oidy  and  docs  not  involve' 
the  ujiddlc  lobe.  'J'liero  arc  not  only  instances  of  complete  al»sence  of  one 
whole  hemisphere,  but  also  of  extensive  bilateral  disi'ase  which  throughout 
life  have  yieldi'd  no  noticeable  symptoms.  Ollii'r  portion.s  of  the  brain 
appear  to  be  able  to  take  on  the  fuiutions  nornudly  [lerformed  by  the  cere- 
bellum. 

'I'he  experiments  of  J.  S.  b'isien  I'ussell  do  not  entirely  confirm  the  ob- 
servatitins  of  Liiciani.  In  the  lirst  |)lace,  the  occurrence  of  asthenia  is  not 
constant,  and  as  to  atony,  while  tiu'  patellar  ti'iidon  rellexes  are  sometimes 
nbsent,  they  are  as  a  rule  intncl  in  pure  cerebellar  lesions.  There  may  be 
even  muscular  rigidity  instead  of  atony.  Ifu.ssell's  experiments  make  it 
seem  likt'ly  that  the  cerebellar  liemisplu're  of  one  side  exercises  constantly 
an  inhibitory  eU'ect  upon  the  activities  of  the  cerebral  hemis[)here  of  the 
opposite  side  ([)rohably  by  way  of  the  brachium  conjunctivum).  Thus  after 
removal  of  one  cerebellar  hemisphere  he  found  that  much  ndlder  faradie 
stimulation  of  the  contra-lateral  motor  area  would  call  forth  n'.oTcments 
of  the  arm  and  leg  than  that  necessary  to  stimulate  the  homo-lateral  motor 
area.  The  epile[)tic  seizures  following  the  adudnistration  of  absinthe  were 
far  greater  on  the  side  of  ablation.  It  is  not  inii)ossible  that  the  explana- 
tion of  the  epilei)tift)rm  attacks  by  no  means  rare  in  cerebellar  disease  is 
here  to  be  sought.  The  most  coninion  symptoms  [a  tumor  of  the  cere- 
bellum are  as  follows: 

Vcr(l(/o,  which  is  more  constant  in  this  than  in  affections  of  any  other 
region  of  the  brain.  Some  believe  this  to  be  due  to  involvement  of  the 
nerviis  vestilmlaris  or  its  nuclei  of  termination,  by  means  of  which  the 
senucircular  canals  are  connected  with  the  cerebellum.  The  symptom  w;;s^ 
])resent  in  48  of  the  cases  of  Krauss's  collection,  not  reported  in  4."].  The 
vertigo  appears  to  be  entirely  independent  of  the  ataxia.  Though  most 
fre((uently  associated,  cither  symptom  may  be  present  without  the  other. 
The  vertigo  of  cerebellar  disease  is  ofien  associated  with  the  feeling  that 
ol)jects  are  revolving  about  the  body,  or  that  the  body  itself  is  moving. 
Headache  Mas  present  in  83  cases.     Vomiting  occurred  in  G9  cases,  not  re- 


y  cxtri'iiir 
11,'    tlic   (•<•- 

al'UT  till' 
II  prcdoiii- 
siii  ol'  lln' 
Hint  stilMtl 
()U1>L'   ol'    11 

0     CllMS     (if 

ai'c-diim  in 
iiis|ic('ilir(l 

iiilMil,   cvst 

l  IdIjc  was 
17  times. 
LTO  iiiiiy  1>1' 
lot  involve 
nee  of  one 
iiroii;^lioiit 
(lie  brain 
y  the  eere- 

nn  llie  oh- 
enia  is  not 
sometimes 
re  may  ho 
s  make  it 
constantly 
ere  of  the 
hus  at'ier 
r  I'aradie 
ovements 
ral  motor 
it  he  were 
explana- 
liseaso  is 
the  cere- 

any  other 
nt  of  the 

hieh  the 
ptom  w;is^ 
4:3.  The 
ngh  most 

10  other, 
iling  that 
moving. 
;s,  not  re- 


TOPK'AK   DIAfiXOSIS. 


08: 


jiorled  in  '.*;i.  Ojilir  iinirilis  was  foiiiid  in  (KI  cases,  tml  reinirlcd  in  23. 
\'ery  nerious  disliirhanceH  ol'  vision  may  result  from  |irensure  on  the  a.|Ue- 
(lucttis  c«'rel»ri,  leading  to  increased  pressure  in  the  tiiiid  veiitricli';  this, 
through  hulging  (d'  the  lloor,  can  directly  injure  the  chia,-m  or  optic  nerve. 

(If  symptoms  which  are  designated  as  nutre  particularly  cereliellar, 
(iliixin  is  the  most  important.  In  cereliellar  ataxia  the  gait  is  irregular  ami 
staggeiing,  often  zigzag,  and  in  attempting  to  walk  the  patient  sways  to 
and  fro  like  a  drunken  nam  (ilnminlir  (rirnxsr  of  the  I'reneli  writers).  As 
a  .  le,  the  patient  walks  and  tends  to  fall  toward  the  alfectcij  .vide,  hut  the 
rule  is  not  certain.  'The  ataxia  of  cereliellar  disease  is  to  he  shai'ply  (liU'er- 
entiated  from  the  ata.xia  (d'  tahes  dorsalis,  from  cortical  ataxia,  and  proh- 
alily  from  the  ataxia  nceompanying  diseases  (d'  the  tegnuMital  portion  of  the 
pons  and  '."■•.i-liral  peduncle.  Cerehellar  ataxia  is  lioth  slali<' and  dynamic. 
The  opening  or  closing  of  the  eyes  is  of  less  inlluence  than  in  s|iinal  ataxia, 
^'ery  important  for  diU'erential  diagnosis  is  the  fact  that  when  the  patient 
lies  in  hcd  movements  tolerahly  well  coordinated  can  lie  carried  out.  The 
coarse  naturi'  of  the  incoilrdination  distinguishes  cerchdlar  ataxia  from 
that  i\\\r  to  lesion  of  the  cerchral  cortex.  In  the  latter  the  liner  movements 
(iiultoiung,  etc.)  are  especially  apt  to  be  involvi-d,  and  there  is  usually 
hcnu-paresis  or  mono-paresis,  and  often  disturbance  <if  muscular  sense  and 
of  the  sti'reognostic  sense  (von  Monakow).  ('crelicdlar  ataxia  nuiy  dcjiend 
upon  the  withdrawal  of  the  inlluence  of  the  cerelicllum  upon  the  cerebrum. 

I'dirsis  of  the  truid<  muscles,  manifest  in  an  inability  to  perform  the 
movements  of  liemling.  erection,  and  lateral  llexion  of  the  trunk,  may  )je 
present  (llughlings  .Jackson).  Hisicn  Wnssell  holds  that  the  jiaralysis  is 
*'  probably  directly  due  to  the  withdrawal  of  the  cerebellar  iidlucnce  from 
the  musch's."' 

Other  less  constant  but  suggestive  symptoms  are  nenralgic  jiains  in  the 
region  of  the  neck  and  occiput;  ])loeking  of  the  veniu  (laleni  and  dilatation 
of  the  lateral  ventricles,  causing  in  children  hydrocephalus;  pressure  on 
the  mid-brain,  jions,  or  mecbdia  oblongata.  ])roducing  ]iaralysis  of  the  ceri'- 
bral  nerves,  rhythmical  coiuractions  of  the  head  or  extrenuties,  nystagmus, 
tremor,  nnarthria,  auditory  or  visual  disturbances.  There  may  be  glyco- 
suria and  l)ilateral  rigidity  from  ])rcssure  on  the  motor  paths.  Sudden 
death  may  occur,  l-'orced  movements,  especially  rotation  (d'  the  trunk, 
forced  ]iositions  (of  the  head  or  truid<),  and  a  peculiar  forced  jiosition  of  the 
eyes  (one  turned  downward  and  to  the  side,  the  other  njiward  and  inward) 
are  almost  ])athognomonic  of  disease  of  one  brachium  pontis  (middle  cere- 
bellar ])eduncle). 

The  reflexes  are  very  variable;  they  were  absent  in  1'^  cases.  In  juire 
cerebellar  lesion  they  are  jirobably  intact  or  exaggerated,  but  when  the 
cerebellar  disease  involves  other  structures,  directly  or  indirectly,  through 
action  at  a  distance,  or  when  there  is  associated  disease  of  the  spnnal  tracts, 
the  reflexes  may  be  abolished. 

Sym))toms  of  general  mental  disturbance  may  accompany  cerebellar  dis- 
ease, but  they  are  not  characteristic.  There  is  often  irritability,  enfeebled 
memory,  and  toward  the  end  sopor  and  coma. 


. 


988 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


II.    APHASIA.* 


The  speech  mechanism  consists  of  receptive,  perceptive,  and  emissive 
centres  in  the  cortex  cerebri,  disturbances  of  wliich  canse  (ijiluisia,  iiiid  cen- 
tres in  the  medulla  which  preside  over  the  niuselcs  of  articulation,  disturb- 
ances of  which  ])ro(luce  (tiuirlliria,  the  condition  of  j^radual  loss  of  })ower  of 
si)eech,  such  as  occurs  in  bulbar  i)aralysis.  To  the  disturbances  of  speech 
resulting  from  lesion  of  the  white  iibres  tlirowin«f  the  lower  nuclei  <,n)vern- 
in,ir  the  speech  muscles  under  the  influence  of  the  cortex,  without  ])riniarv 
injury  to  I'ither  the  cortex  of  the  nuclei  in  the  medulla,  the  term  aphcinia 
has  been  applied  (IJastian). 

TluL'  studies  of  Dax,  JJroca,  Bastian,  Kussmanl,  Wernicke,  Lichtheim, 
and  others  have  widened  enormously  our  knowled,u;e  of  speech  disorders. 
lian«,niaj^"e  is  gradually  aecjuired  by  imitation.  During  (levelo|)incnt  in 
order  that  we  may  make  ourselves  understood  (ex])ressive  com[)onents  of 
speech),  it  is  necessary  that  we  learn  to  understand  the  ex|)rcssi()ns  of 
others  (percc])tive  speech  components).  Thus,  in  teaching  a  child  to  say 
hrIL  the  souiul  of  the  uttered  word  enters  the  alTerent  path  (auditory  nerve) 
aiul  reaches  the  auditory  perceptive  centre,  from  which  an  impulse  is  sent 
to  the  emissive  or  motor  centre  jn'csiding  over  the  nuclei  in  the  medulla, 
througli  which  the  nniscles  of  articulation  are  set  in  action.  The  arc  in 
Lichtheim's  schema  (Fig.  9)  is  a  A,  M  m.  The  child  gradually  accpiires 
in  this  way  DicmoricH  of  llic  soundfi  of  irords,  which  are  stored  at  the  centre 
A,  and  vwlor  memories — the  kiiuesthetic  nuMnories  of  the  coih'dinated  mus- 
cular movements  of  the  lips,  tongue,  and  larynx  necessary  to  utter  words — 
wliich  are  stored  at  the  centre  M  (glosso-kina'stb.etic  centre  of  Bastian). 
In  a  similar  manner,  when  shown  the  bell,  the  child  ac(piires  visual  mrm- 
iric's,  which  are  conveyed  through  the  otitic  nerve  to  the  visual  perceptive 
centres,  o  ().  So  also  with  the  memories  of  the  sound  of  the  bell  when 
sti'uck.  The  memory  ])icture  of  the  sha])e  of  the  bell,  the  memory  of  the 
a])pearance  of  the  word  bell  as  written  or  ]n'inted,  and  the  motor  memories 
of  tlie  muscular  movements  recpiired  to  write  the  word  are  distinct  from  each 
other;  yet  they  are  intimately  ccmnected,  and  form  together  what  is  termed 
the  inird-imaiic  In  addition  to  all  tj.is  the  child  gradually  acquires  in 
his  education  ideas  as  to  the  use  of  the  bell — intellectual  conce])tions — the 
centre  for  wliich  is  represented  at  I  in  the  diagram.  In  volitional  or  intel- 
lectual s|)eech.  as  in  uttering  the  word  hdl,  the  ])ath  would  be  I,  ^I  m,  and 
in  writing  the  word.  1.  M.  \V,  //.  These  various  "  memories"  are  as  a  rule 
stored  or  centred  in  the  left  hemisphere  (see  Fig.  ?•>).  Wlien  the  word 
"  bell  "  is  heard,  the  mental  state  which  results  includes  not  oidy  the  activ- 
ities of  the  aiulitory  perceiition-centre,  but  also  by  association  the  activities 


*  A  large  niunlicr  of  valuable  works  on  aphasia  have  appeared  witiiin  the  past  few 
yeai's.  cliief  of  which  may  be  [ilaoed  Bastian's  recently  IssikmI  monograph  (18!)H).  The 
works  of  Wyllie  .i.;*!  Khler  and  the  lectures  of  Hrainweii  (Rritisii  Medical  .lournal,  18i)7- 
'98).  the  inonop;nii)h  of  Collins,  the  text-book  of  C.  K.  Mills,  and  the  various  publications 
of  l']skri(ljj:e,  von  Monakow's  voliune  in  XothnajT^el's  Ilandljuch,  and  Miralllee's  work  are 
unioug  the  most  important  recent  contributions. 


ArnARTA. 


989 


1  omissivG 

,   1111(1   CC'll- 

1,  disiturb- 
l'  ])()\vur  of 
oi'  s])t'odi 
oi  govern- 
it  primary 
n  aphemia 

Jclitheim, 
disorders. 
il)iiK'nt  in 
)oii('nt.s  of 
fusions  of 
ild  to  say 
ory  nerve) 
Ise  is  sent 
;  medulla, 
Mie  arc  in 
y  ae(|iiires 
the  centre 
lUed  nius- 
r  woi'ds — 

IJastian). 
<iuil  Dicm- 
)erc-ei)tive 
)ell  when 
•ry  of  the 
memories 
from  each 
is  termed 
(|uires  in 
ions — the 

or  intel- 
\1  m,  and 

as  a  rule 

lie  word 
llie  activ- 

aetivitics 

c  past  few 
8!)8).  'V\w 
riial.  1897- 
ul)lioati()ns 
s  work  arc 


of  a  whole  series  of  cerebral  centres,  which  in  the  manifold  experiencer.  of 
life  have  been  oecui)ied  at  one  time  or  another  in  some  way  with  s  uiio 
jisychic  attribute  of  the  external  object,  or  with  conihiiiiii;^-  and  coordinat- 
ing various  impressions  of  it. 

The  relations  of  language  (heard,  read,  spoken,  and  written)   involves 
then  (rt)  sensory  perceptive  centres  (hearing  and  sight  and,  in  the  blind. 


h         in  a        0 

Fia.  9. — Lichtliolm's  sclieiiui.  A,  auditory  area  in  cerebral  cortex,  in  which  are  stored 
the  memories  of  the  sounds  of  words;  «  A,  auditory  conduction  patii  from  cochU'ii 
to  temporal  lobe;  O,  visual  area  in  cerebral  cortex,  perception  centre  for  written  and 
printed  words;  o  0,  visual  conduction  path  from  retina  to  ocipital  lolie :  M.  speech 
centre  in  whicii  are  stored  the  memories  of  the  muscular  moveiueuts  which  produce 
spoken  words  (Hastian's  glosso-kina'sthetic  centre) ;  M  //*,  path  along  which  impulses 
travel  to  innervate  tiie  lower  nuclei  which  govern  the  muscles  concerned  in  speech;, 
.  W,  area  in  cerebral  cortex  in  which  are  storijd  the  memories  of  the  muscular  move- 
ments concerned  in  writing  (liastian's  cheiro-kinicslhetic  centre);  W/(,  patli  along 
which  impulses  travel  to  innervate  the  lower  nuclei  which  govern  the  muscles  used 
in  writing;  I,  areas  of  association  in  cortex  by  means  of  which  the  activities  of  the 
various  sensory  perception  centres  nuiy  be  united  to  higher  units  (conceptions,  ideas, 
thoughts,  etc.),  and  whence  the  centres  M  and  W  may  be  incited. 

touch);  (b)  emissive  or  motor  centres  for  speech  and  writing;  and  (r)  higher 
psychical  centres,  through  which  we  obtain  an  intellectual  concejition  of 
what  is  said  or  written,  and  by  which  we  express  voluntarily  our  ideas  in 
Language. 

Ai)hasic  disturbances  for  convenience  of  description  are  arbitrarily  di- 
vided into  two  chief  forms — sex  sort/  and  motor. 

(1)  Sensory  Aphasia;  Apraxia;  Word-blindness;  Word-deafness. — By 
ai)raxia  is  understood  a  condition  in  which  there  is  loss  or  impairnu'ut  of 
the  power  to  recognize  the  nature  and  characteristics  of  objects.  Persons  so 
aifected  act  "as  if  thtj  ..o  longer  ])ossessed  such  ol)ject  memories,  for  they 
fail  to  recognize  things  formerly  familiar.  A  fork,  a  cane,  a  ])in,  may  be 
taken  up  and  looked  at  by  such  a  ])erson,  and  yet  held  or  used  in  a  manner- 
which  clearly  shows  that  it  awakens  no  idea  of  its  use.  And  this  symp- 
tom, for  which  at  first  the  term  blindness  of  mind  was  used,  is  found  to 
extend  to  other  senses  than  that  of  sight.  Thus  the  tick  of  a  watch,  the 
sound  of  a  bell,  a  melody  of  music,  may  fail  to  arouse  the  idea  which  it 


990 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


formerly  awnkoncd,  and  the  patient  lias  then  deafness  of  mind;  or  an  odor 
or  taste  no  loni^^'r  ealls  up  the  notion  of  the  tiling  smelled  or  tasted;  and 
thus  it  is  found  that  eaeh  or  all  of  the  sensory  organs,  when  called  into  play, 
may  fail  to  arouse  an  intelligent  perccjjtion  of  the  object  exciting  them. 
For  the  general  symjjtoms  of  inability  to  recognize  the  use  or  import  of  an 
object  the  term  apraxia  is  now  employed  "  (Starr). 

A])ra.\iu  may  occur  alone,  but  more  commonly  is  associated  with  varie- 
ties of  sensory  and  motor  aphasia.  The  patient  may  be  able  to  read,  but 
the  words  arouse  no  intelligent  impression  in  his  mind.  While  blind  to 
memory-])ictures  aroused  through  sight,  the  perceptions  may  be  stimulated 
by  touch;  thus  there  are  instances  on  record  of  apraxic  patients  unable  to 
read  by  sight,  who  could  on  tracing  the  letters  by  touch  name  them  cor- 
rectly. Of  the  forms  of  apraxia,  mind-blindness  and  mind-deafness  are  the 
most  important. 

The  cases  of  mind-hlindness  collected  by  Starr  indicate  that  the  lesion 
exists  in  the  left  hemisphere  in  right-handed  persons,  and  in  the  right  hemi- 
si)here  in  left-handed  persons.  The  <lisease  usually  involves  the  angular 
and  supramarginal  gyri  or  the  white  matter  beneath  them.  Blindness  of 
the  "  mind's  eye  "  may  at  times  be  functional  and  transitory,  and  is  asso- 
ciated with  many  forms  of  mental  disturbance.  In  a  remarkable  case  re- 
ported by  Macewen,  the  patient,  after  an  injury  to  the  head,  had  sulferecl 
with  headache  and  melancholia,  biit  there  was  no  paralysis.  He  was  psy- 
chically blind  and  though  he  could  see  everything  perfectly  well  and  could 
read  letters,  ol)jects  conveyed  no  intelligent  impression.  A  man  before 
his  eyes  was  recognized  as  some  object,  but  not  as  a  man  until  the  sounds 
of  the  voice  led  to  the  recognition  through  the  auditory  centres.  The  skull 
was  tre])hined  over  the  angular  gyrus  and  the  inner  table  was  found  to  be 
depressed  and  a  portion  had  been  driven  into  the  brain  in  this  region.  The 
patient  recovered.  Mind-blindnoss  is  the  equivalent  of  visual  amnesia. 
Other  manifestations  of  mind-bli.  ""ness  are  met  with;  thus  a  young  man 
with  secondary  syphilis  had  several  convulsive  seizures,  af^,'r  one  of  which 
he  renuiined  unconscious  for  some  time.  On  awakening,  the  memory-pic- 
tures of  faces  and  places  were  a  blank,  and  he  neither  knew  his  parents  nor 
brothers,  nor  the  streets  of  the  town  in  which  he  lived;  he  had  no  aphasia 
proi)er,  and  no  ])aralysis.  Again,  there  may  be  complete  tactile  arMiesia, 
as  in  the  cases  reported  by  C.  W.  Burr. 

Word-blindness  may  occur  alone  or  with  motor  aphasia.  In  uncom- 
plicated cases  the  patient  is  no  longer  able  to  recall  the  appearances  of 
words,  and  does  not  recognize  them  on  a  printed  or  written  page.  The 
l^atient  may  be  able  to  ]n'onounce  the  letters  and  can  often  write  correctly, 
but  he  cannot  read  understandingly  what  he  has  written.  It  is  rare,  how- 
ever, for  tlie  ])atient  to  be  aide  to  write  with  any  degree  of  facility.  There 
are  instances  in  which  the  patient,  nnable  to  read,  has  yet  been  able  to  do 
mathematical  prol)k'ms  and  to  recognize  playing  cards.  The  lesions  in  cases 
of  word-blindness  is,  in  a  m.ajority  of  cases,  in  the  angular  and  supramar- 
ginal gyri  on  the  left  side.  It  is  commonly  associated  with  hemianopia,  and 
not  infrequently  with  mind-blindness  (Fig.  3). 

Mind-deafness  is  a  condition  in  which  sounds,  though  heard  and  per- 


APHASIA. 


OUl 


or  an  odor 
:asted;  and 
1  into  play, 
ting  tlioin. 
ipoit  of  an 

vvitli  varie- 
)  read,  but 
e  blind  to 
stimulated 
unable  to 
them  cor- 
ess  are  the 

the  lesion 
ight  hemi- 
le  angular 
indness  of 
id  is  asso- 
le  case  re- 
d  suffered 
;  was  i)sy- 
and  could 
an  before 
be  sounds 
The  skull 

nd  to  be 
lion.    The 

amnesia, 
ung  man 
of  which 
nory-pic- 
rents  nor 
a])hasia 

apniesia, 

uncom- 
ances  of 
pc.     The 
orrectly, 
re,  how- 
There 
le  to  do 
in  cases 
]iramar- 
pia,  and 

lid  jier- 


oeived  as  such,  awaken  no  intelligent  })ercei)tions.  A  person  who  knows 
nothing  of  French  has  miiul-ileafness  so  far  as  the  French  language  is 
concerned,  and  though  ho  recognizes  the  words  as  words  when  spoken,  and 
can  repeat  them,  they  awaken  no  auditory  memories.  The  musical  faculties 
may  be  lost  in  ai)hasics,  who  may  become  note-deaf  and  unable  to  ai)})i'e- 
ciate  melodies  or  to  read  music  [ainusia).  This  may  occur  without  the 
existence  of  motor  a})hasia,  and,  on  the  other  hand,  there  are  cases  on 
record  in  which  with  motor  aphasia  for  ordinary  speech  the  patient  could 
sing  and  follow  tunes  correctly.  Mind-deafness  is  also  known  as  auditory 
amnesia. 

Word-deafness  is  a  condition  in  which  the  patient  no  longer  under- 
stands spoken  language.  The  memory  of  the  sound  of  the  word  is  lost, 
and  can  neither  be  recalled  nor  recognized  when  heard.  It  is  usually  asso- 
ciated with  other  varieties  of  aphasia,  though  there  arc  cases  in  which  the 
])atient  has  been  able  to  read  and  write  and  si)eak.  The  lesion  in  word- 
ileafness  has  been  accurately  defined  in  a  number  of  cases  to  be  in  the  pos- 
terior portion  of  the  su])erior  temporal  convolution  and  the  transverse  tem- 
poral gyri  on  the  left  side  (Fig.  3). 

In  ordinary  sensory  aphasia  of  Wernicke's  type  there  is  loss  of  power  to 
understand  spoken  words  and  to  repeat  words  pronounced  before  the  pa- 
tient. The  patient,  as  a  rule,  cannot  read  (alexia),  and  is  usually  unable 
to  express  his  thoughts  in  writing  (agraphia).  Spontaneous  speech  may  be 
somewhat  interfered  with,  and  on  account  of  the  interference  with  speech 
control,  resulting  from  the  loss  of  memory  of  the  sounds  of  words,  there 
may  be  a  little  paraphasia. 

In  the  so-called  .p?/ re  ivord-dcafness  (Wernicke's  subcortical  sensory 
aphasia)  the  symptoms  differ  from  those  of  the  most  common  form  of  sen- 
sory aphasia  in  that  the  power  to  read  and  to  write  are  retained.  Besides, 
there  is  but  little  if  any  paraphasia. 

In  the  so-called  transcortical  sensory  aphasia  the  patient  has  lost  the 
power  of  understanding  spoken  words,  although  he  is  capable  of  spontane- 
ous speech  and  also  of  repeating  words  pronounced  before  him.  Spontane- 
ous writing  is  impossible.  He  can  read  aloud  from  a  manuscript  or  printed 
page,  but  does  not  understand  Avhat  he  roads.    There  is  some  ])araphasia. 

(2)  Ordinary  motor  or  ataxic  aphasia  is  a  condition  in  which  the  mem- 
ory of  the  eU'orts  necessary  to  pronounce  words  is  lost,  owing  to  disturl)- 
ance  in  the  emissive  centres.  This  is  the  variety  long  ago  recognized  by 
liroca,  the  lesion  of  which  was  localized  Ijy  him  in  the  left  inferior  frontal 
convolution.  The  patient  may  not  l.)e  able  to  utter  a  single  word;  more 
commonly  he  can  say  one  or  two  words,  such  as  "  no,"  "  yes,"  and  he  not 
infretiuently  is  able  to  re]ieat  words.  When  shown  an  object,  though  not 
able  to  name  it,  he  may  evidently  recognize  wliat  it  is.  If  told  the  name, 
he  is,  as  a  rule,  unable  to  repeat  it.  A  man  knowing  the  French  and  Ger- 
man languages  may  lose  the  power  of  expressing  his  thoughts  in  them,  while 
retaining  his  mother-tongue;  or,  if  completely  aphasic,  may  recover  one 
before  the  other.  As  the  third  left  frontal  convolution  is  in  close  contact 
with  the  centres  for  the  face  and  arm,  these  are  not  uncommonly  involved, 
with  the  production  of  a  partial  or,  in  some  instances,  a  complete  right- 


992 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


iMi< 


sidt'd  lu'iiiiplcgia.  Alc.riti,  or  inability  to  read,  occurs  with  motor  aphasia 
and  also  witli  word-hlindnt'ss. 

Ah  a  ridi',  in  motor  apiiasia  there  is  also  inability  to  write — (ujraphia. 
'\\\k'1\  there  is  right  brachial  monoplegia  it  is  dillicult  to  test  the  capability, 
but  there  are  instances  of  motor  aphasia  without  paralysis,  in  which  the 
l)o\ver  of  voluntary  writing  is  lost.  The  condition  varies  very  much;  thus 
a  patient  may  not  be  able  to  write  voluntarily  or  I'ron,  dictation,  and  yet 
nuiy  copy  ])crrcctly.  It  is  still  a  question  whether  there  is  a  special  writing 
centre.  Jt  has  been  placed  by  some  writers  at  the  base  of  the  second  irontal 
convolution,  but  it  seems  likely  that  it  coincides  with  ti.e  nu)tor  area  for  the 
upper  extremity.  From  the  above  type,  wiiich  may  be  looked  U|)on  as  the 
ordinary  form  of  motor  aphasia,  two  other  varieties  must  be  se])arated — viz., 
(1)  jjure  word-dumbn'css  and  {2)  the  so-called  transcortical  motor  ai)hasia. 

Pure  ivord-diiiiihness  (subcortical  motor  ajjhasia  of  ijichtheim  and  Wer- 
nicke) is  the  term  a])plied  to  that  complex  of  symptoms  occasionally  met 
with,  in  which,  though  the  power  of  spontaneous  speech  and  of  re])eating 
words  heard  is  lost,  the  individual  can  write,  and  can  read  to  himself  with 
understanding  that  which  is  written  or  printed,  lie  is,  of  course,  unablu 
to  read  aloud. 

Transrurlical  motor  aphakia  is  the  term  applied  by  ^Yernicke  to  that  form 
of  motor  ai»hasia  studied  iirst  by  Lichtheim  in  which  the  ])ower  to  speak 
and  write  spontaneously  is  lost,  though  the  patient  can  understand  spoken 
and  written  words  perfectly,  can  read  aloud,  can  write  to  dictation,  and  can 
copy  another  individual's  writing. 

There  is  a  form  known  as  nii.vcd  aphasia,  in  which  the  patient  under- 
stands what  is  said,  and  speaks  even  long  sentences  correctly,  but  he  con- 
stantly tends  to  misidace  words,  and  does  not  exjjress  his  ideas  in  the  proper 
words.  It  is  precisely  these  cases  which  afford  the  most  exquisite  exanqiles 
of  ])araphasia.  All  grades  of  this  nuiy  be  met  with,  from  a  state  in  which 
only  a  word  or  two  is  mis])laced  to  an  extreme  condition  in  which  the  ])a- 
tient  talks  jargon.  In  these  cases  the  association  tract  is  interrupted  be- 
tween the  auditory  percejjtive  and  the  emissive  centres,  hence  it  is  some- 
times known  as  Wernicke's  aphasia  of  conduction.  The  lesion  is  usually 
in  the  insula  aiul  in  the  convolutions  which  unite  the  frontal  and  tem])oral 
lobes.  liichtheim's  schema,  though  out  of  accord  with  a  number  of  facts, 
is  extremely  useful  to  the  beginner,  and  will  assist  the  student  in  obtaining 
a  rational  idea  of  the  varieties  of  aphasia: 

1.  In  the  condition  of  a]iraxia  or  mind-blindness  the  ideation  centres, 
I,  are  involved,  often  with  the  auditory  and  visual  perceptive  centres,  A 
and  0. 

2.  A  lesion  at  A,  the  centre  for  the  auditory  memories  of  words  (left 
superior  temporal  gyrus),  is  associated  with  Avord-deafness. 

3.  A  lesion  at  0,  the  centre  for  visual  memories  (occipital  cortex),  causes 
word-blindness. 

4.  Interruption  of  the  tracts  uniting  A  M  and  0  M  causes  the  conduc- 
tion aphasia  of  "Wernicke — paraphasia. 

5.  Destruction  of  the  centre  M  (Broca's  convolution)  causes  ordinary 
motor  aphasia,  in  which  the  patient  cannot  express  thoughts  in  speech. 


APHASIA. 


993 


itor  aphasia 

— agraphia. 
!  capahilily. 
wliifh  tlu.' 
tniifli;  Ihu.s 
)n,  and  VL't 
Aid  writiii^^ 
Diul  i'roiital 
uva  for  tile 
[poll  as  llio 
rated — viz., 
or  a])hasia. 
1  and  Wur- 
onally  met 
I'  rc'])oatiii<( 
nisei f  witli 
rse,  iinabie 

)  tliat  form 
T  to  spealv 
nd  spolven 
n,  and  can 

mt  imder- 
it  lie  con- 
tlie  proper 
examples 
in  whicli 
I  the  pa- 
ll ])ted  bc- 
is  somc- 
is  usually 
temporal 
of  facts, 
obtaining 

1  centres, 
entres,  A 

Drds  (left 

v),  causes 

conduc- 

ordinary 
eech. 


A  k"  1  at  M  usually  destroys  also  tlu'  power  of  writing.  The  centre 
for  memories  of  the  movements  made  in  writing,  W,  is  distinct  from  that 
oi'  speech.  Jt  is  called  by  IJastian  the  "  cheiro-kina'sliietic  "  centre.  A 
lesion  at  M,  which  would  destroy  tbe  power  of  voluntary  s|)eech,  might  leave 
o|ien  the  connections  between  O  W  aiul  A  \V,  by  which  tlu'  [)atient  could 
copy  or  write  from  dictation.  According  to  Wernicke's  conception,  pure 
word-deafness  (subcortical  sensory  aphasia)  woidd  be  dm)  to  a  lesion  in  the 
path  fl  A,  transcortical  sensory  apliasia  to  a  lesion  in  the  path  A  1,  jjiire 
word-dumbness  (subcortical  motor  a[)basia)  to  a  lesion  in  tbe  path  M  in, 
and  transcortical  nu»tor  aj)hasia  to  a  lesion  in  the  ])ath  I  M.  Wbile  un- 
doubtedly there  are  groups  of  cases  sc|)arable  clinically  corresp(ui(liiig  to 
these  various  ty|)es,  still  pathological  examinations  have  already  shown 
that  the  nomeiu'laturc  is  faulty  and  will  not  stand,  though  the  number  of 
cases  thus  far  thoroughly  studied  at  autopsy  does  not  sullice  for  the  con- 
struction of  a  conii)lete  classiiicatioii  on  a  jiathological  Ijasis. 

The  ])ro[)lems  of  a])hasia  are  in  reality  excessively  complicated,  and 
the  student  ruist  not  for  a  moment  supi)ose  that  cases  are  as  simple  as 
diagrams  indicate.  A  majority  of  them  are  very  coni[)lcx,  but  with  [)atience 
the  diagnosis  of  the  dilferent  varieties  can  often  be  worked  out. 

The  following  tests  should  be  ap])licd  in  each  case  of  aphasia  after 
having  determined  the  presence  or  absence  of  jiaralyses,  and  whether  the 
])atient  is  right-handed  or  left-handed:  (1)  The  power  of  recognizing  the 
nature,  uses,  and  relations  of  objects — i.  e.,  whether  apraxia  is  jiresi'ut  or 
not;  (2)  the  power  to  recall  the  name  of  familiar  objects  seen,  smelled,  or 
tasted,  or  of  a  sound  when  heard,  or  of  an  object  touched;  (3)  the  jiower 
to  understand  s])oken  words;  (4)  the  capability  of  understanding  jirinted 
or  written  language;  (5)  the  ])ower  of  a])preciating  and  understanding 
musical  tunes;  ((i)  the  power  of  voluntary  speech — in  this  it  is  to  be  noted 
particularly  whether  he  misidaces  words  or  not;  (7)  the  ])ower  of  reading 
aloud  and  of  understanding  Avhat  he  reads;  (8)  the  ])o\ver  to  write  volun- 
tarily and  of  reading  what  he  has  written;  (9)  the  jiower  to  co])y;  (10)  the 
jmwer  to  write  at  dictation;  and  (11)  the  power  of  repeating  words. 

The  medico-lpf/al  cispeds  of  aphasia  are  of  great  importance.  No  general 
])rinci])le  can  be  laid  down,  but  each  case  must  be  considered  on  its  merits. 
Langdon,  in  reviewing  the  whole  question,  concludes:  "  Sanity  established, 
any  legal  document  should  be  recognized  when  it  can  be  ])roved  that  the 
jierson  making  it  can  understand  fully  its  uature  by  any  rece])tive  channel 
(viz.,  hearing,  vision,  or  muscular  sense),  and  can,  in  addition,  express  assent 
or  dissent  with  certainty  to  ])roper  witnesses,  whether  this  expression  be  by 
s|)oken  speech,  written  speech,  or  pantomime." 

Prognosis  and  Treatment. — Tu  young  persons  the  outlook  is  good, 
and  the  power  of  s])eech  is  gradunlly  restored  a])parently  by  the  education 
of  the  centres  on  the  opposite  side  of  the  brain.  In  adults  the  condition  is 
less  hopeful,  particularly  in  the  cases  of  com])lete  motor  a]diasia  with  right 
hemi])legia.  The  patient  may  remain  sjieechless,  though  capable  of  under- 
standing everything,  and  attempts  at  re-education  may  be  futile.  Partial 
recovery  may  occiir,  and  the  patient  may  be  able  to  talk,  but  misidaces 
words.     In  sensory  aphasia  the  condition  may  be  only  transient,  and  the 


]f 


994 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


(lilToront  forms  rarely  persist  alone  without  inipnirnient  of  tlic  powers  of 
expression. 

Tlic  education  of  an  aphasic  person  recjuires  the  greatest  care  and  \)a- 
tience,  particuhirly  if,  as  so  often  luippens,  he  is  emotional  and  irritable. 
It  is  best  to  be^nn  by  the  use  of  detached  letters,  and  advance,  not  too 
rapidly,  to  words  of  only  one  syllable.  Children  often  make  rapid  progress, 
but  in  adults  failure  is  only  too  frequent,  even  after  the  most  painstaking 
cll'orts.  In  the  cases  of  right  hemiplegia  with  aphasia  the  patient  nuiy  be 
taught  to  write  with  the  left  hand. 


/ 


III.    AFFECTIONS    OF   THE    BLOOD-VESSELS. 

1.  IIyper.emia. 

Congestion  of  the  brain  has  in  the  past  played  an  important  part  in 
cerebral  pathology.  Undoubtedly  there  are  great  variations  in  the  amount 
of  blood  in  the  cerebral  vessels;  this  is  universally  conceded,  but  how  far 
these  changes  are  associated  with  a  definite  grouj)  of  symptoms  is  not  quite 
so  clear.  The  whole  subject  has  recently  been  revised  by  ]{.  Geigel,  who 
rightly  insists  that  the  nutrition  of  the  nerve-cells  and  the  possibility  of 
interchange  of  gases  between  the  blood  and  the  cerebral  tissues  is  dependent 
not  only  upon  the  amount  of  blood  in  the  cerebral  vessels,  but  also  upon 
its  chemical  constitution,  and  especially,  it  would  appear,  upon  the  velocity 
of  the  current  in  the  cerebral  capillaries.  The  speed  of  the  blood  flow 
in  the  cerebral  cajjillaries  depeiids,  according  to  this  writer,  much  more 
on  the  tension  of  the  walls  of  the  vessels  than  upon  the  height  of  the  ar- 
terial pressure.  In  many  of  the  conditions  designated  as  "  cerebral  hyper- 
a'mia  "  there  is  really  a  condition  of  lowered  pressure,  for  with  flaccidity 
and  widening  of  the  cerebral  arteries,  due  say  to  paralysis  of  the  sympa- 
thetic, the  arterial  pressure  remaining  constant,  there  must  follow  as  the 
result  of  the  diminution  of  the  tension  of  the  vessel  walls  a  decrease  in  the 
Telocity  of  the  blood-flow.  On  the  other  hand,  spasm  of  the  cerebral 
arteries,  due  say  to  irritation  of  the  sympathetic,  gives  rise  not  to  "  anse- 
mia  "  as  generally  is  su])posed,  hut  through  increase  of  vascular  tension 
to  a  higher  velocity  of  flow  through  the  cerebral  capillaries.  It  has 
been  customary  to  describe  cerebral  hypera^mia  as  being  either  active  or 
l)assive. 

Thus  active  lujpcrcumia  has  been  siipposed  to  he  associated  with  febrile 
conditions,  with  increased  action  of  the  heart,  chilling  of  the  surface,  con- 
traction of  the  superficial  vessels,  and  with  the  sujipression  of  certain  cus- 
tomary discharges.  Among  other  recognized  causes  are  plethora,  func- 
tional irritation,  such  as  is  associated  with  excessive  brain  work,  and  the 
action  of  certain  substances,  such  as  alcohol  and  nitrite  of  amyl. 

Passive  hypera'inia  was  said  to  result  from  obstruction  in  the  cerebral 
sinuses  and  veins,  engorgement  in  the  lesser  circulation,  as  in  mitral  ste- 
nosis, emphysema,  from  pressure  on  the  superior  cava  by  aneurisms  and 
tumors,  and  in  the  venous  engorgement  which  takes  place  in  prolonged 


c  jiowcrs  of 

are  and  pa- 
id irritaMo. 
CO,  nut  too 
id  proifros,«j, 
jminstakiny 
ont  may  bo 


S. 


int  part  in 

tho  amount 

lit  bow  far 

s  not  quite 

Jeigel,  Avlio 

ssibility  of 

dcpondont 

also  upon 

Iio  velocity 

blood  flow 

inch  more 

of  the  ar- 

)ral  hypor- 

flaceidity 

10  sympa- 

ow  as  the 

ase  in  the 

i  cerebral 

to  "  auir- 

ir  tension 

It   has 

active  or 

til  febrile 
'ace,  eon- 
tain  cus- 
ra,  func- 
and  the 

cerebral 
itral  ste- 
sins  and 
rolonged 


AFFECTIONS  OP  THE  BLOOD-VESSELS. 


995 


straining  elTort.s.     In  its*  most  intense  form  it  is  seen  in  tlie  compression  of 
ibe  sujjerior  cava  by  tumors  and  in  death  from  strangulation, 

'JMie  anattmiical  ciiangos  in  congestion  of  the  brain  are  by  no  means 
striking.  Such  an  active  hypent'inia  is  never  visible  post  mortem.  Tiie 
veins  of  the  cortex  are  distended,  the  gray  matter  has  a  deeper  color,  and 
its  vessels  are  full.  The  arteries  at  the  base  and  in  the  Sylvian  iissures 
contain  blood.  Nothing,  however,  can  be  more  uncertain  or  indefinite  tlian 
the  post-mortem  a])i)earances  of  so-called  hyperoiinia  of  the  brain.  The 
most  intense  distention  of  the  vessels  is  seen  in  early  death  during  the 
specific  fevers,  or  in  the  secondary  passive  congestion  due  to  obstructit)n  in 
tlie  superior  cava  or  in  the  lesser  circulation.  In  a  majority  of  those  cases 
of  so-called  l'.ypera.'mia,  while  the  total  mass  of  blood  in  the  brain  may  ex- 
ceed the  normal  by  a  considerable  amount,  yet  the  velocity  of  the  current 
is  so  much  less  than  nornuil,  that  as  a  result  the  brain  really  has  a  smaller 
supply  of  blood  than  is  normal — that  is,  the  patient  actually  sulfers  from 
cerebral  "  aiueniia  "  rather  than  from  "  hypera^mia." 

Symptoms. — There  are  no  characteristic  or  constant  features  of  dila- 
tation of  the  cerebral  blood-vessels.  It  may  exist  in  the  most  extreme  grade 
without  the  slightest  disturbance  of  the  cerebral  functions,  as  is  witnessed 
frequently  in  the  pressure  by  tumors  on  the  superior  vena  cava.  How  far 
the  headache  and  delirium  of  the  early  stage  of  the  infectious  fevers  is  to 
be  assigned  to  dilatation  of  the  blood-vessels  of  the  brain  it  is  not  easy  to 
determine.  The  headache,  dizziness,  and  unpleasant  sensations  in  aortic 
insufhcioncy  and  in  some  instances  of  hypertrophy  of  the  heart  have  been 
attributed  to  the  cerebral  congestion. 

As  a  separate  clinical  entity,  congestion  of  the  brain  rarely  comes 
under  observation.  I  have  no  knowledge  of  instances  associated  with  de- 
lirium, fever,  insomnia,  and  convulsions,  or  of  the  so-called  apoplectiform 
variety  described  by  some  writers.  Very  plethoric  persons  are  subject  to 
attacks  of  headache  with  flushing  of  the  face  and  irritability  of  temper, 
attacks  which  may  recur  frequently  and  are  sometimes  relieved  by  bleed- 
ing at  the  nose.  These  have  usually  been  attributed  to  congestion  of  the 
brain.  AVhen  the  so-called  passive  hypera>mia  reaches  a  high  grade,  there 
may  be  torpor,  dulness  of  the  intellect,  and  ultimately  deep  coma. 

Leubc  suggests  that  the  symptoms  usually  referred  to  active  hypericmia 
in  the  acute  infectious  diseases,  like  diphtheria  and  erysipelas,  or  in  the 
instances  in  which  hypertrophy  of  the  heart  accompanies  disease  of  the 
kidneys,  may  after  all  be  toxic  in  origin,  rather  than  due  to  alteration  in 
the  circulatory  relations.  At  any  rate,  he  believes  that  it  is  not  possible 
to  make  a  diagnosis  of  such  a  hyperamiia.  Flushing  of  the  face  is  by  no 
moans  a  safe  guide.  Possiblv  an  examination  of  the  eye-grounds  may  be 
helpful. 

2.    Ax.EMIA. 

This  may  be  induced  by  loss  of  blood,  either  fpiickly,  as  in  luvmor- 
rhage,  or  gradually,  as  in  the  severe  primary  and  secondary  ana'uiias. 
The  anaemia  may  be  local  and  due  to  causes  which  interfere  with  the  blood 
supply  to  the  brain,  as  narrowing  of  the  vessels  by  endarteritis,  pressure, 


996 


I)1SKA.SP]S  OF  THE  NKIIVOUS  SYSTEM. 


/' 


iiarrowinj:^  of  llic  iiortic  orifice,  or  it  iiiiiy  follow  nn  iiiu'fuinl  distribution 
of  the  blood  in  coiiscciiiciicc  of  dihitnlioii  of  ccrtniii  viiscular  territories. 
Tliiis,  rapid  distention  of  the  intestinal  vessels,  siieli  as  occurs  after  the 
removal  of  ascitic  iluid,  may  cause  sudden  death  from  cerebral  ana'inia. 
The  commonest  illustration  of  Ihis  is  the  l'aintin;j;  lit  from  emotion,  in 
Avhich  the  blood  su|)|)ly  to  the  brain  is  insuirieieni  on  account  of  the  dimin- 
ished arterial  [)ressure.  Aiuemia  of  the  ccri'bra'  vessels  may  bo  canst  d 
by  })ressuro  of  Iluid  in  the  ventricles.  The  partial  ana'inia  residts  from 
obliteration  of  brandies  of  the  circle  of  Willis  by  end)olism  or  throndjosis. 
liipiture  of  one  carotid  sometimes  causes  a  transient  marked  anionna  and 
disturbance  of  function  on  oiu'  side  of  the  brain. 

Tlio  anatomical  comlition  of  the  brain  in  ana-mia  is  very  strikin<i'. 
The  membranes  are  pale,  only  the  large  veins  are  full,  the  small  vessels 
over  the  gyri  arc  emj)ty,  and  an  unusual  amount  of  cerebro-spinal  fluid  is 
l)resent.  On  section  both  the  gray  and  white  matter  look  extremely  pale 
and  the  cut  sui'fai'C  is  moist.     Aery  few  punria  vasrulosa  are  seen. 

Symptoms. — The  ell'ects  of  ana-nua  of  the  brain  are  well  illustrated 
l)y  a  fainting  lit  in  which  loss  of  consciousness  follows  the  heart  weakness. 
AVhen  the  result  of  ha'inorrhage,  there  are  drowsiness,  giddiness,  inability 
to  stand,  Hashes  of  light,  dark  spots  before  the  eyes,  and  noises  in  the  ears; 
the  resjjiration  becomes  hurried;  the  skin  is  cool  and  covered  with  sweat; 
the  pui)ils  are  dilated,  there  may  be  vomiting,  headache,  or  delirium,  and 
gradually,  if  the  bleeding  continues,  consciousness  is  lost  and  death  may 
occur  with  convulsions.  In  ordinary  syncope  the  loss  of  consciousness  is 
usually  transient  and  the  recundjcnt  posture  alone  may  sutlice  to  restore 
the  patient  to  consciousness.  In  the  more  chronic  forms  of  brain  aiuemia, 
such  as  result  from  the  gradual  impoverishment  of  the  blood,  as  in  pro- 
tracted illness  or  in  starvation,  the  condition  known  as  irritable  weakness 
results.  AFcntal  elt'ort  is  diflicult,  the  slightest  irritation  is  followed  by 
undue  cA'citement,  the  patient  complains  of  giddiness  and  noises  in  the 
ears,  or  there  may  be  hallucinations  or  delirium.  These  symptoms  are  met 
■with  in  an  extreme  grade  as  a  result  of  prolonged  starvation. 

These  sym])toms  are  indistinguishable  from  those  due  to  the  so-called 
cerebral  hyperiemia.  The  quality  of  the  blood  is  deteriorated  and  the 
velocity  of  the  blood-flow  is  diminished,  so  that  the  cerebral  nutrition  is 
interfered  with.  It  is  interesting  to  note  that  lack  of  suitable  nutrition 
gives  rise  to  phenomena  of  increased  irritability  in  certain  of  the  cerebral 
centres,  at  least  for  a  time. 

An  interesting  set  of  symptoms,  to  which  the  term  hi/drenceplialoid 
was  applied  by  Marshall  Hall,  occurs  in  the  debility  produced  by  prolonged 
diarrhoea  in  children.  The  child  is  in  a  semi-comatose  condition  with  the 
eyes  open,  the  pupils  contracted,  and  the  fontanelle  depressed.  In  the 
earlier  ])eriod  there  nuiy  bo  convulsions.  The  coma  may  gradually  deepen, 
the  ])upils  become  dilated,  and  there  may  be  strabismus  and  even  retraction 
of  the  head,  symptoms  which  closely  simulate  those  of  basilar  meningitis. 


AF1''K{TI()N'S   OF   THE    IlLOOD  VFSSET-S. 


997 


distrihtitidii 
•  torrit  (tries. 
rs  lifter  the 
nil  aiiii'iiiiii. 
('motion,  ill 
I'  liu'  (liiniii- 
'  1)0  cuiisid 
•osulls  from 
tliroiiihosis. 
uueiiiiii  and 

ry  strikin<r. 
mall  vessels 
iiial  fluid  is 
remely  pale 
uu. 

I  illustrated 
't  weakness. 
Hs,  inability 
in  the  ears; 
with  sweat; 
lirium,  and 
death  may 
.'iousness  is 
'  to  restore 
ill  ana>niia, 

as  in  ])ro- 
-  weakness 

llowod  by 
ses  in  the 
ns  are  met 

.so-called 

and  the 

utrition  is 

nutrition 

e  cerebral 

nccplialoid 
)rolon<red 
with  the 
In  the 
r  deepen, 
detraction 
ingitis. 


!).  (I'Idkma  of  Tin:  IWiain'. 

Tn  the  palholofiy  of  lirain  lesions  (edema  formerly  ])lay('d  a  role  almost 
(•((ual  in  imi)oi'tance  to  conjiestion.  it  occurs  under  the  following  condi- 
tions: In  general  atrophy  of  the  convolutions,  in  which  case  the  (edema 
is  ri'presented  by  an  increase  in  the  cerebro-spiiial  lliiid  and  in  that  (d'  th(( 
meshes  of  the  pia.  In  extreme  venous  dilatation  from  obstruction,  as  in 
mitral  stenosis  or  in  tumors,  there  may  be  a  condition  of  (M)ngestive  (edema, 
ill  which,  in  addition  to  great  lilling  of  the  blood-vessels,  the  substance  of 
the  brain  itself  is  unusually  moist.  'I'lu!  most  acute  oMiema  is  a  local  pro- 
cess found  around  tumors  and  abscesses.  An  intense  infiltration,  local  or 
general,  may  occur  in  l'»right's  disease,  and  to  it,  as  'i'raube  suggesteil.  cer- 
tain of  the  ura-mic  synipt(»nis  may  be  due. 

The  (iiialdiiiicdl  vlnnujcs  are  not  unlike  those  of  ana'inia.  When  the 
(cdcma  follows  progressive  atrophy,  the  lluid  is  chiclly  within  and  beneath 
the  membranes.  The  brain  substance  is  ameniic  and  moist,  and  has  a  wet, 
glistening  appearance,  which  is  very  characteristic.  In  some  instances  the 
(edema  is  more  intense  and  local  and  the  brain  substance  may  look  inlil- 
trated  with  lluid.  The  amount  of  lluid  in  the  ventricles  is  usually  in- 
creased. 

The  si/niploiiis  are  in  great  part  those  of  lessened  l)loo(l-ll()w,  and  are 
not  well  dclined.  As  just  stated,  some  of  the  cerebral  features  of  ura'inia 
may  de})end  n|)on  it.  Of  late  years  cases  have  been  reported  by  Haymond, 
Tenneson,  and  Dcrcuni,  in  which  unilateral  convulsions  or  paralysis  have 
occurred  in  connection  with  chronic  Ih'ight's  disease,  and  in  which  the 
condition  appeared  to  be  associated  with  (edema  of  the  brain.  The  older 
writers  laid  great  stress  upon  an  apoplexia  si'rosa,  which  nuiy  really  have 
been  a  general  (cdeina  of  the  brain.  Inasmuch  as  the  instances  in  which 
(edema  of  the  brain  occurs  are  often  those  in  which  there  is  also  intoxication, 
or  ana'inia.  or  both,  it  is  probably  impossible  to  say  at  the  bedside  definitely 
which  of  these  possible  factors  is  responsible  for  the  sym])toms  in  a  given 
case. 

4.  Cerebral  ILemorriiagi:. 

The  bleeding  may  come  from  branches  of  either  of  the  two  great 
grou})S  of  cerebral  vessels — the  hasal,  comitrising  the  circle  of  Willis  and 
the  central  arteries  passing  from  it  and  from  the  first  ])ortion  of  tin;  cere- 
))ral  arteries,  or  the  cortical  (jroiip,  the  anterior,  middle,  and  the  posterior 
cerebral  vessels.  In  a  majority  of  the  cases  the  luemorrhage  is  from  the 
central  branches,  more  ])articularly  from  those  given  olf  by  the  middle 
cerebral  arteries  in  the  anterior  perforated  spaces,  and  which  sujjply  the 
corpora  striata  and  internal  capsules.  One  of  the  largest  of  these  branches 
Mhich  ])asses  to  the  third  division  of  the  lenticular  nucleus  and  to  the  an- 
terior i)art  of  the  internal  caiisule,  the  lenticulo-striate  artery  of  Duret,  is  so 
fre([uently  involved  in  luemorrhage  that  it  has  been  called  by  Charcot  Ihe 
otienj  of  cerebral  hwiiiarrhatje.  IlLeniorrhages  from  this  and  from  the  len- 
ticulo-thalamic  artery  include  more  than  GO  per  cent  of  all  cerebral  lia^nor- 
rhages.     The  bleeding  may  be  into  the  substance  of  the  brain,  to  which 


998 


DISKASKS  OF  TFIK  NEUVors  SYSTKM. 


.  \ 
/ 


nluiu'  till'  term  ccri-hnil  iipnplc.w  i.s  nii|ilic(l,  or  into  the  mciiibnim's,  in  wlikh 
case  it  is  Icniii'd  niciiiii^cul  lia'mt)rrliii|,'i';  Ixitli,  iiowovcr,  arc  usually  in- 
cluded under  the  leniis  intracranial  or  cerebral  ha'inorrhage. 

Etiolog;y. — The  conditimis  wlncli  produce  lesions  of  the  blood-vos- 
pels  |iliiy  a  very  iiii|»ortaMl  |tiirt;  liius  the  natural  tendency  to  degeneration 
ol'  the  vessels  in  advaneed  lil'e  makes  apoplexy  much  more  common  alter 
the  llt'tieth  year.  It  may,  however,  occur  in  children  under  ten.  Uu  ac- 
count of  the  greater  liability  to  arterial  disease  (associated  probably  with 
muscular  exertion  and  the  abuse  (tf  alcohol),  men  are  more  subjeet  to  cere- 
])ral  Inemorrhage  than  wonu'ii.  Heredity  was  I'ornu'rly  thought  to  be  an 
imporliint  factor  in  this  all'ection,  aiul  the  apo})lectic  hdhiliis  or  build  i> 
Htill  referred  to.  Hy  this  is  mei\nt  a  stout  plethoric  body  of  medium  size, 
with  a  short  neck.  Heredity  inlluences  cerebral  luenu)rrhage  entirely 
through  the  arteries,  and  there  are  families  in  which  these  degeiu'rate  early, 
usually  in  association  with  renal  changes.  The  sectmdary  hy[)ertro[»hy  of 
the  heart  brings  with  it  serious  dangers,  which  have  already  been  discussed 
in  the  section  upon  arteries.  The  special  factors  in  inducing  arterio- 
sclerosis— the  abuse  of  ali-ohol,  immoderate  eating,  syphilis,  and  [trolonged 
muscular  exertion — are  found  to  be  important  antecedents  in  a  large  num- 
ber of  cases  of  cerebral  luunujrrhage.  Chronic  lead  poisoning  ami  gout 
also  may  here  be  mentioned. 

The  eiulocarditis  of  rheumatism  and  other  fevers  nuiy  indirectly  lead 
to  a])oplexy  by  causing  eiid)olism  and  aneurism  of  the  vessels  of  the  brain. 
Cerebral  htemorrhage  occurs  occasioiudly  in  the  specilic  fevers  and  in  pro- 
found alterations  of  the  blood,  as  in  leukuMuia  and  pernicious  anivinia. 
The  actual  exciting  cause  of  the  haMnorrhage  is  not  evident  in  the  majority 
of  cases.  The  attack  may  be  sudden  and  without  any  j)relimimiry  symp- 
toms. In  other  instances  violent  exertion,  particularly  straining  elforts,  or 
the  excited  action  of  the  heart  in  emotion  nuiy  cause  a  rupture. 

Morbid  Anatomy. — The  lesions  causing  apoplexy  are  almost  in- 
variably in  the  cerebral  arteries,  in  which  the  following  changes  may  lead 
directly  to  it: 

(a)  The  production  of  miliary  aneurisms,  rupture  of  which  is  the  most 
common  cause  of  cerebral  ha'morrhage.  The  origin  of  the  miliary  aneu- 
risms is  disputed.  Charcot  thought  they  resulted  from  changes  in  the 
adrcniltiti  (periarteritis).  Others,  with  ]']ichler,  Ziegler.  and  ])irch-IIirsch- 
feld,  find  the  primary  change  in  the  inlima.  The  weight  of  opinion  at 
present,  however,  is  on  the  side  of  the  view  that  the  media  is  first  degen- 
erated (Koth,  Loewenthf  1).  They  occur  most  frequently  on  the  central 
arteries,  l)ut  also  on  the  smaller  branches  of  the  cortical  vessels.  On  sec- 
tion of  the  1)rain  substance  they  nuiy  be  seen  as  localized,  small  dark  bodies, 
about  the  size  of  a  pin's  head.  Sometimes  they  are  seen  in  numbers  upon 
the  arteries  when  carefully  withdrawn  from  the  anterior  ])erforated  spaces. 
According  to  Charcot  and  Bouchard,  who  have  described  them,  they  are 
most  frequent  in  the  central  ganglia.  Tn  apo])lexy  after  the  fortieth  year  if 
sought  for  they  are  rarely  missed.  The  actual  miliary  aneurism,  which 
by  its  rupture  has  occasioned  the  luemorrluige,  may  be  difficult  to  find, 
but  if  one  pours  water  carefully  on  the  area  of  hannorrhage,  or,  better 


ics,  in  wlikh 
usually  in- 

<!     I)|()(I(1-V('S- 

lt'goiu,'rati(Jii 
'ininon  alter 
en.     On  iic- 
uljably  with 
j('(;t  to  CL'iv- 
lit   lo  1)0  an 
or  Ituild   i> 
H'(liuni  size. 
i^'o   cnfirclv 
icratu  t'arly. 
ertropliy  of 
'M  (iiscusst'd 
11",'   arterio- 
I  |in)I()ii<i:('(l 
hivge  miiii- 
;•  and  gout 

rvct]y  K-ad 
the  brain, 
ind  in  pro- 
s  anivniia. 
0  majority 
ary  syinp- 
c'H'orts,  or 

ihiio.^^t   in- 
uiay  load 

the  most 
ary  anou- 
es  in  tho 
h-IIir.sch- 
l)iiiion  at 
st  dogon- 
e  central 

On  sec- 
k  l)odies, 
ors  uixm 
d  spaces, 
they  are 
h  year  if 
1,  wliich 

to  find. 

,  better 


AKI'KCTIoXS   OF   TIIK    MI,(K»I>  AFlSSKLS. 


01»» 


-till,  .subniorgoH  tho  aiioploctic  mass  inr  a  tiiiic.  it  will  usually  be  found 
possible  tu  du  bo,  and  oven  to  liml  the  hole  in  its  wall. 

(//)  Aneurism  id"  tho  braiulies  of  the  cirtle  (d"  Willis.  Theso  nre  by 
no  moans  uncommon,  and  will  be  consideri'd  subsotpiontly. 

{(■)  lindartoritis  and  periarteritis  in  the  icrobral  vessels  most  conuuoidy 
lead  to  apoplexy  by  the  |iro(luotion  of  aneurisms,  either  nuliary  or  coarse. 
Tlu'ro  are  instances  in  which  tho  most  careful  search  fails  to  reveal  any- 
thing but  dilfusc  degeneration  of  the  cerebral  vessels,  particularly  (d'  tin; 
.-nudler  branches;  so  that  wo  must  coneluile  that  spontaiu'ous  rupture  nuty 
occur  without  the  previous  fornuition  of  aneurism. 

{(I)  Increased  ponnoability  of  the  walls  cd"  the  vessels  nuiy  account  for 
ha'iuorrhages  by  dldjinlcsis  without  actual  lupture.  Such  luemorrhagos 
are  not  uiu-omnum  in  cases  (d'  coiitractctl  kidney,  grave  ameuua,  ami  various 
inl'octions  aiul  intoxications. 

'i'he  hivmorrhage  may  be  meningeal,  (orcbral,  or  intraventricular. 

Hfcnin(/c(tl  lucinorrlK.ijc  may  lie  outside  tho  dura,  between  this  mondirane 
and  the  boiu',  or  botwt'cn  the  dura  and  arachnoid,  or  between  the  aracli- 
iioid  and  the  pia  mater.  The  following  are  the  chicd'  causes  of  this  form 
of  luomorrhago:  Fracture  of  the  skull,  in  which  case  tlie  blood  u<ual!y 
comes  from  the  lacerated  meningeal  vessels,  sometimes  from  the  torn  si- 
nuses. In  these  cases  the  blood  is  usually  outside  tho  dura  or  between  it 
ami  the  araclnu)id.  The  next  nu)st  fre(pient  cause  is  rupture  (d'  ancuri>ins 
on  the  larger  cerebral  ves.sols.  'J'ho  blood  is  usually  subarachnoid.  An 
intracerebral  hannorrhage  nuiy  burst  into  the  meninges.  A  special  form 
(if  meningeal  luemorrhage  is  fouiul  in  the  new-born,  associated  with  injury 
(luring  birth.  And  lastly,  meningeal  ha'iiu)rrhage  may  occur  in  tho  con- 
stitutional diseases  and  fevers.  The  blood  nuiy  l)o  in  a  large  (pmutity  at 
the  base;  in  cases  of  ruptured  aneurism,  jtarticularly,  it  may  extend  into 
the  cord  or  upon  the  cortex.  Owing  to  the  greater  frequency  of  tho  aneu- 
risms in  the  middle  cerebral  vessels,  the  Sylvian  fissures  are  often  distended 
with  blood. 

Intracerebral  Jucmorrhaye  is  most  frequent  in  the  neighborhood  of  the 
corpus  striatum,  i)articularly  toward  the  outer  section  of  the  lenticular 
nucleus.  The  luemorrhage  may  be  small  and  limited  to  the  lenticular 
body,  the  thalamus,  and  the  internal  capsule,  or  it  nuiy  extend  into  the 
centrum  senu-ovale,  or  burst  into  the  lateral  ventricle,  or  extend  to  the 
insula.  Ilivmorrhages  confined  to  the  white  matter — the  centrum  semi- 
ovale — are  rare.  Localized  bleeding  may  occur  in  the  crura  or  in  the  ])ons. 
ILemorrhage  into  the  core1)ollum  is  not  uncommon,  and  usually  comes 
from  the  superior  cere])ollar  artery.  The  extravasation  may  be  limited  to 
the  substance  or  rupture  into  the  fcturth  ventricle.  Twice  I  have  known 
sudden  death  in  girls  under  twenty-five  to  be  due  to  cerebellar  liaimorrhage. 

Ventricular  llannorrhaije. — This  occasionally  but  rarely  is  primary,  com- 
ing from  the  vessels  of  tho  i)lexusos  or  of  tlie  walls.  More  often  it  is  sec- 
oiulary,  following  Raunorrhage  into  the  cerebral  substance.  It  is  not  in- 
frequent in  early  life  and  nuiy  occur  during  birth.  Of  94  cases  collected 
by  lulward  Sanders,  7  occurred  during  the  first  year,  and  11  under  the 
twentieth  vear.     In  tho  cases  which  I  have  seen  in  adults  it  has  almost 


1000 


DISK  ASKS  OK  TIIK  NKUVOl'S  SYSTKM. 


iilways  liiTii  caused  liy  rn|itiir('  of  a  vessel  in  llio  nei^'lil)nrli(i(((|  ol'  the  euii- 
(lale  iiiicleiis.  'l'li(>  l)liin<l  may  he  I'oiiikI  in  uiiu  vctitrieh)  only,  but  iiinre 
coiiiiiKmly  it  is  in  Ixttli  lateral  ventricles,  nnd  may  pa^s  into  llu!  third  ven- 
tricle and  thnuij^h  the  ai|nedii(t  of  Sylvins  intn  the  tmirtli  ventricle,  form- 
inj.'  a  c(im|ilele  nntidd  in  lilood  ol'  the  ventricniar  system.  In  these  ca.ies 
the  clinical  pielnre  may  he  thai  of  "'  djuijilvxic  foiKlnii/inilr.'" 

Sul)si'(/unil  ('h(iiii/i's. — The  hlimd  gradually  clianjj;e-.  in  color,  and  nlli- 
nnitely  the  lui'ino^flohin  is  conv«'rted  into  the  reddish-ljrowii  Inematoidin. 
Inllamniiition  ocenrs  aliont  the  a|io|i|eclie  area,  limiting  and  cotdinin;.'  it, 
and  ullinialely  a  delinite  wall  may  he  produced,  inclosin;;'  u  cyst  with  lluid 
contents,  in  other  instances  ti  cyst  is  nut  formed,  but  the  connoctivo  tissue 
]>rol iterates  and  leaves  a  |»ij:menle(l  scar.  In  meiuuireal  haMuorrha^'e  the 
ell'used  hlood  may  he  uradnally  ahsorheil  nnd  leave  only  a  slaiiun;:  of  the 
iimmhranes.  In  other  cases,  particidai'ly  in  infants,  when  the  eH'usion  i-< 
cortical  and  ahundani,  there  may  h('  localized  wasting'  of  the  convolution- 
and  the  production  of  a  cyst  in  the  meninges,  i'ossihiy  certain  of  the 
cases  of  porencephaly  arc  caused  in  this  way. 

Secondary  defeneration  follows,  varyinjf  in  charactor  according  to  the 
location  of  the  ha'moirhage  and  the  actual  damage  done  by  it  to  nerve  cells 
or  their  nu'duUated  axones.  'i'hus,  in  persons  dying  som(!  years  after  a 
cei'i'bral  apo[)le.\y  which  has  produced  hennplegia  (lesion  of  the  nu)tor  area 
in  the  cortex  or  of  the  pyramidal  tract  heading  from  it),  the  di'generation 
may  he  traced  through  the  cerebral  peduncle,  the  ventral  [)art  of  the  pons, 
the  pyramids  of  the  iiu'dulla,  the  iihres  of  the  direct  ])yramidal  trait  of 
the  cord  id'  the  same  side,  and  tho  fibres  of  the  crossed  pyranudal  tract  on 
the  o])p()site  side.  After  buMnorrbagos  in  the  nuddle  and  inferior  fi'ontnl 
gyri  there  follows  degeneration  of  tho  frontal  cerehi'o-cortico-pontal  |>atli, 
going  through  the  anterior  lindj  of  the  internal  capsule  ami  tho  medial 
])oition  of  the  basis  pedunculi  to  the  nuclei  pontis;  also  degeneration  of  the 
fibres  connecting  the  nucleus  iiiedialis  thalami,  and  the  anterior  ])art  of  the 
nucleus  lateralis  thalaud  with  the  cortex  (Flechsig,  v.  ^lonakow). 

When  the  temporal  gyi'i  or  their  white  matter  are  destroyed  by  a  haMii- 
orrbage  the  lateral  seguu'iit  of  the  basis  |)edunculi  degent'rates  (Dejerine). 
Cerebellar  huMuorrhage.  especially  if  it  injure  the  nucleus  dentatus,  may 
lead  to  degeneration  of  the  brachium  eonjunctivum. 

There  may  he  slow  degeneration  in  the  lemniscus  luedialis,  extemling  ;i- 
far  as  the  nuclei  on  the  opposite  side  of  the  nu'dulla  oblongata,  after  luenior- 
rhages  in  the  central  gyri,  hypothalamic  region,  or  dorsal  i)art  of  the  pons. 
Ua'inorrhages  desti'oying  the  occipital  cortex,  or  subcortical  ba'morrliage> 
injuring  tbe  o])lic  radiations,  occasion  slow  degeneration  (cellulipetal)  of  tln' 
radiations  from  the  lateral  geniculate  body,  and  after  a  time  to  markcl 
atro])hy  or  even  disa])pearance  of  its  ganglion  cells. 

Symptoms. — These  may  bo  divided  into  primary,  or  those  connected 
with  the  onset,  and  secondary,  or  those  which  develop  later  after  the  early 
mam'festations  have  ]iassed  away. 

rriiiiari/  ^i/iiijUonis. — rreinonitory  indications  are  rare.  As  a  rule,  tln^ 
patient  is  seized  while  in  full  health  or  about  tbe  ])crformance  of  soni'^ 
every-day  action,  occasionally  an  action  ro(|uiring  strain  or  extra  exertion. 


APPKrTIONS  OF  THK   HLOOO-VKSSKIiS. 


1001 


I  nf  IIk'  (Hil- 
ly, l)ilt  IIIUIC 
11'  tliird  vfii- 
ilriclc,  riiiiii- 

1     tlll'Sf    CIlM'S 

•  ir.  and  ulli^ 
liii'iiiatoiiliii. 
coij lining,'  it, 
Ht  with  lliiid 

K'ctivo  tissue 

ii)rrliii;,M'  tlic 
iiiiii;,'  ol"  the 
('  ciriisioii  i-, 
toiivohitioii^ 
rtiiii)  (if  till' 

•<liii<j;  to  the 

II  nerve  (■ells 
ears  after  a 
'  motor  area 
Ic^c'iieratioii 

of  tllO  JJOIIS, 

(lal  tract  of 
(lal  tract  on 

rior  frontal 
)ontal  path, 

tlio  inc(^lial 
lit  ion  of  the 

part  of  the 
V). 

I)y  a  liu'iii- 

;l)('jerine), 
itatus,  may 

>iten(linif  as 
tvv  luumor- 
f  thi;  pons. 
.Mnorrlia,i;('- 
"tal)  of  the 
to  markcil 

coimectcil 
r  the  early 

11  rule,  till' 
e  ol'  sonii' 
I  exertion. 


Sow  und  then  iiistaiices  are  found  in  uhieh  there  are  sensations  (d'  niindi- 
nesH  or  tili^lin^  or  jiains  in  the  limits,  or  even  choreifnrm  mo\emenls  in  the 
iiiiiscU'8  of  the  opposite  uidu,  II'';  Ho-eidled  prehenu|de;.de  chorea.  In  other 
t  uses  temporary  disi  iirhanees  of  vision  and  of  associated  movements  of  [\h> 
( yc-musclc.-  ha\e  hecn  noted,  liul  none  of  the  prodroniata  of  apoplexy  (the 
so-called  "  warning's ")  is  charaeti'rislic.  The  onset  <d'  the  apo[ile\y,  nn 
(erehral  lucnmrrha^c  is  usually  called,  varies  ;;reatly.  There  may  he  sud- 
den loss  of  consciousness  and  complete  ichixation  (d'  I  lie  extremities.  In 
-uch  instances  the  name  (iixiiilcclic  nlmlxc  is  particularly  ap[»ropriate.  In 
nlher  cases  the  onset  is  jnore  ;,'radual  and  the  loss  of  consciousness  may  not 
occur  fill  a  few  minutes  after  tho  patient  has  fallen,  or  after  the  paralysis 
of  the  liinhs  is  manifest.  Jn  the  typical  apoplectic;  attack  tin;  condition  is 
as  follows:  Thei'e  is  deep  nmoiiscioiisness;  the  patient  cannot  he  roused. 
'The  face  is  injected,  sometimes  cyanotic,  or  of  an  asheii-eray  hue.  The  pu- 
pils vary;  iisiiully  they  are  dilated,  sometimes  uncipial,  and  always,  in  deep 
(iiiiia,  inactive.  If  I  lie  ha-morrhaf^u  bu  so  located  that  it  can  irritate  the 
nucleus  of  the  third  ncrvi;  the  pupils  ar((  contracted  (liH'morrha;^-es  into  the 
pons  or  ventricles).  'The  respirations  are  slow,  noisy,  and  accoiniianied 
with  stertor.  Sometinu's  the  Cheyne-Stokes  rhythm  may  be  present.  The 
chest  nioveiiieiits  on  the  paralyzed  side  may  he  restricted,  in  rare  instances 
on  the  opposite  side.  The  (hecks  are  often  blown  out  during'  expiration, 
with  s|)lntterini.j  of  the  lips.  The  pulse  is  usually  full,  slow,  and  (jf  in- 
creased tension.  The  teinpei'ature  may  be  normal,  but  is  often  f(niiid  sub- 
iioiiual,  and,  as  in  a  case  reported  by  Bastian,  may  siid\  below  !).")°.  In 
cases  of  basal  hii'iiuirrhaiie  the  temperature,  on  the  other  hand,  may  be  hi^h. 
The  urine  and  fa'ces  are  usually  jiassed  involuntarily.  Convulsions  are  not 
(•(iinnu)n.  Jt  may  Ije  dillicult  to  decide  whether  the  condition  is  apojde.xy 
iissociated  with  hemiplejiia  or  sudden  coma  from  other  causes.  An  indica- 
tion of  hcTnipleijia  may  be  discovered  in  the  diirerence  in  the  tonus  of  the 
muscles  on  the  two  sides.  If  the  arm  or  the  lejf  is  lifted,  it  drops  "  dead  " 
(111  the  alTected  side,  while  on  the  other  it  falls  more  slowly.  Iii<.ndity  also 
may  he  present.  Jn  watching'  tlie  movements  of  the  facial  muscles  in  the 
stertorous  res|)iration  it  will  be  seen  that  on  the  ])ara]yzed  side  the  relaxa- 
lion  permits  the  (dieck  to  be  lilown  out  in  a  more  marked  manner.  The 
head  and  eyes  may  be  turned  stron<ily  to  one  side — conjiiuate  (htviation.  Jn 
such  an  event  tlie  turninif  is  luwnrd  the  side  of  tlie  lia'inoi'rha^^e. 

Jn  other  cases,  in  which  the  onset  is  not  so  abi'iipt,  the  itatient  may  not 
lose  consciousness,  but  in  the  course  of  a  few  hours  there  is  loss  of  power, 
unconsciousness  »i-radually  develops,  and  deepens  into  profound  coma.  This 
is  sometimes  termed  iiiuravescent  apo|)lexy.  The  attack  may  occur  duriiiif 
slee]).  'I'he  [)atient  may  be  found  unconscious,  or  wakes  to  lind  that  the 
power  is  lost  on  one  side.  Small  lucmorrha^a's  in  the  territory  of  the  cen- 
tral arteries  may  cause  hemiplegia  without  loss  of  consciousness. 

Usually  within  forty-eij^ht  hours  after  the  onset  of  an  attack,  sorni!- 
times  within  from  two  to  six  hours,  there  is  febrile  reaction,  and  more  or 
less  constitutional  disturbance  associated  with  inflammatory  clian;.ies  about 
the  liaemorrhage  and  ahsor])tion  of  the  l)lood.  '^^Fhe  period  of  inflammatory 
reaction  may  continue  for  from  one  week  to  two  months.  The  patient  may 
r.3 


1002 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


dio  in  this  ronctioii,  or,  if  oonsfion.siu'ss  lias  Ix'on  rofrainod,  tlioro  may  lie 
delirium  or  rt'ciirrfiU'O  ol'  the  eoiiia.  At  this  period  the  so-ealled  early 
ri>:idity  may  develop  in  the  jiaralyzed  limhs.  The  so-called  trophie  changes 
may  oeeiir,  such  as  slou<,diin<j:  or  the  formation  of  vesicles.  The  mo>t 
serious  of  these  is  the  sloughin<j;  eschar  of  the  lower  ])art  of  the  hack,  or  (.ii 
the  paralyzed  side,  wliich  nuiy  ap])ear  within  forty-eij,dit  hours  of  the  onset 
and  is  usually  of  grave  signidcanee.  The  congestion  at  the  bases  of  tlie 
lungs  so  connnon  in  apoplexy  is  regarded  by  some  as  a  trophic  change. 

Conjiiynle  J)erinfi(in. — In  a  right  hemi})legia  the  eyes  and  head  may 
bo  turned  to  the  left  side;  that  is  to  say,  the  eyes  look  toward  the  cerebral 
lesion.  This  is  almost  the  rule  in  the  conjugate  deviation  of  the  head  and 
eyes  which  occurs  early  in  liemiplegia.  When,  however,  convulsions  or 
spasm  develop  or  the  state  of  so-called  early  rigidity  in  hemiplegia,  tlic 
conjugate  deviation  of  the  head  and  eyes  may  be  in  the  opposite  direction; 
that  is  to  say,  the  eyes  look  away  from  the  lesion  and  the  head  is  rotated 
toward  the  convulsed  side.  This  symptom  may  be  associated  with  cortical 
lesions,  particularly,  according  to  some  authors,  when  in  the  neighbor- 
hood of  the  supranuirginal  and  angular  gyri.  It  may  also  occur  in  a  lesion 
of  the  internal  capsule  or  in  the  i)ons,  but  in  the  latter  situation  the  con- 
ii:  'ate  deviation  is  the  reverse  of  that  which  occurs  in  other  cases,  as  the 
patunt  looks  away  from  the  lesion,  and  in  spasm  or  convulsion  looks  toward 
the  lesion.  In  cases  in  which  consciousness  is  restored  and  the  patient  im- 
proves, the  unilateral  paralysis  whici  persists  in  cases  in  which  the  motor 
area,  or  the  i)yramidal  tract  in  any  part  of  its  course,  is  involved  is  known  as 

Hemiplegia. — Hemiplegia  is  complete  when  it  involves  face,  arm,  and 
leg.  or  partial  when  it  involves  only  one  or  other  of  these  parts.  This 
may  be  the  result  of  a  lesion  (a)  of  the  motor  cortex;  (h)  of  the  })yramidal 
fibres  in  the  corona  radiata  and  in  the  internal  ca])sule;  (c)  of  a  lesion  in  the 
cerebral  jjcduncle;  or  (d)  in  the  ])ons  Varolii.  The  situation  of  the  lesions 
and  their  ofrects  are  given  in  Fig.  10.  Ihvmorrhage  is  fcTliaps  the  most 
common  cause,  but  tumors  and  spots  of  softening  may  also  induce  it.  The 
special  details  of  the  hemiplegia  may  here  be  considered.  The  face  (except 
in  lesions  in  the  lower  part  of  the  pons)  is  involved  on  the  same  side  as  the 
arm  and  leg.  This  results  from  the  fact  that  the  facial  muscles  stand  in 
precisely  the  same  relation  to  the  cortical  centres  as  those  of  the  arm  and 
leg,  the  fibres  of  the  upper  motor  segment  of  the  facial  nerve  from  tlir 
cortex  decussating  just  as  do  those  of  the  nerves  of  the  limbs.  The  facial 
paralysis  is  partial,  involving  only  the  lower  portion  of  the  nerve,  so  that 
the  orbicularis  oculi  and  the  fn  ntalis  muscles  are  un involved.  The  sign-' 
of  the  facial  paralysis  ar  usually  well  marked.  There  may  be  a  slight  dilll- 
culty  in  elevating  the  eyebrows  or  in  closing  the  eye  on  the  paralyzed  sido. 
or  in  rare  cases  the  facial  paralysis  is  complete,  but  the  movements  may  bo 
present  with  emotion,  aij  laughing  or  crying.  The  hypoglossal  nerve  also 
is  involved.  In  consequence,  the  patient  cannot  put  out  the  tongue 
straight,  but  it  deviates  toward  the  paralyzed  s'de,  inasmuch  as  the  geuie- 
hyc-glossus  of  the  sound  sale  is  unopposed.  With  right  hemiplegia  there 
may  be  aphasia.  Even  without  marked  aphasia  difficulty  in  speakinu'- 
and  slowness  are  common. 


licro  ma}'  l)i- 
-called  early 
pliic  changes 
The   in(i>t 
L'  back,  or  iiii 
ol"  the  onset; 
bases  of  the 
chan^U'. 
(1  head  may 
the  cerebral 
;lie  head  and 
nvnlsions  (ir 
nipleifja,  the 
ite  direction; 
ad  is  rotated 
with  cortical 
le  neighbur- 
ir  in  a  lesion 
ion  the  con- 
cases,  as  the 
looks  toward 
!  patient  ini- 
h  the  mott>r 
is  known  as 
'0,  arm,  and 
parts.     This 
e  pyramidal 
esion  in  the 
the  lesions 
)s  the  most 
ce  it.     The 
'ace  (except 
side  as  the 
cs  stand  in 
le  arm  and 
e  from  the 
The  facial 
rve,  so  that 
The  si.aii-^ 
slight  dilli- 
alyzed  side, 
nts  may  be 
nerve  also 
die    tongue 
the  genie- 
Iciiia  there 


AFFECTIONS  OF  TFIK   BLOOD-VESSELS. 


\.K  « 


1003 


1 


speaking 


Fio.  10. — Diagram  of  motor  path  from  right  brain.  The  upper  segment  is  black,  the 
lower  red.  The  nuclei  f  the  motor  cerebral  nerves  are  r  a'h  on  the  left  side ;  on 
the  riglit  side  the  cerebral  nerves  of  that  side  are  indi(  A  lesion  at  1  would 

cause  upper  segment  paralysis  in  the  arm  of  the  opp.  o  side — cerebral  mono- 
plegia; at  2,  upper  segment  paralysis  of  ihe  whole  pposite  side  of  the  body — 
hemiplegia;  at  3  (in  the  cms),  upper  segment  paralysis  of  the  opposite  face,  arm  and 
leg,  and  lower  segnem  paralysis  of  the  eye  muscles  on  the  same  side — crossed  paraly- 
sis; at  4  (in  the  lower  part  of  the  pons),  upper  segment  paralysis  of  the  o{posite  arm 
and  leg,  and  lower  segment  paralysis  of  the  face  and  the  external  rectus  on  the  same 
side — crossed  paralysis;  at  5,  upper  segmctit  paralysis  of  all  muscles  represented  be- 
low lesion,  and  lower  segment  paralysis  of  muscles  represented  at  level  of  lesion — 
spinal  paraplegi'i ;  at  6,  lower  segment  paralysis  of  muscles  localized  at  seat  '*  lesion 
— anterior  poliomyelitis.    (Van  G^huchten,  modified.) 


1004 


DISKASES  OF  THE  NERVOUS  SYSTEM. 


/ 


The  arm  is,  as  a  rule,  more  completely  paralyzed  than  the  Iv^.  The 
loss  of  power  may  he  al)soltite  or  partial.  Jn  severe  eases  it  is  at  lii'st  eom- 
l)lete.  Ill  otiicrs,  when  I  hi*  [laralysis  in  the  I'aee  and  arm  is  coiii[)lete 
that  of  the  lej;;  is  only  partial.  'J'he  face  and  arm  may  alone  be  paralyzed, 
wiiile  the  leg  escapes.  Less  commonly  the  leg  is  more  all'eeted  than  the 
arm.  and  the  I'aee  may  lti>  only  slightly  involved 

(."ertain  ninseles  escape  in  hemiplegia,  particularly  those  assoi-iated  in 
synnnetrieal  movements,  as  those  of  the  thorax  and  al)domen.  a  fact  which 
IJroadhent  explains  by  supposing  that  as  the  spinal  nuclei  controlling  these 
movements  on  both  sides  constantly  act  together,  they  may,  by  means  of 
this  intimate  connection,  be  stimulated  by  impulses  coming  from  only  one 
sule  of  the  l)rain.  ^Fhe  degree  of  permanent  paralysis  after  a  hemiplegie 
attack  varies  much  in  diil'erent  cases.  When  the  restitution  is  partial,  it  is 
always,  as  Wernicke  has  j)()inted  out,  certain  groups  of  muscles  which  re- 
cover rather  than  others.  Thus  in  the  leg  the  residual  i)aralysis  coiu-erns 
the  flexors  of  the  leg  and  the  dorsal  flexors  of  the  foot — i.  e.,  the  muscles 
which,  according  to  Ludwig  Mann,  are  active  in  the  second  period  of  walk- 
ing, shortening  the  leg,  and  bringing  it  forward  while  it  swings.  The 
muscles  whieb  lift  the  leg  when  it  rests  u])on  the  ground,  those  used  in  the 
first  i)eriod  of  walking,  include  the  extensors  of  the  leg  and  the  plantar 
flexors  of  the  foot.  These  *'  lengtheners  "  of  the  leg  often  recover  ahnost 
completely  in  cases  in  which  the  i)aralysis  is  due  to  lesions  of  the  ])yramidal 
tract.  In  the  arms  the  residual  paralysis  usually  affects  the  muscle  groups 
wliich  oppose  the  tliumb,  those  which  rotate  the  arm  outward,  and  the  open- 
ers of  the  hand. 

As  a  rule,  there  is  at  first  no  wasting  of  the  paralyzed  limbs. 

Crossed  Hemiplegia. — A  paralysis  in  whieb  there  is  loss  of  function  in 
a  cerebral  nerve  on  one  side  with  loss  of  power  (or  of  sensation)  on  the  oppo- 
site side  of  the  body  is  called  a  crossed  or  alternate  hemiplegia.  It  is  met 
with  in  lesions,  commonly  haemorrhage,  in  the  crus,  the  pons,  and  the  me- 
dulla (Fig,  10,  ',i  and  4). 

(a)  Cms. — The  bleeding  may  extend  from  vessels  supplying  the  corpus 
striatum,  internal  capsule,  and  optic  thalamus,  or  the  hamiorrhage  may  he 
primarily  in  the  crus.  In  the  classical  case  of  Weber,  on  section  of  the 
lower  part  of  the  left  crus  an  oblong  clot  15  mm.  in  length  lay  Just  below 
the  medial  and  inferior  surface.  The  characteristic  features  of  a  lesion 
in  this  locality  are  paralysis  of  arm,  face,  and  leg  of  the  ojtposite  side,  and 
oculo-motor  paralysis  of  the  same  side — the  syndrome  of  Weber.  Sensory 
changes  have  also  been  present.  Haemorrhage  into  the  tegmentum  is 
not  necessarily  associated  wdth  hemiplegia,  but  there  may  be  incomplete 
])aralysis  of  the  oculo-motor  nerve,  with  disturbance  of  sensation  and  ataxia 
on  the  opposite  side  of  the  body.  The  optic  tract  or  the  lateral  geniculate 
body  lying  on  the  lateral  side  of  the  crus  may  be  compressed,  in  which 
event  there  will  be  hemianopsia. 

(h)  Pons  and  Medulla. — Ticsions  may  involve  the  pyramir'Tl  tract  and 
one  or  more  of  the  cerebral  nerves.  If  at  the  lower  aspect  of  d.e  pons,  the 
facial  nerve  may  be  involved,  causing  paralysis  of  the  face  on  the  same 
side  and  hemi{)legia  on  the  opposite  side.     The  fifth  nerve  may  be  involved, 


d 
oi 


AFFECTIONS  OF  THE  RLOOD-VESSELS. 


1005 


i  lc"J,^  The 
it  first  coin- 
is  eomplt'te 
2  piinilyzc'il, 
'd  lliaii  the 

isoi'iated  in 
i'ilct  which 
Min^^  those 
y  int'iuis  of 
n  only  one 
luMuiph'^iie 
lartlal,  it  is 
i  which  re- 
is  concerns 
he  ninscles 
)d  of  walk- 
ings.    The 
ised  in  tlie 
he  ])lantar 
ver  almost 
inrainidal 
clt  groups 
I  the  open- 


mction  in 

tlie  oppo- 

It  is  met 

i  the  me- 

he  corpus 
e  may  be 
m  of  the 
ust  helow 

a  lesion 
side,  and 

Sensory 
intum  is 
complete 
:id  ataxia 
eniculate 
n  which 

ract  and 
)ons,  the 
he  same 
nvolved, 


with  the  (illet  (I he  sensory  tract),  causing  loss  of  si'iisatioii  in  the  area  of 
distrihutiou  of  the  lifth  on  the  same  side  as  the  lesion  and  loss  of  sensation 
on  the  opposite  side  of  the  l)ody. 

tScnsori/  I) i;-^li(rh(i II (■(;.'<  result iiuj  {mm  Cerebral  Ihvtnorrluiijc. — These  are 
varial)le,  Ifemiana'sthesia  may  coexist  with  hemiplegia,  hut  in  many  in- 
stances there  is  oidy  slight  nnmhing  of  sensation.  When  the  hemiana's- 
thesia  is  marked,  it  is  usually  the  result  of  a  lesion  in  the  internal  capsule 
involving  the  retrolenticular  portion  of  the  posterior  limb.  In  (J.  h. 
i)ana's  study  of  sensory  localization  he  found  that  anu'sthesia  of  organic 
cortical  origin  was  always  limited  or  more  jjronounced  in  certain  pai'ts.  as 
the  face,  arm,  or  leg,  and  was  generally  incomplete.  Total  ansesthesia  was 
either  of  functional  or  subcortical  origin.  Marked  aniesthesia  was  much 
uu)re  common  in  softening  than  in  luemorrhage.  Complete  hemiaiui's- 
thesia  is  certainly  rare  in  luemorrhage.  iJisturbance  of  the  s[)ecial  senses 
is  not  connnon.  Iltmianopia  may  exist  on  the  same  side  as  the  lesion,  and 
there  may  he  diminution  in  the  acuteness  of  the  senses  of  hearing,  taste, 
and  smell,  (iowers  thinks  that  homonymous  hemianopsia  of  the  halves  of 
the  visual  helds  opi)Osite  to  the  lesion  is  very  frecpient,  though  often  over- 
looked. 

Psychic  disturbances,  variable  in  nature  and  degree,  may  result  from 
cere'  -al  ha-morrhage. 

'1  lie  Refiexcs  in  Apoplectic  Cases. — During  the  apoplectic  coma  all  the 
reflexes  are  abolished,  but  immediately  on  recovery  of  consciousness  they 
return,  first  on  the  non-hemiplegic  side,  later,  sometimes  only  after  weeks, 
on  the  paralyzed  side.  As  to  the  time  of  return,  especially  of  the  patellar 
reflexes,  nuirked  differences  are  observable  in  individual  cases.  The  deep 
reflexes  later  are  increased  on  the  paralyzed  side,  and  ankle  clonus  may  be 
])resent.  The  })lantar  and  other  superficial  reflexes  are  usually  diminished. 
The  sphincters  are  not  affected. 

The  covrse  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion.  If  slight,  the  hemiplegia  may  disap|)ear  com])letely  within  a  few 
days  or  a  few  weeks.  In  severe  cases  the  rule  is  that  the  leg  gradually  re- 
covers before  the  arm,  and  the  muscles  of  the  shoulder  girdle  and  upper 
arm  before  those  of  the  forearm  and  hand.     The  face  may  recover  (piickly. 

Excej)t  in  the  very  slight  lesions,  in  which  the  hemiplegia  is  transient, 
changes  take  place  Avhich  may  be  grou])ed  as 

Secondary  Sipnptoiiis. — These  correspond  to  the  chronic  stage.  In  a 
case  in  which  little  or  no  improvement  takes  ])lace  within  eight  or  ten 
weeks,  it  will  be  found  that  the  paralyzed  lind)s  imdergo  certain  changes. 
The  leg,  as  a  rule,  recovers  enough  power  to  enable  the  ])atient  to  get 
about,  although  the  foot  is  dragged.  Occasionally  a  recurrence  of  severe 
symptoms  is  seen,  even  without  a  new  lurmorrhage  having  taken  ])lacc.  In 
i)()th  arm  and  leg  the  condition  of  secondary  contraction  or  tate  riyidity  comes 
on  and  is  always  most  marked  in  the  upper  extremity.  The  arm  becomes 
permanently  flexed  at  the  elbow  and  resists  all  attempts  at  extension.  The 
wrist  is  flexed  upon  the  forearm  and  the  fingers  upon  the  hand.  The  ])osi- 
tion  of  the  arm  and  hand  is  very  characteristic.  There  is  frequently,  as 
the  contractures  develop,  a  great  deal  of  pain.    In  the-  leg  the  contracture  is 


louo 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


I'iirt'ly  so  oxtroiiie.  'riio  loss  of  power  is  most  marked  in  the  nuiseles  of 
tlie  foot,  aiul  to  prevent  tiie  toes  from  dragging,  tlie  Icnee  in  wallving 
is  nuich  flexed,  or  more  eommonly  the  foot  is  swung  round  iu  a  half- 
circle. 

The  rellexes  are  at  this  stage  greatly  increased.  These  contractures  are 
permanent  and  ineural)le,  and  ire  associated  with  a  secondary  descending 
j<clerosis  of  the  motor  path.  There  arc  instances,  honever,  in  which  rigid- 
ity and  contracture  do  not  occur,  but  the  arm  remains  flaccid,  the  leg  hav- 
ing regained  its  power.  This  heniiplrf/ie  flnxque  of  Bouchard  is  found  most 
<'ommonly  in  cliildren.  Among  other  secondary  changes  in  late  hemiplegia 
may  he  mentioned  the  following:  Tremor  of  the  alfected  lind)s,  i)ost-para- 
lytic  chorea,  the  mobile  spasm  known  as  athetosis,  arthroi)athies  in  the 
joints  of  the  alfected  side,  and  muscular  atrophy.  Athetosis  and  post- 
hemiplegic chorea  will  ])e  considered  in  the  hemiplegia  of  children.  The 
cool  surface  and  thin  glossy  skin  of  a  hemiplegic  lindj  are  familiar  to  all. 
A  word  may  here  be  said  upon  the  subject  of  muscular  atrophy  of  cerebral 
origin. 

As  a  rule,  atrophy  is  not  a  marked  feature  in  hemiplegia,  but  in  some 
instances  it  does  develop.  It  has  been  thought  to  be  due  in  some  cases  to 
secondary  alterations  in  the  gray  matter  of  the  ventral  horns,  as  in  a  case 
reported  by  Charcot.  Eecently,  however,  attention  has  been  called  by 
♦Senator,  Quincke,  and  others  to  the  fact  that  atrophy  may  follow  as  a  direct 
result  of  the  cerebral  lesion,  the  ventral  horns  remaining  intact.  In 
•Quincke's  case,  atrojihy  of  the  arm  followed  the  development  of  a  glioma 
in  the  anterior  central  convolution.  The  gray  matter  of  the  ventral  horns 
was  normal.  These  atrophies  are  most  common  in  cortical  lesions  involv- 
ing the  domain  of  the  third  main  branch  of  the  Sylvian  artery,  and  in  cen- 
tral lesions  involving  the  lenticulo-thalamic  region.  Their  explanation  is 
not  clear.  The  wasting  of  cerebral  origin,  which  occurs  most  frequently  in 
children,  and  leads  to  hemiatrophy  of  the  muscles  along  with  stunted  growth 
of  the  bones  and  joints,  is  to  be  sharply  separated  from  the  hemiatrophy  of 
the  muscles  of  the  adult  following  within  a  relatively  short  time  upon  the 
liemiplegia. 

Diagnosis. — There  are  three  groups  of  cases  which  offer  increasing 
•difficulty  in  recognition. 

(1)  Cases  in  which  the  onset  is  gradual,  a  day  or  two  elapsing  before 
the  paralysis  is  fully  developed  and  consciousness  completely  lost,  are  readily 
recognized,  though  it  may  be  difficult  to  detei'mine  whether  the  lesion  is 
'due  to  thrombosis  or  to  ha-morrhage. 

(2)  In  the  sudden  apoplectic  stroke  in  which  the  patient  rapidly  loses 
consciousness,  the  difficulty  in  diagnosis  may  be  still  greater,  particularly 
if  the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decided  is  the  existence  of  hemiplegia.  This  may 
be  difficult,  although,  as  a  rule,  even  in  deep  coma  the  limbs  on  the  para- 
lyzed side  are  more  flaccid  and  drop  instantly  when  lifted;  whereas,  on  the 
non-])aralyzed  side  the  muscles  retain  some  degree  of  tonus.  Tlie  reflexes 
may  be  increased  on  the  affected  side  and  there  may  be  conjugate  deviation 
of  the  head  and  eyes.    Rigidity  in  the  limbs  of  one  side  is  in  favor  of  a 


hi 

to 

(1 

CO 

1'^ 

ti( 

is 

V( 
V( 

m 


AFFECTIONS  OF  THE  BLOOD-VEriSELS. 


1(K)\ 


muscles  of 

ill   walking 
in  a  hall'- 


racturcs  arc 
descuiuliiig 
■liit'h  rigid- 
lio  leg  liav- 
round  most 
hemipk'gia 
,  post-para- 
lics  in  the 
and  jjost- 
Jren.  The 
iliar  to  all. 
of  cerebral 

lit  in  some 
ne  cases  to 
3  in  a  case 

called  by 
as  a  direct 
itact.  In 
f  a  glioma 
tral  horns 
ns  involv- 
nd  in  cen- 
anation  is 
|uently  in 
ed  growth 
trophy  of 

upon  the 


ncreasing 


tig  before 

re  readily 

lesion  is 

idly  loses 
rticularly 

Phis  may 
the  para- 
on  the 
reflexes 
deviation 
vor  of  a 


hemiplogic  lesion.    It  is  i)ractically  impossible  in  a  majority  of  these  cases 
to  say  wiietiier  the  lesion  is  due  to  iuemdrrhage.  enil)()lisiii.  or  thrombosis. 

{'6)  J.,ai'ge  ha'morrluige  into  the  ventrieles  or  into  the  })ons  may  {)ro- 
duce  sudden  lo.«s  of  consciousness  willi  eomi)lete  rela.xation,  so  that  tlie 
condition  may  simulate  coma  from  ura'uiia,  diabetes,  ah'oholisni.  diiiiini 
poisoning,  or  epik'[)sy. 

The  previous  history  and  the  mode  of  onset  may  give  valual»U'  infornia- 
tion.  In  ei)ile}isy,  coJivulsions  have  preceded  the  coma;  in  alcoholism,  tiu're 
is  a  history  of  constant  drinking,  while  in  o]iium  poisoning  tlie  coma  de- 
velops more  gradually;  but  in  many  instances  the  dilHculty  is  jiractieally 
very  great,  and  on  more  than  one  occasion  I  have  seen  mortifying  post- 
mortem disclosures  under  these  circumstances.  With  dia'oelic  coma  tlu' 
breath  often  snu'lls  of  acetone.  In  ventricular  lucmorrhage  the  coma  is 
sudden  ami  devehtjis  rapidly.  The  heniiplegic  sym{)toms  may  be  transient, 
quickly  giving  place  to  complete  relaxation.  Convulsions  occur  in  many 
cases,  and  may  be  the  very  vSyni}»tom  to  lead  astray — as  in  a  case  of  ven- 
tric  liar  luvmorriuige  which  occurred  in  a  puerperal  })atient,  in  whom,  natu- 
rally enough,  the  coiulition  was  thought  to  be  xira-mic.  Kigidity  is  often 
present.  In  luemorrhage  into  the  pons  convidsions  are  freipient.  Tlie 
])upils  may  be  strongly  contracted,  conjugate  deviation  may  occur,  and  the 
temperature  is  apt  to  rise  rajjidly.  The  contraction  of  the  pupils  in  pontine 
luemorrhage  naturally  suggests  opium  poisoning.  The  dilference  in  tem- 
jierature  in  the  two  conditions  is  a  valual)le  diagnostic  point.  The  apoplecti- 
form seizures  of  general  paresis  have  usually  been  jjreceded  by  abnornuil 
mental  s3'mptoms,  aiul  the  associated  hemii)legia  is  seldom  permanent. 

It  may  be  impossible  at  first  to  give  a  definite  diagnosis.  Jn  admissions 
to  hospitals  or  in  emergency  cases  the  physician  should  be  ])articularly  care- 
ful about  the  following  points:  The  examination  of  the  head  for  injury 
or  fracture;  the  urine  should  be  tested  for  allmmin,  examined  for  sugar, 
and  studied  microscoi)ically;  a  careful  examiiuition  sliould  be  nuule  of  tlie 
limbs  with  reference  to  their  degree  of  relaxation  or  the  ]iresence  of  rigidity, 
and  the  condition  of  the  reflexes;  the  state  of  the  ])upils  should  be  noted 
and  the  temperature  taken.  The  odor  of  the  breath  (alcohol,  acetone, 
chloroform,  etc.)  should  be  remarked.  Tlu^  most  serious  mistakes  are  made 
in  the  case  of  patients  who  are  drunk  at  the  time  of  the  attack,  a  combina- 
tion by  no  means  uncommon  in  the  class  of  patients  admitted  to  hos])ital. 
Under  these  circumstances  the  case  may  erroneously  be  looked  upon  as  one 
of  alcoholic  coma.  It  is  best  to  regard  each  case  as  serious  and  to  bear  in 
mind  that  this  is  a  condition  in  wliich,  above  all  others,  mistakes  are 
common. 

Prognosis. — From  cortical  ha'morrhage,  unless  very  extensive,  tlie 
recovery  may  be  complete  without  a  trace  of  contracture.  Tliis  is  more 
common  Avhcn  the  ha-morrhage  follows  injury  than  when  it  results  from 
disease  of  the  arteries.  Infantile  meningeal  ha>morrliage,  .in  the  other 
hand,  is  a  condition  which  may  produce  idiocy  or  s]iastic  di]degia. 

Large  luTmorrhagcs  into  the  corona  radiata,  and  esiiecially  those  which 
rupture  into  the  ventricles.  ra])idly  prove  fatal. 

The  hemiplegia  which  follows  lesions  of  the  internal  capsule,  the  result 


lOOS 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


of  rii|)tur(>  of  the  Iciiticulo-striiitt'  artcrv,  is  usually  jxTsistciit  aiul  Tollowcd 
hy  CKiilractiirr.  W  lien  the  ri'tro-U'iiticiilar  liltrua  ol'  tliu  internal  fapsiiir 
aro  iiivolvt'd  thcro  may  ho  licmianivsthc'sin,  and  later,  especially  il'  the  thala- 
mus he  implifatcd,  hciiiicliorca  or  athetosis.  Jii  any  ease  ol"  ciTchral  apo- 
j)le.\y  till'  I'ollowinji,'  symplonis  arc  of  ^^ravc  omen:  pcrsistenee  or  decpcnJiiLr 
of  the  coma  during'  the  second  and  third  day;  rapid  rise  in  temperature 
within  the  first  i'orty-ei;fht  hours  after  the  initial  fall.  In  the  reaction 
which  takes  place  on  the  .second  or  third  day,  the  temperature  usually  rises, 
and  its  ;:;radual  hdl  on  the  third  or  foui'th  day  with  return  of  consciousness 
is  a  favoi'ahle  indication.  The  I'apid  formation  of  hed-sores,  ])articularly 
the  niali<;nant  decul)itus  of  Chai'cot,  is  a  fatal  indication.  The  oi-currence 
of  alhumin  and  su;^ar,  if  ahnndant,  in  the  urine  is  an  unhivorahle  symptom. 
WIkmi  consciousness  returns  and  the  patient  is  im|)rovin^%  the  (juestion 
is  anxiously  asked  as  to  the  paralysis.  ^I'lie  extent  of  this  cannot  he  deter- 
mined for  some  weeks.  With  slight  lesions  it  may  pass  olf  entirely.  If 
persistent  at  the  end  of  a  month  some  grade  of  i)ermanent  jialsy  is  certain 
to  remain,  and  gradually  the  late  rigidity  supervenes. 


(■n( 

lis 

I'es 

l,.v 

mi 

\u<. 

(le 


5.  Emuolism  and  Tiihombosis  (Cerehral  Soflen'uuj). 

{a)  Embolism. — The  end)olus  usually  enters  the  carotid,  rarely  the  verte- 
l)ral  artery.  Jn  the  great  majority  of  cases  it  comes  from  the  left  heart  and 
is  either  a  vegetation  of  a  fresh  endocarditis  or,  more  commonly,  of  a  recur- 
ring endocaj'ditis,  or  from  the  segments  involved  in  an  idcei'ative  ])rocess. 
Less  often  the  end)olus  is  a  ])orti()n  of  a  clot  which  has  formed  in  the  au- 
ricular ap])endix.  Portions  of  clot  from  an  aneurism,  thromhi  from  athe- 
roma of  the  aorta,  or  from  the  territory  of  the  pulmonary  veins,  may  also 
cause  hlocking  of  the  hranches  of  the  circle  of  Willis.  In  the  puer]ieral 
condition  cerehral  endjolism  is  not  intreipient.  It  may  occur  in  women 
with  heart-disease,  hut  in  other  instances  the  heart  is  iininvolved,  and  the 
condition  has  heen  thought  to  he  associated  with  the  development  of  heart- 
clots,  owing  to  increased  coagulahility  of  the  l)lood.  A  majority  of  cases 
of  emholism  occur  in  heart-disease,  (S!)  ])er  cent  (Saveliew).  Cases  are  rare 
in  the  acute  endocarditis  of  rheumatism,  chorea,  and  fehrile  conditions.  It 
is  much  nutre  common  in  tlu'  secondary  recurring  endocarditis  which  at- 
tacks old  sclerotic  valves.  The  emholus  most  frcnpiently  passes  to  the  left 
middle  cere1)ral  artery,  as  it  enters  the  left  carotid  oftenor  than  the  right 
hecause  of  the  more  direct  course  of  the  hlood  in  the  former.  The  ])oste- 
rior  cerehral  and  the  vcrtehral  are  less  often  affected.  A  large  plug  may 
lodge  at  the  hifurcation  of  the  lia^^dai'.  Kudjolisni  of  the  cerehral  vessels  is 
rare. 

Eml)olism  occurs  more  frecpiently  in  women,  owing,  no  douht,  to  the 
greater  frecpiency  of  mitral  stenosis.  Contrary  to  this  general  statement, 
N'ewton  Pitt's  statistics  of  7;)  cases  at  Guy's  ITos])ital  indicate,  however, 
that  males  are  more  frequently  afTected;  for  in  this  series  there  were  44 
males  and  .^T)  f;>mnles.    Saveliew  gives  54  per  cent  in  women. 

{h)  Thrombosis. — Clotting  of  hlood  in  the  cerehral  vessels  occurs  (1) 
about  an  embolus,  (2)  as  the  result  of  a  lesion  of  the  arterial  wall  (either 


AFFECTIONS  OF  THE   BLOOD-VESSHLS. 


looa 


md  followed 

iliill  Ciipsiilc 
ii'  llic  Ihiila- 
•I'rclM'iil  iiiH)- 

•I"    lIcOpl'llillMr 

tempo  ralurc 

I  lie  reaetioii 
isiially  1'i.ses, 
^naeiousiioss 
piirtieiilarly 
'  oeciinviiei' 
lo  syiiiptoiii. 
ho  (|iies(i()ii 
<il  lie  (loter- 

II  ti  rely.  If 
;y  is  eortaiii 


y  the  vorte- 
t  heart  and 

of  a  reeiii'- 
ivo  ])rocess. 

in  the  au- 
I'runi  athe- 
3,  may  als^o 
'  puer])oral 

in  women 
(1,  and  the 
t  of  heart- 
ty  of  cases 
OS  ai'e  rare 
litions.     Tt 

which  at- 
to  the  loft 

the  ri<?ht 
riio  ])08te- 

plu<T  may 
1  vessels  is 

l)t,  to  the 

statement. 

however, 

3  were  44 

)ceurs  (1) 
ill  (either 


endarteritis  with  or  without  atheroma  or,  parlieiiiarly,  tlie  syphilitic  arteri- 
tis), (3)  in  aneurisms  both  coarse  and  miliary,  and  (I)  very  rarely  as  a  direct 
residt  of  ahnormal  conditions  of  tiio  hlood.  Thronihosis  occasionally  ln|- 
lows  lijiation  of  the  carotid  artery.  The  thronihosis  is  most  common  in  the 
middle  cerebral  and  in  the  basilar  arteries.  Aceordiii;,'  to  Kolisko,  softeii- 
in<;  of  limited  areas,  sullicient  to  induce  hemiplegia,  may  Ite  caused  by  sud- 
(U'li  collapse  of  certain  cerebral  arteries  from  cardiac  weakness. 

Aiiiiltiiiiicdl  Chiuujvx. —  Dejicnei'ation  and  softening  of  the  territory  sup- 
plied by  the  vessels  is  the  ultimate  result  in  both  embolism  and  thrombosis. 
IJlocking  in  a  terminal  artery  may  bo  followed  l)y  infarction,  in  which  the 
territory  may  either  bo  deeply  inliltrated  with  blood  (liiemorrhagic  infarc- 
tion) or  bo  simply  pale,  swollen,  and  necrotic  (aiiiomic  infarction).  (Jrad- 
iially  the  process  of  softening  proceeds,  the  tissue  is  infiltrated  with  serum 
and  is  moist,  the  nerve  fibres  (U'genorate  and  become  fatty.  The  neuroglia 
is  swollen  and  (edematous.  The  color  of  the  softened  area  do]>ends  upon 
the  amount  of  blood.  The  hiomoglobin  undergoes  gradual  transformation, 
and  the  early  rod  color  may  give  place  to  yellow.  Formerly  much  stress 
was  laid  upon  the  diirerence  between  inl,  i/clluir,  and  while  softening.  The 
red.  and  yellow  are  seen  chiolly  on  the  cortex.  Sometimes  the  red  softening 
is  i)articularly  marked  in  cases  of  embolism  and  in  the  m'ighborhood  of 
tumors.  The  gray  matter  shows  many  iiuiu-tiform  luemorrhagos — capillary 
apoph'xy.  There  is  a  variety  of  yellow  softening — the  phnjiics  juuiics — 
common  in  elderly  persons,  which  occurs  in  the  gray  matter  (d'  the  convolu- 
lioiis.  The  s])ots  are  from  1  to  '2  cm.  in  diameter,  soiiu'times  are  angular  in 
shape,  the  edges  cleanly  cut,  and  the  softened  area  is  represented  by  either 
a  turbid,  yellow  material,  or  in  some  instances  there  is  a  space  crossed  by 
fine  trabecuhe,  in  the  meshes  of  which  there  is  lluid.  AVhite  softening 
occurs  most  frequently  in  the  white  matter,  and  is  soon  best  about  tumors 
and  abscesses.  Inllammatory  changes  are  common  in  and  aliout  tlu'  soft- 
ened areas.  When  the  endiolus  is  derived  from  an  infected  focus,  as  iu 
ulcerative  endocarditis,  sup])uration  uiay  follow.  The  final  changes  vary 
very  much.  The  degenerated  and  dead  tissue  elements  are  gradually  but 
slowly  removed,  and  if  the  region  is  small  may  be  ro})laced  by  a  growth  of 
connective  tissue  and  the  formation  of  a  scar.  If  large,  the  resor])tion 
results  in  the  formation  of  a  cyst.  It  is  surprising  for  how  long  an  area 
oi  softening  nuiy  ])orsist  without  much  change. 

The  position  and  extent  of  the  softening  depend  upon  the  obstructed 
artery.  An  embolus  which  blocks  the  middle  cerebral  at  its  origin  involves 
not  only  the  arteries  to  the  anterior  ])erforated  space,  but  also  the  cortical 
branches,  and  in  such  a  case  there  is  softening  in  the  neighborhood  of  the 
corpus  striatum,  as  well  as  in  part  of  the  region  supplied  by  the  cortical 
vessels.  The  freedom  of  anastomosis  between  these  branches  varies  a  good 
deal.  Thus,  there  are  instances  of  embolism  of  the  middle  cerebral  artery 
in  which  the  softening  has  oidy  involved  the  territory  of  the  central 
branches,  in  which  case  blood  has  reached  the  cortex  through  the  anterior 
and  posterior  cerebrals.  "When  the  middle  cerebral  is  blocked  (as  is  ])erha]is 
oftenest  the  case)  beyond  the  point  of  origin  of  the  central  arteries,  one  or 
other  of  its  branches  is  usually  most  involved.     The  embolus  may  lodge 


1010 


DISKASRS  OP  THE  NKRVOUS  SYSTKM. 


in  the  vi'sscl  iiassiti,:,'  to  tlic  tliinl  IVdiitiil  convolution,  or  in  tlio  iirtcry  of 
the  ascending  Iroiiial  or  iisccndiiig  parietal;  or  it  may  lodge  in  the  hraneh 
])a.<sing  to  the  siipraniargiiial  and  angular  gyri,  or  it  may  enter  tlie  lowest 
l)raneli  which  is  distrihuted  to  the  n|t[)er  convolutions  of  the  temporal  lobe. 
'I'hese  ari'  pi'actically  terminal  arteries,  and  instances  freipicntly  occur  of 
softening  Hunted  to  a  part,  at  any  rati",  of  the  territory  supplied  hy  them. 
Some  of  till'  most  accurate  focalizing  lesions  are  produced  in  this  way. 

Symptoms. — Ivxtensive  thrond)otie  softening  may  exist  without  any 
symptoms.  It  is  not  uncommon  in  the  jjost-mortem  examination  of  tin; 
bodies  of  elderly -persons  to  lind  the  jildfjucs  jdiiiics  scattered  over  the  con- 
volutions. So,  too,  softening  may  take  i»lace  in  the  "silent"  regions,  as 
they  are  termed,  without  exciting  any  symptoms.  When  the  central  or 
cortical  branches  of  the  middle  cerebral  arteries  are  involved  the  symp- 
toms are  similar  to  those  of  ha'niorrhage  from  the  same  arteries.  Permanent 
or  transient  hemiplegia  results.  When  the  central  arteries  are  involved 
the  softening  in  the  internal  capsule  is  commonly  followed  by  permanent 
hemi|degia.  There  are  certain  peculiarities  associated  with  embolism  and 
Avith  thrombosis  respectively. 

In  enibuJisin  the  i)atient  is  usually  the  subject  of  heart-trouble,  or  there 
exist  some  of  the  conditions  already  mentioned.  The  onset  is  sudden, 
without  premonitory  symptoms.  AVhen  the  embolism  blocks  the  left  middle 
cerebral  artery  the  hemiplegia  is  usually  associated  with  aphasia.  In  ihrom- 
hnsis,  on  the  other  hand,  the  onset  is  more  gradual;  the  ])atient  has  ])re- 
viously  comi)lained  of  headache,  vertigo,  tingling  in  the  lingers;  the  speech 
may  have  been  embarrassed  for  some  days;  the  jjatient  has  had  loss  of 
memory  or  is  incoherent,  or  paralysis  begins  at  one  part,  as  the  hand,  and 
extends  slowly,  and  the  hemi])legia  may  l)e  incomplete  or  variable.  Abrui)t 
loss  of  consciousness  is  much  less  connnon,  and  when  the  lesion  is  small 
consciousness  is  retained.  Thus,  in  thrombosis  due  to  syphilitic  disease, 
the  hemiplegia  may  come  on  gradually  without  the  slightest  disturbance 
of  consciousness. 

The  hemijdegia  following  thrombosis  or  embolism  has  practically  the 
characteristics,  both  primary  and  secondary,  described  under  hannorrhage. 

The  following  nmy  be  the  effects  of  blocking  the  different  vessels: 
(a)  Yerlehral. — The  left  branch  is  more  frequently  plugged.  The  eil'ects 
are  involvement  of  the  nuclei  in  the  medulla  and  symptoms  of  acute  bulbar 
paralysis.     It  rarely  occurs  alone;  more  commonly  with 

(/>)  r>locking  of  the  basilar  nrfcri/.  When  this  is  entirely  occluded,  there 
may  be  bilateral  ]iaralysis  from  involvement  of  both  motor  paths.  Bulbar 
symptoms  may  be  iiresent;  rigidity  or  spasm  may  occur.  The  temperature 
may  rise  ra]iidly.    The  symjjtoms,  in  fact,  are  those  of  apo])lexy  of  the  pons. 

(c)  The  pastcrior  cerebral  supplies  the  occipital  lobe  on  its  medial  sur- 
face and  the  greater  ])art  of  the  temporo-sphenoidal  lobe.  If  the  main  stem 
be  thrombosed  there  is  hemianopia  with  sensory  aphasia.  Localized  areas  of 
softening  may  exist  without  symptoms.  Blocking  of  the  main  occipital 
branch  (arteria  occi])i talis  of  Duret),  or  of  the  arteria  calcarina,  passing 
to  the  cuneus  may  be  followed  by  hemianopia.  Hemianesthesia  may  re- 
sult from  involvement  of  the  posterior  part  of  the  internal  capsule.     Not 


II 

sij 

o(| 

Itl 

w 


tr 


AFKKCTIONS  UF  TIIK   HLUOD-VKSSKLH. 


lull 


tlic  nrtory  of 

11    <lu'   Itlllllcll 

t'l'  I  lie  louc-t 
•in|ii)rjil  IuIh'. 
itly  occur  ol' 
it'«l  by  tliciii. 
til  is  way. 
without  any 

ittioii    dl"    tilt! 

vcr  tlie  coii- 
rc'^'ioiis,  as 

0  f'ciitral  or 

1  the  synip- 
IV'rnianoiit 

irc  involved 

])('niiancnt 

iltolism  and 

Jle,  or  there 
is  sudden, 
left  middle 
In  t/tniin- 
nt  has  ])re- 
the  speech 
lad  loss  of 
''  ]iand,  and 
Ic.    Abriij)t 
on  is  small 
tic  disease, 
listurbance 

itically  tlie 
norrhafje. 
nt  vessels: 
riie  ell'ects 
ute  bulbar 

ided,  til  ere 
5.  Bulbar 
niperature 

the  pons, 
lodial  sur- 
iiain  stem 
d  areas  of 

occipital 
I,  passin;:: 
I  may  re- 
Lilc.     Not 


infre(iuently  symmetrical  thrombosis  of  the  occipital  arteries  of  the  two 
sides  occurs,  as  in  l''("irstcr's  \vcll-l<iio\vn  case.  Still  niori'  fre(|uent  is  the 
nci'urrence  of  thrombosis  of  a  branch  ol'  the  posterior  cerebral  of  one  hemi- 
sphere and  a  branch  of  the  middle  cerebral  of  the  other  (von  Monakou). 
It  is  in  such  cases  that  the  most  pronounced  instances  of  apraxia  are  met 
with. 

((/)  liilcriKil  ('(iniliil. — The  symptoms  are  variable.  As  is  well  known, 
the  vessel  is  in  a  majority  of  cases  ligated  without  risk.  In  other  instances 
transient  hemiplegia  follows;  in  others  again  the  hemiplegia  is  {)ernuinent. 
These  variations  depend  on  the  anastomoses  in  the  circle  of  Willis.  If 
these  are  large  and  free,  no  paralysis  follows,  but  in  cases  in  which  the  pt)S- 
tcrior  communicating  and  the  anterior  communicating  vessels  are  small  or 
ab.sent,  the  j)aralysis  may  persist.  In  No.  7  of  my  Klwyn  series  of  cases  of 
infantile  hemiplegia,  the  woman,  ag''d  twenty-four,  when  six  years  old,  had 
the  right  carotid  ligated  for  abscess  following  scarlet  fever,  with  the  result 
of  ])ermanent  hemiplegia.  lUoeking  of  the  internal  carotid  within  the 
skull  by  thrombosis  or  eml'olism  is  followe<l  by  liemi])legia,  coma,  and  usu- 
ally death.  The  clot  is  rarely  confined  to  the  carotid  itself,  but  sjireads 
into  its  branches  and  may  involve  the  ophthalmic  artery. 

((')  Middle  ('cirbnd. — This  is  the  vessel  most  commonly  involved,  and, 
as  already  mentioned,  if  plugged  before  the  central  arteries  are  given  oil", 
jiermanent  hemiplegia  usually  follows  from  softening  of  the  internal  cap- 
sule, blocking  of  the  branches  beyond  this  point  may  be  followed  i)y 
hemiplegia,  which  is  more  likely  1  >  be  transient,  involves  chielly  the  arm 
and  face,  and  if  on  the  left  side  is  ass(/ciated  with  aphasia.  The  individual 
branches  passing  to  the  inferior  frontal  (producing  typical  motor  a[)liasia 
if  the  disease  be  on  the  left  side),  anterior  and  jiosterior  central  gyri  (usually 
causing  total  henii])legia),  to  the  supramarginal  and  angular  gyri  (giving 
rise,  if  the  throml)osis  be  on  the  left  side,  probably  without  exce])tion  to 
the  so-called  jjure  (or  subcortical)  alexia,  usually  also  to  right-sided  hemi- 
anopsia), or  to  the  temporal  gyri  (in  which  event  with  left-sided  thrombosis 
word-deafness  results)  may  be  ])lugged. 

(f)  Anterior  Cerehrah — No  symptoms  may  fo]h)w,  and  even  when  the 
branches  which  su])i)ly  the  ])aracental  lobule  and  the  top  of  the  ascending 
convohitions  are  plugged  the  branches  from  the  middle  cerebral  are  usually 
able  to  cfTect  a  collateral  circulation  in  these  parts.  ]\rono])legia  of  the  leg 
may,  however,  result.  Hebetude  and  dulness  of  intellect  nuiy  occur  with 
^jbstruction  of  the  vessel. 

There  is  unquestionably  greater  freedom  of  communication  in  the  cor- 
tical branches  of  the  different  arteries  than  is  usually  admitted,  although 
it  is  not  possible,  for  exam]ile,  to  inject  the  posterior  cerebral  through  the 
nniddle  cerebral,  or  the  middle  cerebral  from  the  anterior;  but  the  absence 
of  softening  in  some  instances  in  which  smaller  branches  are  blocked  shows 
how  com]ilete  may  be  the  com])ensation,  jirobahly  by  way  of  the  capillaries. 
The  dilatation  of  the  collateral  branches  may  take  place  very  rapidly;  thus 
a  ]iatient  with  chronic  nephritis  died  about  twenty-four  hours  after  the 
hemijdegic  attack.  There  were  recent  vegetations  on  the  mitral  valve  and 
an  embolus  in  the  right  middle  cerebral  artery  just  beyond  the  first  two 


1012 


DISHASKS  (»F  TIIK   NKKVUUS  SYSTEM. 


l)riiii(li('s.  Tile  (•(■iitnil  |i<>i'tioii  of  till'  lii'iiiis|)li('r('  wiis  swnllcii  mul  ti'dt'iini- 
Iniis.  'I'lii'  li^^lit  jintciior  ccrcltnil  was  ^Tciitly  dilattMl,  ami  l»_v  iiicasui'i'iiu'iit 
its  (liaiiictcr  was  t'oiiiid  to  lie  nearly  tliicc  tiiiics  that  of  lli*'  left. 

Treatment   of  Cerebral   Hsemorrhag^e   and  of  Softening. 

— 'riic  |iati('iit  .»lioiil(l  lit'  |ilii(r(l  on  his  hack,  wilh  the  head  hi;^h,  tiii'  iii'i  k 
free,  kcjit  ahsdiiitciv  tiuift,  and  iiH'a.«-im's  iniMii'dialciy  taken  to  reduce  the 
arterial  pressure.  Of  ihe^'  the  most  rapid  and  satisfactory  is  veiieseetion. 
which  should  he  practised  whenever  the  arti'i'ial  tension  is  much  incruased. 
With  a  small  pidse  of  low  tension  and  sij^iis  of  cardiac  wcidvuess  it  is  contra- 
indicated.  The  chii'f  dilliculty  is  in  determinin;^'  whether  the  apo|)le.\y  is 
really  i\\\t.'  to  luemorrha^re,  or  to  thromhosis  or  end)olisni,  since  in  tlu'  latter 
group  of  cases  hleedin;,'  prohahly  does  harm.  As  a  rule,  however,  in  middle- 
a^cd  nu'U  with  arti'rio-sclerosis,  an  aeci'utuated  aortic  second  sound,  and 
hypertrophy  of  the  left  ventricle,  hleedin;,^  is  indicated.  Iloi'sley  and  Spen- 
cer have  I'eceutly,  on  experimental  j(r(mnds,  recomnu'uded  the  pi'actice, 
formei'ly  employi'd  empirically,  of  compression  of  the  carotid,  particularly 
in  the  in;^ravescent  foini;  or  even,  in  suitable  eases,  passinj?  a  ligature  round 
the  vessel.  An  iee-ha^''  nuiy  he  placed  on  the  head  and  hot  hottU'S  to  the 
I'eet.  The  liowels  should  he  freely  opened,  either  hy  calomel,  or  croton 
oil  placed  on  I  he  toi\j,nie.  Counter-irritation  to  the  neck  or  to  the  foot  is 
not  necessary.  Catheterization  (d'  the  bladder  may  he  necessary,  especially 
if  the  patient  remain  Ion;:;  unconscious.  When  dyspno'a,  stert(U'.  and  si^Mis 
of  mechanical  obstruction  are  present,  tlu'  patient  should  be  turned  on  the 
side,  as  recomnu'iided  liy  JJowles,  Tiiis  procedui'e  also  lessens  the  lial)ilily 
to  conffostion  id'  the  lun^s. 

Special  care  should  be  taken  to  avoid  bed-sores;  and  if  l)ottles  are  used 
to  the  I'eet,  they  should  not  be  too  hot,  since  blisters  imiy  be  readily  caused 
by  much  lower  temperature  than  in  health.  Jn  the  fever  of  reaction,  aconite 
may  ln'  indi(>ated,  but  should  be  cautiously  used.  Stimulants  are  not  neces- 
sary, unless  the  pulse  becomes  feeble  and  siuns  of  collapse  superveiu'.  Xo 
di^^italis  is  to  be  ^nveu.  During'  recovery  the  patient  should  be  still  kept 
entirely  at  rest,  evi'U  in  the  nuldest  eases  remaining  in  bed  for  at  least  four- 
teen days.  The  ice-ba<,f  should  still  be  kejtt  at  the  head.  The  diet  should 
be  li^ht  and  no  medicine  otber  than  some  placebo  should  be  administered, 
at  least  during-  the  first  month  after  the  hiumorrhago.  Attention  should 
be  paid  to  the  posit it)n  occupied  by  the  jmralyzed  lind)  or  lind)s,  which  if 
swollen  may  be  wrapped  in  cotton  l)atting  or  llannel. 

The  tre.itmeut  of  xafliniinrj  from  thrombosis  or  embolism  is  very  un- 
satisfactory. Venesection  is  not  indicated,  as  it  lowers  the  tension  and 
rather  ])romotes  clotting.  If.  as  is  often  the  case,  tlie  heart's  action  is  feeble 
and  irregular,  stimulants  and  small  doses  of  digitalis  may  be  given  with, 
if  necessary,  ether  or  ammonia.  The  bowels  should  be  kept  open,  but  it  is 
not  well  to  p^irge  actively,  as  in  haunorrhage. 

In  the  tlirombosis  which  follows  syjihilitic  disease  of  the  arteries,  and 
"which  is  met  Avith  most  freijuontly  in  nuui  between  twenty  and  forty  (in 
whom  the  hemiplegia  often  sets  in  <vithout  loss  of  consciousness),  the  iodide 
of  potassium  should  be  freely  used,  giving  from  20  to  30  grains  three  times 
a  day,  or,  if  necessary,  larger  doses.     If  the  syphilis  has  been  recent,  mer- 


cui 

oi 

dui 

cell 

ml 

111] 

lie 


AFFKCTIOXS  OF  Tlir:   lU.ooD-VRSSKLS. 


1018 


1111(1  (I'dciiiii- 
iicasuiviia'iit 

Joftening. 

Il,     lIlC    IllM   k 

I't'dlU'c  (111- 
vcm'Sfctjoii, 

I  iiififiisfd. 
it  i.s  coiitni- 
iljxtpk'xy  is 

II  till'  lilt  In- 
ill  iiiiddlc- 

i«»mid,  mid 
iiiid  S|(cii- 
u  pructico, 
•firficidarly 
tint'  round 

tics    to    1|)(. 

or  cioton 

the  IVot  is 

cspcciidly 

iiiid  sit,riis 

It'll  on  tJio 

If   liMhililv 

s  ixve  iisrd 
ily  cniiscd 
11,  iu'onilt' 
i<>(  nows- 

■I'llO.      Xo 

slill  kopt 
cast  foiir- 
ct  should 
inistcrcd. 
11  slioidd 
MJiicli  ir 

very  iin- 
>'nn\  and 
is  fcohic 
en  M'itli, 
but  it  is 

•ios,  and 
orty  (in 
e  iodide 
ce  times 
it,  inor- 


( iirials  l»y  inunction  are  also  indicntcd.  Pnictically  these  are  the  oidy  cases 
(d'  henii|de;,Ma  in  which  sve  sec  satisfactory  results  from  treatnicnt. 

<)|ierati\<'  ticMtnienl  has  heeri  sii^'-^rested,  and  wlii-n  the  diagnosis  of  >iih- 
dui'al  hieniorrha^'e  can  he  made  it  is  justiliahle.  An  attempt  to  reach  a 
central  lucniorrha^^'c  in  the  nei^hhorhood  (d'  the  internal  capsule  would  only 
increase  the  (laina<,'e  to  the  hraiii  siihstauce.  Very  little  eaii  he  done  for 
the  heiniple^'ia  which  remains.  The  dama;;e  is  too  often  irreparahle  ami 
|ieiiiianeiit,  and  it  is  very  improhahle  that  iodide  of  potassium,  or  any 
other  remedy,  hastena  in  liie  slightest  ch'^ree  Malure's  dealing;  with  the 
hlood-(dot. 

The  paraly/ed  limhs  may  l)c  ^rently  nihhed  once  ov  twice  a  day,  and 
this  should  he  systematically  carried  out,  in  order  to  maintain  the  nutri- 
tion of  the  muscli's  ami  to  prevent,  if  possible,  contractures.  'I'he  massaj,'*' 
should  not,  however,  l)e  hc^iun  until  at  least  ten  days  after  the  attack.  The 
riihhin^f  should  he  hurdnl  the  hody,  and  should  not  lie  continued  for  more 
than  lifteen  minutes  at  a  time.  After  the  lapse  of  a  fortni;^lil,  or  in  severe 
cases  a  month,  the  mus(des  may  he  stimulate(l  hy  the  faradic  current:  faradie 
stimulation  alternating'  with  massa;:e,  especially  if  applied  to  the  anta;,'onists 
(d'  the  muscles  wliich  ordinarily  underj^d  contracture,  is  id'  very  j;reat  service, 
even  in  cases  where  there  can  he  hut  little  hope  of  any  retiiin  (d'  voluntary 
movement.  When  contractures  develop,  electricity  properly  applied  at 
intervals  may  still  he  of  some  henelit  al<ui<:  with  the  passive  movenieiits  and 
frictions. 

Ill  a  case  of  complete  liemiph'<i:ia,  the  fi'iends  should  at  the  outset  lie 
frankly  told  that  the  (diances  of  full  recovery  are  sli,i>lit.  I'ower  is  usually 
ri'st(U'ed  in  the  le;^'  siitlicient  to  enahle  the  ])atient  to  ;xet  ahout,  hut  in  the 
majority  of  iiistanct's  the  liner  niovt'meiits  of  the  hand  are  permanently  lost. 
The  general  health  should  he  looked  after,  the  howels  re,i;iilated.  ami  the 
seci'ctions  of  the  skin  and  kidneys  ki'|)t  active,  lii  permaueut  liemipleji;ia 
in  persons  above  the  middle  jieriod  of  life,  more  or  less  mental  weakness  is 
apt  to  follow  the  attai'k.  and  the  ])atient  may  become  iri'itable  and  emo- 
tional. 

.\nd.  lastly,  when  heniijilefiia  has  persisted  for  more  than  three  months 
and  contractures  Iiavo  develo])ed,  it  is  the  duty  of  tlii'  physician  to  explain 
to  the  i)atient,  or  to  his  friends,  that  the  condition  is  ])ast  reli(d'.  that  medi- 
cines and  ek'ctricity  will  do  no  pood,  and  that  there  is  no  possible  hope  oi' 
cure. 

n.    A.VIM'inSM    OF    TTri',    CKTllUUtAl.    AiniMUKS. 

]\riliary  anciii'isuis  are  not  included,  but  rtd'erence  is  unuh'  only  to  aneu- 
rism of  the  lar<:;er  l)ranehes.  The  condition  is  not  uncommon.  There  were 
1"^  instances  in  my  first  SOO  autopsies  in  Montreal.*  Hi  is  is  a  considerably 
larger  proportion  than  in  Xewton  Titt's  c(dlection  from  Guy's  Hospital, 
19  times  in  9.000  ins]>octions. 

Etiology. — ]\rales  are  more  fretpiently  atrected  than  fenuiles.  Of  my 
13  cases  7  were  males.     The  disease  is  most  common  at  the  middh'  period 

*  Canada  Medical  and  Surgical  Journal,  vol.  xiv. 


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lOU 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


of  life.  One  ol'  my  cases  was  a  lad  of  six.  Pitt  ilcscriljcs  one  at  the  saiin' 
age.  Tlie  chief  causes  are  («)  en(hirteritis,  eitJier  simple  or  syphilitic,  which 
leads  to  weakness  of  the  wall  and  dilatation;  an<l  (h)  emholisni.  As  i)ointed 
out  hy  Church,  these  aneurisms  are  often  found  with  endocarditis.  I'itt, 
in  his  recent  study  of  the  suhject,  concludes  that  it  is  exceptional  to  find 
cerebral  aneurism  unassociated  with  fungating  endocarditis.  The  em- 
bolus disappears,  and  dilatation  follows  the  secondary  inllamniatory  changes 
in  the  coats  of  the  vessel. 

Morbid  Anatomy. — The  middle  cerebral  liranches  arc  most  fre- 
quently involved.  Jn  my  ]"3  cases  the  distribution  on  the  arteries  was  as 
follows:  Internal  carotid,  1;  middle  cerebral,  5;  basilar,  3;  anterior  coui- 
municating,  3.  Excei)t  in  one  case  they  were  saccular  and  communicated 
with  the  lumen  of  the  vessel  by  an  orilice  smaller  than  the  circumference 
of  the  sac.  In  the  15-1  cases  which  make  up  the  statistics  of  Lebert, 
Durand,  and  Bartholow  the  middle  cerebral  was  involved  in  -1:4,  the  basilar 
in  41,  internal  carotid  in  23,  anterior  cerebral  in  14,  posterior  communi- 
cating in  S,  anterior  communicating  in  8,  vertebral  in  7,  i)osterior  cere- 
bral in  (),  inferior  cerebellar  in  3  (Gowers).  The  size  of  the  aneurism 
varies  from  that  of  a  pea  to  that  of  a  walnut.  The  hicmorrhage  may  be 
entirely  meningeal  with  very  slight  laceration  of  the  brain  substance,  but 
the  l)]eeding  may  he,  as  Coats  has  shown,  entirely  within  the  substance. 

Symptoms. — The  aneurism  may  attain  considerable  size  and  cause 
no  symi)toms.  In  a  majority  of  the  cases  the  first  intimation  is  the  ru])ture 
and  the  fatal  apoplexy.  Distinct  symptoms  are  most  frecjuently  caused  by 
aneurism  of  the  internal  carotid,  which  may  compress  the  ojjtic  nerve  or  the 
connnissure,  causing  neuritis  or  paralysis  of  the  third  nerve.  A  murmur 
nuiy  be  audible  on  auscultation  of  the  skull.  Aneurism  in  this  situation 
may  give  rise  to  irritative  and  pressure  symptoms  at  the  base  of  the  brain 
or  to  hemianopsia.  In  the  remarkable  case  reported  by  "Weir  ]\litchell  and 
Dcrcum  an  aneurism  compressed  the  chiasma  and  produced  bilateral  tem- 
])oral  hemianopsia. 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 
the  fifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  imjjossible.  The  larger  sacs  produce  the 
sym})tonis  of  tumor,  and  their  rupture  is  usually  fatal. 


7.  Endarteritis. 

In  no  grou])  of  vessels  do  we  more  frequently  see  chronic  degenera- 
tive changes  than  in  those  of  the  circle  of  Willis.    The  condition  occurs  as: 

(a)  Arfcrio-scJerosis,  producing  localized  or  diffused  thickening  of  the 
intima  with  the  formation  of  atheromatous  patches  or  areas  of  calcification. 
Til  the  later  stages,  as  seen  in  elderly  ])eo])le,  the  arteries  of  the  circle  of 
AVillis  may  he  dilated,  stiff,  or  almost  universally  calcified. 

(h)  Si/philU'c  Eiularferitis. — As  already  mentioned  under  the  section 
of  syjdiilis,  gummatous  endarteritis  is  specially  prone  to  attack  the  cere- 
bral vessels.    It  has  in  itself  no  specific  characters — that  is  to  say,  it  is  im- 


AFFECTIONS  OF  THE  BLOoD-VESSELS. 


1015 


tlic  saiiitj 
:ic,  wliicli 
.8  poiiitnl 
tis.  I'itt, 
til  to  liml 
The  0111- 
y  clmiigi's 

most  fi'o- 
les  was  as 
rior  CO lu- 
ll unicated 
iiiil'cronco 
1'  Leburt, 
he  basilar 
3omniuni- 
rior  cere- 
uneurisni 
:e  may  be 
ance,  but 
itance. 
lud  cause 
le  rupture 
caused  Ijy 
Fve  or  the 
murmur 
situation 
the  brain 
cliell  and 
eral  tem- 

rves  from 
isilar  may 

jduce  the 


ciegenera- 
occurs  as: 
itT  of  the 
cification. 
I  circle  of 

le  section 

the  core- 

,  it  is  im- 


]iossible  in  given  sections  to  pick  out  an  endarteritis  syphilitica  from  an 
oi'dinary  endarteritis  obliteran-:.  On  tlie  otber  hand,  as  already  stated,  the 
iKjdular  periarteritis  is  never  seen  except  in  syphilis. 

8.  TjiifOMBOSis  or  tiik  I'kukhhal  Simsics  and  Vi:ins. 

The  condition  may  be  primary  or  secondary.  Lebert  (IS.Tl)  and  Ton- 
nele  were  among  the  hrst  to  recognize  the  condition  clinically. 

Primary  thrombosis  of  the  sinuses  and  veins  is  rare.  It  occurs  ((/)  in 
cliildreii,  itarticularly  during  the  first  six  months  of  life,  usually  in  c(ni- 
]iection  with  diarrhcea.  It  has,  in  my  exiierience,  been  a  rare  condition. 
1  have  never  seen  an  example  of  spontaneous  thrombosis  of  tl:e  sinuses  in 
a  child,  and  only  two  instances,  both  in  connection  with  meningitis,  in 
which  the  cortical  veins  contained  clots.  Ciowers  lielieves  that  it  is  of  fre- 
quent occurrence,  and  that  thrombosis  of  the  veins  is  not  an  uncommon 
cause  of  infantile  hemiplegia. 

{!))  In  connection  witii  chlorosis  and  anivmia,  the  so-called  aulochthonons 
sinus-thrombosis.  Brayton  Ball  has  called  attention  to  this  interesting  asso- 
ciation, and  has  reported  1  case  and  collected  10  or  11  others  from  the  litera- 
ture. All  were  in  girls  with  anannia  or  chlorosis.  The  longitudinal  sinus 
is  most  frequently  involved.  The  thrombosis  of  the  cerebral  sinuses  in 
such  cases  is  usually  associated  with  venous  thromboses  in  other  parts  of 
the  body,  and  the  patients  die,  as  a  rule,  in  from  one  to  three  weeks. 

(c)  In  the  terminal  stages  of  cancer,  jihthisis,  and  other  chronic  dis- 
eases thrombosis  may  gradually  occur  in  the  sinuses  and  cortical  veins.  To 
the  coagulum  developing  in  these  conditions  the  term  marantic  thrombus 
is  ap])lied. 

Secondary  thrombosis  is  much  more  frequent  and  follows  extension  of 
inflammation  from  contiguous  parts  to  the  sinus  wall.  The  C(mimon  causes 
are  disease  of  the  internal  ear,  fracture,  compression  of  the  sinuses  by 
tumor,  or  suppurative  disease  outside  the  skull,  particularly  erysi])clas,  car- 
Ininele,  and  parotitis.  In  secondary  cases  the  lateral  sinus  is  most  frequently 
involved.  Of  57  fatal  cases  in  which  ear-disease  caused  death  with  cerebral 
lesions,  there  were  22  in- which  thrombosis  existed  in  the  lateral  sinuses 
(Pitt).  Tuberculous  caries  of  the  temporal  l)one  is  often  directly  responsible. 
The  thrombus  may  be  small,  or  may  fill  the  entire  sinus  and  extend  into 
the  internal  jugular  vein.  In  more  than  one  half  of  these  instances  the 
thrombus  was  suppurating.  The  disease  spreads  directly  from  the  necrosis 
on  the  posterior  wall  of  the  tympanum.  According  to  Yoltolini,  the  in- 
flammation extends  by  way  of  the  petroso-mastoid  canal.  It  is  not  so  com- 
mon in  disease  of  the  mastoid  cells. 

Symptoms. — Primary  thrombosis  of  the  longitudinal  sinus  may  occur 
without  exciting  symptoms  and  is  found  accidentally  at  the  post  mortem. 
There  may  be  mental  dulncss  with  headache.  Convulsions  and  vomiting 
may  occur.  In  other  instances  there  is  nothing  distinctive.  In  a  patient 
who  died  under  my  care,  at  the  Philadelphia  Hospital,  of  phthisis,  there 
was  a  gradual  torpor,  deepening  to  coma,  without  convulsions,  localizing 
symptoms,  or  optic  neuritis.     The  condition  was  thought  to  be  due  to  a 


1010 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


tcrmiiiii]  iiicnin<:itis.  Jii  tho  clilorosis  cases  the  lieiid  syiiiptoins  have,  as  ii 
rule,  been  marked.  iJall's  patient  Avas  dull  and  stupid,  had  voniitin^f, 
dilatation  ot  the  i)ui)ils,  and  double  choked  disks.  Sliglit  paresis  of  the 
lett  side  occurred.  An  intcesting  i'eature  in  her  case  was  the  deveIo[)- 
nient  of  swelling  of  tiu'  left  leg.  In  tiie  cases  reported  by  xVndrews,  (,'hurch, 
Tuckwell,  Isaiubard  Owen,  and  Wilks  the  patients  had  headache,  voiuil- 
ing,  and  delirium.  Paralysis  was  not  i)resent.  In  Dou-Ias  Powell's  case, 
with  .similar  synii)tonis,  there  was  loss  of  powi-r  on  the  left  side,  iiristowe 
reports  a  case  of  great  interest  in  an  antrniic  girl  of  nineteen,  who  had  con- 
vulsions, drowsiness,  and  vomiting.  Tenderness  and  swelling  develoi)cd 
in  the  position  of  the  riglit  iiitei'nal  jugular  vein,  aH<l  a  few  (hiys  later  on 
the  o])posite  side.  The  diagiu)sis  was  rendered  deiinite  by  the  occurrence 
of  phlebitis  in  the  veins  of  the  right  leg.     The  patient  recovered. 

The  onset  of  such  symptoms  as  have  been  mentioned  in  an  anicmic  or 
chlorotie  girl  should  lead  to  the  susi)icion  of  cerebral  thromljosis.  In  in- 
fants the  diagnosis  can  rarely  be  made.  Involvement  of  the  cavernous  sinus 
nuiy  cause  cedema  about  the  eyelids  or  prominence  of  the  eyes. 

Jn  the  secondary  lliroiiihi  the  syni[)toms  are  commoidy  those  of  septi- 
caMuia.  For  instance,  in  over  10  ])er  cent  of  Pitt's  cases  the  mode  of  death 
was  b^•  pulmonary  ])ytemia.  This  autlior  draws  the  following  important 
coiu  lusions:  (1)  The  disease  s[)rea(ls  i)ftener  from  the  ]»osterior  wall  of 
the  middle  ear  than  from  the  luastoid  cells.  (',?)  The  otorrluea  is  gener- 
ally of  some  standing,  l»ut  not  always.  (;{)  Tiie  onset  is  sudden,  the  cliief 
symptoms  being  ])yrexia,  rigors,  pains  in  the  occi|)ital  region  and  in  the 
neck,  associated  with  a  septicuMuic  coiuhtion.  (4)  Well-marked  optic  neu- 
ritis may  l)e  ])resent.  (--))  The  appearance  of  acute  local  pulmonary  mis- 
chief or  of  distant  suppuration  is  almost  conclusive  of  thrombosis.  ((>) 
The  average  duration  is  about  three  weeks,  and  death  is  generally  from 
pulmonary  ])ya'mia.  The  chief  points  in  the  diagnosis  may  be  gathereil 
from  these  statements. 

Pitt  records  an  interesting  case  of  recovery  in  a  boy  of  ten,  who  had 
otorrluea  for  years  and  was  admitted  with  fever,  earache,  tenderness,  and 
cedema.  A  week  later  he  had  a  rigor,  and  optic  neuritis  developed  on  the 
right  side.  The  mastoid  was  explored  unsuccessfully.  The  fever  and 
chills  persisting,  two  days  later  the  lateral  sinus  was  explored.  A  mass  of 
foul  clot  was  removed  and  the  Jugular  vein  was  tied,  after  which  the  boy 
made  a  satisfactory  recovery. 

According  to  Criesinger  there  is  often  associated  with  thrond)osis  of 
the  lateral  sinus  veimus  stasis  and  painful  a'dema  behind  the  ear  and  in  the 
neck.  The  external  jugular  vein  on  the  diseased  side  may  be  less  dis- 
tended than  on  the  opposite  side,  since  owing  to  the  thrombus  in  the  lateral 
sinus  the  internal  jugular  vein  is  less  full  than  on  the  normal  side,  and  the 
blood  from  the  external  jugular  can  flow  more  easily  into  it  (Gerhardt). 

Treatment. — In  marantic  individuals  roborants  and  stimulants  are  in- 
dicated. The  position  assumed  in  bed  should  favor  both  the  arterial  and 
venous  circulation.  The  clothing  should  not  restrict  the  neck,  and  care 
should  be  taken  to  avoid  hendiitg  of  the  neck. 

The  internal  administration  of  potassium  iodide  and  calomel  has  been 


AFFECTIONS   OF   THE   BLOOT)-VESSELS. 


1017 


ave,  as  a 
,'Oinitinjf, 
is  oi:  tlio 

dL'VL'lu[)- 

,  Cluuvh, 
D,  voinit- 
'ir.s  case, 
JJristowe 
had  cuii- 
levol()|»cd 
later  uii 
X'urreiue 

ia!mic  or 

In  in- 

ous  sinus 

of  s('|)ti- 
of  (loath 
iniKii'tant 
■   wall   of 
is  ^■(■iicr- 
the  chief 
d  ill  the 
^)iic'  iieii- 
iry  mis- 
is.  _  (li) 
lly  froiii 
a  the  red 

who  had 

ess,  and 

1  on  the 

ver   and 

mass  of 

the  hoy 

ibosis  of 
id  in  the 
less  dis- 
le  lateral 
and  the 
rdt). 
s  are  in- 
jrial  and 
md  care 

las  been 


recommended  in  the  autochthonous  forms,  Init  no  treatment  is  likely  to  he 
of  any  avail. 

The  secondary  forms,  especially  those  followiii};  u\H)n  ilisease  of  the 
middle  ear,  are  often  amenaiile  to  operation,  and,  especially  recently,  many 
lives  have  been  saved  by  8ur<,dcal  intervention  after  extensive  sinus  tiirom- 
bosis.  Macewcji's  work  On  ryojj;enic  Infective  Diseases  of  the  llrain  and 
Spinal  Cord  contains  the  most  exhaustive  i»resentation  of  the  subject  of 
sinus  thrombosis  and  its  treatment. 

{).    HkMIPLKGIA    l.V    ClIILDHKX. 

Etiology. — Of  135  cases,  (iU  were  in  boys  and  75  in  <,nrls.  ({i^lit 
hemiplegia  occurred  in  T9,  left  in  50.  In  15  cases  the  condition  was  said 
to  be  eonirenital. 

In  a  jureat  majority  tlie  disease  sets  in  durinjj:  the  first  or  second  year; 
thus  of  the  total  number  of  cases,  1)5  were  under  two.  Cases  above  the 
fifth  year  are  rare,  only  10  in  my  series.  Xeither  alcoholism  nor  syphilis 
in  the  jiarents  ai)[)ears  to  ])lay  an  important  role  in  this  alfection.  Dilli- 
cult  or  abnormal  labor  is  responsible  for  certain  of  the  cases,  particularly 
injury  with  the  forcciis.  Trauma,  such  as  falls  or  i)uncturin<,'  woimds, 
is  nu)re  rare.  The  condition  followed  ligation  of  the  common  carotid  in 
one  case. 

Infectious  diseases..  All  the  authors  lay  special  stress  upon  this  factor. 
In  19  cases  in  my  series  the  disease  came  on  during  or  just  after  one 
of  the  s[)ecinc  fevers.  I  saw  one  case  in  which  during  the  height  of  vac- 
cination convulsions  develoi)ed,  followed  by  hemii)legia.  In  a  great  ma- 
jority of  the  cases  the  disease  sets  in  with  a  convulsion,  in  which  the  child 
may  remain  for  several  hours  or  longer,  and  after  recovery  the  jiaralysis 
is  noticed. 

Morbid  Anatomy. — Jn  an  analysis  which  I  have  made  of  <J<)  au- 
to])sies  reiiorted  in  the  literature,  the  lesions  may  be  grouped  under  three 
headings: 

(a)  Embolism,  thrombosis,  and  IhTmorrhage,  comprising  IG  cases,  in 
7  of  which  there  was  blocking  of  a  Sylvian  artery,  and  in  9  lucmorrhage. 
A  striking  feature  in  this  group  is  the  advanced  age  of  onset.  Ten  of  the 
case?  occurred  in  children  over  six  years  old. 

(/;)  Atro])hy  and  sclerosis,  comprising  50  cases.  The  wasting  is  either 
of  groups  of  convolutions,  an  entire  lo])e,  or  the  whole  hemisphere.  The 
meninges  are  usually  closely  adherent  over  the  affected  region,  though 
sometimes  they  look  normal.  The  convolutions  are  atrophied,  firm,  and 
hard,  contrasting  strongly  uith  the  normal  gyri.  The  sclerosis  may  be 
dilfuse  and  A\ldespread  over  a  hemisphere,  or  tlier'"  may  be  nodular  ))ro- 
jections — the  hypertrojihic  sclerosis.  Some  of  the  cases  show  reraarkaljle 
unilateral  atrophy  of  the  hemisphere.  In  one  of  my  cases  the  atropliied 
hemisphere  weighed  1G9  grammes  and  the  normal  one  653  grammes.  The 
brain  tissue  may  be  a  mere  shell  over  a  dilated  ventricle. 

(c)  Porencephalus,  which  was  present  in  21  of  the  90  autopsies.  This 
term  was  applied  by  Ileschel  to  a  loss  of  substance  in  the  form  of  cavities 


1013 


DISEASES  OF  TIIH   NERVOUS  SYSTEM. 


/ 


and  cysts  at  tlie  surface  of  the  l)rain,  citlicr  opciiiii;:;  into  and  hounded  hy 
tlie  araclinoid,  and  even  i)assin<j;  deeply  into  the  henusi»liere,  or  reaehinu 
to  tlic  ventricle.  In  the  study  hy  Audrey  of  103  cases  of  poreucephalus, 
lieniiplegia  was  mentioned  in  (J8  cases. 

Practically,  then,  in  infantile  heniiplcria  cortical  sclerosis  and  poren- 
cephalus  are  the  important  anatomical  conditions,  'i'he  ])rimary  chan;;(' 
in  the  majority  of  these  cases  is  still  unknown.  lV)rence])lialia  may  result 
from  a  defect  in  development  or  from  luemorrhaffe  at  birth,  'i'he  etiolo;,fy 
is  clear  in  the  limited  nund)er  of  cases  of  lia'morrhaj,^',  emholism,  and 
thrombosis,  but  there  remains  the  lari^e  <iroui>  in  which  the  linal  chan<ii' 
is  sclerosis  and  atrophy.  What  is  the  prinuiry  lesion  in  these  instances? 
The  clinical  history  shows  that  in  nearly  all  these  cases  ihe  onset  is  sud- 
den, with  convulsions — often  with  sli;^dit  fevei.  Striimpell  believes  that 
this  condition  is  due  to  an  irdlammation  of  the  gray  matter — ])()lio-en- 
cephalitis — a  view  which  has  not  been  very  widely  accepted,  as  the  ana- 
tomical proofs  are  wanting.  CJowers  suggests  that  thrombosis  nuiy  be  })reS" 
ent  in  some  instances.  This  might  i)robably  account  for  the  final  condi- 
tion of  sclerosis,  but  clinically  thrombosis  of  the  veins  rarely  occurs  iu' 
healthy  children,  whicb  api)ear  to  be  those  most  freciuently  attacked  by 
infantile  hemiplegia,  and  ])ost-nu)rtem  proof  is  yet  wanting  of  the  associa- 
tion of  thrombosis  with  the  disease. 

Symptoms. — (a)  The  onset.  The  disease  may  set  in  suddenly  with- 
out si)asms  or  loss  of  conscionsness.  In  more  than  half  the  cases  the  child 
is  attacked  with  partial  or  general  convulsions  and  loss  of  consciousness, 
which  may  last  from  a  few  hours  to  many  days.  This  is  one  of  the  most 
striking  features  in  the  disease.  Fever  is  usually  present.  The  hemi- 
l)legia,  noticed  as  the  child  recovers  consciousness,  is  generally  comi)lete.. 
Sometimes  the  paralysis  is  not  complete  at  first,  but  develojjs  after  subse- 
([uent  convulsions.  The  right  side  is  more  f-cnpiently  aifected  than  the 
left.     The  face  is  commonly  not  involved. 

(b)  IJesidual  symptoms.  In  some  cases  the  paralysis  gradually  disap- 
pears and  leaves  scarcely  a  trace  as  the  child  grows  up.  The  leg,  as  a 
rule,  recovers  more  rapidl}^  and  more  fully  than  the  arm,  and  the  paraly- 
sis may  be  scarcely  noticeable.  In  a  majority  of  cases,  however,  there  is- 
a  characteristic  hemipiegic  gait.  The  })aralysis  is  most  marked  in  the 
arm,  which  is  nsually  wasted;  the  forearm  is  flexed  at  right  angles,  the 
hand  is  flexed,  and  the  fingers  are  contracted.  Motion  may  be  almost  com- 
pletely lost;  in  other  instances  the  arm  can  be  lifted  above  the  head.  Late 
rigidity,  which  almost  always  develops,  is  the  symptom  which  suggested 
the  name  hcmii)legia  spastica  cerchralis  to  Heine,  the  orthopaedic  surgeon 
who  first  accurately  described  these  cases.  It  is,  however,  not  constant. 
The  limbs  may  be  quite  relaxed  even  years  after  the  onset.  The  reflexes 
are  usually  increased.  In  several  instances,  however,  I  have  known  them 
to  be  absent.     Sensation  is,  as  a  rule,  not  disturbed. 

Aphasia  is  a  not  uncommon  symptom,  and  occurred  in  IG  cases  of  my 
series — a  smaller  numl)eB  than  that  given  in  the  series  of  Wallenberg, 
Gaudard,  and  Sachs. 

Mental  Defects. — One  of  the  most  serious   consequences   of  infantile 


ounded  by 
r  rcacliiiiL,' 
.'iicc'phalus, 

Hid  ixjreii- 
iry  cliniijzc 
may  rcsiill 
lu;  oliulo.uy 
olisiii,  and 
mil  c'hanjic' 

instances? 
ist't  is  sud- 
lieves  tiiat 
— polio-en- 
s  the  ana- 
ay  bo  pros- 
inal  fundi- 

occurs  in- 
t  tacked  by 
ho  associa- 

lonly  with- 
s  the  child 
isciousnoss, 
f  tho  most 
The  b.omi- 

completc. 
I'tor  subse- 

Ihan  the 

dly  disap- 

Icg,  as  a 

le  ])araly- 

r,  there  is- 

:ed  in  the 

ingles,  the 

most  com- 

}ad.     Late 

suggested 

ic  surgeon 

constant. 

10  reflexes 

own  them 

ises  of  my 
allenberg, 

infantile 


AFFECTIONS  OF  TllH   IILOOD-VESSKLS. 


lui 


<t 


hemiplegia  is  the  failure  of  mental  development.  A  considerable  iiuml)fr 
of  these  cases  drift  into  (he  institutions  i'nr  feeble-minded  children,  'riirce 
gra(h's  may  be  distingiiisiied — idiocy,  which  is  most  common  when  llie 
hemiplegia  has  existed  from  birth;  imbecility,  which  often  increases  willi 
tho  develoi)ment  of  e])ilepsy;  and  feeljh'-mindedness,  a  retarded  rather 
than  an  arrested  develoi)ment. 

EjiUrpsij. — Of  tho  cases  in  my  series,  -11  were  subjects  of  coiivul>ive 
seizures,  one  of  the  most  distressing  se(|Mels  of  the  disease.  'J'he  seizures 
may  be  either  transient  attacks  of  iwlit  iikiL  true  Jacksonian  tits,  begin- 
ning in  and  eontined  to  the  alfected  side,  or  general  convidsions. 

rost-hctniph'nic  lilovciiiciils. — It  was  in  cases  of  this  sort  that  Weir 
Mitchell  iirst  described  the  post-hemii)legic  movements.  'J'hey  are  ex- 
tremely common,  and  wore  present  in  'M  of  my  series.  There  may  be 
cither  slight  tremor  in  the  aU'ected  muscles,  or  incoordinate  choreiforiu 
movements — the  so-called  post-henuplegic  chorea — or,  lastly. 

Athetosis. — In  this  condition,  described  by  Jlammond,  there  are  remark- 
able spasms  of  the  i)aralyze(l  extremities,  chielly  of  tne  lingers  and  toes, 
and  in  rare  instances  of  the  muscles  of  the  mouth.  The  movemi-nts  are 
involuntary  and  somewhat  rhythmical;  in  the  hand,  movements  of  adduc- 
tion or  abduction  and  of  sui)ination  an<l  pronation  follow  each  other  in 
orderly  sociueuce.  There  may  be  hypcrextension  of  the  fingers,  during 
which  they  are  spread  wide  ai)art.  This  condition  is  much  more  frc(]uent 
in  children  than  in  adults.  In  the  latter  it  may  be  combined  with  hemi- 
amvsthesia,  and  the  lesion  is  not  cortical,  but  basic  in  the  neighlxtrhood  of 
the  thalamus.  The  movements  arc  sometimes  increased  by  emotion.  They 
usually  persist  during  sleei). 

Treatment. — The  possibility  of  injury  to  the  brain  in  protracted 
labor  and  in  forceps  cases  should  be  borne  in  mind  by  tho  ])ractitioner. 
The  former  entails  the  greater  risk.  In  infantile  hemiplegia  tho  })liysician 
at  the  outset  sees  a  case  of  ordinary  convulsions,  })erlia})s  more  i)rotracte(l 
and  severe  than  usual.  These  should  bo  checked  as  rapidly  as  possible 
by  the  use  of  the  bromides,  the  application  of  cold  or  heat,  and  a  brisk 
purge.  During  convulsions  chloroform  niiy  bo  administered  with  safety 
even  to  the  youngest  children.  AVhen  th  paralysis  is  established  not  much 
can  be  hoped  from  medicines.  In  only  rare  instances  does  the  paralysis 
entirely  disappear.  "When  the  recovery  is  partial  the  "  residual  ]iaralysis  " 
is  similar  to  that  seen  in  other  lesions  of  the  upper  motor  segment.  Thus 
in  the  lower  extremity  it  is  the  flexors  of  tho  leg  and  the  dorsal  flexors  of 
the  foot  which  are  most  often  permanently  paralyzed  (Wernicke).  The 
indications  are  to  favor  the  natural  tendency  to  improve  by  maintaining  tho 
general  nutrition  of  the  child,  to  lessen  the  rigidity  and  contractures  by 
massage  and  passive  motion,  and  if  necessary  io  correct  deformities  by 
mechanical  or  surgical  measures.  Much  may  be  done  by  careful  manipula- 
tion and  rubbing  and  the  a])i)lication  of  a  ])r()por  apparatus.  In  children 
the  aphasia  usually  disappears.  The  epilepsy  is  a  distressing  and  obstinate 
symptom,  for  which  a  cure  can  rarely  be  anticipated.  Prolonged  jieriods 
of  quiescence  are,  however,  not  uncommon.  In  the  Jacksonian  fits  the 
bromides  rarely  do  good,  unless  there  is  much  irritability  and  excitement. 


Ell 


1020 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Opcralivo  iiioiisiircs,  wliidi  Iimvc  hccii  ciirricd  out  in  scvcrnl  cnsos,  liavo  not, 
a,s  u  nik',  been  .siiL'fu.s.srul.  'J'ia'  lialiilily  tu  r(.'»-'l)l('-iiiiii(k'iliic,'!5S  is  liiu  jiiosl 
serious  outlook  in  the  iuranlilu  ceTobral  palsies,  in  many  cases  the  ilaniayi; 
is  irreparahle,  and  idiocy  and  indjecilily  result.  With  ])atient  training'  and 
..  itii  care  many  ol'  the  cliildreii  reach  a  I'air  measure  ui'  iutelligence  and 
self-reliance. 


IV.    TUMORS,    INFECTIOUS    GRANULOMATA,    AND    CYSTS 

OF    THE    BRAIN. 


/ 


I 


The  follo\vin<j:  are  the  most  common  varieties  of  new  ^I'owtlis  williin 
the  cranium: 

(1)  Infectious  Granulomata.—(r/)  Ttihcirlc,  which  may  form  lar<-e  or 
small  ^irowllis,  usually  multiple.  Tuberculosis  of  the  jilaiids  or  bones  jiuiy 
be  coexistent,  but  the  tuberculous  disease  of  the  brain  may  occur  in  the 
abseiu-e  of  other  clinically  recognizable  tubei'culous  lesions.  The  disease  is 
most  fre((uent  early  in  life.  Tliree  ft)urths  of  the  cases  occur  under  twenty, 
and  one  half  of  the  patients  are  under  ten  years  of  age  ((Jowers).  Of  2\yj 
cases  of  tumor  in  persons  under  nineteen  collected  from  various  sources 
by  Starr,  152  were  tubercle.  The  nodules  are  most  numerous  iu  the  cere- 
bellum and  about  the  base. 

{!))  K^i/phildiiia  is  nu)st  commonly  found  in  the  henuspheres  or  about 
the  pons.  The  tunu)rs  are  supei'licial,  attached  to  the  arteries  or  the  me- 
ninges, and  rarely  grow  to  a  large  size.  'J'hey  may  l)e  multiple.  Tlu'  third 
nerve  is  |)arti(ularly  prone  to  syphilitic  infiltration,  and  ])tosis  is  conniU)u. 

(2)  Tumors. — (r)  Ulioma  and  XcKroi/lionut. — These  vary  greatly  in  ap- 
])enrance.  They  may  be  lirm  and  hard,  almost  like  an  area  of  sclerosis, 
or  soft  and  very  vascular.  They  persist  remarkably  for  many  years.  Klebs 
has  called  attention  to  the  occurrence  of  elements  in  them  not  unlike  gan- 
glion-cells. Tumors  of  this  character  may  contain  the  "  Sjjinnen  "  or  s])ider 
cells;  enormous  spindle-sha])ed  cells  with  single  large  nuclei;  cells  like  the 
ganglion-cells  of  nerve-centres  with  nuclei  and  one  or  more  ])rocesses;  and 
translucent,  baml-like  libres,  tai)ering  at  each  end,  which  result  from  a 
vitreous  or  hyaline  transformation  of  the  large  spindle-eells.  A  sei)aratc 
type  is  also  recognizable,  in  which  the  cells  resemble  the  e})endymal  epi- 
thelium. 

(d)  SairuiiKi  occurs  most  commonly  in  the  membranes  of  the  brain  and 
in  the  pons.  It  forms  some  of  the  largest  and  most  diffusely  infiltrating 
of  intracranial  growths.  Like  carcinoma,  sarcoma  of  the  brain  is  usually 
of  very  ra])id  growth, 

(c)  Carcinoma  not  infre(|uently  is  secoiulary  to  cancer  in  other  parts. 
It  is  seldom  ])rimary.  Occasionally  cancerous  tumors  have  been  found  in 
symmetrical  parts  of  the  brain. 

(f)  Other  varieties  occur,  such  as  fibroid  growths,  which  usually  develop 
from  the  membranes;  bony  tumors,  which  grow  sometimes  from  the  falx, 
psammoma,  and  cholesteatoma.  Fatty  tumors  are  occasionally  found  on 
the  corpus  callosum. 


s,  have  not, 
is  the  most 

111*!   (Illlllil^C 

i'liiiiing  anil 
liguuco  ami 


0    CYSTS 

vths  \vitliin 

ni  lai'.n'o  or 
•  hones  jiuiy 
ccur  in  the 
10  tliseaso  is 
idor  twenty, 
s).  Of  2dd 
ous  sources 
in  the  eere- 

L's  or  about 
or  tile  ine- 

Tlie  third 
('oniinon. 
atly  in  ap- 
)f  sclerosis, 

rs.     Klehs 

unlike  jian- 

"'  or  spider 

Is  like  the 
cesses;  and 
lilt  i'roni  a 
A  SO] )a rate 
dynial  ejii- 

brain  and 

infiltrating 

is  usually 

ther  parts. 
1  found  in 

ly  develop 
1  the  falx, 
found  on 


Tl'MoUS,  INFKCTIOl'S  GUAXfLo.M ATA,  AND  t'YSTS  (>F  TIIK  I'.I{AIX.    [i  oi 

{'•i)  Cysts. — ('/)  'I'hese  occur  between  the  nieiuhranes  am!  the  hrain,  as 
;i  result  ot  luemorrhage  or  of  sol'teniiij^'.  I'orencephalus  is  ,i  sinjiiel  of  eoii- 
:  iiiiial  atrophy  .ir  of  hieniorrhaiie,  or  may  he  due  lo  a  developmental  de- 
hct.  Hydatid  cysts  have  lieeii  refiTred  to  in  (lie  sectii»n  on  pai'asites.  An 
iiitercstin;:  varietv  cd'  cvst  is  that  which  fulhiws  severe  itijui'v  to  the  >kull 
in  early  life. 

Symptoms. — (1)  General. — The  followinjr  nre  the  most  iin|)or(ant: 
llcfKlaclii',  eiliier  dull,  aching,  and  eonliiuious,  (»r  sharp,  stabbing,  aud  [lar- 
I'xysmal.  Jt  may  be  dilTiised  over  the  entire  head;  someliines  it  is  limited 
In  the  back  or  fnuit.  When  in  the  back  nf  tlu'  head  it  ni;iy  exteinl  down 
the  neck  (esi»ecially  in  (uniors  in  the  posterior  fossa),  and  when  in  the  front 
it  may  be  accompanied  with  neuralgic  pains  in  the  face.  Occasionally  the 
pain  may  be  veiw  localized  and  associated  with  tenderiu'ss  on  pressui'e. 

Opiir  iiniiilis  (iccurs  iu  four  liftlis  (d'  r.ll  the  cases  ((iowers).  It  is  usu- 
:dly  double,  but  occasionally  is  found  in  only  one  eye.  A  growth  may  de- 
\elop  slowly  and  attain  coiisiderahle  size  without  prodnciug  optic  neuritis. 
On  the  other  hand,  it  may  occur  with  a  vei'y  small  tumor.  J.  A.  ^hirtin, 
liiiiii  an  extensive  analysis  of  the  literature  with  reference  to  the  localizing 
valiU'.  concludes:  When  there  is  a  dilTereiice  in  the  amount  of  the  neuritis 
iu  each  eye  it  is  more  than  twice  as  probable  that  the  tumor  is  on  the  side 
of  the  most  marked  neuritis.  It  is  constant  in  tumors  of  the  corpijra 
(piadrigemina,  ])resent  in  S!)  })er  cent  of  cen'bellar  tumors,  and  absent  in 
nearly  two  thirds  of  the  cases  of  tumor  of  the  pons,  medulla,  and  of  the 
corpus  callosuni.  It  is  least  frecjuent  in  cases  of  tuberculous  tumor;  most 
common  in  cases  of  glioma  and  cystic  tumors. 

Voinilinii  is  a  common  filature,  and  with  heai'.iche  and  optic  neuritis 
makes  up  the  characteristic  clinical  picture  of  cerebral  tumor.  An  impor- 
tiiut  point  is  the  absence  of  definite  ridation  to  the  meals.  A  chemical  e.\- 
iiuiination  shows  that  the  vomiting  is  independent  (d'  digestive  ilisturliances. 
it  may  be  very  obstinate,  i)articularly  in  growths  of  the  cerebellum  and 
the  ])ons. 

Giddiness  is  often  an  early  symptom.  The  patient  comjilains  of  vertigo 
on  rising  suddenly  or  on  turning  quickly.  Mental  Dislarhanre. — The  jia- 
tient  may  act  in  an  odd,  unnatural  manner,  or  there  may  be  stupor  and 
heaviness.  The  patient  may  become  emotional  or  silly,  or  symptoms  re- 
>enil)ling  hysteria  may  develop.  Cinirulsiiiiitt,  either  general  and  resembling 
true  epilepsy  or  localized  (Jacksonian)  in  character.  There  may  l)e  shiciiuj 
'if  llic  jiiilse,  as  in  all  cases  of  increased  intracranial  ])ressure. 

i'i)  Localizing  Symptoms. — Focal  symptoms  often  occur,  but  it  must  not 
lie  forgotten  that  these  may  be  indirecUij  })roduced.  The  smaller  the  tumor 
and  the  less  marked  the  general  sym[)toms  of  cerebral  compression,  the 
iiKire  likely  is  it  that  any  focal  symptoms  occurring  are  of  direct  origin. 

(d)  Central  Motor  Area. — The  symptoms  are  either  irritative  or  destruc- 
tive in  character.  Irritation  in  the  lower  third  may  jjroduce  spasm  in  the 
niuscles  of  the  face,  in  the  angle  of  the  mouth,  or  in  the  tongue.  The 
spasm  with  tingling  may  be  strictly  limited  to  one  muscle  grou])  before  ex- 
tending to  others,  and  this  Segnin  terms  the  si(jna1  sijntptoni.  The  middle 
third  of  the  motor  area  contains  the  centres  controlling  the  arm,  and  here, 
G4 


1022 


DISKASKS  (IF   TIIK   NKUVOl'S  SVSTHM. 


/' 


ti)(i,  llic  spnHin  may  bo<,'in  in  (Ih'  fiii^'crs,  in  the  tluiml),  in  the  niu-iclcs  of 
llu)  wrist,  or  in  tlio  shoulder.  In  tlio  upper  third  of  tho  motor  areasj  thi; 
irritation  may  produce  spasm  Ix'jfiiiiiiiij;  in  the  toes,  in  the  aid\h'-;.  or  in  thi' 
musi'les  of  the  lej,'.  Jn  many  instances  tho  patient  can  (h'termine  accu- 
rately the  jjoint  of  ori^nn  of  tho  spasm,  and  tiioro  are  im|»ortant  sonsorv 
disturbances,  such  as  nuiid)ness  and  tinj,ding.  whicli  may  Ite  felt  lirst  at 
the  rcf^ion  all'ected. 

Jn  all  cases  it  is  important  to  di'termiiie,  llrst,  the  point  ol'  oi'i^in,  the 
siijnal  tfij  III  plum;  second,  the  order  or  march  of  tho  spasm;  and  third,  the 
subse([uent  condition  of  the  i)arts  lirst  alfected,  whetlier  it  is  a  state  of 
l)aresis  or  aiuesthesia. 

])estructive  lesions  in  the  nu)tor  zone  cause  paralysis,  which  is  often 
])roce(K'd  by  local  convulsive  seizures;  there  may  be  a  mcjnoplegia,  as  of 
the  let,',  and  convulsive  seizures  in  the  arm,  often  duo  to  irritation  in  these 
centres.  Tumors  in  the  noi^'hborhootl  of  the  motor  area  may  cause  local- 
ized spasms  and  sul)se([Uently,  as  the  centres  are  invaded  by  the  growth, 
paralysis  occurs.  On  the  left  side,  growths  in  tho  third  frontal  or  Broca's 
convolution  may  cause  motor  aphasia. 

(Ii)  Prcfroiildl  liCijioii. — Neither  motor  nor  sensory  disturbance  may 
be  ])resent.  'i'he  general  symi)toms  are  often  well  marked.  Tho  most 
striking  feature  of  growths  in  this  region  is  mental  torpor  and  gradual 
ind)ecility.  In  its  extension  downward  the  tnnu)r  may  involve  on  tho  left 
side  the  lower  frontal  convolution  and  produce  aphasia,  or  in  its  progress 
backward  cause  irritative  or  destructivo  lesions  of  tho  motor  area.  Ex- 
ophthalmos on  the  side  of  the  tumor  may  occur  and  bo  helpful  in  diagnosis, 
as  in  the  case  reported  by  Thomas  and  Keene. 

{(•)  Tumors  in  tho  parteb-occipilal  lohc  may  grow  to  a  large  size  without 
causing  any  symptoms.  There  may  bo  word-blindness  and  mind-blindness 
when  tho  angular  gyrus  and  its  underlying  white  matter  is  involved,  and 
paraphasia. 

((/)  Tumors  of  the  occlpilal  lohe  produce  hemianopia,  and  a  bilateral 
lesion  may  ])roduce  blindness.  Tumors  in  this  region  on  the  left  hemi- 
sphere may  be  associated  with  word-blindness  and  mind-blindness. 

(c)  Tumors  in  the  tempuraJ  Johe  may  attain  a  largo  size  without  produc- 
ing symi)toms.  In  tluir  growth  they  involve  the  lower  motor  controls  On 
the  left  side  involvement  of  the  first  gyrus  and  the  transverse  temporal 
gyri  (auditory  sense  area)  may  be  associated  with  word-deafness. 

(/)  Tumors  growing  in  the  neighborhood  of  the  basal  (jaiKjlia  produce 
liemi})legia  from  involvement  of  the  internal  capsule.  Limited  growths  in 
either  tho  nucleus  caudatus  or  the  nucleus  lontiformis  of  the  corjjus  striatum 
do  not  necessarily  cause  paralysis.  Tumors  in  tho  thalamus  opticus  may 
also,  when  small,  cause  no  symptoms,  L.it  increasing  thoy  may  involve  the 
fibres  of  the  sensory  portion  of  tho  internal  capsule,  producing  homianopiii 
and  sometimes  hemiana}sthesia.  Growths  in  this  situation  are  apt  to  cans 
early  optic  nouritis,  and,  growing  into  tho  third  ventricle,  may  cause  a  dis- 
tention of  the  lateral  ventricles.  In  fact,  pressure  symptoms  from  this 
cause  and  paralysis  due  to  involvement  of  the  internal  capsule  are  the  chief 
symptoms  of  tumor  in  and  about  these  ganglia.     If  tho  ventrolateral  grouj' 


may 

vom 

toni! 

noui 

lie 

fron 

I'.rai 

terla 

stan( 

latoi 


TUMORS,  INFI'XrriOUS  OIIANULOMATA,  AND  CVSTS  OF  TIIK  RRAIX.  1023 


111-   tUVilS  111': 

c-i,  (ir  in  till' 
nniiic!  tu't-u- 
1 11  lit  sensory 

fell    first    ill 

1'  origin,  tilt' 
1(1  thlrt-l,  tlif 
id  a  state  o[ 

liich  is  often 
ipk'f^ia,  as  i>t 
ilion  in  tlie-c 
y  cause  loeal- 
,'  the  ^n-owUi, 
tal  or  Ik-uca's 

;urbance  may 
I.  The  most 
•  and  j^radiuil 
ve  oil  tlie  lei't 
n  its  progress 
;or  area.  Kx- 
il  in  diagnosis, 

re  size  without 

nind-blindness 

involved,  and 

nd  a  bilateral 

the  left  hemi- 

Inoss, 

ithont  pvoduc- 

ir  centre.^.     On 

verse  temporal 

less. 

(inijlia  produce 

ted  growths  in 

)rpus  striatum 
AS  opticus  may 

ay  involve  tlu' 

iig  hemianopiii 
ire  apt  to  cause 
lay  cause  a  dis- 

onis  from  tlii^ 
le  are  the  chiet 
trolatcral  groui 


of  niulei  in  the  llialaimis  he  involved  IJnre  may  he  nnilaleral  disturbances 
of  cutaneous  and  iniisi  iilar  sense,  lieniicliorea,  or  niovenient  ataxia. 

(Jrowliis  in  the  ciivpin-a  (inndiinviitina  are  rarely  linuted,  but  iiutst  coni- 
nionly  inv(dve  the  crura  cerebri  as  wi'li.  Ocular  symptoms  are  marked. 
'I'lie  pupil  I'eilex  is  lost  and  there  is  nyslngmu-;.  In  the  gradual  gioulli 
the  third  nerve  is  invtdved  as  it  passes  through  the  cnis,  in  which  case  ihcie 
will  be  oculo-niotor  [laialysis  on  one  side  and  hcmi|ilcgi;i  on  the  other,  a 
conddnatioii  almost  characteristic  of  unilateral  disi'ase  of  the  cms. 

(//)  'rumors  (d'  the  pons  and  iitcihilhi.  'I'lu'  symptoms  are  chietly  tlio>e 
of  pressure  up(tn  the  nerves  emerging  in  this  region,  in  disease  of  the 
pons  the  nerves  may  be  involved  alone  or  with  the  pyramidal  tract.  Of  ."i-.' 
cases  analyzed  hy  Mary  Putnam  Jacohi,  there  were  I'A  in  which  the  cerebral 
nerves  were  involved  ahuu',  liJ  in  which  the  Iiud)s  were  all'ected,  aiul  '^i>  in 
which  there  was  hemi|)legia  anil  involvement  (d'  the  nerves.  Twenty-two 
of  t.ic  lattei'  had  what  is  known  as  alternate  paralysis — i.e.,  involvi'ment 
of  the  nerves  on  one  side  and  of  the  linihs  on  the  opposite  side.  In  I  cases 
there  were  no  motor  symptoms.  Jn  tnherculosis  (or  syphilis)  a  growth 
at  the  inferior  and  inner  aspects  of  the  cms  may  cause  jiaralysis  of  the 
third  nerve  on  one  side,  and  of  the  face,  tongue,  and  limhs  on  the  oppi-.-^lie 
side  {."^yndronu!  of  Weber).  A  tumor  growing  in  the  lower  part  of  the  pons 
usually  involves  the  sixth  nerve,  ])ro(lucing  internal  strabismus;  the  seventh 
nerve,  producing  facial  paralysis;  and  the  auditory  nerve,  causing  deaf- 
ness. Conjugate  deviation  of  the  eyes  to  the  side  opposite  that  on  which 
there  is  facial  paralysis  also  occurs.  When  the  motor  cerebral  nervi's  are 
involved  tlie  ])aralyses  are  of    he  ))eriphcral  type  (lower  segment  paralyses). 

Tumors  of  the  medulla  may  involve  the  cerebral  nerves  alone  or  cause 
in  some  instances  a  combination  of  hemiplegia  with  paralysis  of  the  nerves. 
Paralyses  of  the  nerves  are  helpful  in  topical  diagnosis,  but  the  fact  must  not 
be  overlooked  that  one  or  more  of  the  cerebral  nerves  may  be  paralyzed  as 
a  result  of  a  much  increased  general  intracranial  jiressure.  Signs  of  irrita- 
tion in  the  ninth,  tenth,  and  elcveiitli  nerves  are  usually  ])resent,  and  pro- 
duce dilhculty  in  swallowing,  irregular  action  of  the  heart,  irregular  respii'a- 
lion,  vomiting,  and  sometimes  retraction  of  the  head  and  neck.  The  hypo- 
glossal nerve  is  least  often  alTccted.  The  gait  may  be  unsteady  or,  if 
there  is  jiressuro  on  the  cerebclluni,  ataxic.  Occasionally  there  are  sen- 
sory symptoms,  numbness,  and  tingling.  Toward  the  end  convulsions  may 
occur. 

Diagnosis. — From  the  general  symptoms  alone  the  existence  of  tumor 
may  be  determined,  for  the  combination  of  headache,  optic  neuritis,  and 
vomiting  is  distinctive.  A  gradual  increase  in  the  intensity  of  the  symp- 
toms is  usually  seen.  It  must  not  he  forgotten  that  severe  headache  and 
nouro-retinitis  may  be  caused  by  Bright's  disease.  Tlie  localization  must 
he  gathered  from  the  consideration  of  the  symptoms  above  detailed  and 
from  the  data  given  in  the  section  on  Topical  Diagnosis  of  Diseases  of  the 
lirain.  jMistakes  are  most  likely  to  occur  in  connection  with  unemia,  hys- 
teria, and  general  paralysis;  but  careful  consideration  of  all  the  circum- 
stances of  the  case  usually  enables  the  practitioner  to  avoid  error.  Auscul- 
tatory percussion  is  occasionally  of  service  in  localization. 


1024 


DISEASHS  OF  TUI':   NKKVoUS  SYSTEM. 


Prognosis. — Sypliililic  tumors  nlniu'  me  iinicimlik'  to  lucdicul  (rcat- 
iiiciit.  'rubtTciildUS  jiiowtlis  occasionally  ccasu  to  ^tow  and  iH-conic  calci- 
(icd.  The  ;:lioniala  and  lil)roinata,  parlicnlaily  wlicn  llic  latter  ^^row  I'lmii 
(lie  iiieniiiriines,  may  last  I'or  years.  1  have  descrihed  a  case  ol'  small,  hard 
glioma,  in  which  I  he  .lacksonian  epilepsy  persisted  for  fourteen  vears. 
Ilnghliuiis  -Jackson  has  reporU'd  ca>es  ol'  ^^lioma  in  which  tlu-  symptoms 
l;i>ted  |(ir  over  ten  years.  'The  more  rapidly  ;:ro\\in^'  sarcomata  usually 
pro\e  liiial  in  from  six  to  eij;hteen  months.  Death  may  \ii'  siulden.  par- 
ti* idarly  in  growths  near  the  medulla;  more  comuionly  it  is  due  to  coma 
in  con>c(picnce  of  ^^radual  increase  in  the  int  racr;iiual  pressure'. 

Treatment. — {a)  Mcilical.- — If  there  is  a  suspicion  (d'  syphilis  the 
iodide  of  potas>iuin  and  mercury  should  he  ;;iven.  Xowhi're  do  we  seti 
moi'e  brilliant  therapeutical  I'lfeets  than  in  i-ertain  cases  of  ccrehial  ;ium- 
mata.  The  iodide  ,-liould  he  ^iven  in  incieasin^'  doses,  in  t  uherculous 
tumors  the  outlook  is  less  favorahle,  IIkuil;!!  instances  of  cure  are  reiiorti'd, 
and  there  is  |)ost-niortem  evidence  to  show  that  the  solitary  tuhercidous 
lunwu's  may  underbid  chan<;es  and  become  obsolete.  A  jicneral  toiuc  treat- 
jueid  is  indicated  in  these  cases.  The  headache  usually  demands  ])rompt 
treatment.  The  iodide  of  potassium  in  full  doses  sometimes  gives  marked 
relief.  An  ice-cap  J'or  the  head  or,  in  the  occipitnl  headache,  the  appli- 
cation of  the  J'a(iuelin  cautery  may  be  tried,  'i'ne  bromides  are  nol  of 
much  use  in  the  headache  from  this  cause,  and,  as  the  last  resort,  mor- 
])hia  must  be  given.  I''or  the  convulsions  bronude  of  pota.ssiuiu  is  of  little 
service. 

(h)  Siin/lfdI. — 'I'umors  ot  the  brain  have  been  successfully  removed  by 
.Macewen,  ilorsley.  Keen,  and  others.  The  nundjer  of  cases  for  oi>eration, 
however,  is  small.  Four  iifths  at  least  of  all  the  eases  are  probably  un- 
suitable, or  of  such  a  nature  as  to  render  an  operation  fatal.  The  most 
advantigeous  cases  are  the  localized  fibromata  growing  from  the  dura  and 
only  com|iressing  the  hrain  subsiance,  as  in  Keen's  remarkable  ease.  The 
safety  with  which  the  exploratory  operation  can  be  made  warrants  it  in  all 
doubtful  cases. 


V.    INFLAMMATION    OF    THE    BRAIN. 

1.    AcUTli    EXCEI'IIALITIS. 

A  focal  or  diffuse  inflaniniation  of  the  brain  substance,  usually  of  the 
gray  matter  (poliencephalitis),  is  met  with  {a)  as  a  result  of  traunui;  (h) 
in  certain  intoxications,  alcohol,  food  poisoning,  and  gas  poisoning;  and  {<■) 
following  the  acute  infections.  The  anatomical  features  are  those  of  an 
acute  ha'morrhagic  ])olienceithalitis,  corresponding  in  histological  details 
with  acute  ])olio-myeliiis.  Focal  forms  are  seen  in  ulcerative  endocarditis. 
in  ■which  the  gray  matter  may  ])resent  deeply  luvmorrhagic  areas,  firmer 
than  the  surrounding  tissue.  In  the  fevers  there  may  be  more  extensive 
regions,  involving  two  or  three  convolutions.  This  acute  ha?morrhagic 
]ioliencephalitis  superior  is  thought  by  Striimpell  to  be  the  essential  lesion 
in  infantile  hemiplegia.    Localizing  symptoms  are  usually  present,  though 


INFLAMMATION   oF  THE   lUlAIN. 


Ullin 


rdical  (ii'at- 
fcoiiio  calLi- 
r  '^vnw  rriiiu 
'  .small,  hard 
rtec'ii   ycai's, 

10  symptoiiisj 
iiata  usually 
^iiihU'M.  par- 
luc  to  c'oiua 

syj)liilis  the 
'  do  we  st't! 
rt'lttal  <iiiui- 

tuhtTcidoUs 

ire  n'|)iirt('d, 

tuhiTculous 

tonic  trcal- 

inds  ])roiu|it 

ives  inaiiuul 

',  the  a|)|)li- 

aiv  not  of 

resort,  luor- 

11  is  of  little 

rt'iuovod  l)y 
)r  operation, 
irobably  un- 
Tlie  nicst 
be  dura  and 
'  case.  The 
nts  it  iu  all 


ually  of  the 
trauma;  (h) 
iii<i;  and  (r) 
tho.se  of  an 
fical  details 
mdocanlitis. 
reas,  firmer 
re  extensive 
lajmorrhasiic 
mtial  lesion 
ent,  thoiigli 


ihcy  may  be  obscured  in  tlie  severity  of  the  <reneral  infeitiun.  The  most 
ivpical  encephalitis  aceoniiiaiues  tlu'  nieiiin^'itis  in  cerehro-spinal  fever. 

In  acute  mania,  in  delirium  tremens,  in  chorea  insaniens,  in  the  mani- 
aciil  form  of  e.\o[»lithalnuc  jioitre,  and  in  the  Ho-called  cerebral  forma  of  the 
malijiuant  fevers  the  j^ray  cortex  is  (h'e|)ly  con;,'ested,  moist,  and  swollen, 
antl  with  the  recent  liner  methods  of  re.-earch  will  |»i'obably  show  chan^^'S 
which  may  be  classed  as  encephalitis. 

'J'he  ni/iiiiiloins  are  not  very  dellnite.  In  severe  f(»rms  they  are  those  of 
■  in  acute  infection;  some  ca.ses  have  i)ee'.i  mistaken  for  typhoid  fever.  The 
onset  may  be  abrupt  in  an  individual  appareidly  hi-allhy.  Other  ca^es 
have  occurred  in  the  convah'scence  from  the  fevers,  particulaily  inllueii/.a. 
One  of  .].  .1.  I'utinim's  cases  followed  mumps.  The  <j:eneral  sym|ttoms  are. 
tlio>e  which  accompany  all  severe  acute  alfections  of  the  Ijrain — headache, 
.-omnolence,  coma,  delirium,  vomitinji',  etc.  The  local  symptoms  are  very 
varied,  dependin;^:  on  the  extent  of  the  lesions,  am'  n«ay  be  irritative  or 
paralytic.  I'sually  fatal  within  u  few  weeks,  cases  may  duig  on  for  weeki* 
or  mouths  and  recover. 

2.  Auscioss  oi'  'rill':  IJkain. 

Etiology. — Suppui'ali<in  of  the  brain  substance  is  rar(dy  if  ever  pri- 
mary, but  results,  as  a  I'lde,  from  extension  of  inllamnuit  ion  from  nei^^h- 
l)orin<f  parts  or  infection  from  a  distance  throuiih  the  blood.  The  (pu'stion 
(if  idiopathic  brain  abscess  need  scarcely  be  considere(|.  lliou;;li  occa-ion- 
ully  instances  occur  in  which  it  is  exiremely  dillicull  to  assign  a  tause. 
There  are  three  inii)ortant  etiological  factors: 

(1)  Trauma.  Falls  upon  the  head  or  blows,  with  oi-  without  alji'asiou 
of  the  skin.  More  commotdy  it  follows  fi-acture  or  |)unctui'ed  wounds,  ju 
this  gnuip  meningitis  is  fre((uently  associated  with  the  abscess. 

{'i)  J>y  far  the  most  important  iiifective  foci  are  those  which  ai'ise  in 
direct  extension  from  disease  of  the  nnddle  ear  or  of  the  mastoid  cells. 
From  the  roof  of  the  mastoid  antrum  the  infection  readily  passes  to  the 
sigmoid  sinus  and  induces  an  infective  throndiosis.  In  other  instances  the 
dura  beconu's  involved,  and  a  sub-dural  al)scess  is  formed,  which  may 
readily  involve  the  arachnoid  or  the  pia  mater.  In  another  group  the  in- 
llamuiiition  extends  along  the  lymph  si)aces,  or  the  throndjosed  veins,  into 
till'  substance  of  the  brain  and  causes  sui)puration.  ^lacewen  thinks  that 
without  local  areas  of  meningitis  the  infective  agents  may  be  carried 
through  the  lymph  and  blood  channels  into  the  cere])ral  substance.  In- 
fection which  extends  from  the  roof  of  the  mastoid  process  is  most  likely 
to  be  followed  by  abscess  in  the  temporal  Iol)e,  while  infection  exten(^ing 
from  the  ])osterior  wall  canses  most  freiiueiitly  sinus  thrombosis  and  cere- 
Ijcllar  abscess. 

(3)  In  septic  processes.  Absces:>  of  the  brain  is  not  often  found  in 
l)y;enua.  In  ulcerative  endocarditis  multiple  foci  of  suppuration  are  com- 
mon. Localized  bone-disease  and  su]>puration  in  the  liver  are  occasional 
causes.  Certain  inflammations  in  the  lungs,  particularly  bronchiectasis, 
■which  was  present  iu  IT  of  38  cases  of  these  so-called  "  pulnioual  cerebral 


102G 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


/ 


al).scesscs  "  collected  by  K.  T.  "Williamson,  arc  liable  to  be  followed  by  ab- 
scess. It  is  an  (leiiisional  eoinplication  of  einpyeiiia.  Abscess  of  the  brain 
may  foP.j\v  tlie  specilic  fevers.  Uristowe  lias  called  attention  to  its  occur- 
rence fs  a  sequel  of  influenza.  The  largest  nnniljer  of  cases  occur  between 
the  twentieth  and  fortieth  years,  and  tlie  condition  is  more  fre(|Uent  in  men 
tlian  in  women.  Jlolt  'las  coilecti'd  2i)  cases  in  children  under  live  years 
of  age,  the  chief  causes  of  which  were  otitis  media  and  trauma. 

Morbid  Anatomy. — The  abscess  may  be  solitary  or  multiple,  dif- 
fuse or  circumscribed.  Practically  any  one  of  the  dilterent  varieties  of 
pyogenic  bacteria  may  be  concerned.  The  bacteriological  examination 
often  shows  a  mixture  of  dill'erent  varieties.  Occasionally  cultures  are 
sterile,  owing  to  death  of  the  bacteria.  In  the  acute,  raj)idly  fatal  cases 
following  injury  the  suppuration  is  not  limited;  but  in  long-standing  cases 
the  abscess  is  enclosed  in  a  deiinite  capsule,  which  may  have  a  thickness  of 
from  3  to  5  mm.  The  ])us  varies  much  in  a})i)earance,  depending  upon 
the  age  of  the  abscess.  In  early  cases  it  may  be  mixed  with  reddish  debris 
and  softened  brain  matter,  but  in  the  solitary  encapsulated  abscess  the  pus 
is  distinctive,  having  a  greenish  tint,  an  acid  reaction,  and  a  peculiar  odor, 
sometimes  like  that  of  suli)huretted  hj'drogen.  The  brain  substance  sur- 
rouiuling  the  abscess  is  usually  cedematous  and  infiltrated.  The  size  varies 
from  that  of  a  walnut  to  that  of  a  large  orange.  There  are  cases  on  record 
in  which  the  cavity  has  occupied  the  greater  portion  of  a  hemisphere.  Mul- 
tiple abscesses  are  usually  snuill.  In  four  fifths  of  all  cases  the  abscess  is 
solitary.  Suppuration  occurs  most  frequently  in  the  cerebrum,  and  the 
temporal  lobe  is  more  often  involved  than  other  parts.  The  cerebellum  is 
the  next  most  common  seat,  jjarticularly  in  connection  with  ear-disease. 

Symptoms. — Following  injury  or  operation  tlie  disease  may  run  an 
aaite  course,  with  fever,  headache,  delirium,  vomiting,  and  rigors.  The 
symptoms  are  those  of  an  acute  meningo-encephalitis,  and  it  may  be  very 
difficult  to  determine,  unless  there  are  localizing  symptoms,  whether  there 
is  really  suppuration  in  the  brain  substance.  In  the  cases  following  ear 
disease  the  symptoms  may  at  first  be  those  of  meningeal  irritation.  There 
may  be  irritability,  restlessness,  severe  headache,  and  aggravated  earache. 
Other  striking  symjjtoms,  ])articularly  in  the  more  prolonged  cases,  are 
drowsiness,  slow  cerebration,  vomiting,  and  optic  neuritis.  In  the  chronic 
form  of  brain  abscess  which  may  follow  injury,  otorrha}a,  or  local  lung 
trouble,  there  may  be  a  latent  period  ranging  from  one  or  two  weeks  to 
several  months,  or  even  a  year  or  more.  In  the  "  silent "  regions,  when 
the  abscess  becomes  encapsulated  there  may  be  no  symptoms  whatever 
during  the  latent  period.  During  all  this  time  the  patient  may  be  under 
careful  observation  and  no  suspicion  be  aroused  of  the  existence  of  sup- 
puration. Then  severe  headache,  vomiting,  fever,  set  in,  perhaps  with  a 
chill.  So,  too,  after  a  blow  upon  the  head  or  a  fracture  the  symptoms  of 
the  lesion  may  be  transient,  and  months  afterward  cerebral  symptoms  of  the 
most  aggravated  character  may  develop. 

The  localization  of  the  lesion  is  often  diOicult.  In  or  near  the  motor 
region  there  may  be  convulsions  or  ])aralysis,  and  it  is  to  be  remembered 
that  an  abscess  in  the  temporal  lobe  may  compress  the  lower  motor  centres 


)t': 


)\V('(1  hy  al)- 
II I'  the  brain 
0  its  ucc-iir- 
iiir  between 
iK'ut  ill  men 
!!'  live  years 

ultiple,  dif- 
varieties  of 
Dxaniination 
.•iiltiires  are 

fatal  cases 
nding  eases 
tliiclvness  of 
nding  upon 
ddisli  debris 
3CSS  tlie  pus 
culiar  odor, 
jstance  sur- 
e  size  varies 
's  on  record 
here.  Mul- 
le  abscess  is 
m,  and  the 
3rebellum  is 
■-disease, 
may  run  an 
igors.  The 
nay  be  very 
letlier  there 
allowing  ear 
ion.  There 
ed  earache. 
I  cases,  are 
tlie  elironic 

local  luug 
'0  weeks  to 
'ions,  when 
IS  whatever 
ly  be  under 
nee  of  sup- 
laps  with  a 
rmptoms  of 
toms  of  the 

•  the  motor 
■emembered 
)tor  centres 


INFLAMMATION   OP  THE   BRAIN. 


1027 


mid  produce  paralysis  of  the  arm  and  face  and  on  the  left  side  PaiiPO  aphasia. 
A  large  abscess  may  exist  in  the  frontal  lobe  without  causing  paraly^^is,  but 
ill  these  cases  there  is  almost  always  some  mental  dulness.  In  the  tcm[)oral 
jnbe,  the  common  seat,  there  may  bo  no  focalizirg  sym[)tonis.  So  also  in 
the  parieto-occipital  region;  though  liere  early  examination  may  lead  to 
I  he  detection  of  heniianopia.  Jn  abscess  of  the  cerel)ellum  vomiting  is  com- 
mon. Jf  the  middle  lobe  is  atfected  there  may  be  staggering — cerebellar 
incoiirdination.  Localizing  symjitonis  in  tiie  pons  and  other  parts  arc  still 
more  uncertain. 

Diagnosis. — In  the  acute  cases  there  is  rarely  any  doubt.  A  considera- 
t''>n  of  i)ossible  etiological  factors  is  of  the  higlu'st  importance.  The  history 
of  injury  followed  by  fever,  marked  cerebral  symptoms,  the  development 
of  rigors,  delirium,  and  perhaps  i)aralysis,  make  the  diagnosis  certain.  In 
chronic  ear-disease,  such  cerebral  symptoms  as  drowsiness  and  torpor,  with 
irregular  fever,  suj)ervening  U])on  the  cessation  of  a  discharge,  should  ex- 
cite the  suspicion  of  abscess.  Cases  in  which  sui)purative  ])r()ct'sses  exist 
in  the  orbit,  nose,  or  naso-pharynx,  or  in  which  tiiere  has  been  subcutaneous 
])hlegmon  of  the  head  or  neck,  a  parotitis,  a  facial  erysi])elas,  or  tu])erculous 
or  syphilitic  disease  of  the  bones  of  the  skull,  should  be  carefully  watched, 
and  immediately  investigated  should  cerebral  symptoms  appear.  It  is  par- 
ticularly in  the  chronic  cases  that  difficulties  arise.  The  symptoms  resem- 
ble those  of  tumor  of  the  brain;  indeed,  they  are  those  of  tumor  i)lus  fever. 
Choked  disk,  however,  so  commonly  associated  \,  itii  tumor,  is  very  fre- 
(juently  absent  in  abscess  of  the  brain.  In  a  patient  with  a  history  of  trauma 
or  with  localized  lung  or  pleural  troidjle,  who  for  weeks  or  months  has  had 
slight  headache  or  dizziness,  the  onset  of  a  rapid  fever,  cs])ecially  if  it  be  in- 
termittent and  associated  with  rigors,  intense  headache,  and  vomiting,  point 
strongly  to  abscess.  The  pulse-rate  in  cases  of  cerebral  abscess  is  usually 
accelerated,  but  cases  are  not  rare  in  which  it  is  slowed.  ]\[acewen  lays  stress 
u])on  the  value  of  ])ercussion  of  the  skull  as  an  aid  in  diagnosis.  The  note, 
which  is  uniformly  dull,  becomes  much  more  resonant  when  the  lateral 
A-entriclcs  are  distended  in  cerebellar  abscess  and  in  conditions  in  which  the 
vena'  Galeni  are  compressed. 

It  is  not  always  easy  to  determine  whether  the  meninges  are  involved 
with  the  abscess.  Often  in  ear-disease  the  condition  is  that  of  meningo- 
encephalitis. Sometimes  in  association  with  acute  ear-disease  the  symp- 
toms may  simulate  closely  cerebral  meningitis  or  even  abscess.  Indeed, 
Cowers  states  that  not  only  may  these  general  symptoms  be  produced  by 
ear-disease,  but  even  distinct  optic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in 
dealing  with  these  cases,  owing  to  the  impunity  with  which  the  brain  can 
be  explored.  In  ear-disease  free  discharge  of  the  inflammatory  ])roducts 
should  be  promoted  and  careful  disinfection  ])ractised.  The  treatment  of 
injuries  and  fractures  conies  within  the  scope  of  tlie  surgeon.  The  acute 
symptoms,  such  as  fever,  headache,  and  delirium,  must  be  treated  by  rest, 
an  ice-cap,  and,  if  necessary,  local  dejdetion.  In  all  cases,  when  a  reason- 
able susyiicion  exists  of  the  occurrence  of  abscess,  the  trephine  should  be 
used  and  the  brain  explored.     The  cases  following  ear-disease,  in  which 


1028 


DISEASES  OF  THE  NERVOUS  SYSTEM, 


tlio  sn]tinirfitIon  is  in  llic  ioniporfil  lolic  or  in  the  ('crclx'lliim,  olTcr  tlio  most 
l'iiv(»ral)ie  cliaiu't'S  oi'  rt'cuvcry.  The  lociiiiziition  can  raivly  bo  niado  ai-- 
curatoly  in  tiicso  cases,  jiiid  the  o])erat()r  must  he  guided  more  by  general 
anatomical  and  ])athological  kno\vledge.  In  cases  of  injury  the  tre})liin(' 
shoidd  be  a])iilie(l  over  tlie  scat  of  the  blow  or  the  fracture.  In  ear-disea.-e 
the  suppuration  is  most  fre(juent  in  the  tem[)oral  lobe  or  in  the  ci-rebt'llum, 
and  tlie  operation  should  be  jjcrfornu'd  at  the  ])oints  most  accessiljle  to  these 
regions.  And,  lastly,  a  most  important,  one  might  almost  say  essential, 
factor  in  the  successful  treatment  of  intracranial  supi)uration  is  an  intelli- 
g(>nt  knowledge  on  the  }.,..  c  of  the  surgeon  oi  the  work  and  works  of  William 
Macewen. 


/ 


^li^ 


m 


VI.  HYDROCEPHALUS. 

Definition. — A  condition,  congenital  or  acquired,  in  which  there  is 
a  great  accumulation  of  fluid  within  the  ventricles  of  the  brain. 

The  term  hydrocephalus  has  also  been  ai)i)lied  to  the  collection  of  fluid 
between  the  cortex  of  the  brain  and  the  skull,  known  in  this  situation  as 
1i.  extennis  or  /(.  ex  vacuo,  a  condition  common  in  cases  of  atrophy  of  the 
brain  substance,  met  with  in  old  age,  after  luemorrhages,  softenings,  or 
scleroses,  in  lingering  and  cachectic  diseases,  as  cancer,  chronic  nej)hritis, 
chronic  alcoholism,  and  sometimes  in  rickets.  Occasionally  the  disease  is 
caused  by  meningeal  cysts.  A  true  dropsy,  however,  of  the  arachnoid  sac 
probably  does  not  occur. 

The  cases  may  be  divided  into  three  groups — idiopathic  internal  hydro- 
cephalus (serous  meningitis),  congenital  or  infantile,  and  secondary  or  ac- 
quired. 

(1)  Serous  Meningitis  (Quincke)  (Tdiopalhic  Iniernnl  Jlijdroccpludus ; 
Ani/io-neur(){ic  Jl  ijdnircjihalus). — This  remarkable  form,  described  by 
Quincke,  is  very  important,  since  a  knowledge  of  the  condition  nuiy  explain 
very  anomalous  and  ])uzzling  cases.  It  is  an  ependymitis  causing  a  serous 
effusion  into  the  ventricles,  with  distention  and  pressure  effects.  It  may  be 
comjiared  to  the  serous  exudates  in  the  jjleura  or  in  synovial  membranes. 
It  is  not  certain  that  the  process  is  inflammatory,  and  Quincke  likens  it  to 
the  angio-neurotic  o'doma  of  the  skin.  In  very  acute  cases  the  ependyma 
may  be  smooth  and  natural  looking;  in  more  chronic  cases  it  may  be  thick- 
ened and  sodden.  The  exudate  does  not  differ  from  the  normal,  and  if  on 
hnnbar  jiuncture  a  fluid  is  removed  of  a  specific  gravity  above  1.009,  with 
all)umin  above  two  per  one  thousand,  the  condition  is  more  likely  to  be 
]iydroce])halus  from  stasis,  secondary  to  tumor,  etc. 

Both  children  and  adults  are  affected,  the  latter  more  frequently.  In 
the  acute  form  the  condition  is  mistaken  for  tuberculous  or  purulent  men- 
ingitis. There  arc  headache,  retraction  of  the  neck,  and  signs  of  increased 
intracranial  pressure,  choked  disks,  slow  pulse,  etc.  Fever  is  usually  ab- 
sent, but  I  have  seen  one  case  with  recurring  paroxysms  of  fever,  and  Mortxjn 
Prince  has  described  a  similar  one.  In  both  the  exudate  was  clear  and  the 
c])endyma  not  acutely  inflamed.  Quincke  has  reported  cases  of  recovery. 
In  the  chronic  form  the  symptoms  r.re  those  of  tumor — general,  such  as 


HYDROCEPHALUS. 


1029 


or  the  most 
0  nuulo  ac- 
hy goiu'i'al 
lie  trt'phiiu' 
car-disease 
cerolx'llum, 
blu  to  tlicsi' 
y  essential, 
<  an  intelli- 
of  William 


ch  there  is 

ion  of  Huid 
situation  as 
pliy  of  the 
tenin<>s,  or 
'  nephritis, 
i  disease  is 
chnoid  sac 

'nal  liydro- 
lary  or  ac- 

'•oce  phalli  s; 
cribed  1  ly 
lay  explain 
g'  a  serous 
It  ma}'  be 
lembranes. 
ikens  it  to 
ependyma 
r  be  thick- 
and  if  on 
.009,  with 
vely  to  be 

ently.  In 
lent  men- 

in creased 
sually  ab- 
id  ]\IortOn 
r  and  the 

recovery. 
I,  such  as 


headache,  slight  fever,  somnolence,  and  delirium;  and  local,  as  exophthal- 
mos, oi)tic  neuritis,  spasms,  and  rigidity  of  muscles  and  i)araly>;is  of  the 
cerebral  nerves.  J{cinarkab!e  exacerbations  occur,  and  the  .<ymi)toms  vary 
in  intensity  from  day  to  day.  Iiccovery  may  follow  after  an  illness  of  many 
weeks,  and  some  of  the  rej)orted  cases  of  di.sappearance  of  all  symi)toms  of 
brain  tumor  belong  in  this  category. 

(2)  Congenital  Hydrocephalus. — The  enlarged  head  nuiy  obstruct  labor; 
nu)re  frequently  the  condition  is  noticed  some  time  after  Ihrth.  The  cause 
is  unknown.    It  has  occurred  in  several  members  of  the  same  family. 

Tlie  anatomical  condition  in  thes*^  ases  offers  no  ele\  to  the  nature  of 
the  trouble.  The  lateral  ventricles  are  enormously  distended,  Init  the 
e[)endyma  is  usually  clear,  sonu'times  a  little  thickened  and  granular,  and 
the  veins  large.  The  choroid  jtlexuses  are  vascukr,  sometimes  sclei'otic,  but 
often  natural  looking.  The  third  ventricle  is  enlarged,  the  a(iueduct  of 
Sylvius  dilated,  and  tiie  fourth  ventricle  may  be  distended.  The  (puintity 
of  lluid  may  reacli  sevi-ral  litres.  It  is  limpid  and  contains  a  trace  of  albu- 
min and  salts.  The  changes  in  consequence  of  this  enormous  ventricular 
distention  are  remarkable.  The  cerebral  cortex  is  grcUly  stretched,  and 
over  the  middle  region  the  thickness  may  amount  to  no  more  than  a  IVw 
millimetres  without  a  trace  of  the  sulci  or  convolutions.  The  basal  ganglia 
are  ilattoned.  The  skull  enlarges,  and  the  circumb'rence  of  the  head  of 
a  child  of  three  or  four  years  may  reach  ,'^5  or  even  30  inches.  The  sutures 
widen,  Wormian  bones  develop  in  tliem,  and  the  bones  of  the  cranium 
become  exceedingly  thin.  The  veins  are  marked  beneath  the  skin.  A  iluc- 
tuation  wave  may  sometimes  l)e  obtained,  and  Fisher's  brain  murmur  may 
be  heai'd.  '^IMie  orbital  plates  of  the  frontal  bone  are  depressed,  causing 
exophthalmos,  so  that  the  eyeballs  cannot  be  covered  by  the  eyelids.  The 
small  size  of  the  face,  widening  somewhat  above,  is  striking  in  comparison 
with  the  enormously  ex])anded  skull. 

Convulsions  may  occur.  Tlie  reflexes  are  increased,  the  child  learns  to 
Malk  late,  and  ultimately  in  severe  cases  the  legs  become  feeble  and  some- 
times spastic.  Sensation  is  much  less  affected  than  motility.  Choked  disk 
is  not  uncommon.  The  mental  condition  is  variable;  the  child  nuiy  be 
l)right,  but,  as  a  rule,  there  is  some  grade  of  imijoeility.  The  congenital 
cases  usually  die  within  tlie  first  four  or  five  years.  The  process  may  Ije 
arrested  and  the  patient  may  reach  adult  life.  Cases  of  this  sort  are  not 
very  imcommon.  Even  when  extreme,  the  mental  faculties  may  be  retained, 
as  in  Bright's  ct>lebrated  ]iatient,  (*ardinal,  who  lived  to  the  age  of  twenty- 
nine,  and  whose  head  was  translucent  when  the  sun  was  shining  behind 
Jiini.  Care  must  be  taken  not  to  mistake  the  rachitic  head  for  liydro- 
ce})halus. 

(3)  Acquired  Chronic  Hydrocephalus. — This  is  stated  to  l)e  occasionally 
]>rimary  (idio]iathic) — that  is  to  say,  it  conies  on  s])(mtaneously  in  the 
adult  without  observaljle  lesion.  Dean  Swift  is  said  to  have  died  of  hydro- 
cei)lialus,  but  ^liis  seems  very  unlikely.  It  is  based  U])on  the  statement 
that  "he  (^Ir.  AVhiteway)  o]iened  the  skull  and  found  much  water  in  the 
brain,"  a  condition  no  doubt  of  /(.  ex  vacuo,  due  to  the  wasting  associated 
Mith  his  prolonged  illness  and  jtaralysis.    In  nearly  all  case-  there  is  either 


lono 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


a  tumor  at  tlio  base  of  tlio  I)Tain  or  in  the  tliird  M-ntriclo,  wliioli  romiircspog 
the  veiue  (Jaleni.  The  passage  I'rom  the  third  to  llie  t'oiirtli  veiilriele  may 
be  closed,  eitlier  l)y  a  tumor  or  by  parasites.  More  rarely  the  foramen  of 
jMaf^endie,  throuj^di  which  the  ventricles  communicate  with  the  cerebro- 
spiual  m('iiin<,'es,  becomes  closed  by  menin<j:;itis.  These  conditions,  occur- 
ring in  adults,  may  ])rodv.ce  the  most  extreme  hydrocephalus  Mithout  any 
i-nlargement  ot  tiie  head.  Even  when  the  tumor  begins  early  in  life  there 
may  be  no  expansion  of  the  skull.  Jn  the  case  of  a  girl  aged  sixteen,  blind 
from  her  third  year,  the  head  was  not  unusually  large,  the  ventricles  were 
enormously  distended,  and  in  the  liolandic  region  the  brain  substance  was 
only  5  mm.  in  thickness.  A  tumor  occu])ied  tiie  third  ventricle,  in  a  case 
of  cholesteatoma  of  the  floor  of  the  third  ventricle,  in  which  the  symi)toms 
])ersisted  at  intervals  for  eight  or  nine  years,  the  ventricles  were  enormously 
distended  without  enlargement  of  the  skull.  In  other  instances  the  sutures 
se])arate  and  the  head  gradually  enlarges. 

The  symjjtoms  of  hydrocephalus  in  the  adult  are  curiously  variable. 
In  the  first  case  mentioned  there  were  early  headaches  and  gradual  blind- 
ness; then  a  i)rolonged  period  in  whii  h  she  was  able  to  attend  to  her  studies. 
Jleadaches  again  supervened,  the  gait  became  irregular  and  somewhat 
ataxic.  Death  occurred  suddenly.  In  'be  other  case  there  were  prolonged 
attacks  of  coma  with  a  slow  pulse,  and  on  one  occasion  the  patient  remained 
nnconscious  for  more  than  three  months.  Gradually  i)rogressing  optic 
neuritis  without  focalizing  sym})toms,  headache,  and  attacks  of  somnolence 
or  coma  are  suggestive  symptoms.  These  cases  of  acquired  ^yonic  hydro- 
cephalus cannot  be  certainly  diagnosed  during  life,  though  in  certain  in- 
stances the  conditi(>n  may  be  suspected. 

Treatment. — Very  little  can  be  done  to  relieve  hydroce])hahis.  Medi- 
cines are  ])owerless  to  cause  the  absorntion  of  the  fluid.  ^lore  rational  is 
the  system  of  gradual  compression,  w.  ..^  or  without  the  withdnnval  of  small 
<[uanlities  of  the  fluid.  The  compression  may  be  made  by  means  of  broad 
])lasters,  so  a])i)lied  as  to  cross  each  other  on  the  vertex,  and  another  may 
be  i)laced  round  the  circumference.  In  the  meningitis  serosa  Quincke  ad- 
vises the  nse  of  mercury. 

Of  late  years  pnncture  of  the  ventricles,  an  ojieration  which  has  been 
abandoned,  has  been  revived;  it  has  been  resorted  to  in  the  meningitis 
serosa.  "When  pressure  symptoms  are  marked  Quincke's  procedure  may  be 
used.  lie  recommends  puncture  of  the  suljarachnoid  (■■^c  between  the  third 
and  the  fourth  lumbar  vcrtebrre.  x\t  this  point  the  S'anal  cord  cannot  be 
touched.  The  advantages  are  a  slower  removal  of  fluid  and  less  danger  of 
collapse. 


NEURITIS. 


1031 


itric'k'  may 
[oraiiR'u  i»i' 
le  ct'R'hro- 
)ns,  occiir- 
itliout  any 
I  lil'e  tlioro 
tocn,  blind 
riclos  were 
stance  was 
In  a  (?a!?e 
symptoms 
inormonsly 
;lie  sutures 

y  varialjle. 
lual  blind- 
ler  studies, 
somewhat 
pj'olonged 
t  remained 
sing  optic 
omnolence 
nic  hydro- 
certain  in- 
ns. Medi- 
rational  is 
il  of  small 
s  of  broad 
other  may 
lincke  ad- 
has  been 
meningitis 
re  may  be 
the  third 
cannot  be 
danger  of 


YI.    DISEASES   OF  THE  PERIPHERAL   NERVES. 

I.    NEURITIS   (Inflammation  of  the  Bundles  of  Nerve  Fibres), 

Xeuritis  may  be  localized  in  a  single  nerve,  or  (jvucral,  involving  a  large 
ninnber  of  nerves,  in  which  case  it  is  usually  known  as  inullipU'  ncurilis  or 
IKilj/iu'urilis. 

Etiology. — Localized  neiirills  arises  from  (ii)  cold,  which  is  a  very  fre- 
(jucnt  cause,  as,  for  example,  in  the  facial  nerve.  Tliis  is  sometiuu's  known 
as  rheumatic  neuritis,  (h)  Traumatism — wounds,  Idows,  direct  i)ressure  on 
the  nerves,  the  tearing  and  stretching  which  follow  a  dislocation  or  a  frac- 
ture, and  the  hypodermic  injection  of  ether.  I'nder  this  section  come  also 
the  professional  j)alsies,  clue  to  i)ressure  in  the  exercise  of  certain  occupa- 
tions, (c)  Extension  of  intlammation  from  neighboring  parts,  as  in  a  neuri- 
tis of  the  facial  nerve  due  to  caries  in  the  temporal  bone,  or  in  that  met 
with  in  syphilitic  disease  of  the  bones,  disease  of  the  joints,  and  occasionally 
in  tunu)rs. 

Miilliph'  neurilis  has  a  very  complex  etiology,  the  causes  of  which  may 
be  classilied  as  follows:  (a)  The  j)oisons  of  infectious  diseases,  as  in  leprosy, 
diphtheria,  typhoid  fever,  small-jjox,  scarlet  fever,  and  occasionally  in  other 
forms;  {b)  the  organic  poisons,  comprising  the  dilfusible  stimulants,  such 
as  alcohol  and  ether,  bisulphide  of  carbon  and  naj)htha,  and  the  metallic 
bodies,  such  as  lead,  arsenic,  and  mercury;  (c)  cachectic  conditions,  such  as 
occur  in  aniemia,  cancer,  tuberculosis,  or  marasmus  from  any  cause;  (d)  the 
<?ndemic  neuritis  or  beri-beri;  and  (e)  lastly,  there  are  cases  in  which  none 
•of  these  factors  prevail,  but  the  disease  sets  in  suddenly  after  overexertion 
or  exposure  to  cold. 

Morbid  Anatomy. — Tn  neuritis  due  to  the  extension  of  inflamma- 
tion the  nerve  is  usually  swollen,  infiltrated,  and  red  in  color.  The  inflam- 
mation may  be  chiefly  perineural  or  it  may  pass  into  the  deeper  ])ortion — 
interstitial  neuritis — in  which  form  there  is  an  accumulation  of  lymphoid 
elements  between  the  nerve  bundles.  The  nerve  fibres  themselves  may  not 
appear  involved,  but  there  is  an  increase  in  the  nuclei  of  the  sheath  of 
Schwann.  The  myelin  is  fragmented,  the  nuclei  of  the  internodal  cells  are 
swollen,  and  the  axis  cylinders  present  varicosities  or  undergo  granular  de- 
generation. I'ltimately  the  nerve  fibres  may  be  completely  destroyed  and 
re])laced  by  a  fibrous  connective  tissue  in  which  much  fat  is  sometimes  de- 
posited— the  lipomatoiir     "iiritis  of  Leyden. 

In  other  instances  tne  condition  is  termed  parenchijniatous  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  secondary  or  Wallerian 
degeneration,  which  follows  when  the  nerve  fil)re  is  cut  off  from  the  cell 
body  of  the  neurone  to  which  it  belongs.  The  ^'ledullary  substance  and  the 
axis  cylinders  are  chiefly  involved,  the  intersutial  tissue  being  but  little 
altered  or  only  affected  secondarily.  The  myelin  becomes  segmented  and 
divides  into  small  globules  and  grannies,  and  the  axis  cylinders  become 
granular,  broken,  sul)divided,  and  ultimately  disappear.  The  nuclei  of  the 
sheath  of  Schwann  proliferate  and  ultimately  the  fibres  are  reduced  to  a 


r^vi"'f  |i| 


ion2 


DISK  ASKS  OF   THE  XEllVOUS  SYSTEM. 


/ 


'i 


!  1 1 


stiiti'  of  !ilr(t|i]ii('  iiilx's  witliiiiit  ii  triicc  of  the  iioriiml  stnictiirc.  The  imis- 
cli's  coniH'(t('<l  with  IIk!  fl('<iriit'i'iitt.'(l  lUTVcs  usually  isliow  marked  atrophii,' 
cliauyt's,  and  in  sonu'  instances  the  clian^ic  in  the  nerve  sheath  ajipears  to 
extend  directly  to  the  intei'stitial  tissue  of  the  muscles — the  neuritis  fusciaits 
of  j'licldiorst. 

Symptoms.— (^0  Localized  Neuritis. — As  a  rule  the  constitutional 
(listurhauees  are  slight.  The  most  important  sym))tom  is  ])ain  of  a  horin;,^ 
or  stabbin;,'  character,  usually  felt  in  the  course  of  the  nerve  and  in  the 
])arts  to  which  it  is  distributed.  The  nerve  itself  is  sensitive  to  pressure, 
probably,  as  Weir  Mitchell  su<;-^csts,  owin;,^  to  the  irritation  of  its  nervi 
nervorum.  'I'he  skin  may  be  sli<;htly  reddened  or  even  (edematous  over 
the  seat  of  the  iiitlammation.  Mitchell  luis  described  increase  in  the  tem- 
])erature  and  sweating'  in  tlie  alTected  reijion,  and  such  tro[»liic  disturbances 
as  effusion  into  the  joints  and  herpes.  The  function  of  the  muscle  to  which 
the  nerve  fibres  are  distributed  is  im]»aired,  motion  is  painful,  and  there 
may  be  twitchin-is  or  contractions.  The  tactile  sensation  of  the  i)art  may 
be  somewhat  deadened,  even  when  the  pain  is  -greatly  increa.seiL  In  the 
more  chronic  cases  of  local  neuritis,  such,  for  instance,  as  follow  the  dis- 
location of  the  humerus,  the  h  'alized  pain,  which  at  first  nuiy  lie  severe, 
gradually  disappears,  though  some  sensitiveness  of  the  brachial  plexus  may 
persist  for  a  long  time,  and  the  nerve  cords  may  be  felt  to  ])e  swollen  and 
lii'm.  The  pain  is  varialile — sometimes  intense  and  distressing;  at  others 
not  causing  much  inconvenience.  Xnnd)ness  and  formication  nuiy  ])e  pres- 
ent and  the  tactile  sensation  may  be  greatly  im[)airi'd.  The  motor  disturb- 
ances are  marked.  I'ltimately  there  is  extreme  atroj)hy  of  the  muscles. 
Contractures  may  occur  in  the  fingers.  The  skin  may  be  reddened  or  glos.sy, 
the  subcutane(nis  tissue  cedematous,  and  the  nutrition  of  the  nails  may  be 
defective.  Jii  the  rheumatic  neui'itis  subcutaneous  libroid  noiltdes  may 
develoj). 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  upward — 
the  so-called  ascending  or  migratory  neuritis — and  involve  the  birger  nerve 
trunks,  or  even  reach  the  s]iinal  cord,  causing  subacute  myelitis  (Gowers). 
The  condition  is  rarely  seen  in  the  neuritis  from  cold,  or  in  that  which 
follows  fevers;  but  it  occurs  most  frecjuently  in  traumatic  neuritis.  J.  K. 
Mitchell,  in  his  mf)nograpli  On  Injuries  of  Xerves  (1895),  concludes  that 
the  larger  nerve  trunks  are  nujst  susce])tib]e,  and  that  the  neuritis  may 
spread  either  U])  or  down,  the  former  being  the  most  conouon.  The  paraly- 
sis secondary  to  visceral  disease,  as  of  the  bladder,  may  be  due  to  an  ascend- 
ing neuritis.  The  inflannnation  may  extend  to  the  nerves  of  the  other  side, 
either  through  the  spinal  cord  or  its  membranes,  or  without  any  involve- 
ment of  the  nerve  centres,  the  so-calh'd  sympathetic  neuritis.  The  elec- 
trical changes  in  localized  neuritis  vary  a  great  deal,  depending  upon  the 
extent  to  which  the  nerve  is  injured.  The  lesion  may  be  so  slight  that  the 
nerve  and  the  muscles  to  which  it  is  distributed  may  react  normally  to  both 
currents;  or  it  may  be  so  severe  that  the  ty]>ical  reaction  of  degeneration 
develops  "within  a  few  days — i.  e..  the  nerve  does  not  resjjond  to  stimula- 
tion by  either  current,  Mhile  the  muscle  reacts  only  to  the  galvanic  current 
and  in  a  peculiar  manner.    Tlie  contraction  caused  is  slow  and  lazy,  instead 


NErUITLS. 


WdS 


'I'Ik!    llUIS- 

il  iitl'ophii; 
iipltcarri  to 
is  fdscidits 

>titution;il 
r  a  boring 
111(1  in  the 
)  prc'riHiirc, 
f  ils  ncrvi 
It  OILS  over 
1  the  tem- 
sturhanees 
e  U:  which 
and  thei'e 

part  may 
I.  In  the 
\v  tile  tlis- 

)e  severe, 
ilexns  nia_\ 
vollen  and 

at  otiu'i's 
ly  l)e  pre.s- 
)r  disturl)- 
e  ninscles. 
I  or  gh)ssy, 
ils  may  be 
iliiles   may 

upward — 
rger  nerve 

(Gowers). 
hat  Mhieh 
tis.  J.  K. 
ludes  that 
iritis  may 
he  paraly- 
:in  ascend- 
Dtlier  side. 
y  involve- 

The  elec- 

npon  the 
i  that  tlie 
ly  to  both 
2;en  oration 
0  stinuda- 
ic  enrrent 
^y,  instead 


of  sliarp  ami  (piick  as  in  the  iiorniMl  imixle,  ami  the  AiiC  contraetion  is 
usually  stronger  than  the  ('('  coiilraftic.n.  lU'tween  tlu'se  two  extremes 
there  are  many  ditVeri'iit  grades,  and  a  carelid  electrical  examination  is  most 
important  as  an  aid  to  diagmois  and  prognosis.'" 

'i'lie  tluration  varies  I'rom  a  few  days  to  weeks  or  months.  A  slight  trau- 
matic neuritis  may  pass  oil'  in  a  tlay  or  two,  while  the  severer  cases,  such  as 
follow  unrc(luced  dislocation  of  the  liiimeni>,  may  persist  for  months  or 
never  be  completely  relieved. 

(fi)  Multiple  Neuritis. — This  presents  a  complex  symiitomatology.  The 
following  are  the  most  important  groups  of  'jises: 

(1)  Anile  Fdirile  I'oli/iiciirilis. — The  attack  follows  exposure  io  i-old 
or  overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  onset 
resembles  that  of  an  acute  infectious  disease.  There  may  be  a  delinite 
chill,  pains  in  the  back  and  limbs  or  joints,  so  that  the  case  may  be  tlKnighl 
to  be  acute  rheumatism.  The  temperature  risi's  rapidly  and  may  reach 
1();5°  or  101°.  'I'licre  are  headache,  loss  (d'  appetite,  and  the  general  symp- 
toms of  acute  infection.  The  limbs  and  back  ache.  Intense  i)ain  in  the 
nerves,  however,  is  by  no  means  constant.  'J'ingling  and  formication  are 
felt  in  the  (ingers  and  toes,  and  there  is  increased  sensitiveness  of  the  iiervo 
trunks  or  of  the  entire  limb.  Loss  of  mu,<cular  power,  first  marked,  per- 
hajis,  in  the  legs,  gradually  comes  on  and  extends  with  the  features  of  an 
ascending  jtaralysis.  In  other  ca.  vs  the  ])aralysis  begins  in  the  arms.  I'he 
extensors  of  the  wrists  and  the  flexors  of  the  ankles  are  early  aU'ecled,  so 
that  there  is  foot  and  wrist  drop.  In  severe  cases  there  is  general  loss  of 
nniscnlar  power,  i)roducing  a  llabliy  paralysis,  which  may  extend  to  the 
muscles  of  the  face  and  to  the  intercosta.ls,  and  respiration  may  be  carried 
on  by  the  diajjhragm  alone.  'I'he  muscles  soften  and  waste  rai)idly.  There 
may  be  only  hyjiera'sthesia  with  .soreness  and  stiffness  f)f  the  limbs;  in  some 
cases,  increased  sensitiveness  with  anu'sthesia;  in  other  instances  the  sen- 
sory disturbances  are  slight.  The  clinical  ]ticture  is  not  to  be  distinguished, 
in  many  cases,  from  Landry's  paralysis;  in  others,  from  the  subacute  mye- 
litis of  Duchenne. 

The  course  is  variable.  In  the  most  intense  forms  the  patient  may  die 
in  a  week  or  ten  days,  with  involvement  of  the  respiratf)ry  muscles  or  from 
Jtaralysis  of  the  heart.  As  a  rule  in  cases  of  moderate  severity,  after  )»er- 
sisting  for  five  or  six  Aveeks,  the  condition  remains  stationary  and  then  slow 
improvement  begins.  The  jiaralysis  in  some  muscles  may  jiersist  for  many 
months  and  contractures  may  occur  from  shortening  of  the  muscles,  but 
even  when  this  occurs  the  outlook  is,  as  a  ruh",  good,  although  the  ])ar  .sis 
may  have  lasted  for  a  year  or  more. 

(2)  Beciirriiifi  Mvlliph  NeiirHis. — Tiider  the  term  poli/iiciiriUs  rccurnna 
]Mary  SherAvood  has  described  from  Kichhorst's  clinic  2  cases  in  ailults — 
in  one  case  involving  the  nerves  of  the  right  arm,  in  the  other  both  legs. 
In  one  patient  there  Avere  three  attacks,  in  the  other  tAvo,  the  distribution 
in  the  A'arions  attacks  being  identical.  The  snbject  has  recently  been  fully 
discnssed  by  IL  M.  Thomas  (Phila.  :\red.  Jour.,  1898,  i). 

*  See  uiulcr  Facial  Paralysis. 


10.34- 


DISKASKS  OF  THE  NEIiVOL'S  SYSTEM. 


{'.])  Akdliolir  Nnivilh. — Tliis,  pcrlinps  tlio  most  inipnrtnnl  form  of  mul- 
i\\)\e  iifiiritis,  was  ^n'Mpliiciilly  dcst  rilti'd  in  J,s-j-.'  hy  JaiiK's  .lacksoii,  Sr.,  of 
iJostoii.  W'ilks  i'(.'C()<,Miizf(l  it  as  alcoholic  parapl(';,Ma,  but  the  start iiij^-poiiit 
of  tlic  rc'ci'iit  rt'scarclu's  on  the  disonso  dates  from  the  observations  of 
hiMiPinl,  of  Koiicn.  Of  late  years  our  knowledi^'e  of  the  disease  has  ex- 
tended rapidly,  owin;,'  to  the  researches  of  lliiss,  I.eyden,  James  Hoss,  15n/- 
zard,  and  Jlenry  Jinn.  Jt  occnrs  most  frecpicntly  in  women,  particularly 
steady,  cpiiet  tipplers.  Its  a|)pearance  may  he  the  lirst  revelation  to  the 
])hysician  or  to  the  family  of  hahits  of  secret  drinkin<f.  The  onset  is  usuallv 
j^radnal,  and  may  he  preceded  for  weeks  or  months  hy  nenralj;ic  })ains  and 
tin^din<,'  in  the  feet  and  hands.  Convulsions  are  not  uncommon.  Fever  is 
rare.  The  paralysis  ^n-adually  sets  in,  at  first  in  the  feet  and  lejjs,  and  then 
in  the  hands  and  forearms.  The  extensors  are  all'ected  more  than  the  ilexors,. 
so  that  there  is  wrist-drop  and  foot-droj).  The  paralysis  may  he  thus  lim- 
ited and  not  extend  lii<,dier  in  the  limbs.  ]n  other  instances  there  is  i)ara- 
])le<,Ma  alone,  while  in  the  most  extreme  eases  all  the  extremities  are  in- 
volved. In  rare  instances  the  facial  muscles  and  the  sphincters  are  also 
alfected.  1'he  sensory  symptoms  are  very  variable.  There  are  cases  in  which 
there  are  numbness  and  tin<;lin<f  only,  without  ^M-eat  })ain.  In  other  cases 
tiiere  are  severe  burninj^  or  borin<jf  ]»ains,  the  nerve  trunks  are  sensitive,  and 
the  muscles  are  sore  when  grasped.  The  hands  and  feet  are  frecjuently 
swollen  and  congested,  i)articnlarly  when  held  down  for  a  few  moments. 
'J'he  cutaneous  rellexcs  as  a  rule  are  preserved.  The  deep  reflexes  are  usually 
lost. 

The  course  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after  \w\'- 
sisting  for  weeks  or  months  imi)rovement  gradually  begins,  the  muscles 
regain  their  jiower,  and  even  in  the  most  desperate  cases  recovery  may 
follow.  The  extensors  of  the  feet  may  remain  ])aralyzed  for  some  tinie» 
and  give  to  the  patient  a  distinctive  walk,  the  so-called  stepptuje  gait,  char- 
acteristic of  pcri])heral  neuritis.  It  is  sometimes  known  as  the  pseudo-tabetic 
gait,  although  in  reality  it  could  not  well  be  mistaken  for  the  gait  of  ataxia. 
The  foot  is  thrown  forcibly  forward,  the  toe  lifted  high  in  the  air  so  as  not 
to  trip  u])on  it.  The  heel  is  brought  down  first  and  then  the  entire  foot. 
It  is  an  awkward,  clumsy  gait,  and  gives  the  patient  the  appearance  of  con- 
stantly stepping  over  obstacles.  Among  the  most  striking  features  of  alco- 
holic neuritis  are  the  mental  symptoms.  Delirium  is  common,  and  there 
may  be  hallucinations  with  extravagant  ideas,  resembling  somewhat  those 
of  general  paralysis.  In  some  cases  the  ]iicture  is  that  of  ordinary  delirium 
tremens,  but  the  most  peculiar  and  almost  characteristic  mental  disorder  is 
that  so  well  described  by  AVilks,  in  which  the  patient  loses  all  appreciation 
of  time  and  place,  and  descril)es  with  circuinstantial  details  long  journeys 
which,  he  says,  he  has  recently  taken,  or  tells  of  ])ersons  whom  he  has  just 
seen. 

(4)  'MuUiple  Nevrilis  in  flic  Infrctioiis  Diseases. — This  has  been  already 
referred  to,  ]>articularly  in  diphtheria,  in  Avhich  it  is  most  common.  The 
peri])hcral  nature  of  the  lesion  in  these  instances  has  been  shown  by  ])ost- 
mortem  examination.  The  outlook  is  usually  favorable  and,  except  in  dijih- 
theria,  fatal  cases  are  uncommon.     ]\rultiple  neuritis  in  tuberculosis,  dia- 


NEUUITIS. 


1035 


1111  of  niiil- 
soii,  Sr.,  (tf 
irtiiif^-poiiit 
rvalioiis  of 
ase  lias  cx- 

Itoss,  JJiiz- 
piirticiiliirlv 
lion  to  tilt.' 
!t  is  u^uallv 
3  pains  and 
1.  I"Y'vor  is 
s,  and  tlion 

tlu'  llcxors, 
L'  thus  lini- 
t're  is  para- 
tios  arc  in- 
Ts  arc  also 
us  in  which 
olhor  cast's 
isitivo,  and 

I'reqiiontly 
■  moments, 
are  usually 

j.  after  ])(>r- 
10  muscles 
ovcry  may 
iome  timc% 
<>ait,  cliar- 
ido-tabctie 
:  of  ataxia, 
r  so  as  not 
ntire  foot, 
ice  of  con- 
es of  alco- 
aiul  there 

hat  those 
y  delirium 
ilisorder  is 
preciation 
:  journeys 

?  has  just 

n  ah-eady 
urn.  The 
1  by  post- 
t  in  diph- 
losis,  dia- 


lietcs,  and  sypliilis  is  of  tlio  sanu'  nature,  hcin^'  prohalily  diK^  lo  toxic  mate- 
rials ahsorhcd  into  the  hlood. 

(.-))  Arsrnicdl  ami  Sdhiniliir  Xciiiilis. — 'I'he  arsciiiciil  neuritis  is  not 
common;  only  a  sin;fle  instance  of  it  has  come  iiikKt  my  oh^.rviition. 
Only  one  case  to  my  know  led  j^e  has  foUowed  the  use  of  l-'owler's  solution 
in  my  ward  or  dis|)cnsiiry  practice,  aIthou;^di  1  iim  in  the  iiahit  of  ^dviiij; 
in  chorea  and  ana'Uiia  doses  which  might  be  regarded  us  excessive.  The 
most  common  causes  are  accidental  poisoning,  as  in  the  cases  reported  by 
Mills.  In  a  case  of  M.  (>.  Ciith'r  tlie  ]»atient  got  the  iirsciiic  from  grceii- 
piipcr  tags,  which  he  was  in  the  habit  of  putting  in  his  iiioiith.  The  gcncnil 
syiiii»toiiis  ari'  not  unlike  tiiose  of  alcoholic  piinilysis;  tlii'  weakness  of 
the  extensors  is  marki'd  and  the  slvpiuuic  gait  characteristic.  The  neuritis 
i\\w  to  lead  has  been  discussed  in  the  consideration  of  lead  |M)isoning.  The 
special  involvement  of  the  motor  nerves  and  the  great  frecpiency  of  the 
occurrence  of  wrist-drop  are  the  peculiarities  of  this  form,  'i'lie  changes- 
in  the  cell  bodies  of  the  neurones  in  casi's  of  poisoning  with  h-ad  and  arscniu 
have  recently  been  studied  by  Lugaro  by  means  of  the  method  of  Xissl. 

A  similar  form  of  neuritis  is  caused  by  the  bisuli)hide  of  carbon  aud  by 
the  protracted  use  of  tea  (M.  A.  Starr). 

(())  J'Jiideiiiic  Neuritis,  Beri-beri,  has  been  considered  under  the  Infec- 
tious Diseases. 

AnSBSthesia  Paralysis. — Here  ])erhai)S  may  mf)st  approjiriately  he  con- 
sidered the  forms  of  ])aralysis  following  the  use  of  anu'sthctics.  Much  has 
been  written  in  the  ])ast  few  years  U])on  this  subject,  which  has  been  very 
fully  considered  by  (Jarrigues  (American  Joiiriud  of  the  Medical  Sciences, 
181)7,  i).    There  are  two  groups  of  cases: 

1.  Pressure  paralysis,  in  Avhich,  owing  to  the  ]iosition,  the  nerves  have 
been  compressed,  either  the  humerus  against  the  brachial  jjIcxus  or  the 
musculo-si)iral  against  the  table.  The  i)ressure  most  freipicntly  occurs 
when  the  arm  is  elevated  alongside  the  head,  as  in  laparotomy  done  in  the 
Trendelenberg  position,  or  held  out  from  the  body,  as  in  breast  am])utations. 
Instances  of  ])aralysis  of  the  crural  by  Robb's  leg-holder  are  also  reported. 

2.  Paralysis  from  cerebral  lesions  during  etherization.  In  (UU'  of  (Jar- 
rigues'  cases  paralysis  followed  the  o])eration,  and  at  the  autopsy,  seven 
weeks  later,  softening  of  the  l)rain  was  found.  Apoplexy  or  embolism  may 
develop  during  tlie  ana'sthesia.  In  IMontreal  a  cataract  operation  was  ])er- 
formed  on  an  old  man.  He  did  not  recover  from  the  aiurstbetic;  I  found 
])ost  mortem  a  cerebral  hivmorrhage.  A  man  was  admitted  to  ihe  Phila- 
deli)hia  ITos]>ital  on  the  2r)th  completely  comatose;  the  day  ])reviously 
ether  had  been  given  for  a  minor  o])eration.  He  never  recovered  conscious- 
ness, ])ut  remained  deejdy  comatose,  with  great  muscular  relaxation,  low 
temperature,  97.5°,  and  noisy  respirations;  he  died  on  the  2Sth.  There  was, 
unfortunately,  no  autopsy.  Ei)ile])tic  convolutions  mry  occur  during  the 
anaesthesia,  and  may  even  prove  fatal.  The  i)ossil)ility  has  to  be  considered 
of  paralysis  from  loss  of  blood  in  ])rolonged  operations,  though  I  have  no 
personal  knowledge  of  any  such  cases. 

And,  lastly,  a  paralysis  might  result  from  the  toxic  affects  of  the  ether 
in  a  very  protracted  administration. 


lo;{(} 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Diagnosis. — 'I'lic  clfctricul  (•(iiiditiiui  in  iiiiiltiiili'  iiciiiilis  is  thus  dc- 
pcrilicd  liy  Allcii  Stiirr:  "  Tlic  cxciliiliility  is  very  rapidly  and  markedly 
(•lianjft'(';  Imt  the  coiiditions  wliicii  liavi'  iiccii  oliscrvt'd  mi'  ([iiito  various. 
Soiiicliiiit','!  tlicrc  is  a  siiiipU'  diniiiuilinn  oi'  cxcitaitilily,  and  tiicn  a  vrry 
stronj;  I'ai'adic  or  j^^nivanic  ( iirri'iit  is  nccdi'd  tn  produce  contractions.  Kre- 
(lUcntly  ;i'l  laradic  excilaliility  is  lost  and  then  the  muscles  contrai-t  to  a 
jialvanic  current  tn\\y.  In  this  condition  it  may  require  a  very  stroiijjf  pil- 
vanic  current  to  juodiu-e  contraction,  and  thus  far  it  is  quite  pathognomonic 
n\'  neuritis.  l''or  in  anteiior  polio-myelitis,  where  the  muscles  respond  to 
galvanism  only,  it  does  not  re(|uire  a  strong  current  t(j  cause  a  motion  until 
sonii'  months  nftcr  the  invasion. 

" 'i'he  actiini  of  the  (lilVei'cnt  poles  is  not  unil'iuni.  in  many  cases  the 
contraction  of  the  muscle  when  stimulated  with  the  positive  pole  is  gri'atcr 
than  when  stimulated  with  the  negative  pole,  aiul  the  contractions  may  ho 
sluggish.  Then  llu'  reaction  of  degeneration  is  preseid.  Hut  in  some  casej; 
the  normal  condition  is  I'ound  and  the  negative  pole  prodiu-es  stronger 
contractions  than  the  positive  pole.  A  loss  of  J'aradic  irritability  and  a 
marked  decrease  in  the  galvanic  irritahility  of  the  muscle  and  nerve  are 
thererore  important  sym|itoms  of  midti|)le  ncuiitis."' 

'I'here  is  rarely  any  dilliculty  in  distinguishing  tlio  alcoliol  cases.  The 
comhination  of  wrist  and  fool  drop  with  congestion  of  the  hands  and  i'eet, 
and  the  ])cculiar  delirium  already  referred  to,  is  quite  characteristic.  I'he 
rapidly  advancing  cases  with  paralysis  of  all  extremities,  often  reaching 
to  the  face  and  involving  the  sphincters,  are  more  C()mnu)nly  regarded  as 
of  sj)inal  origin,  hui  the  general  opinion  seems  to  point  strongly  to  the 
fact  that  all  such  cases  are  pi'ripheral.  The  less  acuto  cases,  in  which  the 
])aralysis  gradually  involves  the  legs  and  arms  with  ra|»id  wasting,  simu- 
late closely  aiul  are  usually  confounded  with  the  subacute  atrojjhie  spinal 
jtaralysis  of  Duchenue.  The  diagnosis  from  loconu)tor  ata.xia  is  rarely 
ditVicult.  The  sli'/)p((<i('  gait  is  entirely  ditTcrent  fi'oni  that  of  tabes.  There 
is  rarely  jiositive  incoilrdination.  The  ])atient  can  usually  stand  well  with 
the  eyes  closed.  Foot-drop  is  not  common  in  locomotor  ataxia.  The  light- 
ning pains  are  absent  and  there  are  lu)  |)U[»ilIary  symi)toms.  The  etiology, 
too,  is  of  moment.  The  ])atient  is  recovering  from  a  ])aralysis  which  has 
been  more  extensive,  or  from  arsenical  poisoning,  or  he  has  diabetes. 

Treatment.^ — 1^'st  in  bed  is  essential.  In  the  acute  cases  with  fever, 
the  salicylates  and  anti])yrin  are  recommended.  To  allay  the  intense  pain 
morphia  or  the  hot  applications  of  lead  water  and  laudanum  are  often 
required.  Cireat  care  must  he  exercised  in  treating  the  alcoholic  form, 
and  the  ])hysician  must  not  allow  himself  to  he  deceived  hy  the  statements 
of  the  relatives.  It  is  sometinu's  exceedingly  dillicult  to  get  a  history  of 
spirit-drinking.  In  the  alcoholic  form  it  is  well  to  reduce  the  stimulants 
gradually.  If  there  is  any  tendency  to  hed-sores  an  air-hed  should  be  used 
or  the  patient  placed  in  a  continuous  hath.  Gentle  friction  of  the  mus- 
cles may  he  applied  from  the  outset,  and  in  the  later  stages,  when  the  atro- 
]ihy  is  marked  and  the  ])ains  have  lessened,  massage  is  prohahly  the  most 
reliable  means  at  our  command.  Contractures  may  be  gradually  overcome 
by  passive  movements  and  extension.     Often,  with  the  most  extreme  de- 


NErUoMATA. 


loai 


is   tllllS  (Ic- 

1  murkiMlly 
ito  vari(jii8. 
lnii  a  very 
i'liis.  Fro- 
iitnict  to  a 

stroll^f  ;;ill- 

oj^Mionionic 
rc'spoiul  to 

otioii  until 


V    CilSC: 


iiti 


I'  IS  tfrcatci" 
)iis  may  Ijo 
soiiio  casi'^j 
'S  stron;i;iT 
ility  and  a 
lUTvo  ail' 

■a  SOS.  The 
s  and  feet, 
istie.  Tho 
II  rcacliiii-,' 
t'^^ai'dt'd  as 
gly  to  the 
which  the 
\n<r,  siniii- 
)hii,'  spinal 
I  is  rarely 
OS.    There 

well  Avith 
The  li-ht- 
e  etiolo,iiy, 
which  has 
;es. 

ivith  fever, 
tense  pain 

are  often 
olic  form, 
statements 
history  of 
stimulants 
Id  be  nsed 
'  the  mns- 
1  the  atro- 
r  the  most 
'  overcome 
itreme  de- 


formity from  coidraclnre.  recovery  is,  in  lime,  still   possihle.     'i'lie  inlt-r- 
rii|ilcd  current  is  nsetiil  when  the  acute  staj^e  is  passed. 

Of  inlernal  remedies,  strychnia  is  of  value  and  may  he  ^ivcn  in  in- 
creasing' doses.  Arsenic  also  may  he  cmphiyi'd,  and  if  there  is  a  history  of 
."•yphilis  the  ioilide  (d'  [iota.ssinm  and  meieiiry  may  he  ^i\i'n. 


II.     NEUROMATA. 

Tumors  situated  on  nerve  lihres  may  consist  (d'  nerve  suhslance  proper, 
the  true  neuromata,  or  (d'  lihrous  tissue,  the  false  neuromata.  Tlie  true 
iieiii'onia  usually  contains  nerve  (Ihres  oidy,  or  in  rare  instances  gan<,dion 
cells.  Cases  of  ^Mn;,dionic  or  medullary  neuroma  are  extremely  rare;  sonu" 
nf  them,  as  LaiU'creanx  sii^i'^csts,  are  uiidouhtedly  instances  of  malforma- 
tion of  the  hrain  suhstaiice.  In  other  instances,  ns  in  the  case  which  I 
reported,  the  tumor  is,  in  all  prohahility,  a  glioma  with  cells  closely  re.sein- 
hling  those  of  the  central  nervous  system.  The  true  fascicular  lu'iiroma 
occurs  ill  the  form  of  the  small  siihcutaneous  painful  tumor — hthcrrula 
tlohintsa — which  is  situated  on  the  nerves  of  the  skin  about  the  joints,  some- 
times on  tl'.,  face  or  on  the  breast.  It  is  not  always  nuule  up  of  nerve  libres, 
hut  nuiy  he,  as  shown  by  IIo^-^mii,  an  adenomatous  growth  of  the  sweat 
glands. 

The  true  neuromata,  as  a  rule,  are  not  painful,  ami  occasionally  are 
found  associated  with  the  nerve  libres  in  various  regions.  Those  which 
develop  at  the  ends  and  along  the  course  of  the  nerves  of  tho  stum|t  after 
amputation  consist  of  connective  tissue  and  of  niedullated  and  nou-nu'dul- 
lated  nerve  fibres.  The  most  remarkable  form  is  the  plcrifann  nciiroiiia, 
in  which  the  various  nerve  cords  are  occupied  l)y  many  hundreds  of  tunujrs. 
Tho  cases  are  usually  congenital.  The  tumors  occur  in  all  the  nerves  of 
the  body.  One  of  the  most  remarkable  is  that  described  by  Prudden.  tlie 
specimens  of  which  are  in  tho  medical  museum  of  Columbia  College,  Xew 
Yoi'k.  There  were  over  lAS'i  distinct  tumors  distributi'd  on  the  nerves 
of  the  body.  1{.  W.  Smith's  s])lendi(l  monograph  on  neuronuita  has  Ijeen 
reprinted  this  year  (1898)  by  the  Xew  Sydenham  Society. 

Neuromata  rarely  cause  sy]u]>tonis,  except  the  subcutaneous  ])ainful 
tumor  or  those  in  the  amputation  stump.  Here  they  may  be  very  painful 
and  cause  great  distress,  ^fotor  symptoms  are  somctinu's  present,  particu- 
larly a  constant  twitching,  l-'jiilepsy  has  sometimes  been  associateil,  and 
relief  has  followed  removal  of  the  growths. 

The  only  available  treatnu'ut  is  excision.  The  subcutaneous  painful 
tumor  does  not  return,  and  excision  contplet(dy  relieves  the  symptoms.  On 
the  other  hand,  the  amputation  neuronuUa  nuiy  recur. 


65 


1088 


mSKASFW  OP  TFIR   NKUVOUS  SVSTKM. 


III.    DISEASES   OF  THE   CEREBRAL   NERVES. 

Oi.i'ACToiiv  \i;iivi;s  ani>  'ritAcxs. 

The  fimctioiis  of  tlu'si'  nerves  may  lie  disturbed  at  (heir  origin,  in  the 
nnsal  niiicoiis  ineiiibraiie.  at  tlie  l»idl),  in  the  course  o|'  the  tract,  or  at  tlie 
centres  in  liie  hrain.  'I'lie  disturhances  niny  l)e  nuuiil'estcd  in  suhjeclive 
sensations  of  snuH,  conipletc  hiss  of  the  sense,  and  occasionally  in  hyper- 
a'sthesia. 

{(i)  Siihjrrlirr  Snisaliinis ;  Pdrnsniin. — irallucinations  of  this  kind  are 
found  in  the  insane  and  in  epilepsy.  'J'he  aura  nuiy  he  re[)rescnted  hy  an 
unpleasant  odor,  descrihed  as  resenihling  chloride  of  lime,  hurning  rajfs,. 
or  feathers.  In  a  few  cases  with  these  subjective  sensations  tumors  have 
been  found  in  the  hippocamjii.  Jn  rare  instances,  afti-r  injury  of  the  head 
the  sens  is  jierverted — odors  of  the  most  dill'ercut  character  may  be  alike, 
or  the  od(n'  may  be  changed,  as  in  a  jiatient  noted  by  Morel  1  Mackenzie, 
who  for  some  time  could  not  touch  cooked  !;■  it,  as  it  smelt  to  her  exactly 
like  stiidxing  lish. 

(h)  /iinrtisrd  snisilivoipss,  or  hi/pornsmiii,  oc(  iirs  chielly  in  nervous,  hys- 
terical women,  in  whom  it  may  sometimes  be  developed  so  greatly  that,  like 
a  dog,  they  can  recognize  the  diU'erenee  bi-twecn  individuals  hy  the  odor 
alone. 

{(■)  Anosmia;  Loss  of  lite  Sense  of  Smell. — 'JMiis  may  he  produced  l)y: 
(1)  All'ections  of  the  origin  of  the  nerves  in  the  mucous  memlirane,  which 
is  perha|)s  the  most  frecpient  cause.  Jt  is  by  no  means  uncommon  in  asso- 
ciation with  chronic  nasal  catarrh  and  polypi.  In  paralysis  of  the  fifth 
nerve,  the  sense  of  smell  may  be  lost  on  ^he  all'ected  side,  owing  to  inter- 
ference with  the  secretion. 

It  is  doubtful  whether  the  cases  of  loss  of  smell  following  the  inhala- 
tions of  cry  foiii  or  strong  odors  should  come  under  this  or  under  the 
central  divisioii. 

(2)  The  les'ons  of  the  bulb  or  of  the  tracts.  Tn  falls  or  blows,  in  caries 
of  the  bones,  and  in  meningitis  or  tumor,  the  bulbs  or  the  olfactory  tracts- 
may  be  involved.  After  an  injury  to  the  head  the  loss  of  smell  may  be  the 
only  sym])toni.  ^fackenzio  notes  a  case  of  a  surgeon  who  was  thrown  from 
his  gig  and  lighted  on  his  head.  The  injury  was  slight,  hut  the  anosmia 
which  followed  Mas  ])crsistent.  Tn  locomotor  ataxia  the  sense  of  smell  may 
be  lost,  ])ossibly  owing  to  atro])hy  of  the  nerves. 

(n)  Lesions  of  the  olfactory  centres.  There  are  congenital  cases  in 
which  the  structures  have  not  been  developed.  Cases  have  heen  reported 
hy  lieevor,  Tlughlings  Jackson,  and  others,  in  which  anosmia  has  been 
associated  with  disease  in  the  hemis])here.  The  centre  for  the  sense  of 
smell  is  ])laced  hy  Ferrier  in  the  uncinate  gyrus.  Flechsig  describes  (1)  a 
frontal  centre  in  the  base  of. the  frontal  lohe  and  (2)  a  temporal  centre  in 
the  uncus. 

To  test  the  sense  of  smell  the  jmngont  hodies.  such  as  ammonia,  which 
act  upon  the  fifth  rerve,  should  not  be  used,  but  such  substances  as  cloves,, 
peppermint,  and  musk.    This  sense  is  readily  tested  as  a  routine  matter  in 


DISKASKS  OF  TIIK  CEIIKURAL   NKItN  T.S. 


1U31) 


in,  in  tlu' 
or  ut  tlu- 
'iil)j('ctivi' 

ill    ll^ilLT- 

kiiul  jirc 
led  \t\  ail 
liii^'  niji.s 
iiors  Imve 
I  lie  liciid 
1)0  alike, 
lackuiizic, 
ur  exactly 

voiis,  liys- 
tliat,  like 
the  odor 

lucetl  l)y: 

lie,  wliifli 

n  ill  asso- 

the  (ii'th 

to  iiiter- 

10  inliala- 
iiidor  the 

in  caries 
t)ry  tracts' 
ay  1)0  tlie 
)\vn  from 

anosmia 
hicll  may 

cases  in 

reported 

has  l)een 

sense  of 

l)cs  (1)  a 

centre  in 

ia,  which 
as  cloves^ 
tnatter  in 


brain  cases  hy  )iavin>,'  t\Mi  or  three  hottles  containin;,'  the  es.«*ential  oil-i. 
Ill  all  iiistaiues  a  rhinoncopical  examination  shuiild  he  made,  as  the  chii- 

(litinli  may  he  due  to  lucal,  lliit  central  causes,      'I'he  lirilhmnl  is  lllis;lti>lne- 

torv  even  in  the  cases  iliic  to  local  lesions  in  the  nostrils. 

Oi'Tic  N  i;i(\  i:  AM)  'I'll Aci'. 

( 1 )  l.rsiniis  (if  I  It  I'  h'riinii. 

These  are  oi  importance  to  the  physician,  and  information  of  the  jfreat- 
cst  value  may  ho  ohtained  hy  a  Hystematic;  examination  of  the  eye-;,M'ounds. 
Only  a  hrief  rcfcreiu'c  can  lieic  he  iiunle  tn  the  ninre  iniportant  (d'  the  ap- 
pearances. 

(k)  Retinitis. — 'I'his  occurs  in  certain  p'lieral  all'ectii»ns.  iiKire  |iarticu- 
larly  in  r>ri;,dil's  disease,  ssphilis,  leuku'inia,  and  aiuemia.  The  cdiiiniiin 
feature  in  all  these  states  is  the  occurrence  of  Inemorrhafio  and  the  deve|i)p- 
meiit  of  opacitii's.  'I'here  may  also  he  a  dill'use  cloudiness  due  to  eirusioii 
(d'  seruiii.  The  luemorrha^'cs  are  in  the  layer  ol  nerve  lihres.  'I'hey  vaiT 
^leatly  in  size  and  for:-,,  l)ut  often  follow  the  course  of  vessi'ls.  When 
recent  the  color  is  hri^dit  red,  hut  they  gradually  chan^'e  ami  old  h:i'iiioi- 
iha<i:es  are  almost  black.  The  white  spots  are  duo  either  to  llbrinoiis  exudate 
or  to  fatty  dejicneration  of  the  retinal  elements,  and  occasionally  to  accumu- 
lation of  leiicocyti's  or  to  a  localized  sclerosis  of  the  retinal  elements,  'i'he 
more  important  of  the  forms  of  retinitis  to  be  reco^Miizccl  are: 

Alhuininiirlc  irliiiilis,  which  occurs  in  chronic  nephritis,  |)articnlarly  in 
ilie  interstitial  or  contracted  form.  The  percentajfo  of  cases  atl'ected  is  from 
1,')  to  '2').  'I'here  are  instances  in  which  these  retinal  chauj^es  'ire  associated 
vith  the  <iraniilar  kidney  at  a  sta^c  when  tl;e  amount  of  alounieii  may  he 
slif^dit  or  transient;  but  in  all  such  instances  it  will  lie  found  that  there 
is  a  marked  arterio-sclerosis.  (lowers  recognizes  a  dej^i-nerative  foiiii  (nio-t 
common),  in  whicli,  with  the  retinal  cbanjies.  there  may  be  scarcely  any 
alteration  in  the  disk;  a  ha'inorrhaji'ic  form,  with  many  ha'inorrhaj;es  and 
l)ut  slight  signs  of  inllammation;  and  an  inllammatory  form,  in  which 
there  is  much  swelling  of  the  ri-tina  and  obscuration  of  the  di.  k.  It  is  note- 
worthy that  in  some  instances  the  inllammation  of  the  optic  nerve  |)re- 
dominates  ovi-r  the  retinal  changes,  and  one  may  he  in  doubt  for  a  time 
whether  the  condition  is  really  associated  with  the  renal  changes  or  de- 
jiendent  n])on  intracranial  disease. 

Siiiihilitic  nefixHis. — Tn  the  acipiired  form  this  is  less  common  than 
choroiditis.  Tn  inherited  syphilis  irlliiilis  jiiijiHciihisd  is  sometimes  met 
with. 

Iiefiiiitis  ill  Anwrnid. — Tt  has  long  been  known  that  a  ]iatient  may 
become  blind  after  a  large  haemorrhage,  either  sudileidy  or  within  two  or 
three  days,  and  in  one  or  both  eyes.  Occasionally  the  loss  may  be  ])erma- 
nent  and  com])lete.  Tn  some  of  these  instances  a  neuro-retinitis  has  })ei'n 
found,  probably  sufficient  to  account  for  the  symptoms.  Tn  the  more 
chronic  ana'mias,  particnlarly  in  the  ]iernicions  form,  retinitis  is  common, 
as  determined  first  by  Quincke. 

Tn  wnhria  retinitis  or  nenro-retinitis  may  bo  present,  as  noted   !iy 


I 


1040 


DISKASKS  OF  THE   NERVOUS  SYSTEM. 


Sto]>lioii  ^fafkonzic.  It  is  seen  only  in  llic  cliroiiic  casi's  with  iiniviuia,  and 
in  my  c'.\|)(.'ririict'  is  iidt  lU'arly  so  vdmiimn  |ir(iiiiirti(inatrly  as  in  ])t'niieious 
aiia'iiiia. 

Lcukaiiiir  li'rliiiilis. —  In  this  aU'ri-ion  thf  retinal  veins  arc  hirye  and 
(listcnih'd;  tlicre  is  also  a  iieculiar  retinitis,  as  (h'serihed  hy  Liel)Vuich.  Jt 
is  not  very  eonnnon.  It  existed  in  oidy  o  of  lU  eases  ol'  whieli  I  liave  notes 
of  I'xamination  of  tlie  retina.  There  are  niinierous  ha'niorihages  and  white 
or  yellow  areas,  which  may  he  lar<ie  and  ])roniinent.  Jn  one  ot  my  eases 
till'  retina  ]>ost  nioi'tcni  was  dotti'd  with  many  small,  opacjue,  white  sjjots, 
looking  like  little  tnniors,  the  larger  of  which  had  a  diameter  of  nearly 
2  mm.  In  Case  l;5  of  my  scries  the  Icnka'mia  was  diagnosed  hy  Xorris  and 
J)e  Schweinitz,  at  whose  clinic  the  patient  had  ai)i)lied  oji  acconnt  of  failing 
vision,  from  the  condition  of  tho  eye-grounds  alone. 

Ifetinitis  is  also  found  occasionally  in  diahett'S,  in  purpura,  in  chronic 
lead  poisoning,  and  sometimes  as  an  idiopathic  all'cction. 

(b)  Functional  Disturbances  of  Vision.— (1)  Toxic  Anumrosi.'i. — This 
occurs  in  uraMuia  and  may  follow  convulsions  or  come  on  indcpi'ndently. 
The  condition,  as  a  rule,  persists  only  for  a  day  or  two.  This  foim  of 
amaurosis  occurs  in  ])oisoning  hy  lead,  alcolud,  and  occasionally  hy  quinine. 
it  seems  more  jirohahle  that  the  pois(ms  act  on  the  centres  and  not  on  the 
retina. 

(2)  Tobacco  Ai'ihli/opld. — The  loss  of  sight  is  usually  gradual,  e(|ual  in 
lioth  eyes,  and  alTects  ])articularly  the  centre  of  the  lield  of  vision.  The 
eye-grounds  may  be  normal,  but  occasionally  there  is  congestion  of  the 
disks.  On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is 
found  in  all  cases.  I'ltimately,  if  the  use  of  tobacco  is  continued,  organic 
changes  nuiy  develoj)  with  atrophy  of  the  disk. 

(;{)  ]fi/slrric(il  A  iiidiirosix. — ^[ore  frequently  this  is  loss  of  acuteness 
of  vision — andilyopia — bid  the  loss  of  sight  in  one  or  both  eyes  may  ap- 
parently be  complete.  The  condition  will  be  mentioned  subseiiuently  under 
hysteria. 

(-t)  3'(\////-W;'/((i'//rs'.s' — )iiiclaliij)l(t — the  condition  in  which  objects  are 
clearly  seen  during  the  day  or  by  strong  artificial  light,  but  become  invisible 
in  the  shade  or  in  twilight,  and  licnicnilopia,  in  which  objects  cannot  l)e 
clearly  seen  without  disticss  in  daylight  or  in  a  strong  artificial  light,  but 
are  readily  seen  in  a  dcci)  shade  or  in  twilight,  are  functional  anomalies  of 
vision  which  rari-ly  come  under  the  notice  of  the  physician.  It  may  occur 
in  epidemic  form. 

(.-))  Hrliiuil  ]iii/icr(Vsllics!(i  is  sometimes  seen  in  hysterical  women,  but 
is  not  found  frequently  in  actual  retinitis.  I  have  seen  it  once,  however, 
in  albunnnuric  retinitis,  and  once,  in  a  marked  degree,  in  a  ])atient  with 
aortic  insidliciency,  in  whose  retiiiii)  there  were  no  signs  other  than  the 
throl)bing  arteries. 


(?)   Lcfi'Dis  (if  llir  Opllr  Xr  rr. 

(^/)  Optic  Neuritis  (Pii/)inilis:  Clml-rd  Disl-). — Tn  the  first  stage  there 
is  congestion  of  the  disk  and  the  edges  are  blurred  and  striated.  In  the 
second  stage,  the  congestion  is  more  marked,  the  swelling  increases,  the 


JJISHASES  OF   THE  CERKnilAL   XEliVES. 


1041 


iviniii,  and 
|ii'i'iii(.'iuu.s 

largo  and 

•  ri'ich.  It 
liavc  notes 

and  wliik; 

my  casi's 

liitc  fipots, 

oi'  nearly 
N'ori'is  and 
:  <>r  Tailing 

in  clironic 

hwx.— This 
jtrndontly. 
is  form  of 
ly  (iuinino. 
lot  on  the 

.  C'(|ual  in 
iion.  The 
on  of  the 
d  green  is 
d,  organic 

acutencss 
s  may  a])- 
iitly  under 

bjoets  are 
e  invisilile 
cannot  bo 
light,  but 
omalies  of 
may  occur 

)iu('n,  but 

,  however, 

tient  with 

than  the 


:age  there 
I.  In  tlie 
cases,  tlic 


f^triation  also  is  more  visible.  'J'he  |thysiologii'al  cii|t|>ing  disa|)|)ears  and 
ha'morrhages  are  n(»t  nncoinmon.  The  arterii-s  presi'nl  little  ehange,  flu; 
veins  are  dilated,  and  the  disk  may  swell  greatly.  In  slight  grades  of  in- 
llammation  the  swelling  gradually  subsides  and  occasionally  the  iicrvr  n'- 
covers  coni])lett'ly.  In  instances  in  wliieh  the  swelling  and  exudate  are 
very  great,  the  subsidence  is  slow,  and  when  it  tinally  disappears  there  is 
coni|)lete  atrophy  of  the  nerve.  The  retina  not  infre(|iu'iitly  participates 
in  the  inllaniuiation,  which  is  then  a  neuro-retinitis. 

This  condition  is  of  the  greatest  importance  in  diagnosis,  it  may  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exten- 
sive ])a])illitis  the  sight  may  for  a  time  Itc  good. 

Optic  neuritis  is  seen  oi-casionally  in  amemia  and  lead  poisoning,  more 
commonly  in  Bright's  disease  as  neuro-retinitis.  It  occurs  occasionally  as 
a  jjrimary  idiopathic  alfection.  The  frecjucnt  connection  with  intracranial 
disease,  j)articularly  tumor,  maki's  its  ])it'senee  of  great  value  to  practi- 
tioners. The  nature  of  the  growth  is  without  intluence.  In  over  DO  per 
cent  of  such  instances  the  })a])illitis  is  bilateral.  It  is  also  found  in  menin- 
gitis, either  the  tuberculous  or  the  simi»le  form.  In  meiungitis  it  is  easy 
to  see  hoAV  the  inilammation  may  extend  down  the  nerve  sheath,  in  the 
case  of  tumor  it  was  thought  at  first  that  a  choked  disk  resulted  from  in- 
creased pressure  uithin  the  skull.  It  is  now  jnore  commonly  rt'garded, 
however,  as  a  descending  neuritis. 

(i)  Optic  Atrophy. — This  may  be:  (1)  A  ]>rimary  afTection.  There  is 
an  hereditary  form,  in  which  the  disease  has  developed  in  all  the  males  of 
a  family  shortly  after  i)uberty.  A  large  number  of  the  cases  of  i)rimary 
atrophy  are  associated  with  s])inal  disease,  ])articularly  locomotor  ataxia. 
Other  causes  Avliich  have  been  assigned  for  the  primary  atrophy  are  cold, 
sexual  excesses,  diabetes,  the  specific  fevers,  alcohol,  and  lead. 

{2)  Secondary  atro])liy  results  from  cerebral  diseases,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  most  commonly  of  all,  as  a  secpience  of  i)a- 
l)illitis. 

The  o])hthalmoscopic  apjiearanccs  are  different  in  the  cases  of  i)riniary 
and  secondary  atrojthy.  ]n  the  former,  the  disk  has  a  gi'ay  tint,  tlu'  edges 
are  well  defined,  and  the  arteries  look  alnu)st  normal;  whereas  in  the  con- 
secutive atro])hy  the  disk  has  a  staring  opaque-white  aspect,  with  irregular 
outlines,  and  the  arteries  are  very  small. 

The  symptom  of  optic  atrophy  is  l(>ss  of  sight,  ])roportionate  to  the 
damage  in  the  nerve.  The  change  is  in  lliree  directions:  '"(I)  Diminished 
acuity  of  vision;  (2)  alteration  in  the  held  of  vision;  and  (3)  altered  per- 
ception of  color  "  (Gowers).    The  outlook  in  primary  atrophy  is  bad. 

(3)  Affections  of  Ihc  Chiasma  and  Tract. 

At  the  chiasma  the  o]>tic  nerves  undergo  partial  decussation.  Each 
optic  tract,  as  it  leaves  the  chiasma,  contains  nerve  fibres  which  originate 
in  the  retina^  of  both  eyes.  Thus,  of  the  fibres  of  the  right  tract,  part  have 
come  through  the  chiasma  without  decussating  from  the  temporal  half 
of  the  right  retina,  the  other  and  larger  })ortion  of  the  fibres  of  the  tract 


1042 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


/ 


have  decussated  in  the  chiasina,  coming  as  tliey  do  from  tlie  left  optic  nerve 
and  the  nasal  half  of  the  retina  on  the  left  side.  The  lihres  which  cross 
are  in  the  middle  portion  of  the  ehiasma,  while  the  direct  iibres  are  on  each 
side.  The  following  are  the  most  important  changes  which  ensue  in  lesions 
of  the  tract  and  of  the  ch'asma: 

{a)  Unildlcral  Affection  of  Trad. — If  on  the  right  side,  this  produces 
loss  of  function  in  the  temporal  half  of  the  retina  on  the  right  side,  and  on 
the  nasal  half  of  the  retina  on  the  left  side,  so  that  there  is  only  half  vision, 
and  the  patient  is  blind  to  objects  on  the  left  side.  This  is  termed  homony- 
mous hemianoi)ia  or  lateral  hemianopia.  The  fibres  passing  to  the  right 
half  of  each  retina  being  involved,  necessarily  the  left  half  of  each  visual 
held  is  blind.  The  hemianoj)ia  may  be  ])artial  and  only  a  portion  of  the 
half  field  may  be  lost.  The  unaffected  visual  fields  may  have  the  normal 
extent,  but  in  some  instances  there  is  considerable  reduction.  "When  the 
left  half  of  one  field  and  the  right  half  of  the  other,  or  vice  versa,  are  blind, 
the  condition  is  known  as  heteronymous  liemiano})ia. 

(b)  Disease  of  the  Chiasma. — (1)  A  lesion  involves,  as  a  rule,  chiefly 
the  central  portion,  in  which  the  decussating  fibres  pass  which  supply  the 
inner  or  nasal  halves  of  the  retina^  producing  in  consequence  loss  of  vision 
in  the  oiiter  half  of  each  field,  or  what  is  known  as  temporal  hemianopia. 

(2)  If  the  lesion  is  more  extensive  it  may  involve  not  only  the  central 
portion,  but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which 
case  there  would  be  total  blindness  in  one  eye  and  temporal  hemianopia 
in  the  other. 

(3)  Still  more  extensive  disease  is  not  infrequent  from  pressure  of  tu- 
mors in  this  region,  the  whole  chiasma  is  involved,  and  total  blindness 
results.  The  different  stages  in  the  process  may  often  be  traced  in  a  single 
case  from  tem])oral  hemianopia,  then  complete  Llindness  in  one  eye  with 
temporal  hemianopia  in  the  other,  and  finally  complete  blindness. 

(4)  A  limited  lesion  of  the  outer  part  of  the  chiasma  involves  only  the 
direct  fibres  passing  to  the  temporal  halves  of  the  retinte  and  inducing 
blindness  in  tlie  nasal  field,  or,  as  it  is  called,  nasal  hemianopia.  This,  of 
course,  is  extremely  rare.  Double  nasal  hemiano])ia  may  occur  as  a  mani- 
festation of  tabes  and  in  tumors  involving  the  outer  fibres  of  each  tract. 


(4)  Affections  of  tlie  Tract  and  Centres. 

The  o])tic  tract  crosses  the  crus  (cerebral  peduncle)  to  the  hinder  part 
of  the  ojitic  thalamus  and  divides  into  two  portions,  one  of  which  (the 
lateral  root)  cfoes  to  the  pulvinar  of  the  thalamus,  the  lateral  geniculate 
Itody,  and  to  ihe  anterior  quadrigeminal  body  (superior  colliculus).  From 
these  parts,  in  which  the  lateral  root  terminates,  fibres  pass  into  the  pos- 
terior part  of  the  internal  capsule  and  enter  the  occipital  lobe,  forming  the 
fibres  of  the  optic  radiation,  which  terminate  in  and  about  the  cuneus,  the 
region  of  the  visual  percoiitive  centre.  The  fibre's  of  the  medial  division  of 
the  tract  ]iass  to  the  medial  geniculate  body  and  to  the  posterior  quadri- 
geminal body.  The  medial  root  contains  the  fibres  of  the  conimissura  in- 
ferior of  V.  Gudden,  which  are  believed  to  have  no  connection  with  the 


l)tic  nerve 
lieh  cross 
•e  on  cacli 
in  lesions 

produces 
e,  and  on 
all'  vision, 

liomony- 
tlie  right 
ich  visual 
on  of  the 
le  normal 
When  the 
are  blind, 

e,  chiedy 
apply  the 
of  vision 
anopia. 
le  central 
in  which 
imianopia 

ire  of  tu- 
hlindness 
1  a  single 

eye  with 
ss. 

only  the 
inducing 

This,  of 
1  a  niani- 
.  tract. 


ider  part 
licli  (the 
3niciilate 
I.     From 


DISEASES  OP  THE  CEREBRAL  NERVES. 


1043 


the 

pos-          1 

nmg 

the          1 

leus, 

the          1 

I'ision  of          1 

quadri-          | 

•sura 

in- 

vith 

the 

CUNEUS 


A-S''*- 


UFr 


M  8 


'SU  A^ 


Fig.  11. — Diagram  of  visual  paths.  (From  Vialet,  modified.)  OP.  N.,  Optic  'nerve. 
OP.  C,  Optic  chiasm.  OP.  T..  Optic  tract.  OP.  R.,  Optic  radiations.  GEN.,  Genic- 
ulate body.  THO.,  Optic  tlialamus.  C.  QU.,  Corpora  quadrigemina.  C.  C.  Corpus 
callosum.  V.  S.,  Visual  speech  centre.  A.  S.,  Auditory  speech  centre.  31.  S.,  ]Motor 
speech  centre.  A  lesion  at  1  causes  blindness  of  that  eye;  at  3,  bi-temponil  heinia- 
nopia;  at  3,  nasal  hemianopia.  Symmetrical  lesions  at  3  and  ii'  would  cause  bi-nasal 
hennanopia;  at  4,  hemianopia  of  both  eyes,  with  hemianopic  pupillary  inaction;  at 
5  and  6,  hemianopia  of  both  eyes,  pupillary  reflexes  normal ;  at  7,  amblyopia,  espe- 
cially of  opposite  eye  ;  at  8,  on  left  side,  word-blindness. 


r 


1U44 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


/ 


retinop.  It  is  still  hold  by  some  ])li}si()l()>,Msts  that  the  cortical  visual  centre 
is  not  confined  to  tiie  occipital  lobe  alono,  but  embraces  the  occipito-angular 
region. 

A  lesion  of  the  fibres  of  the  optic  path  anywhere  between  the  cortical 
centre  and  the  chiasma  will  })roduee  heniiano})ia.  The  lesion  may  be  situ- 
ated: {(i)  In  the  optic  tract  itself,  (h)  In  the  region  of  the  thalamus, 
lateral  geniculate  body,  and  the  corpora  quadrigemina,  into  which  the 
larger  part  of  each  tract  enters,  (c)  A  lesion  of  the  fibres  passing  from  the 
centres  just  mentioned  to  the  occipital  lobe.  This  may  be  either  in  the 
hinder  part  of  the  internal  capsule  or  the  white  fibres  of  the  optic  radiation. 
{(/)  licsion  of  the  cuneus.  Jiilateral  disease  of  the  cuneus  may  result  in 
total  l)lindness.  (c)  There  is  clinical  evidence  to  show  that  lesion  of  the  an- 
gular gyrus  may  be  associated  with  visual  defect,  not  so  often  hemianopia 
as  crossed  amblyopia,  dimness  of  vision  in  the  opposite  eye,  and  great  con- 
traction in  the  field  of  vision.  Lesions  in  this  region  are  associated  with 
mind  blindness,  a  condition  in  which  there  is  failure  to  recognii  j  the  nature 
<jf  objects. 

The  effects  of  lesions  in  the  optic  nerve  in  different  situations  from  the 
retinal  ex})ansion  to  the  brain  cortex  are  as  follows:  (1)  Of  the  optic  nerve 
— total  blindness  of  the  corresponding  eye;  (2)  of  the  optic  chiasma,  either 
tem])oral  hemianopia,  if  the  central  ])art  alone  is  involved,  or  nasal  hemi- 
anopia, if  the  lateral  region  of  each  chiasma  is  involved;  (3)  lesion  of  the 
optic  tract  between  the  chiasma  and  the  lateral  geniculate  body,  pro- 
duces lateral  hcmianoi)ia;  (4)  lesion  of  the  central  fibres  of  the  nerve  be- 
tween the  geniculate  bodies  and  the  cerebral  cortex  produces  lateral  hemi- 
anopia; (5)  lesion  of  the  cuneus  causes  lateral  hemianopia;  and  (G)  lesion 
of  the  angular  gyrus  may  be  associated  with  hemianopia,  sometimes  crossed 
amblyopia,  and  the  condition  known  as  mind  blindness.  (See  Fig.  11,  with 
accomi)anying  explanation.) 

Diagnosis. — The  student  or  practitioner  must  have  a  clear  idea  of 
ihe  physiology  of  the  nerve  centres  before  he  can  appreciate  the  symptoms 
or  undertake  the  diagnosis  of  lesions  of  the  optic  nerve.  Having  deter- 
mined the  presence  of  hemianopia,  the  question  arises  as  to  the  situation 
of  the  lesion,  whether  in  the  tract  between  the  chiasma  and  the  geniculate 
bodies  or  in  the  central  portion  of  the  fibres  between  these  bodies  and  the 
visual  centres.  This  can  be  determined  in  some  cases  by  the  test  known 
as  Wernicke's  hemiopic  jnipiUnn/  inaction.  The  pupil  reflex  depends  on 
the  integrity  of  the  retina  or  receiving  membrane,  on  the  fibres  of  the  op- 
tic nerve  and.  tract  which  transmit  the  impulse,  and  the  nerve  centre  at 
the  termination  of  tiie  optic  tract  which  receives  the  impression  and  trans- 
mits it  to  the  third  nerve  along  \vhich  the  motor  impulses  pass  to  the  iris. 
If  a  bright  light  is  thrown  into  the  eye  and  the  pupil  reacts,  the  integrity 
of  this  reflex  arc  is  demonstrated.  It  is  possible  in  cases  of  lateral  hemi- 
anopia so  to  throw  the  light  into  the  eye  that  it  falls  upon  the  blind  half 
of  the  retina.  If  when  this  is  done  the  pupil  contracts,  the  indication  is 
that  the  reflex  arc  above  referred  to  is  perfect,  by  which  we  mean  that  the 
optic  nerve  fibres  from  the  retinal  expansion  to  the  centre,  the  centre 
itself,  and  the  third,  nerve  are  uninvolved.     In  such  a  case  the  conclusion 


DISEASES  OP  THE  CEREBRAL  NERVES. 


1045 


isual  centre 
)it()-angular 

the  cortical 
lay  be  situ- 
!  tlialaimis, 

which  the 
ig  i'roiu  tlie 
ther  in  the 
c  radiation, 
y  result  in 
1  oi'  the  an- 
heinianopia 

great  con- 
L'iated  with 

the  nature 

IS  from  the 
optic  nerve 
sma,  either 
uisal  henii- 
sion  of  the 
body,  pro- 
!  nerve  be- 
teral  hcmi- 
((j)  lesion 
nes  crossed 
ig.  11,  with 

lar  idea  of 
symptoms 
'ing  deter- 
e  situation 
geniculate 
es  and  the 
est  known 
ejjcnds  on 
of  the  op- 
centre  at 
and  trans- 
;o  the  iris. 
!  integrity 
3ral  hemi- 
blind  half 
li cation  is 
1  that  the 
he  centre 
jonclusion 


would  1)0  justified  that  the  cause  of  the  heniianopia  was  central;  that  is, 
situated  beyond  the  geniculate  body,  either  in  the  lil)r('s  of  tiie  oplic  radi- 
ation or  in  the  visual  cortical  centres.  If,  on  the  other  hand,  when  the 
light  is  carefully  throwji  on  the  hciiiio])ic  half  of  the  retina,  the  jjupil  re- 
mains inactive,  the  conclusion  is  justifiable  that  tliiTe  is  interruption  in  tiu! 
j)ath  Itetween  the  retina  and  the  nucleus  of  the  tiiird  nerve,  and  tliat  tlie 
licmianopia  is  not  central,  but  dependent  upon  a  lesion  situated  in  the  optic 
tract.  This  test  of  Wernicke's  is  sometimes  dillicult  to  obtain.  It  is  best 
pert'ormed  as  follows:  "  'J'he  patient  Ijeing  in  a  dark  or  nearly  dark  room 
with  the  lamp  or  gas-light  behind  his  head  in  the  usual  ])osition,  1  bid  him 
look  over  to  the  other  side  of  the  room,  so  as  to  exclude  accommodative 
iris  movements  (which  are  not  necessarily  associated  with  the  relle.v).  Then 
I  throw  a  faint  light  from  a  plane  mirror  or  from  a  large  concave  mirror, 
held  well  out  of  focus,  upon  the  eye  and  note  the  size  of  the  pupil.  With 
my  other  hand  1  now  throw  a  beam  of  light,  fo<  ussed  from  the  lam])  l)y  an 
ophthalmosco])ic  mirror,  directly  into  the  optical  centre  of  the  eye;  then 
laterally  in  various  })ositions,  and  also  from  above  and  below  the  e((uator 
of  the  eye,  noting  the  reaction  at  all  angles  of  incidence  of  the  ray  of  light." 
(Seguin.) 

The  significance  of  hemianopia  varies.  There  is  a  functional  hemi- 
anopia  associated  with  migraine  and  hysteria.  In  a  considerable  j)roi)or- 
tion  of  all  cases  there  are  signs  of  organic  brain-disease.  In  a  certain  num- 
ber of  instances  of  slight  lesions  of  the  occipital  lobe  hemiacliroiiiatoj)sia 
has  been  observed.  The  homonymous  halves  of  the  retina  as  far  as  the 
fixation  point  are  dulled,  or  blind  for  colors.  IIemii)legia  is  common,  in 
which  event  the  loss  of  power  and  blindness  arc  on  the  same  side.  Thus, 
a  lesion  in  the  left  hemisphere  involving  the  motor  tract  produces  right 
hemiplegia,  and  when  the  fibres  of  the  optic  radiation  are  involved  in  the 
internal  capsule,  there  is  also  lateral  hemianopia,  so  that  objects  in  the  field 
■of  vision  to  the  right  are  not  perceived.  Ilemiana'sthesia  is  not  uncommon 
in  such  cases,  owing  to  the  close  association  of  the  sensory  and  visual  tracts 
at  the  posterior  part  of  the  internal  capsule.  Certain  forms  of  aphasia 
also  occur  in  many  of  the  cases. 

The  optic  aphasia  of  Freund  may  be  mentioned  here.  The  ])atient  after 
an  apoplectic  attack,  though  able  to  recognize  ordinary  objects  shown  to 
him  is  unable  to  name  them  correctly.  If  he  l)e  ])i'nnitted  to  touch  the 
object  he  may  be  able  to  name  it  cpiickly  and  correctly.  Freund's  optic 
ajihasia  differs  from  mind-blindness,  since  in  the  latter  affection  the  objects 
seen  are  not  recognized.  Optic  a])liasia,  like  word-blindness,  never  occurs 
alone,  but  is  always  associated  with  hemianopia,  or  mind-blindness,  and 
often  also  with  word-deafness.  In  the  cases  which  have  thus  far  come  to 
autopsy  there  has  always  been  a  lesion  in  the  white  matter  of  the  occipital 
lobe  en  the  left  side. 

Motor  Nkrvks  of  the  Eyeball. 

Third  Nerve  (N'ervus  ocvlomolorius). — The  nucleus  of  origin  of  this 
jierve  is  situated  in  the  floor  of  the  aqueduct  of  Sylvius;  the  nerve  passes 


1()40 


DTSEASKS   OP  THE   NERVOUS  SYSTEM. 


thntugh  f  s  at  tlio  sido  of  which  it  cnierges.     Passinfjf  along  tho  wall 

of  the  C'a\  is  sinus,  it  enters  the  orbit  through  the  sphenoidal  iissuie 

and  su])i)lies,  hy  its  superior  braneii,  the  levator  pali)ebriL'  superioris  and 
the  suj)erior  rectus,  and  by  its  inferior  branch  the  internal  and  inferior 
recti  muscles  and  the  inferior  ()bli<[ue.  Jiranches  pass  to  the  ciliary  muscle 
and  the  constrictor  of  the  iris.  Lesions  nuiy  ailect  the  nucleus  or  the  nerve 
in  its  course  and  cause  either  paralysis  or  s})asm. 

Paralysis. — A  nuclear  lesion  is  usually  associated  with  the  disease  of 
the  centres  for  the  other  eye  muscles,  producing  a  condition  of  general  oph- 
thalmoplegia, ^lore  commonly  the  nerve  itself  is  involved  in  its  course, 
either  by  meningitis,  gummata,  or  aneurism,  or  is  attacked  by  a  neuritis,  as 
in  diphtheria  and  locomotor  ataxia.  Complete  i)aralysis  of  the  third  nerve 
is  accompanied  by  the  following  symptoms: 

Paralysis  of  all  the  muscles,  excejjt  the  superior  oblique  and  external 
rectus,  by  which  the  eye  can  be  moved  outward  and  a  little  downward  and 
inward.  There  is  divergent  strabismus.  There  is  ptosis  or  drooping  of 
the  upper  eyelid,  owing  to  paralysis  of  the  levator  palpebrtu.  The  pupil  is 
usually  dilated.  It  does  not  contract  to  light,  and  the  power  of  accom- 
modation is  lost.  The  most  striking  features  of  this  paralysis  are  the 
external  strabismus,  with  diplopia  or  double  vision,  and  the  ptosis.  In 
very  many  cases  the  affection  of  the  third  nerve  is  partial.  Thus  the 
levator  palpebral  and  the  superior  rectus  may  be  involved  together,  or  the 
ciliary  muscles  and  the  iris  may  be  affected  and  the  external  muscles  may 
escape. 

There  is  a  remarkable  form  of  recurring  oculo-motor  paralysis  affect- 
ing chiefly  women,  and  involving  all  the  branches  of  the  nerve.  In  some 
cases  the  attacks  have  come  on  at  intervals  of  a  month;  in  others  a  much 
longer  period  has  elapsed.  The  attacks  may  persist  throughout  life.  They 
are  sometimes  associated  with  pain  in  the  head  and  sometimes  with  mi- 
graine.    Mary  Sherwood  has  collected  from  the  literature  23  cases. 

Ptosis  is  a  common  and  important  symptom  in  nervous  affections.  We 
may  here  briefly  refer  to  the  conditions  under  which  it  may  occur:  (a)  A 
congenital,  incurable  form,  which  is  frec^uently  seen;  (b)  the  form  associ- 
ated with  definite  lesion  of  the  third  nerve,  either  in  its  course  or  at  its 
nucleus.  This  may  come  on  with  paralysis  of  the  superior  rectus  alone  or 
with  paralysis  of  the  internal  and  inferior  recti  as  well,  (c)  There  are 
instances  of  complete  or  partial  ptosis  associated  with  cerebral  lesions  with- 
out any  other  branch  of  the  third  nerve  being  paralyzed.  The  exact  po- 
sition of  the  cortical  centre  or  centres  is  as  yet  unknown,  (d)  Hysterical 
ptosis,  which  is  double  and  occurs  with  other  hysterical  symptoms,  (c) 
Pseudo-])tosis,  due  to  affection  of  the  sympathetic  nerve,  is  associated  with 
symptoms  of  vaso-motor  palsy,  such  as  elevation  of  the  temperature  on  the 
affected  side  with  redness  and  o-dema  of  the  skin.  Contraction  of  the  pupil 
exists  on  the  same  side  and  the  eyeball  appears  rather  to  have  shrunk  into 
the  orbit,  (f)  In  idiopathic  muscular  atrophy,  when  the  face  muscles  are 
involved,  there  may  be  marked  bilateral  ptosis.  And,  lastly,  in  weak,  deli- 
cate women  there  is  often  to  be  seen  a  transient  ptosis,  particularly  in  the 
morning. 


DISEASES  OP  THE  CEIIEIJUAL  NEliVES. 


1U47 


n^  tlio  wall 
)i(lal  fissure 
)orioris  and 
11(1  iiircrior 
iaiy  niusclo 
ir  the  nerve 

!  disease  of 
eueral  oph- 
its  course, 
neuritis,  as 
tliird  nerve 

id  external 
nward  and 
Tooping  of 
ho  pupil  is 

of  accom- 
3is  are  the 
ptosis.     In 

Thus  the 
her,  or  the 
uscles  may 

)'sis  affect- 
In  some 
rs  a  much 
ife.  They 
with  mi- 
-es. 

ions.  We 
:ur:  (a)  A 
rm  associ- 
;  or  at  its. 
s  alone  or 
There  are 
ions  with- 
oxact  po- 
lysterical 
onis.  (p) 
ated  with 
re  on  the 
the  pupil 
runk  into 
iscles  are 
eak,  deli- 
■ly  in  the 


Among  the  most  important  of  tho  symptoms  of  the  third-nerve  paraly- 
sis are  those  which  relate  to  tiie  ciliary  muscle  and  iris. 

Cucloplci/iii,  paralysis  of  the  ciliary  muscle,  causes  loss  of  the  power  of 
accommodation.  J)istant  vision  is  clear,  hut  near  ohjects  cannot  he  prop- 
erly seen,  in  eonse((uence  the  vision  is  indistinct,  hut  can  he  restored  l)y 
the  use  of  convex  glasses.  This  may  occur  in  one  or  in  hoth  eyes;  in  the 
latter  case  it  is  usually  associated  with  disease  in  the  nuclei  of  the  nerve. 
<'ycloplegia  is  an  early  and  frequent  symptom  in  diphtheritic  jiaralysis  and 
occurs  also  in  tahes. 

Iridopleyia,  or  paralysis  of  the  iris,  occurs  in  three  forms  (flowers). 

{(i)  Acaiiinnodatire  iridoplcf/ia,  in  which  the  })upil  does  not  diminish  in 
size  during  the  act  of  accommodation.  To  test  for  this  the  patient  should 
look  first  at  a  distant  and  then  at  a  near  ohject  in  the  same  line  of  vision 

(h)  lieflcx  Iridoiih'i/ia. — The  path  for  the  iris  reflex  is  along  the  optic 
nerve  and  tract  to  its  termination,  then  to  the  nucleus  of  the  third  nervs 
and  along  the  trunk  of  this  nerve  to  the  ciliary  ganglion,  and  so  through 
the  ciliary  nerves  to  the  eyes.  Each  eye  should  he  tested  seiiarately,  the 
other  one  heing  covered.  The  pat"  nt  should  look  at  a  distant  ohject  in  a 
dark  part  of  the  room;  then  a  l.ght  is  hrought  suddenly  in  front  of  the 
eye  at  a  distance  of  three  or  four  feet,  so  as  to  avoid  the  elfect  of  accommo- 
dation. Loss  of  this  iris  reflex  with  retention  of  the  accommodation  con- 
traction is  known  as  the  Argyll  Rohertson  pupil. 

(c)  Loss  of  the  Skin  L'effex. — If  the  skin  of  the  neck  is  pinched  or 
pricked  the  pupil  dilates  rcflexly,  the  afferent  im])ulses  heing  conveyed 
along  the  cervical  sympathetic.  Erb  jiointed  out  that  this  skin  reflex  is 
lost  usually  in  association  with  the  reflex  contraction,  hut  the  two  are  not 
necessarily  conjoined.  In  iridoplegia  the  pupils  are  often  small,  particu- 
larly in  s])inal  disease,  as  in  the  characteristic  small  ])U])ils  of  tabes — spinal 
myosis.     Iridoplegia  may  coexist  with  a  pupil  of  medium  size. 

Inequality  of  the  pupils — aniscoria — is  not  infrequent  in  progressive 
paresis  and  in  tabes.     It  may  also  occur  in  perfectly  healthy  individuals. 

Spasm. — Occasionally  in  meningitis  and  in  hysteria  there  is  sjiasm  of 
the  muscles  suiiplied  hy  the  tliird  nerve,  ]iarticularly  the  internal  rectus 
and  the  levator  palpebral  The  clonic  rhythmical  spasm  of  the  eye  muscles 
is  known  as  iiystagmKs.  in  which  there  is  usually  a  bilateral,  rhythmical, 
involuntary  movement  of  the  eyeballs.  The  condition  is  met  with  in  many 
congenital  and  acquired  brain  lesions,  in  albinism,  and  sometimes  in  coal- 
mi  ners. 

Fourth  Nerve  (Xemis  trorldcnris). — This  sup]ilies  the  superior  o1)lique 
musele.  In  its  course  around  the  outer  surface  of  the  crus  and  in  its 
]inssage  into  the  orbit  it  is  liable  to  be  compressed  by  tumors,  by  aneurism, 
or  in  the  exudation  of  basilar  meningitis.  Its  nucleus  in  the  upper  part 
of  the  fourth  ventricle  may  be  involved  by  tumors  or  undergo  degeneration 
with  the  other  ocular  nuclei.  The  superior  oblique  muscle  acts  in  such  a 
way  as  to  direct  the  eyeball  downward  and  rotates  it  slightly.  The  jiaralysis 
causes  defective  downward  and  inward  movement,  often  too  slight  to  be 


1048 


DISKASKS  OP  THE  NKUVOUH  SYSTKM. 


/ 


iKiticcd.     'I'lic   licid   is  iiicliiHMl   sdiiicwlial    forward   jiiiil   tnwiinl  llio  sound 
silk',  mid  tlicic  is  doiil)l('  vision  wiioji  the  |ijiti<'iit  looks  down. 

Sixth  Nerve  (Xrmis  (ilxliirnis). — 'I'iiis  nerve  enier<j:es  n\.  tlie  junction  of 
the  pons  iind  nie(lullii,  tlien,  |)iissin^^  rorwiird,  it  enters  the  orhit  and  su[»- 
])lies  tlie  exlerna!  rectus  muscle.  It  is  aU'eeted  liy  meningiti.s  at  the  base, 
hy  ^uniuiata  or  olher  tiuuors,  and  sonieliines  hy  c(dil.  'I'here  i.s  internal 
st  raitisiuus,  and  tlu-  eye  eaiiuol  lie  Inrneil  outward.  J  )i|i|o|»iii  occurs  on 
lookiuir  towai'd  tiu'  |»araly/.e(l  siile. 

"  When  tlie  nuideus  is  all'ected  there  is,  in  addition  to  [laraly-is  of  the 
external  rectus, inahilityof  the  internal  rectus  ol'  theoppo.site  eye  to  turn  tluit 
eye  inward.  As  a  conse(|nence  ol'  thi.s  the  axes  of  the  eyes  are  kept  i)arallel 
and  hotli  ai'c  con ju^ately  deviated  to  the  op|)osite  side,  away  from  the  side 
of  lesion.  The  reason  (d'  this  is  that  the  nucleus  of  the  sixth  nerve  sends 
fibres  up  in  the  pons  to  that  i)art  of  the  umdeus  of  the  ojjposite  third 
nerve  Avhich  suj)])lies  the  internal  recUis.  A\'e  thus  have  ])aralysis  of  the 
intermd  rectus  without  the  nucleus  -jf  the  third  nerve  being  involved, 
owing  to  its  receiving  its  nervous  impulses  for  parallel  movement  from 
the  sixth  nucleus  of  the  opposite  side.  As  the  sixth  nucleus  is  in  such 
]u'oximity  to  the  facial  ni'rve  in  the  siibstance  of  the  pons,  it  is  fre(juently 
found  that  the  whole  of  the  face  on  the  same  side  is  paralyzed,  and  gives 
the  electrical  reaction  of  degeneration,  so  that  with  a  lesion  of  the  left 
sixth  nucleus  there  is  conjugate  deviation  of  hoth  eyes  to  the  rifjhl — i.  e., 
paralysis  of  the  hd't  externid  and  the  right  internal  rectus,  and  sometimes 
complete  ])nralysis  of  the  Irfl  side  of  the  face"  (Heevor). 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye. — Gowers 

divides  them  into  tlve  groups: 

(a)  Liinilaliun  of  MoveiHcnt. — Thus,  in  paralysis  of  the  external  rectus, 
the  eyeball  cannot  be  moved  outward.  When  the  paralysis  is  incomplete 
the  movement  is  deficient  in  pro])ortion  to  the  degree  of  the  palsy. 

{}))  SIrahisiHUs. — The  axes  of  the  eyes  do  not  corres])ond.  Thus,  pa- 
ralysis of  the  internal  rectus  causes  a  divergent  s(|uint;  of  the  external 
rectus,  a  conveigent  squint.  At  first  this  is  only  evident  when  the  eyes  are 
moved  in  the  direction  of  the  action  of  the  weak  muscle,  but  may  become 
constant  by  the  contraction  of  the  opposing  muscle.  The  deviation  of  the 
axis  of  the  aU'ected  eye  from  parallelism  with  the  other  is  called  the  pri-> 
mary  deviation. 

(c)  Secondary  Dcvialion. — If,  Avhilc  the  patient  is  looking  at  an  ob- 
ject, the  sound  eye  is  covered,  so  that  he  fixes  the  object  looked  at  with 
the  affected  eye  only,  the  sound  eye  is  moved  still  further  in  the  same  di- 
rection— e.  g.,  outward — with  paralysis  of  the  opposite  internal  rectus. 
This  is  known  as  secondary  deviation.  It  depends  upon  the  fact  that,  if 
two  muscles  are  acting  together,  -when  one  is  weak  and  an  effort  is  made 
to  contract  it,  the  increased  effort — innervation — acts  powerfully  upon  the 
other  muscle,  causing  an  increased  contraction. 

((/)  Erroneous  Projcrlion. — "  "We  judge  of  the  relation  of  external  ob- 
jects to  each  other  by  the  relation  of  their  images  on  the  retina;  but  we 
judge  of  their  relation  to  our  own  body  by  the  position  of  the  eyeball 


DISKASKS  OF  TITR  CEIlKFMtAL   XKUVHS. 


ln4S> 


I    llio 


Kllllllil 


jiiiictioii  (if 
lil  iiiid  siip- 
iit  (Ik;  hiiM', 

is  iiitonuil 
I  occurs  on 

lysis  of  the 
l«)  turn  tliiit, 
c|)t  j)arall(.'l 
'Ui  llio  side 
Nerve  sends 
><>sile  third 
ysis  of  tlio 
;  involved, 
Mient  from 
is  in  such 
frequently 
,  and  gives 
of  the  left 
•i;/Jit — i.  e., 
sometimes 

3. — Gowers 

•nal  rectus, 
incomplete 

y- 

Thus,  pa- 
c  external 
le  eyes  are 
ay  become 
ion  of  the 
d  the  prin 

at  an  ob- 
?d  at  with 
3  same  di- 
lal  rectus. 
efc  that,  if 
"t  is  made 
upon  the 

ternal  ob- 
i;  but  we 
16  eyeball 


ns  indicated  to  us  by  the  innervation  we  jrive  to  llie  ucuhir  muscles" 
((ii)wers).  With  the  eyes  at  rest  in  tlie  niid-|H(sition,  an  ultjeet  at  wliicii 
we  are  looking  is  directly  opposite  nur   I'iiee.     Turning   tlie  eyes   to  one 

side,  we  recognize  tiiat  dhject  in  tlie  middle  (if  |l:e  Held  or  tn  llir  .-ide  (if 
this  t'ormer  i)osition.  We  estinuite  the  degree  hy  the  amount  of  movement 
of  the  eyes,  ami  when  tiie  object  nmves  and  we  I'dlhiw  it  we  judge  of  its 
position  bv  the  amount  of  movement  of  the  eyeballs.  When  one  (Kular 
niuscle  is  weak,  the  increased  innervation  givi'S  the  impression  oi  a  greater 
nu)Vement  of  the  eye  than  has  really  taken  jilace.  The  mind,  at  the  same 
time,  receives  the  idea  that  the  ohject  is  further  on  om-  side  than  it  really 
is,  and  in  an  attempt  to  touch  it  the  linger  may  go  beyond  it.  As  the 
(•(piilibrium  of  the  body  is  in  a  huge  part  maintained  by  a  knowledge  of 
the  relation  of  external  objects  to  it  obtained  hy  the  action  of  the  eye  mus- 
cles, this  erroneous  projection  resulting  from  paraly>is  disturbs  the  liar- 
nu)nv  of  these  visual  impressions  and  may  lead  to  giddiness — (tcular  vertigo. 

{<■)  J)()nl)lc  ]'i.si(iii. — This  is  one  of  the  most  disturbing  featui'cs  of 
paralysis  of  the  eye  muscles,  'i'he  visual  axes  do  not  correspond,  so  that 
there  is  a  double  image — diplopia.  That  seen  by  the  sound  eye  is  termed 
the  true  image;  that  by  the  j)aralyzed  eye,  tlu'  false.  In  simple  oi'  homon- 
ymous (liploi»ia  the  false  image  is  "  on  the  same  side  of  the  other  as  the  eye 
by  which  it  is  seen."  In  crossed  diplopia  it  is  on  the  other  side.  In  con- 
vergent sfpiint  the  diplopia  is  simple;  in  divergent  it  is  crossed. 

Ophthalmoplegia. —  Cnder  this  term  is  described  a  chronic  progressive 
paralysis  of  the  ocular  muscles.  Twi)  forms  are  recognizi'd— ophthalmo- 
])legia  e.rleniu  and  ophthalmoplegia  inlcnia.  The  conditions  may  occur 
se|)arately  or  together  and  are  described  by  (lowers  under  nuclear  ocular 
palsy. 

Ophlliahnoph'i/id  e.rlcnia. — The  condition  is  one  of  more  or  less  com- 
plete palsy  of  the  external  muscles  of  the  eyeball,  due  usually  to  a  slow 
degeneration  in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of 
tumors  or  to  basilar  meningitis.  It  is  often,  but  not  necessarily,  associate(l 
with  o])hthalmo])legia  interna.  Siemerling,  in  a  monograph  on  the  sul)- 
ject,  states  that  G;i  cases  are  on  record.  In  only  II  of  these  could  sy|)hilis 
be  positively  determined.  The  levator  muscles  of  the  eyelids  and  the 
superior  recti  arc  first  involved,  and  gradually  the  other  muscles,  so  that 
the  eyeballs  are  fixed  and  the  eyelids  droop.  There  is  sometimes  slight 
])rotrusion  of  the  eyeballs.  The  disease  is  essentially  chronic  and  may  last 
for  many  years.  It  is  found  particularly  in  association  with  general  paraly- 
sis, locomotor  ataxia,  and  in  progressive  muscular  atro])hy.  Mental  dis- 
orders were  present  in  11  of  the  03  cases.  With  it  may  be  associated 
atro]ihy  of  the  optic  nerve  and  affections  of  other  cerebral  nerves.  Occa- 
sionally, as  noted  by  liristowe,  it  may  be  functional. 

OphlltaJinopkf/ia  inlcnia. — Jonathan  Hutchinson  applied  this  term  to 
a  ])rogressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  iJUjiil- 
larv  action  and  the  power  of  accommodation.  When  the  intermd  ami  ex- 
ternal muscles  are  involved  the  affection  is  known  as  total  ophthalmoplegia, 
and  in  a  majority  of  the  cases  the  two  conditions  are  associated.  In  some 
instances  the  internal  form  may  depend  upon  disease  of  the  ciliary  ganglion. 


1050 


DISKASKS  OP  THR  NEI'VOUS  SYSTKM. 


/ 


\Vliil(>,  lis  II  mil',  (i|ililliiilm(nil('jfiii  is  n  chronic  jiroccss,  there  is  nn  acute 
fiiriii  iissociiilcd  witli  hiciiKirriuif^nc  Bol'tcniiij,'  of  the  nuclei  of  the  ocuhir 
inu.sch'!i.  'J'iieiv  i.s  usually  nuirked  ciu'ehral  disturhance.  It  was  to  this 
form  that  Wernicke  ^aw  the  name  |)olio-ence|thali(is  superior. 

Treatment  of  Ocular  Palsies. — it  is  important  to  ascertain,  it 
])ossil)le,  the  cause.  Tiie  I'ornis  associated  with  h)coniotor  ataxia  are  ol)- 
Btinate,  and  resist  treatment.  Occasionally,  however,  a  palsy,  complete  or 
partial,  may  ])ass  away  spontaneously.  The  ;,M'oup  of  casi'S  associated  with 
chronic  deji,('ncrative  chan;;cs,  as  in  pro<;rcssive  paresis  and  hidhar  j)araly- 
sis,  is  I'l.le  allected  hy  treatnu-nt.  On  the  other  hand,  in  syphiliiie  cases, 
mercury  and  iodide  of  ])otassium  are  indicated  and  are  often  henelicial. 
Arsenic  and  strychnia,  the  latter  hypoderniieally,  may  be  enii)loyed.  In 
any  case  in  which  the  onset  is  acute,  with  pnin,  hot  fomentations  and  coun- 
ter-irritation or  leeches  applied  to  the  temple  ^Mve  re'ief.  The  direct  treat- 
ment by  electricity  has  been  extensively  employed,  but  jirohably  without 
any  si)ecial  ell'ect.  The  diplo])ia  nuiy  be  relieved  l)y  the?  us(!  of  prisms,  or 
it  nuiy  ])e  necessary  to  cover  the  alfected  eye  with  an  opaque  glass. 


fli^ 


ii' 

ill 

I 


Fifth  Nkrve  {Nervits  (ritjeniinus). 

Pamhj.'^is  may  result  from:  (a)  Disease  of  the  pons,  particubirly  liirm- 
orrhage  or  jiatches  of  sclerosis,  (h)  Injury  or  disease  at  the  base  of  the 
brain.  Fracture  rarely  involves  the  nerve;  on  the  other  hand,  meningitis. 
acute  or  chronic,  and  caries  of  the  bone  are  not  uncommon  causes,  (r) 
The  branches  nuiy  be  atrected  as  they  ])ass  out — the  first  division  by  tumors 
])ressing  on  the  cavernous  sinus  or  by  aiu'urism;  the  second  and  third 
divisions  by  growths  which  invade  the  si)lieno-maxillary  fossa.  (</)  I'ri- 
nuiry  neuritis,  which  is  rare. 

Symptoms. — i>i)  Sensory  Portion. — Disease  of  the  fifth  nerve  may 
cause  loss  of  sensation  in  the  parts  su])])lied,  including  the  ludf  of  the  face, 
the  corresjionding  side  of  the  head,  the  conjunctiva,  the  mucosa  of  the  li]is, 
tongue,  bard  and  soft  palate,  and  of  the  nose  of  the  same  side.  The 
r.na>sthesia  may  be  preceded  by  tingling  or  pain.  The  muscles  of  the  face 
flre  also  insensible  and  the  movements  may  be  slower.  The  sense  of  smell 
is  interfered  with.  There  is  disturbance  of  the  sense  of  taste.  Then- 
tire,  in  addition,  hvphic  changes;  the  salivary,  lachrymal,  and  buccal  secre- 
tions may  be  lessened,  abrasions  of  the  mucous  mem])ranes  heal  slowly, 
and  tlie  teeth  may  become  loose.  The  eye  inflames,  the  cornere  become 
cloudy  and  may  ulcerate.  It  was  formerly  held  that  these  symptoms  only 
■occurred  when  the  Gasserian  ganglion  was  alfected.  but  of  late  years  this 
has  been  completely  removed  for  obstinate  neuralgia  without  producing 
any  trophic  disturbance.  This  apparent  contradiction  is  not  yet  explained. 
ITer])es  may  develop  in  the  region  supplied  by  the  nerve,  usually  the  upper 
branch,  and  is  associated  with  much  pain,  which  may  be  peculiarly  endur- 
ing, lasting  for  months  or  years  (Ciowers).  In  her])es  zoster  with  the  neu- 
ritis there  may  lie  slight  enlargement  of  the  cervical  glands. 

(h)  Motor  Portion. — The  inability  to  use  the  muscles  of  mastication  on 
the  affected  side  is  the  distinguishing  feature  of  paralysis  of  this  portion  of 


|,i.. 


DISKASKS  OP  TIIK  CKUKIUCAh   NKUVKS. 


ll>5l 


'0  irt  nil  lunite 

)i'  tho  ocular 

M'as  to  this 

asccrtiiiii,  if 
laxia  aro  oh- 
,  coiiipli'te  (ir 
sociatt'd  willi 
ulhar  paraly- 
tiiilitic:  cases, 
'II  liciicficial. 
iiploycd.  Jii 
lis  and  coim- 

dircct  trcat- 
iilily  witliout 
)l'  prisms,  or 
ass. 


iilarly  liaMii- 
base  of  tlic 

,  moniiiojitis. 
causes,     (r) 

II  ])y  iuiiiors 

I  and  tliird 
I.     ((/)  Pri- 

ncrvo  may 
of  tlie  face, 
of  the  li]is, 
side.     The 
of  tlie  face 
ISO  of  smell 
ste.     There 
uccal  secro- 
loal  slowly, 
003  become 
ptoms  only 
^  years  this 
l)ro(1uciii.i;' 
:  explained. 
'  the  upper 
irly  endur- 
h  the  nou- 

tication  on 
portion  of 


the  nerve.  It  is  rec(ij.Mii/ed  by  placing,'  the  lin;.'er  on  the  niasseler  and  leni- 
pmal  muscles,  and,  when  the  patient  closes  the  jaw,  tin*  I'eebleness  of  their 
(•(tntniction  is  noted  if  paraly/ed,  the  external  pterygoid  cannot  movo 
llu!  jaw  toward  the  unall'ected  side;  and  when  depressed,  the  jaw  deviate!* 
to  the  paralyzed  side.  'I"he  motor  paralysis  of  tiie  lirth  nerve  is  almost  in- 
variably a  result  of  involvement  ul  the  nerve  after  it  has  left  the  nucleus. 
Cases,  however,  have  been  associated  with  cortical  lesions,  liirt  concludes, 
from  his  case,  that  the  cortical  motor  centre  for  the  tri^^'eminus  is  in  tho 
ni'iirhborhood  of  the  lower  third  of  the  anterior  central  convolution. 

SjKtsm  of  llie  Muscles  of  Maslinition. — Trismus,  the  masticatory  spasm 
of  Koinber;,',  may  be  tonic  or  clonic,  and  is  either  an  associaltid  piieiiouu!- 
Mon  in  j,'eneral  convulsions  or,  more  larely,  an  independent  alTection.  in 
the  tonic  form  the  jaws  are  kept  close  to{,'ether — lock-jaw — or  can  be  sepa- 
rated only  for  a  short  space.  The  muscles  (d"  mastication  can  be  seen  in 
contraction  and  felt  to  he  hard;  the  spasm  is  often  painful,  'i'liis  tonic 
(ontraction  is  an  early  symptom  in  tetanus,  and  is  sometimes  seen  in  tetany. 
A  form  of  this  tonic  s|)asin  occurs  in  hysteria.  Occasionally  trismus 
follows  exposure  to  cold,  and  is  said  to  be  due  to  rcllcx  irritation  from 
the  teeth,  the  mouth,  or  caries  of  the  jaw.  It  may  also  be  a  symptom 
of  organic  disease  due  to  irritation  near  the  motor  nucleus  of  the  liltli 
nerve. 

Clonic  spasm  of  the  muscles  su]i])lied  by  the  fifth  occurs  in  the  form  of 
rapidly  reijcated  contractions,  as  in  '*  chattering  teeth."  This  is  rai'e  apart 
from  general  conditions,  though  cases  i;re  on  record,  usually  in  women  late 
in  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  has 
been  found.  In  another  form  of  clonic  spasm  sometimes  seen  in  chorea, 
there  are  forcible  single  contractions.  Ciowers  mentions  an  instance  of  its 
occurrence  as  an  isolated  alfection. 

(r)  (lusfalonj. — Loss  (d"  the  sense  of  taste  in  the  anterior  two  thirds  .of 
the  tongue,  as  a  rule,  follows  paralysis  of  the  fifth  nerve.  The  gustatory 
libres  pass  from  the  chorda  tympani  to  the  lingual  branch  of  the  fifth, 
hisease  of  the  fifth  nerve  is,  however,  not  always  associated  with  loss  of 
taste  in  the  anterior  ])art  of  the  tongue,  in  which  case  cither  the  taste 
libres  escape,  or  the  disease  is  within  the  pons  where  these  fibres:  are  sepa- 
rate from  those  of  sensation.  It  may  be  that  the  ncrvus  intermedins  of 
Wrisberg  carries  the  taste  fibres. 

The  didfi/iosis  of  disease  of  tho  trifacial  nerve  is  rarely  difficult.  It 
must  be  remembered  that  the  ])rcliminary  ])ain  and  hypera'sthesia  are 
sometimes  mistaken  for  ordinary  n«  uralgia.  The  loss  of  sensation  ajid  the 
pidsy  of  the  muscles  of  mastication  are  readily  determined. 

Treatment. — When  the  pain  is  severe  morphia  may  be  re(|uired  and 
local  a])])lications  are  nscful.  If  there  is  a  sus])icion  of  syphilis,  appro[)ri- 
ate  treatment  should  be  given.     Faradization  is  sometimes  beneficial. 

Facial  Xerve. 

Paralysis  (BelVs  Pnlsj/). — The  facial  or  seventh  may  be  paralyzed  by 
(1)  lesions  of  the  cortex — supranuclear  i)al.'^y;  (•■?)  lesions  of  the  nucleus 


1 


1053 


hISKASKS   OF  TIIK    NKItVofS  SVsTKM. 


nil 


ilscll';  or  (:i)  iiivn|\tiiii'iit  111'  llic  iirrvc  triiiiK  in  ils  turtiiuiis  ctmi'Kc  w  i 

till'   |i(i|is  iiImI   llu-<itlL:ll    tlir   Willi   of   llu>  Hkllll. 

1.  t< II /mill IK  liar  /ninil'isis,  iliic  to  lesion  of  tlic  cortex  or  of  the  faeiiil 
iWtrvH  in  tiie  cnioiin  nitliutii  or  inleriial  eii|i<iile,  is,  ns  a  rule,  a>soeialei! 
with  herniph'^'ia.  It  iiiav  he  caused  hy  liiiiiors,  ahscess,  clironic  inllaninia- 
tioii,  or  softenin;;  in  the  cortex  or  in  the  re^^ioii  of  the  inlcriial  ca|isnh.'.  Il 
is  (listiiij^iiished  from  the  |ieri|ilieriil  form  hy  \ve!l-marl<eil  characttTrt — the 
persistenc*'  of  the  normal  electrical  cxcitahility  of  hotli  nerves  and  iiiuscle- 
and  tlieahsence  of  involvement  of  the  upper  hranclie>  (d'  the  nerse,  >o  tlinl 
the  oi'hiciilaris  palpehranim  iind  frontalis  muscle  are  spared,  in  rare  in- 
HtaticcH  thi'Sv'  Miuwtdcs  are  paralyzed.  A  ftiird  dill'cience  is  that  in  this  form 
the  voluntary  movements  are  more  impaired  than  the  emotional.  There 
arc  instances  of  cortical  facial  paralysis — m(inoplc|:ia  facialis — associated 
M'ith  lesions  in  the  centre  for  the  face  muscles  in  the  lower  Uolandic  re- 
^'ion.  Is(dated  paralysis,  due  to  involvement  of  the  ner\i'  lihics  in  their 
path  to  the  nucleus,  is  uncommon.  In  the  jireat  majority  of  cases  supra- 
nuclear facial  paralysis  is  part  of  a  h<'niiplei,da.  Paralysis  is  on  the  same 
Hide  as  that  of  the  arm  and  le;;  hecaiisc  the  facial  muscles  hear  jireci'  -ly  the 
same  relation  to  the  cortex  as  the  spinal  muscles,  'i'lie  niich'i  of  ori^nn  on 
either  side  of  the  middle  line  in  the  mcdiillM  arc  united  hy  deeus.sntin;^^ 
ilhrcs  with  the  coi'tical  centre  on  the  opposite  side  (see  l''i^'.  1  1).  A  few  lihres 
reach  the  nucleus  from  the  cerehral  corti'X  of  the  same  side  (Melius,  lloche). 

'4.  The  inirlriir  /iiiriili/sis  caused  hy  lesions  of  the  nerve  centres  in  the 
ine(liilla  is  not  common  alone;  hut  is  seen  occasionally  in  tumors,  chronic 
s(d'tenin{i,  and  hieniorrha^^c.  \\\'  have  had  one  instance  of  its  involvement  in 
anterior  polio-myiditis.  in  diphtheria  this  centre  may  also  he  involved. 
The  sym!)tonis  are  |)ractically  similar  to  th»tse  of  an  all'ectiou  of  the  nerve 
iihre  itself — infranuclear  paralysis. 

;?.  I iiri)liriiinit  of  llie  Nerve  Tniid'. — Paralysis  may  result  from: 

{(i)  Involvement  of  the  nerve  as  it  ])asses  tlirou<;h  the  pons — that  is, 
hetween  its  nucleus  in  the  lloor  of  the  fourth  ventricle  and  the  jxiint  of 
cMiicrpence  in  the  ])ostero-lateral  aspect  of  the  ])ons.  The  specially  inter- 
estin,!,'  feature  in  connection  with  involvi'inent  of  this  ])art  is  the  production 
of  what  is  called  alternating  or  crossed  panili/sis,  the  face  heinjj  involved  on 
the  same  side  as  the  lesion,  and  the  arm  and  lejj:  on  the  o])posit(?  side,  since 
the  motor  jiatli  is  involved  ahove  the;  ])()int  of  decussation  in  the  me(lulla 
(Fif?.  11).  This  occurs  only  when  the  lesion  is  in  the  lower  section  of  the 
pons.  A  lesion  in  the  up)>er  half  of  the  pons  involves  the  lihres  not  of  the 
outj^oin^  nerve  on  the  same  side,  hut  of  the  fihres  from  the  hemispheres 
hefore  they  have  crossed  to  the  nucleus  of  the  op])osite  side.  In  this  case 
there  would  of  course  he,  ns  in  hemijilegia,  ])aralysis  of  the  face  and  lind)s 
on  the  side  opposite  to  the  lesion.  The  palsy,  too,  would  resemble  the  cere- 
hral form,  involvini,'  only  the  lower  fihres  of  the  facial  nerve. 

(h)  The  nerve  may  he  involved  at  its  point  of  enu'rjfence  hy  tumors, 
fiummata,  menijigitis,  or  occasioiudly  may  he  injured  in  fracture  of  the 
base. 

{(•)  In  passing  through  the  Fallo])ian  canal  the  nerve  may  he  involved 
in  disease  o:':  the  car,  particularly  by  caries  of  the  hone  in  otitis  media. 


1 


DISKASES  OK  TIIK  CKUKinfAIi   N'KUVKS. 


KC.T 


iilt's<>  w  ithiii 
)!'  llir  I'liciiil 

ll.xSOcillttMl 

(!  iiilliiiiiiini- 
(■a|)siilL>.  1 1 
niclcrs — llif 
mill  iiiiiscli's 
I'i'M',  so  tlitit 
III  riirc  ill- 
ill  this  I'linii 
Mill,  'riicic 
— iissticiiilcil 
lidliiiidic  rc- 
)ITH  in  their 
cases  siipra- 
1)11  the  same 
preei'  -ly  till' 
III'  oiiniii  oil 

dccussatiii;^ 
A  few  lilire^ 
Ills,  Il(telie). 
lltri'H  iti  the 
lors,  chronic 
^•olvemciit  ill 
he  ilivohed. 
of  the  nerve 

from: 

)ns — that  is, 
the  ])oiiit  of 
}cially  intor- 
e  production 

involved  on 
t(!  side,  since 

the  medulla 
3ction  of  the 
es  not  of  the 

heinisphercs 

In  this  case 
ce  and  liinljs 
ible  the  cere- 

3  l)y  tumors, 
cture  of  the 

■  ])C  involved 
otitis  media. 


This  is  a  coiiiiiniii  (iiii>e  in  children,  i  have  .■.ecu  two  instantcs  follow  utiti.-i 
in  puerperal  fever. 

{(/)  \h  the  nerve  einer^'i's  from  the  Hlylojd  foramen  it  is  exposed  to 
injuries  ami  hlows  which  not  inficcpieiitly  ciiii>e  pnralysis.  'The  lihres  may 
lie  cut  in  the  removal  of  tumors  in  tiiis  re;;ion,  or  the  paraly-is  may  In; 
(iiused  Iiy  pressure  (d'  the  forceps  in  an  instrumental  delivery. 

(/')  Ivxposurc  to  cold  is  the  iiio.-.t  common  cause  nf  facial  |iaralysis,  in- 
ihiciii;^'  a  neuritis  id'  the  nerve  within  the  l''allopinii  canal. 

(/)  Syphilis  is  not  an  infre(pient  caii-*e.  and  the  paralysis  may  devehip 
early  with  tin;  secondary  sympltuiis. 

(//)  It  may  develop  willi  herpes. 

/•'(iiiiil  (liiilri/in  is  a  rare  condition  occasionally  found  in  nlTections  at 
the  hiise  (d'  the  hraiii,  lesions  in  the  pons,  simidtaiieoiis  involvement  of  the 
nerves  in  ear  disease,  and  in  diplit  lu'ritic  paralvsis.  hisease  of  the  nuclei 
or  symmetrical  involvement  of  the  cortex  nii;:lit  also  produce  it.  It  may 
(i((  iir  as  a  con;,fcnital  all'ection.  ||.  M.  Thomas  has  descrihed  two  cases  in 
one  family. 

Symptoms.  —  in  the  peripheral  facial  paraly>is  all  the  hramhes  id' 
I  lie  iiei\('  are  involved,  'i'lie  lace  on  the  atl'ecled  side  is  iminohile  and  can 
iieilher  lie  moved  at  will  nor  participate  in  a*"  emotional  nioveiiieiits.  The 
-kin  is  smooth  and  the  wrinkles  are  ciraced,  a  point  particularly  noticc- 
ahle  on  the  foridiead  of  elderly  persons.  The  eye  cannot  he  closed,  the 
lower  lid  droops,  and  the  eye  waters.  On  tlu'  all'i'cted  side  the  an;.de  of 
till'  month  is  lowered,  and  in  dri'ikinj;  the  lips  are  not  kept  in  close  ajtposi- 
tion  to  the  ^lass,  so  that  the  liipiid  is  apt  to  run  out.  In  sniilin*^'  or  lau;^di- 
iii^f  the  contrast  is  most  striking:,  as  the  alfcclcd  side  does  not  move,  which 
;.:ives  a  curious  uncipial  appearance  to  the  two  sides  of  the  face.  The  eye 
cannot  he  closed  nor  can  the  forehead  he  wrinklcil.  in  lonj^-staudin^ 
cases,  wlu'ii  the  reaction  of  de>feneration  is  present,  if  the  patient  tries  to 
close  the  eyes  while  lookinj,'  lixedly  at  an  ohject  the  lids  on  the  s(uind  side 
close  firmly,  Itiit  on  the  paralyzed  side  there  is  (Uily  a  narrowing'  of  tin; 
palpehral  orilice,  and  the  eye  is  turned  upward  and  outward  hy  the  inferior 
ohli(pie.  On  askinji'  the  jiatient  to  show  his  upper  teclli.  the  aiiLile  of  the 
mouth  is  not  raised.  In  all  these  movements  the  face  is  drawn  to  the  sound 
>ide  hy  the  action  (d'  the  muscles.  Speaking;  may  he  slij^htly  interfered 
with,  owin;;;  to  the  impi'rfectiiui  in  the  formaticm  of  the  lahial  sounds. 
\\'liistlin;j:  cannot  he  performed.  In  cliewin<:  tlu;  food,  owing  to  the  paraly- 
sis of  the  hiiccinator,  particles  c(dlect  on  tli'  all'ected  side.  The  paralysis 
(if  the  nasal  muscles  is  seen  on  asking  the  patient  to  snilf.  Owing  to  the 
fact  that  the  lips  aic  drawn  to  the  sound  side,  the  tongue,  when  protruded, 
liioks  as  if  it  were  pushed  to  the  ]iaralyzed  side;  hut  on  taking  its  position 
I'l'oiii  the  ii.cisor  teeth,  it  will  he  found  to  he  in  the  middle  line.  The  rellex 
movements  are  lost  in  this  peripheral  form.  It  is  usually  stated  that  the 
palate  is  paralyzed  on  the  same  side  and  that  the  uvula  deviates.  J'oth 
<Jowers  and  Jlughlings  Jackson  (h'liy  the  existence  of  this  involvement  in 
ilie  great  majority  of  cases,  and  Ilorsley  and  Beevor  have  shown  that  these 
parts  are  innervated  hy  the  accessory  nerve  to  the  vagus. 

AVlien  the  nerve  is  involved  within  the  canal  hetween  the  jrcnu  and  the 


1U51 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


ilJIi; 


'.;  t- 


origin  of  tlic  cliorila  tynipani,  tlic  sense  of  taste  may  l)e  lost  in  tlie  anterior 
])art  of  the  ton<,Mic  on  tiie  all'eeted  side,  o\vin<f  probably  to  injury  to  tlie 
nervus  interniedius  of  Wrisberj,'.  When  tlie  nerve  is  damaged  outside  the 
skull  the  sense  of  taste  is  unaU'ected.  Hearing  is  often  impaired  in  faeial 
])aralysis,  most  commoidy  by  preceding  ear-disease.  The  paralysis  of  tho 
stiipedius  vuisele  may  lead  to  increased  sensitiveness  to  musical  notes. 
]Ierpes  is  t,)metimes  associated  with  facial  jiaralysis.  Pain  is  not  eomnioii, 
but  there  may  be  neuralgia  about  the  ear.  The  face  on  the  aU'ected  side 
may  be  swollen. 

T!ie  electrical  reactions,  which  arc  those  of  a  perijdicral  palsy,  have  con- 
siderable iniportance  from  a  prognostic  standpoint.  ]']rb's  rules  are  as 
follows:  If  there  is  no  change,  either  faradic  or  galvanic,  the  ])rogn()si.> 
is  good  and  recovery  takes  ])lace  in  from  fourteen  to  twenty  days.  If  the 
faradic  and  galvanic  excitability  of  the  nerve  is  only  lessened  and  that  of 
the  muscle  increased  to  the  galvanic  current  and  the  contraction  formula 
altered  (the  contraction  sluggish  AnC*>C't'),  the  outlook  is  relatively  good 
and  recovery  will  j)robably  take  ])lace  in  from  four  to  si.x  weeks;  occasion- 
ally in  from  eight  to  ten.  When  the  reaction  of  degeneration  is  present — 
that  is,  if  the  faradic  and  galvanic  excitability  of  the  nerves  and  the  faradic 
excital)ility  of  the  muscles  are  lost  and  the  galvanic  excitability  of  the 
muscle  is  ([uantitatively  increased  and  (jualitatively  changed,  and  if  the 
mechanical  excitability  is  altered — the  prognosis  is  relatively  unfavorable 
and  the  recovery  may  not  occur  for  two,  six,  eight,  or  even  lifteen  months. 

The  course  of  facial  ]»aralysis  is  usually  favorable.  The  onset  in  the 
form  following  cold  is  very  rapid,  developing  ])erha]^s  within  twniy-four 
hours,  but  rarely  is  the  ])ara]ysis  permanent.  Eecurring  attacks  have  been 
descrdjcd;  Sinkler  mentions  five.  On  the  other  hand,- in  the  paralysis  from 
injury,  as  by  a  blow  on  the  mastoid  process,  the  condition  may  remain. 
"When  permanent,  the  muscles  are  entirely  toneless.  In  som  instances  con- 
tracture develo])s  as  the  voluntary  power  returns,  and  the  natural  folds 
and  the  wrinkles  on  the  affected  side  may  be  deepened,  so  that  on  looking 
at  the  face  one  at  first  may  have  the  impression  that  the  affected  side  is 
the  soiind  one.  This  is  corrected  at  once  on  asking  the  patient  to  smile, 
■when  it  is  seen  which  side  of  the  face  has  the  most  active  movement.  Are- 
tanis  noted  the  dillicidty  sometimes  experienced  in  determining  which  side 
was  affected  until  the  patient  spcke  or  laughed. 

The  diagnosis  of  facial  paralysis  is  usually  easy.  The  distinction  be- 
tween the  ])eripheral  and  central  form  is  hapcd  on  facts  already  mentioned. 

Treatment. — In  the  cases  which  result  from  cold  and  are  probably 
due  to  neuritis  within  the  l)ony  canal,  hot  applications  first  should  he  made; 
suhsequently  the  thermo-cantery  nuiy  be  used  lightly  at  intervals  of  a 
day  or  two  over  the  mastoid  ])rocess,  or  small  blisters  applied.  If  the 
ear  is  diseased,  free  discharge  for  the  secretion  should  he  obtained.  The 
continuous  current  may  be  employed  to  keep  u])  the  nutrition  of  the  mus- 
cles. The  positive  y)ole  should  he  placed  behind  the  ear,  the  negative  one 
along  the  zygomatic  and  other  muscles.  The  application  can  he  made  daily 
for  a  quarter  of  an  hour  and  the  ]iatient  can  readily  be  taught  to  make  it 


himself  before  the  looking-glass. 


^Massage  of  the  muscles  of  the  face  is  also 


DISEASES  OF  THE  CEIIEUUAL  NEUVES. 


I(i5i> 


tlic  nntcridr 
ijury  to  the 
outsido  tlic 
:v(l  in  facial 
ilysis  of  tjie 
isical  ]iot(-'.<. 
lot  coiiiinoi), 
iiircetud  side 

y,  have  con- 
rulori  are  as 
10  ])ro<j;iio^is 
lays.  If  the 
and  that  of 
ion  fornuda 
ativcly  good 
cs;  occasion- 
is  present — 
I  tlie  faradie 
)ili'ty  of  the 

and  if  tlie 
unfavoraljle 
een  montlis. 
3nset  in  tlie 
twniy-foiir 
:s  have  been 
ralysis  from 
nay  remain, 
stances  con- 
atural  fohls 

on  iookini^ 
cted  side  is 
nt  to  smile, 
ment.     Are- 

whicli  side 

tinction  bo- 
mentioned, 
re  probably 
Id  be  made; 
ervals  of  a 
ed.     If  the 
lined.     The 
of  the  mus- 
icgativc  one 
made  daily 
to  make  it 
face  is  also 


useful.    A  course  of  iodide  of  jjotassium  may  bo  ;^Mven  even  when  there  is 
no  indication  of  syphilis. 

In  some  of  tlie  traumatic  cases  the  possibility  of  surgical  interference 
may  be  considered.  Jn  a  patient  with  chronic  otitis  media  of  twenty-three 
years'  duration  and  secondary  mastoid  disease  liloodgood  operated  in  ^lay, 
18'JO,  Complete  facial  ])aralysis  followed.  I'liglit  weeks  later  the  facial 
nerve  was  exposed  in  its  canal  and  found  to  be  almost  completely  sevt-red. 
The  ends  were  brought  together  and  the  wound  allowed  to  till  with  blood- 
clot,  which  organized.  F(nir  months  later  the  jiatieut  had  improved,  and 
olio  year  and  six  months  from  the  operation  the  jiowor  had  returned  to  all 
the  muscles  except  the  occipito-l'roiitalis  and  the  depressor  of  the  lower  lip. 
The  resjionse  to  galvanic  and  faradie  currents  was  normal. 

Spasm. — The  spasm  may  be  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  facial  nerve  and  may  be  unilateral  or  bilateral. 

It  is  known  also  by  the  name  of  mimic  s[)asm  or  of  convulsive  tic.  Sev- 
eral dilfereut  aU'ectioiis  are  usually  considered  under  the  name  of  facial 
or  mimic  spasm,  but  we  shall  here  speak  only  of  the  simple  spasm  of  the 
facial  muscles,  either  ])riniary  or  following  ])aralysis,  and  shall  not  in- 
clude the  eases  of  habit  s])asm  in  children,  or  the  tic  cniivulsif  of  the 
French. 

Gowers  recognizes  two  classes — one  in  which  there  is  an  organic  lesion, 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  reflex  causes,  such 
as  the  irritation  from  carious  teeth  or  the  i)rosence  of  intestinal  wonii-. 
The  disease  usually  occurs  in  adults,  whereas  the  habit  si)asni  and  the  lie 
('Diinilsif  of  the  French,  often  confounded  with  it,  are  most  common  in 
children.  True  mimic  spasm  occasionally  comes  on  in  childhood  and  per- 
sists. In  the  case  of  a  school-mate,  the  affection  was  nuirked  as  early  as 
the  eleventh  or  twelfth  year  and  still  continues.  When  the  result  of  or- 
ganic disease,  there  has  usually  been  a  lesion  of  the  centre  in  the  cortex,  as 
in  the  case  reported  by  Ik-rkeley,  or  pressure  on  the  nerve  at  the  base  of 
the  brain  by  aneurism  or  tumor. 

Symptoms. — The  s])asm  may  involve  only  the  muscles  annind  the 
(ye — blepharospasm — in  which  case  there  is  constant,  ra])id,  tpiick  action 
of  the  orbicularis  palpebrarum,  which,  in  association  with  ])hotopliol)ia, 
may  be  tonic  in  character.  ]\[ore  commonly  the  spasm  affects  the  lateral 
facial  muscles  with  those  of  the  eye,  and  there  is  constant  twitching  of  the 
side  of  the  face  with  partial  closure  of  the  eye.  The  frontalis  is  rarely  in- 
volved. In  aggravated  cases  the  doiiressors  of  the  angle  of  the  mouth,  the 
levator  menti,  and  the  jdatysma  myoides  are  affected.  This  spasm  is  con- 
fined to  one  side  of  the  face  in  a  majority  of  cases,  though  it  may  extend 
and  become  bilateral.  It  is  increa.sed  by  emotional  causes  and  involunlaiy 
movements  of  the  face.  As  a  rule,  it  is  ])ainloss,  but  there  may  be  tender 
points  over  the  course  of  the  fifth  nerve,  particularly  the  sujiraorbital 
branch.  Tonic  spasm  of  the  facial  muscle  may  follow  paralysis,  and  is  said 
to  result  occasionally  from  cold. 

The  ontlook  in  facial  spasm  is  always  dubious.  A  majority  of  the  cases 
persist  for  years  and  arc  incurable. 


w^m 


1056 


DISEASES  t)F   THE  NERVOUS  SYSTEM. 


Treatment. — Sources  of  irritation  sliould  bo  looked  for  and  rcniovcd. 
\Vlicii  a  |iaiiirul  s|)ot  i>  iircHciit  over  the  tiftli  nerve,  l)listerin<i;  or  the  appli- 
eatioii  of  ihe  tjii'riiio-eaiitery  may  relieve  it.  1 1 yi»oderniic  injections  of 
strychnia  may  In-  tried,  Imt  are  of  doubtful  l)t'Melil.  Weir  Mitciiell  recom- 
men<ls  the  free/iu<f  of  the  cheek  I'or  a  lew  miuute.s  (hiily  or  every  second 
(hiy  with  the  spi'ay,  and  this,  in  some  instances,  is  l)euelicial.  Often  the  re- 
lief is  transient;  the  cases  return,  and  at  every  clinic  nuiy  be  seen  half  u 
(h)zeu  or  more  of  such  patieiits  wiio  have  run  the  <,f!imut  ol'  all  ineasurcs 
without  material  improvement.  Operative  interference  may  be  resorted  to 
in  severe  cases,  althou<i:h  not  much  can  Ijc  expected  of  it. 


/ 


AlDlTOUY    XkHVK. 

The  ci^dith,  known  also  as  porCw  mollis  of  the  seventh  pair,  passes  from 
the  ear  throu<iii  tiie  internal  auditory  meatus,  and  in  reality  consists  of  two 
separate  nerves — the  cochlear  and  vestibular  roots.  These  two  roots  have 
entirely  different  functions,  and  may  therefore  be  best  considered  sejjarately. 
The  cochlear  nerve  is  the  one  connected  with  the  organ  of  Corti,  and  is  con- 
cerned in  hearing.  The  vestil)ular  nerve  is  connected  with  the  vestibule 
and  semicircuhir  canals,  and  has  to  do  with  the  nuiintenance  of  equilibrium. 


The  Cochlear  Xerre. 

The  cortical  centre  for  hearing  is  in  the  temporo-sphenoidal  lobe.  Pri- 
mary disease  of  the  anditory  nerve  in  its  centre  or  intracranial  conrse  is 
nncommon.  ^lore  frequently  the  terminal  branches  are  affected  within  the 
labyrinth. 

{(i)  Affcclioii  of  Ihe  Coiiiral  Cenlre. — In  the  monkey,  experiments  indi- 
cate that  the  superior  tem])oral  gyrus  re])resents  the  centre  for  hearing.  In 
man  the  cases  of  disease  indicate  that  it  has  the  same  situation,as  destruction 
of  this  gyrns  on  the  left  side  results  in  word-deafness,  which  may  be  defined 
as  an  inability  to  understand  the  meaning  of  words,  though  they  may  still 
be  heard  as  sounds.  The  central  auditory  ])ath  extending  to  the  cortical 
centre  from  the  terminal  nuclei  of  the  cochlear  nerve  may  ])e  involved  and 
produce  deafness.  This  may  result  from  involvement  of  the  lateral  lemnis- 
cus from  the  presence  of  a  tumor  in  the  corpora  quadrigemina,  especially 
if  it  involve  the  ])Osterior  quadrigeminal  bodies  from  a  lesion  of  the  internal 
geniculate  body,  or  it  may  be  associated  with  a  lesion  of  the  internal  cap- 
sule. 

(h)  Lesions  of  Ihe  iirrre  al  Ihe  hase  of  the  brain  may  result  from  the 
pressiire  of  tumors,  meningitis  (particbirly  the  cerebro-spinal  form),  haem- 
orrhage, or  traumatism.  A  primary  degeneration  of  the  nerve  may  occur 
in  locomotor  ataxia.  Primary  disease  of  the  terminal  nuclei  of  the  cochlear 
nerve  (niicleus  nervi  cochlearis  dorsalis  and  nucleus  nervi  cocblearis  ven- 
tralis)  is  rare.  I>y  far  the  most  interesting  form  residts  from  ei)idcmic 
cerebro-s]iinal  meningitis,  in  which  the  nerve  is  frequently  involved,  caus- 
ing ])ernianent  deafness.  In  young  children  the  condition  results  in  deaf- 
mutism. 


DISEASES  OP  THE  CEREBRAL  NERVES, 


1057 


1(1  rcniovfd. 
11'  llio  ai)iili- 
iijoctions  of 
.'ht'll  rccom- 
wvy  second 
>l'k'ii  tlie  ro- 
Hc'cn  luilf  a 
\\[  measures 
!  resorted  to 


passes  from 
iisists  of  two 
3  roots  liave 
d  seiiaratel}'. 
,  and  is  con- 
he  vestil)ule 
equilibrium. 


1  lobe.  Pri- 
ial  course  is 
1  witliin  the 

inu'uts  indi- 
liearing.  In 
5  destruction 
y  be  defined 
ley  may  still 

the  cortical 
nvolved  and 
teral  lemnis- 
a,  es])ecially 

the  internal 
nternal  eap- 

dt  from  the 
form),  luvm- 
e  may  occur 
the  cochlear 
'Idearis  vcn- 
)m  e])idemic 
i-nlved,  caus- 
ults  in  deaf- 


(r)  In  a  majority  of  the  cases  associated  with  auditory-norvc  syniptoms 
the  lesion  is  in  the  internal  ear,  either  i»rimary  or  tlie  result  of  extension 
(it  disease  of  the  middle  ear.  'J'wo  <,n'oups  of  symptoms  may  he  produced — 
Jiyperii'sthesia  and  irritation  and  diminished  function  or  nervous  deafness. 

(1)  Jli/peni'sl  lies  ill  and  lirildlion. — This  may  he  due  to  altered  func- 
tion of  the  centre  as  well  as  of  the  nerve  ending.  True  hyi)era'sthesia — ■ 
hyi)eracusis — is  a  condition  in  whicli  sounds,  sonietinies  even  those  inaudi- 
ble to  other  ])ersons,  are  heard  with  great  intensity.  It  occurs  in  hysteria 
and  occasionally  in  cerebral  disease.  As  already  mentioiu-d,  in  [)aralysis 
of  the  stapedius  low  notes  may  be  heard  with  intensity,  in  dysa'sthesia, 
or  dysacusis,  ordinary  sounds  cause  an  unpleasant  sensation,  is  commonly 
happens  in  connection  with  headache,  Avhen  ordinary  noises  are  badly 
borne. 

Tinnitus  (tiiriinn  is  a  term  employed  to  designate  certain  subjective 
sensations  of  ringing,  roaring,  ticking,  and  whirring  noises  in  the  ear.  It  is 
a  very  common  and  often  a  distressing  symptom.  It  is  associated  with  many 
forms  of  ear-disease  and  may  result  from  pressure  of  wax  on  the  drum.  It 
is  rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Sudden 
intense  stimulation  of  the  nerve  may  cause  it.  A  form  not  uncommonly 
met  with  in  medical  ])ractice  is  that  in  which  the  i)atient  hears  a  continual 
hritit  in  the  ear,  and  the  noise  has  a  systolic  intensification,  usually  on  one 
side.  I  have  twice  been  consulted  by  physicians  for  this  condition  under 
the  belief  that  they  had  an  internal  aneurism.  A  systolic  murmur  may  be 
heard  occasionally  on  auscultation.  It  occurs  in  conditions  of  anirmia  and 
neurasthenia.  Subjective  noises  in  the  ear  may  precede  an  e])ile])tic  seizure 
and  are  sometimes  present  in  migraine.  In  whatever  form  tinnitus  exists, 
though  slight  and  often  regarded  as  trivial,  it  occasions  great  annoyance 
and  often  mental  distress,  and  has  even  driven  patients  to  suicide. 

The  diapnosis  is  readily  made;  but  it  is  often  extremely  dilficult  to  de- 
termine u])on  what  condition  the  tinnitus  depends.  The  relief  of  con- 
stitutional states,  such  as  an.Tmia,  neurasthenia,  or  gout,  may  result  in 
cure.  A  careful  local  examination  of  the  ear  should  always  ])e  made.  One 
of  the  most  worrying  forms  is  the  constant  clicking,  sometinu's  audil)le 
many  feet  away  from  the  ])atient,  and  due  probal)ly  to  clonic  s])asm  of  the 
muscles  connected  witli  the  Eustachian  tube  or  of  the  levator  ])alati.  The 
condition  may  yiersist  for  years  unchanged,  and  then  disa])pear  suddenly. 
The  ])idsating  forms  of  tinnitus,  in  which  the  sound  is  like  that  of  a  sys- 
tolic hrvif,  are  almost  invariably  subjective,  and  it  is  very  rare  to  hear  any- 
thing with  the  stethosco])e.  It  is  to  be  remembered  that  in  children  there 
is  >',  systolic  brain  murr  iir,  best  heard  over  the  ear,  and  in  soine  instances 
appreciable  in  the  adult. 

(2)  Diminished  Function  or  Nervous  Deafness. — In  testing  for  nervous 
deafness,  if  the  tuning-fork  cannot  be  heard  when  ])laced  near  the  meatus, 
but  the  vibrations  are  audible  by  placing  the  foot  of  the  tuning-fork  against 
the  temporal  bone,  the  conclusion  may  be  drawn  that  the  deafness  is  not 
due  to  involvement  of  the  nerve.  The  vibrations  are  conveyed  through 
the  temporal  bone  to  the  cochlea  and  vestibule.  The  watch  may  be  used 
for  the  same  purpose,  and  if  the  meatus  is  closed  and  the  watch  is  heard 

66 


1058 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


better  in  contact  with  the  mastoid  process  than  wlicn  opposite  the  open 
meatus,  tlie  deafness  is  jjpohahly  not  nervous.  I'raelieally,  dislurhaiiee  ol 
the  J'uiK-tion  ol'  the  auditory  nerve  is  not  a  very  I'recpient  sym])lum  in 
brain-disease,  hut  in  all  eases  the  I'unetion  of  tlie  nerve  should  he  carefully 
tested. 

TJic   Vcslibahir  Xerre. 

The  most  freqnent  symptoms  met  with  in  association  with  disease  of  tlu^ 
vestihular  nerve  and  its  central  connections  are  vertigo,  nystagmus,  and 
loss  of  coordination  of  tiie  muscles  of  the  head,  neck,  and  eyes. 

Auditory  Vertigo — Mfinifere's  Disease. — In  18(!1  ^Meniere,  a  French  phy- 
sician, descrihed  an  aiVection  characterized  by  noises  in  the  ear,  vertig  > 
(which  might  be  a.ssociated  with  loss  of  consciousness),  vomiting,  and,  in 
many  cuses,  progressive  loss  of  hearing.  The  term  is  now  used  to  include 
all  caM.s  of  sudden  vertigo  accompanied  by  noises  in  the  ear  and  deafness. 
The  frequency  of  vertigo  with  car  symjitoms  is  striking.  '^JMius,  of  10(j  cases 
noted  by  lowers,  in  which  there  was  definite  vertigo,  in  'J4  ear  symptoms 
wore  present,  either  tinnitus  or  deafness  or  both. 

Symptoms. — The  attack  usually  sets  in  suddenly  wit',  a  buzzing  noise 
in  the  ears  and  the  patient  feels  as  if  he  was  reeling  or  staggering,  lie 
may  feel  himself  to  be  reeling,  or  the  o])jects  about  him  may  seem  to  be 
turning,  or  the  phenomena  may  be  condjined.  The  attack  is  often  so 
abru])t  that  the  patient  falls,  though,  as  a  rule,  he  has  time  to  steady  him- 
self by  grasping  some  neighboring  ol)jcct.  There  may  be  slight  but  transiei:t 
loss  of  consciousness.  In  a  few  minutes,  or  even  less,  the  vertigo  passes 
off  and  the  patient  becomes  pale  and  nauseated,  a  clammy  sweat  breaks  out 
on  the  face,  and  vomiting  may  follow. 

The  deafness,  which  is  always  of  a  nervous  character,  may  be  in  only 
one  ear  and  is  never  complete.  As  a  rule,  the  patients  have  no  affection 
of  the  middle  oar.  The  tinnitus  is  described  as  cither  a  roaring  or  a  throb- 
bing sound.  Ocular  syni]itoms  may  be  present;  thus,  jerking  of  the  eye- 
balls or  nystagmus  may  develop  during  the  attack,  or  diplopia. 

Labyrinthine  vertigo  is  paroxysmal,  coming  on  at  irregular  intervals. 
Sometimes  weeks  or  months  may  elajjse  between  the  attacks;  in  other 
cases  there  may  be  several  attacks  in  a  day.  The  disease  rarely  occurs  in 
young  persons,  is  most  frequent  after  the  fortieth  year,  and  is  more  com- 
mon in  men  than  in  women. 

The  pathology  of  the  disease  has  been  much  discussed,  and  there  are 
many  theories.  It  seems  to  be  tolerably  certain  at  present  that  the  disturb- 
ances of  equilibrium,  including  the  vertigo,  are  dependent  upon  a  disturb- 
ance of  the  functions  of  the  vestibular  nerve  or  of  the  organs  with  whicli 
this  nerve  is  connected,  either  in  its  peripheral  distribution  or  by  means  of 
its  central  connection.  The  auditory  symptoms  often  accompanying  it  are 
doubtless  always  due  to  involvement  of  the  cochlear  nerve  or  its  peripheral 
or  central  connections. 

Diagnosis. — The  combination  of  tinnitus  with  giddiness,  with  or 
without  gastric  disturbance,  is  suflficient  to  establish  s  diagnosis.  There 
are  other  forms  of  vertigo  from  which  it  must  be  distinguished.    The  form 


DISEASES  OK  THE  CEREBRAL  NERVES. 


1059 


0  the  open 

Lurl)imfC'  ol 
yiiildoiu  ill 
j(i  carui'ully 


seasie  of  the 
ignuis,  and 

•■rcnch  pliy- 
L'ar,  verti^  > 
ug,  and,  in 
[  to  include 
id  deafness. 
:)l'  10(5  cases 
r  symptoms 

izzing  noise 
^ering.  lie 
seem  to  l)e 
is  often  so 
steady  liim- 
iit  transiei.t 
rtigo  passes 
;  brcak'5  out 

be  in  only 

10  affection 

or  a  tlirol;- 

of  the  eyc- 

ir  intervals. 

s;  in   other 

y  occurs  in 

more  coni- 

d  there  arc 
the  disturh- 
n  a  disturb- 
with  which 
jy  means  of 
nying  it  arc 
s  peripheral 

ss,   with   or 
Dsis.     There 
The  form 


known  aa  gastric  vertigo,  whicli  is  associated  witli  dyspepsia  and  occurs 
most  commoidy  in  persons  uH  middle  age,  is,  as  a  rule,  readily  distinguished 
by  the  absence  of  tinnitus  or  evidences  of  disturbance  in  the  function  of 
the  auditory  nerve.  'I'bis  variety  of  vertigo  is  much  less  common  than 
Trousseau's  descrii)tion  would  lead  us  to  believe.  It  is  im])ortant  to  note 
the  close  connection  of  vertigo  with  ocular  defects. 

The  cardio-vascular  vertigo,  one  of  the  most  couimon  forms,  occurs  in 
cases  of  valvular  disease,  particularly  aortic  insulliciency,  and  as  frequently 
in  arterio-sclerosis. 

Endemic  I'arahjlic  Vcrtif/o. — In  ])arts  of  Switzerland  and  France  there 
is  a  remarkable  form  of  vertigo  described  by  (Jcrlier,  which  is  characterized 
by  nttacks  of  ])aretic  weakness  of  the  extremities,  falling  of  the  eyelids, 
remarkable  depression,  but  with  retention  of  consciousness.  It  occurs  also 
in  northern  Japan,  where  Miura  says  it  develo])s  paroxysmally  among  the 
farm  laborers  of  both  sexes  and  all  ages.    Jt  is  known  there  as  h-iihisnf/dri. 

Aural  vertigo  must  be  carefully  distinguished  from  attacks  of  prlit  Dial, 
or,  indeed,  of  definite  epilepsy.  It  is  rare  in  pvtil  mal  to  have  noises  in  the 
car  or  actual  giddiness,  but  in  the  aura  preceding  an  epileptic  attack  the 
])atient  may  feel  giddy.  Giddiness  and  transient  loss  of  consciousness  nuiy 
be  associated  with  organic  disease  of  the  brain,  more  ])articularly  with 
tumor.  Vomiting  also  may  be  present.  A  careful  investigation  of  the 
symptoms  will  usually  lead  to  a  correct  diagnosis. 

The  outlook  in  ]\Ieniere's  disease  is  uncertain.  While  many  cases  re- 
cover completely,  in  others  deafness  results  and  the  attacks  recur  at  shorter 
intervals.  In  aggravated  cases  the  patient  constantly  suffers  from  vertigo 
and  may  even  be  confined  to  his  bed. 

Treatment. — Uromide  of  iwtassium,  in  2()-grain  doses  three  times  a 
day,  is  sometimes  beneficial.  If  there  is  a  history  of  sy])hilis,  the  iodide 
should  be  administered.  The  salicylates  are  recommended,  and  Charcot 
aJvises  quinine  to  cinchonism.  In  cases  in  which  there  is  increase  in  the 
arterial  tension,  nitroglycerin  may  ])e  given,  at  first  in  very  small  doses,  but 
increasing  gradually.  It  is  not  S])ccially  valuable  in  IMeniere's  disease,  but 
in  the  cases  of  giddiness  in  middle-aged  men  and  women  associated  with 
arterio-sclerosis  it  sometimes  acts  very  satisfactorily.  Correction  of  errors 
of  refraction  is  sometimes  followed  by  prompt  relief  of  the  vertigo. 

Glosso-pharyxgeal  Neiive  {Ncrrus  (jlossopJiari/nfjevs). 

The  ninth  nerve  contains  both  motor  and  sensory  fibres  and  is  also  a 
nerve  of  the  special  sense  of  taste  to  the  tongue.  It  supplies,  by  its  motor 
branches,  the  stylo-pharyngeus  and  the  middle  constrictor  of  the  ])harynx. 
The  sensory  fibres  are  distrilmted  to  the  upper  part  of  the  pharynx. 

Symptoms. — Of  nuclear  disturbance  we  know  very  little.  The 
pharyngeal  symptoms  of  bulbar  jiaralysis  are  probably  associated  with  in- 
volvement of  the  nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is 
rare,  but  it  may  be  compressed  by  tumors  or  involved  in  meningitis.  Dis- 
turbance of  the  sense  of  taste  may  result  from  loss  of  function  of  this  nerve, 
in  which  case  it  is  chiefly  in  the  posterior  part  of  the  tongue  and  soft  pal- 


1060 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


ntc.  CiowoTP,  however,  states  that  there  is  no  case  on  record  in  which  loss 
of  taste  ill  these  re^nons  lias  Ix'cn  produced  l)y  disease  oi'  the  roots  oi"  the 
j,dosso-|ihar}ii<i-eiil;  wiiereas,  on  tiie  otlier  luiiid,  disease  oi"  tlie  root 
of  the  flftli  nerve  may  canse  htss  of  taste  on  tlie  hack  as  well  as  the  front 
of  the  tongue,  as  it  the  taste  fihres  of  the  glosso-i)haryngeal  came  from  the 
tifth. 

The  general  distiirhances  of  the  sense  of  taste  may  here  he  hrielly  referred 
to.  JiOss  of  the  sense  of  taste — (Ujcusia — may  he  caused  hy  disturbance  of 
tiu'  ])erii)heral  cud  organs,  as  in  aifections  of  the  mucosa  of  the  tongue. 
Tiiis  is  very  conunon  in  the  dry  tongiic  of  fever  or  the  furred  tongue  of 
dysjiepsia,  under  which  circumstances,  as  the  saying  is,  everything  tastes 
alike.  Strong  irritants  too,  sucli  as  jjcpper,  tobacco,  or  vinegar,  may  dull 
or  diminish  the  sense  of  taste.  Complete  loss  may  he  due  to  involvement 
of  the  nerves  either  in  their  conrse  or  in  the  centres.  Disturbance  in  the 
sense  of  taste  is  most  commonly  seen  in  involvement  of  the  fifth  nerve, 
and  it  may  l)e  that  this  nerve  alone  suhserves  the  function.  Perversion  of 
the  sense  of  taste — paroijeusis — is  rarely  found,  except  as  an  hysterical 
numifestation  and  in  the  in.sane.  Increased  sensitiveness  is  still  more  rare. 
There  arc  occasional  suhjective  sensations  of  taste,  occurring  as  an  aura 
in  e])ilepsy  or  as  ])art  of  the  hallucinations  in  the  insane. 

To  test  the  sense  of  taste  the  patient's  eyes  should  he  closed  and  small 
quantities  of  various  suhstances  a])plied.  The  sensation  should  bo  per- 
ceived before  the  tongue  is  withdrawn.  The  following  are  the  most  suitable 
tests:  For  hitter,  quinine;  for  sweetness,  a  strong  solution  of  sugar  or  sac- 
charin; for  acidity,  vinegar;  and  for  the  saline  test,  common  salt.  One 
-of  the  most  important  tests  is  the  feeble  galvanic  current,  which  gives  the 
well-known  metallic  taste. 


PxEUMOGASTRic  Neuve  {Nei'vus  vagus). 

T'le  tenth  nerve  has  an  important  and  extensive  distribution,  supply- 
ing the  pharynx,  larynx,  lungs,  heart,  oesojdiagus,  and  stomach.  The  nerve 
may  be  involved  at  its  nucleus  along  with  the  sjnnal  accessory  and  the  hypo- 
glossal, forming  what  is  known  as  bulbar  paralysis.  It  may  be  compressed 
hy  tumors  or  aneurism,  or  in  the  exudation  of  meningitis,  simple  or  syphi- 
litic. In  its  course  in  the  neck  the  trunk  may  be  involved  by  tumors  or 
in  wounds.  It  has  been  tied  in  ligature  of  the  carotid,  and  has  been  cut 
in  the  removal  of  deep-seated  tumors.  The  trunk  may  be  attacked  by 
neuritis. 

The  affections  of  the  vagus  are  best  considered  in  connection  with  the 
distribution  of  the  separate  nerves. 

(a)  Pharyngeal  Branches. — In  combination  with  the  glosso-pharyngeal 
the  branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  the 
muscles  and  mucosa  of  the  pharynx  are  supplied.  In  paralysis  due  to 
involvement  of  this  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in  the 
course  of  the  nerve,  as  in  diphtheritic  neuritis,  there  is  difficulty  in  swal- 
lowing and  the  food  is  not  passed  on  into  the  oesophagus.  If  the  nerve  on 
one  side  only  is  involved,  the  deglutition  is  not  much  impaired.    In  these 


DISEASES  OF  THE  fEllEIUlAL  NEltVES. 


1061 


which  loss 

lots  ol'  Iho 

till!    root 

tliL'  front 

3  from  the 

ly  referred 
ir banco  of 
le  tongue. 

tongue  of 
ling  tastes 
,  may  dull 
ivolvement 
nee  in  tlie 
ifth  nerve, 
['version  of 

hysterical 
more  rare. 
IS  an  aura 

and  small 
Id  bo  per- 
)st  suitable 
gar  or  sac- 
salt.  One 
I  gives  the 


n,  supply- 
The  nerve 
the  hypo- 
lompressed 
!  or  syphi- 
tumors  or 
3  been  cut 
tacked  by 

1  with  the 

jharyngcal 
which  the 
sis  due  to 
or  in  the 
;y  in  swal- 
e  nerve  on 
In  these 


cases  the  particles  of  food  freciueiitly  pass  into  (lie  la.ynx,  and,  when  the 
soft  palate  is  involved,  into  the  posterior  naics. 

Spasm  of  the  pharynx  is  always  a  functional  disorder,  usually  occur- 
ring in  hysterical  and  nervous  j)eople.  (lowers  mentions  a  ease  of  a  gentle- 
man who  could  not  cat  unless  alone,  on  account  of  the  inability  to  swallow 
in  the  presence  of  others  from  spasm  of  the  i)liarynx.  This  spasm  is  a  well- 
marked  feature  in  hydroj)liobia,  and  1  have  seen  it  in  a  case  of  pseudo- 
hydrophobia. 

(b)  Laryngeal  Branches. — 'I'he  superior  laryngeal  nerve  supplies  tlu^ 
mucous  membrane  of  the  larynx  above  the  cords  and  the  crico-tliyrnid  mus- 
cle. The  inferior  or  recurrent  laryngeal  curves  around  the  arch  of  the 
aorta  on  the  left  side  an<l  the  subclavian  artery  on  the  right,  passes  along 
the  trachea  and  supplies  the  mucosa  below  the  cords  and  all  the  muscles  of 
the  larynx  except  the  crico-thyroid  and  the  epiglottidean.  lOxperiments  have 
shown  that  those  motor  nerves  of  the  ]meumogastrie  are  all  derived  from 
the  spinal  accessory.  The  remarkable  course  of  the  recurrent  laryngi'al 
nerves  renders  them  liable  to  itressuro  by' tumors  within  the  thorax,  par- 
ticularly by  aneurism.  The  following  are  the  most  imiiortant  forms  of 
l)ara]ysis: 

(1)  Bihifrrnl  Parali/sis  of  the  Abductors. — Tn  this  condition,  the  ])os- 
terior  crico-arytenoids  are  involved  and  the  glottis  is  not  opened  during 
inspiration.  The  cords  may  1)0  close  together  in  the  ])osition  of  phonation, 
and  during  ins])i ration  may  be  brought  even  nearer  together  by  the  pressure 
of  air,  so  that  there  is  only  a  narrow  chink  through  which  the  air  whistles 
with  a  noisy  stridor.  This  dangerous  form  of  laryngeal  ]»aralysis  occurs 
occasionally  as  a  result  of  cold,  or  may  follow  a  lai'vugcal  catarrh.  The 
posterior  muscles  have  been  found  degenerated  when  the  others  were 
healthy.  The  condition  may  be  produced  by  pressure  upon  both  vagi,  or 
n])on  ])oth  recurrent  nerves.  As  a  central  affection  it  occurs  in  tabes  and 
bulbar  paralysis,  but  may  be  seen  also  in  hysteria.  The  characteristic  sym|)- 
toms  are  inspiratory  stridor  with  unimpaired  ])lionation.  Possibly,  as 
Gowers  suggests,  many  cases  of  so-called  hysterical  spasm  of  the  glottis  are 
in  reality  abductor  paralysis. 

(2)  Unilateral  Abductor  Paralysis. — This  frcipiontly  results  from  the 
pressure  of  tnmors  or  inA'olvement  of  one  recurrent  nerve.  Aneurism  is 
by  far  the  most  common  cause,  though  on  the  right  side  the  nerve  may  be 
involved  in  thickening  of  the  pleura.  The  symptoms  are  hoarseness  or 
roughness  of  the  voice,  such  as  is  so  common  in  aneurisiTi.  Dyspniea  is  not 
often  present.  The  cord  on  the  affected  side  does  not  move  in  inspiration. 
Subsequently  the  adductors  may  also  become  involved,  in  which  case  the 
phonation  is  still  more  imjiaired. 

(3)  Adductor  Paralysis. — This  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.  It  is  common  in  hysteria, 
particularly  of  women,  and  causes  the  hysterical  a])houia,  which  may  come 
on  suddenly.  It  may  result  from  catarrh  of  the  larynx  or  from  overuse  of 
the  voice.  In  laryngoscopic  examination  it  is  seen,  on  attempt  at  phonation, 
that  there  is  no  power  to  bring  the  ccrds  together.  In  this  connection  the 
following  table  from  Gowers'  work  wi..  be  found  valuable  to  the  student: 


10»!2 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Symptoms. 


Signs. 


Lksion. 
Total  biluterul  palsy. 


Totul  iinilutenil  i)ul8y. 


Total  abductor  palsy. 


Unilateral     abductor 


Adductor  palsy. 


No  voice ;  no  coufjli ;  lioth   cords    niodcr- 

atridor  only  on  deep  in-  ately  abducsted  and  nio- 
spiration.  tionless. 

Voice    low    j)itcbed  One     cord     moder- 

and  lioarse;  no  couf;;b  ;  ately  abducted  and  mo- 
stridor  al)8ent  or  sligbt  tioidess,  the  other  mov- 
on  deep  breathing.  ing    freely,    and    even 

beyond  the  middle  lino 

in  phonation. 

Voice  little  changed;  Both  cords  near  to- 

cough  normal ;  inspini-    gether,  and  during  in- 

tion  difficult  and  long,    spiration  not  separated, 

with  loud  stridor.  but  even  drawn  nearer 

together. 
Symptoms       incon-  One  cord   near  the 

elusive ;  little  affection    middle  line  not  moving    palsy, 
of  voice  or  cough.  during  inspiration,  the 

other  normal. 

Xo    voice  ;    perfect  Cords  normal  in  po- 

cough ;    no    stridor   or    sition  and  moving  nor- 

dyspnoea.  mally     in    respiration, 

but  not  brought  to- 
gether on  an  attempt 
at  phonation. 

Spasm  of  the  Muscles  of  the  Larynx. — In  this  the  adductor  muscles  are 
involved.  It  is  not  an  uncommon  affection  in  children,  and  has  already 
been  referred  to  as  laryngismus  stridulus.  Paroxysmal  attacks  of  laryngeal 
sy)asni  are  rare  in  the  adult,  but  cases  are  described  in  which  the  patient, 
usually  a  young  '.'1,  wakes  at  night  in  an  attack  of  intense  dyspnoea,  which 
may  persist  lon^,  enough  to  produce  cyanosis.  Liveing  states  that  they  may 
rei)lace  attacks  of  migraine.  Tliey  occur  in  a  characteristic  form  in  loco- 
motor ataxia,  forming  the  so-called  laryngeal  crises.  There  is  a  condition 
known  as  spastic  aphonia,  in  which,  when  the  patient  attempts  to  speak, 
phonation  is  com])letely  prevented  l)y  a  spasm. 

Disturbance  of  the  sensory  nerves  of  the  larynx  is  rare. 

Ano'slhcsia  may  occur  in  bulbar  paralysis  and  in  diphtheritic  neuritis — 
a  serious  condition,  as  portions  of  food  may  enter  the  windpipe.  It  is 
usually  associated  with  dysphagia  and  is  sometimes  present  in  hysteria. 
Ilyperwsthesia  of  the  larynx  is  rare. 

(c)  Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  union  of 
branches  of  the  vagi  and  of  the  sympathetic  nerves.  The  vagus  fibres  sub- 
serve motor,  sensory,  and  probably  trophic  functions. 

(1)  Motor. — The  fibres  which  inhibit,  control,  and  regulate  the  cardiac 
action  pass  in  the  vagi.  Irritation  may  produce  slowing  of  the  action.  Czer- 
mak  could  slew  or  even  arrest  the  heart's  action  for  a  few  beats  by  pressing 
a  small  tumor  in  his  neck  against  one  pneumogastric  nerve,  and  it  is  said 


DISHASKS  OP  TIIK  CKIIKHIIAL  NKllVKS. 


1UC3 


ON. 

tend  i)til8y. 

itoral  piilsy. 


ictor  palsy. 


abductor 


palsy. 


muscles  are 
lias  already 
>f  laryngeal 
he  patient, 
noca,  which 
it  they  may 
fm  in  loco- 
1  condition 
s  to  speak. 


!  neiiritis — 
)ipe.  It  is 
n  hysteria. 

e  union  of 
fibres  sub- 

the  cardiac 
;ion.  Czer- 
by  pressing 
d  it  is  said 


tliat  the  same  can  bo  produced  1)y  forcible  l)ilateral  pressure  on  the  cnrotid 
ciiiial.  There  are  iiistniiccs  in  wiiich  persons  appear  to  have  bad  vohui- 
tary  control  over  tiie  action  of  tiie  iieait.  (  lu-yne  mentions  tiie  case  of 
Colonel  Townsbend,  "  who  could  die  or  expire  when  he  pleased,  and  yet 
by  an  elTort  or  somebow  come  to  life  again,  which  it  seems  he  bad  some- 
times tried  before  be  had  sent  for  us."  Ketarchition  of  the  heart's  action 
lias  also  followed  accidental  ligature  of  one  vagus.  Irritation  at  the  nuclei 
may  also  be  accomi)anied  with  a  neurosis  of  this  nerve.  On  the  other  hand, 
when  there  is  complete  paralysis  of  the  vagi,  the  inhil)itory  action  may  bo 
abolished  and  the  acceleratory  inlluences  have  full  sway,  'i'he  heart's 
action  is  then  greatly  increased,  'i'his  is  seen  in  some  instances  of  diph- 
theritic neuritis  ami  in  involvement  of  the  nerve  by  tumors,  or  its  accidental 
removal  or  ligature.  ('om])lete  loss  of  function  of  one  vagus  may,  however, 
not  be  followed  by  any  symptoms. 

(2)  Sensari/  sym])toms  on  the  part  of  the  cardiac  branches  are  very 
varied.  Normally,  the  heart's  action  proceeds  regularly  without  the  ))ar- 
ticijjation  of  consciousness,  but  the  unpleasant  feelings  and  sensations  of 
]mlpitation  and  pain  are  conveyed  to  the  brain  through  this  nerve.  How 
far  the  fd)res  of  the  pneumogastric  are  involved  in  angina  it  is  im))ossiblc 
to  say.  The  various  disturbances  of  sensation  are  described  under  the  car- 
diac neuroses. 

(d)  Pulmonary  Branches. — "We  know  very  little  of  the  ]ndmonary 
branches  of  the  vagi.  The  motor  fd)res  are  stated  to  control  the  action  of 
the  bronchial  muscles,  and  it  has  long  been  held  that  asthma  may  be  a  neu- 
rosis of  these  fibres.  The  various  alterations  in  the  respiratory  rhythm  are 
probably  due  more  to  changes  in  the  centre  than  in  the  nerves  themselves. 

(e)  Gastric  and  (Esophageal  Branches. — The  muscular  movements  of 
these  parts  are  presided  over  by  the  vagi  and  vomiting  is  indtu'ed  through 
them,  usually  rellexly,  but  also  by  direct  irritation,  as  in  meningitis.  Spasm 
of  the  cesophagus  generally  occurs  with  other  nervous  ])henomena.  (ias- 
tralgia  may  sometimes  be  due  to  cramp  of  the  stomach,  but  is  more  com- 
monly a  sensory  disturbance  of  this  nerve,  due  to  direct  irritation  of  the 
])eripheral  ends,  or  is  a  neuralgia  of  the  terminal  filires.  Hunger  is  said 
to  be  a  sensation  aroused  by  the  imeumogastric,  and  some  forms  of  nervous 
dyspepsia  probably  de])end  upon  disturbed  function  of  this  nerve.  The 
severe  gastric  crises  which  occur  in  locomotor  ataxia  are  due  to  central 
irritation  of  the  nuclei.  Some  describe  exophthahiiic  goitre  under  lesions 
of  the  vagi. 

Si'ixAL  Accessory  Nerve  (Xrrrus  arcessnriiis). 

Paralysis, — The  smaller  or  internal  ])art  of  this  nerve  joins  the  vagus 
and  is  distributed  through  it  to  the  larvngeal  muscles.  The  larger  external 
]iart  is  distributed  to  the  sterno-mastoid  and  trapezius  muscles. 

The  nuclei  of  the  nerve,  particularly  of  the  accessory  part,  may  be  in- 
A-olved  in  bulbar  paralysis.  The  nuclei  of  the  external  ])ortion,  situated 
as  they  are  in  the  cervical  cord,  may  be  attacked  in  progressive  degenera- 
tion of  the  motor  nuclei  of  the  cord.  The  nerve  may  be  involved  in  the 
exudation  of  meningitis,  or  be  compressed  by  tumors,  or  in  caries.     The 


lor4 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


/ 


si/niplotiis  of  paralysis  ol"  the  accessory  portion  which  joins  the  vaj,'us  have; 
already  heen  ^'iven  in  I  lie  account  of  the  palsy  of  the  larynj^cul  branches 
of  the  piu'iiin<)j,'astri(;.  Disease  or  compression  of  the  external  portion  is 
followed  liy  jiandysis  of  the  sti-rno-niasloid  ami  of  the  trapezius  on  the 
same  side.  In  |)aralysis  of  one  terno-mastoid,  the  patient  rotates  the  head 
with  dilliculty  to  the  opposite  side,  hut  there  is  no  torticollis,  thon<,'h  in 
some  eases  the  head  is  held  ohlitpiely.  As  the  trapezius  is  supplied  in  part 
from  the  cervical  nerves,  it  is  not  completely  paralyzed,  hut  the  |)()rtinn 
which  passes  from  the  occipital  hone  to  the  acromion  is  functionless.  The 
{)aralysis  of  the  nniscle  is  well  seen  when  the  patient  draws  a  deep  hreath 
or  shrugs  the  shoulders.  The  middle  portion  of  the  trapezius  is  also  weak- 
ened, the  shoulder  droops  a  little,  and  the  angle  of  the  sca]»ula  is  rotated 
inward  hy  the  action  of  the  rhomboids  and  the  levator  anguli  scai)ula'. 
JOIevatioii  of  thi'  arm  is  impaired,  for  the  trapezius  does  not  iix  the  scapula 
ns  a  point  from  which  the  deltoid  can  work. 

Jn  j)rogre.«sive  muscular  atrophy  we  sometimes  see  bilateral  i)aralysis 
of  these  muscles.  'JMuis,  if  the  sterno-mastoids  are  all'ected,  the  head  tends 
to  fall  back;  when  the  trapezii  are  involved,  it  falls  forward,  a  characteristic 
attitude  of  the  head  in  many  cases  of  progressive  muscular  atrophy,  Gowers 
suggests  that  lesions  of  the  accessory  in  dillicult  labor  nuiy  account  for  those 
cases  in  which  during  the  first  year  of  life  the  child  has  great  dilliculty  in 
holding  up  the  head.  Jn  children  this  drooping  of  the  head  is  an  impor- 
tant symj)tom  in  cervical  meningitis,  the  result  of  caries. 

The  treatment  of  the  condition  de])ends  much  upon  the  cause.  In  the 
central  nuclear  atroj)hy  but  little  can  be  done.  In  paralysis  from  pressure 
the  pym])toms  may  gradually  Ix;  relieved.  The  paralyzed  muscles  should 
be  stimulated  by  electricity  and  massage. 

Accessory  Spasm.— (7'cir/iroWi.s;  Wrytud-.) — The  forms  of  spasm  af- 
fecting the  cervical  muscles  are  best  considered  here,  as  the  muscles  sup- 
plied by  the  accessory  are  chiefly,  though  not  solely,  responsible  for  the 
condition.    The  following  forms  may  be  described  in  this  section: 

(a)  Coixjcnilal  TorfioilUs. — This  condition,  also  known  as  fixed  torti- 
collis, depends  xiyion  the  shortening  and  atrophy  of  the  sterno-mastoid  on 
one  side.  It  occurs  in  children  and  may  not  ])e  noticed  for  several  years 
on  account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it 
has  only  recently  come  on.  It  affects  the  right  side  almost  exclusively.  A 
remarkable  cirenmstance  in  connection  with  it  is  the  existence  of  facial 
asymmetry  noted  by  Wilks,  which  appears  to  be  an  essential  part  of  this 
congenital  form.  It  occurred  ii  6  cases  rejiorted  by  Golding-Bird.  In 
congenital  wryneck  the  sterno-mastoid  is  shortened,  hard  and  firm,  and  in 
a  condition  of  more  or  less  advanced  atrophy.  This  must  be  distinguished 
from  the  local  thickening  in  the  sterno-mastoid  due  to  rupture,  which  may 
occur  at  the  time  of  birth  and  produce  an  induration  or  mnscle  callus. 
Although  the  sterno-mastoid  is  almost  always  atTected,  there  are  rare  cases 
in  which  the  fibrons  atro])hy  affects  the  trajiezius.  This  form  of  wryneck 
in  itself  is  unimportant,  since  it  is  readily  relieved  by  tenotomy,  but 
Golding-T^ird  states  that  the  facial  asymmetry  persists,  or  indeed  may,  as 
shown  by  photographs  in  my  case,  become  more  evident.     With  reference 


DISKASKS  OF  THE  CKUKIlllAL  NKIIVKS. 


10G5 


:;  vngus  liavo 
t'ul  hraiitlii's 
111  portion  is 
L'ziiis  on  tlio 
itcs  tilt'  liciid 
^,  tli()ii<f|i  ill 
[•lit'd  in  part 

tlio  portion 
on  less.     Tin." 

•  Iccp  l)roatli 
18  nl.so  wwik- 
la  is  rotated 
uli  scapula-. 

llu!  scai)ula 

al  i)aralysis 
!  licad  tends 
liaractcristic 
liy.  (jowers 
nt  for  those 
dilliculty  in 
s  an  impor- 


isc. 


In  tl 


10 


nn  pressure 
icles  should 

spasm   a  f- 

lUSClcS   SU))- 

ble  for  the 
n: 

fixed  torti- 
niastoid  on 
veral  years 
ing  that  it 
isively.  A 
e  of  facial 
art  of  this 
-Bird.  In 
•ni,  and  in 
tinguishod 
A'liicli  may 
ele  callus. 

rare  cases 
f  wryneck 
tomy,  hut 
d  may,  as 

reference 


to  the  palh()loi;y  o**  tlie  alTcclion,  (ioldin^'-llird  cuncludcs  tliat  the  facial 
asyninictry  and  the  lorticollis  arc  integral  parts  oi  dUc  alVectinn  wiiidi  has 
a  central  ori^nn  ami  is  the  counter[)art  in  the  liead  and  neck  of  inl'antile 
paralysis  with  talipes  in  tiie  foot. 

(h)  t>ji(isni<iilic  Wri/iinlt-. — Two  varieties  of  this  spasm  occur,  the  tonic 
and  the  clonic,  which  may  alti'rnatc  in  the  same  case;  or,  a-<  is  most  com- 
mon, they  are  separate  and  remain  so  from  the  outset.  The  disease  is 
most  I'riMiucnt  in  adults  and,  according  to  (Jowers,  more  comiiiou  in  I'enudes. 
In  this  country  it  is  certainly  more  frctpieiit  in  males.  Of  the  S  oi'  K)  cases 
which  canu'  under  my  ohservalion  in  .Montreal  and  lMiiladcl|ihia,  all  were 
nudes.  In  lemales  it  may  he  an  hysterical  manil'estali(»ii,  There  may  he 
a  nuirked  neurotic  I'amily  history,  hut  it  is  usually  impossihie  to  lix  upon 
any  definite  etiological  I'aetor.  Some  ca.<cs  have  followeil  cold;  others 
a  blow. 

The  symptoms  are  well  defined.  In  the  tonic  form  the  contracted 
stcrno-nuistoid  draws  the  occijiut  toward  the  shoidder  of  the  alTected  side; 
the  chin  is  raised,  and  the  face  rotated  to  the  other  shoulder.  The  sterno- 
mastoid  may  be  affected  alone  or  in  association  with  tho  trapezius.  When 
the  latter  is  imidicated  the  head  is  depressed  still  more  toward  the  same 
side.  In  long-standing  cases  these  muscles  are  ])rominent  and  very  rigid. 
There  may  be  some  curvature  of  the  spine,  the  convexity  of  which  is  toward 
the  sonnd  side.  The  cases  in  which  the  spasm  is  clonic  are  much  more 
distressing  and  serious.  The  s])asm  is  rarely  limited  to  a  single  muscle. 
The  slcrno-nuistoid  is  almost  always  involved  and  rotates  the  head  so  as  to 
a))])roximate  the  mastoid  ])rocess  to  the  inner  end  of  the  clavicle,  turning 
the  face  to  the  opposite  side  and  raising  the  eliin.  When  with  this  the 
trapezius  is  affected,  the  dejiression  of  the  head  toward  the  same  side  is 
more  marked.  The  head  is  drawn  somewhat  backward;  the  slunddi-r,  too, 
is  raised  by  its  action.  According  to  (Jowers,  the  splenius  is  associated 
with  the  sterno-mastoid  abont  half  as  fretpiently  as  the  trapezius.  Its  action 
is  to  incline  the  head  and  rotate  it  slightly  toward  the  same  side.  Other 
mnscles  may  be  involved,  such  as  the  scalenus  and  ])latysma  myoides;  and 
in  rare  cases  the  head  may  be  rotated  by  the  dee])  cervical  muscles,  the 
rectus  and  obliquns.  There  are  cases  in  which  the  spasm  is  bilateral,  caus- 
ing a  backward  movement — the  retro-collic  spasm.  This  nuiy  be  either 
tonic  or  clonic,  and  in  extreme  cases  the  face  is  horizontal  and  looks  uy)ward. 

These  clonic  contractions  may  come  on  without  warning,  or  be  ])re- 
coded  for  a  time  by  irregular  pains  or  stiffness  of  the  neck.  The  jerking 
movements  recur  every  fe\v  moments,  and  it  is  im])ossible  to  keep  the  head 
still  for  more  than  a  minute  or  two.  In  time  the  muscles  undergo  hyper- 
trophy and  may  be  distinctly  larger  on  one  side  than  the  other.  In  some 
cases  the  pain  is  considerable;  in  others  there  is  simply  a  feeling  of  fatigue. 
The  spasms  cease  during  sleep.  Enuition,  excitement,  and  fatigue  increase 
them.  The  spasm  may  extend  from  the  muscles  of  the  neck  and  involve 
those  of  the  face  or  of  the  arras. 

The  disease  varies  much  in  its  course.  Cases  occasionally  got  well,  but 
the  great  majority  of  them  persist,  and,  even  if  temjjorarily  relieved,  the 
disease  freqiiently  recurs.    The  aflection  is  usually  regarded  as  a  functional 


P'i*l    !■    !J 


KHW) 


DISK  ASKS  OF  TIIK  NKUVOUS  SYSTKM. 


/ 


Tit'iirosiK,  l)ut  it  Ih  jtoi^HiMy  due  to  (listiirhiinco  of  tlio  cortionl  f^fiitrcs  prcnid- 
ing  over  tlic  iiiiiscli's. 

Treatment.— Ti'iii I )()rnry  relief  is  Boinetimes  oltained;  a  i)ermi»nent 
cure  iH  e\(  »'|ilii)Miii.  Various  drug's  have  been  used,  htit  rarely  with  lieiielit. 
Orcasioiially,  larj^e  (h)ses  of  hroinith;  will  lessen  the  intensity  of  the  spasuj. 
Morphia,  suhcutuneously,  has  been  successful  in  some  reported  cases,  hut 
there  is  the  great  danger  of  estahlishing  the  morphia  hahit.  (lalvanism 
may  he  tried.  Counter-irritation  is  |)rohahly  useless.  Fixation  of  ihe  head 
mechanically  can  rarely  he  horiu'  hy  the  patient.  These  ol»stinate  I'ases  fall 
ultimately  into  the  hands  of  the  surgiM»n,  and  the  (»perations  of  stretchin*;, 
division,  and  excision  of  the  acces.sory  m-rve  and  division  of  the  muscles 
have  heen  tried.  The  last  does  not  check  the  spasm,  and  may  aggravate 
the  syinptoms.  Temporary  relief  nuiy  follow,  hut,  as  a  ride,  the  condition 
returns.  Jfisien  Wussell  thinks  that  resection  of  the  ])osterior  branches  of 
the  upper  cervical  nerves  is  nu)st  likely  to  give  relief,  and  this  has  been 
done  by  Keen  and  others. 

((•)  'Vho  ninltliiiii  sjxism  of  children  may  here  ho  mentioned  as  involving 
eh  icily  the  muscles  innervated  by  the  accessory  nerve.  It  may  be  a  simple 
trick,  a  form  of  habit  s|»asm,  or  a  ithenomenon  of  epilepsy  (K.  nutans),  in 
which  ease  it  is  associated  with  transient  loss  of  consciousness.  A  similar 
nodding  spasm  may  occur  in  older  children.  In  women  it  sometimes  occurs 
ns  an  hysterical  manifestation,  commonly  as  part  of  the  so-called  salaam 
convulsion. 

IIvrooLossAL  Nerve. 

This  is  the  motor  nerve  of  the  tongue  and  for  most  of  the  muscles  at- 
tached to  the  liyoid  bone.  Its  cortical  centre  is  probably  the  lower  part  of 
the  anterior  central  gj'rus. 

Paralysis. — <  '  Ural  Lcslnn. — The  tongue  is  often  involved  in  hemi- 
plegia, and  tlK  Js  may  result  from  a  lesion  of  the  cortex  itself,  or  of 
the  fibres  ,<ass  to  the  medidla.  It  does  not  occur  alone  and  is 
considcro(  hemiplegia.  There  is  this  dilTerence,  however,  between 
the  cortical  uud  other  forms,  that  the  muscles  on  both  sides  of  the  tongue 
may  be  more  or  less  affected  but  do  not  waste,  nor  are  their  electrical  re- 
actions disturbed. 

{'i)  Xiiclear  and  infra-nuclenr  lesions  of  the  hypoglossal  result  from 
slow  iirogressive  degeneration,  as  in  bulbar  paralysis  or  in  locomotor  ataxia; 
occasionally  there  is  acute  softening  from  obstruction  of  the  vessels. 
The  nuclei  of  both  nerves  are  usually  affected  together,  but  may  be  attacked 
separately.  Trauma  and  lead  poisoning  have  also  heen  assigned  as  causes. 
The  fibres  may  be  damaged  by  a  tumor,  and  at  the  base  by  meningitis: 
or  the  nerve  is  sometimes  involved  in  the  condylar  foramen  by  disease  of  the 
skull.  'It  may  he  involved  in  its  course  in  a  scar,  as  in  Birkett's  case,  or 
compressed  by  a  tumor  in  the  parotid  region,  as  in  a  case  at  present  under 
my  care.  x\s  a  result,  t'  tc  is  loss  of  function  in  the  nerve  fibres  and  the 
tongue  undergoes  atrop  on  the  affected  side.  It  is  protruded  toward  the 
paralyzed  side  and  may  show  fibrillary  twitching. 

The  symptoms  of  involvement  of  one  hypoglossal,  either  at  its  centre 


iitrofl  prt'sid- 

i  pormancnt, 
willi  liciiclit. 
r  llic  spa.^iii. 

(1    CIISCS,     llllt 

(iaIvaiiiHiii 
<>l  llio  head 
lie  i-asos  fall 
r  strt'lcliin^', 
(lie  iiuisclcs 
ly  a^f<,'mvatc; 
le  condition 
l)ranclu's  of 
lis  has  hccii 

na  involvinf:^ 

be  a  simple 

nutans),  in 

A  similar 

Linu's  occurs 

lUcd  salaam 


muscles  at- 
)wer  part  of 

ed  in  liomi- 
itself,  or  of 

lone  and  is 

er,  between 
the  tongue 

lectrical  re- 

rosult  from 
otor  ataxia; 
the  vessels, 
be  attacked 
1  as  causes, 
meningitis; 
sense  of  the 
;t's  case,  or 
3sent  under 
res  and  the 
toward  the 

;  its  centre 


DISKASRS  OK  TlIK  Sl'INAL  NKUVKS. 


U)G7 


or  in  its  courso,  arc  tliose  nf  unilateral  paralysis  and  atrophy  of  the  tongue. 
When  protruded,  it  is  pushed  toward  the  airrctcd  side,  and  there  are  lihrd- 
lary  twitchings.  'i'lie  alro]ihy  is  usually  nuirkcd  and  the  nuu'ous  memi)rano 
on  the  alfeeted  Hide  !«  thrown  into  folds.  Articulation  Ih  not  much  im- 
paired in  the  unilateral  alfectiion.  There  is  u  remarkable  triad  of  symptoms, 
to  which  ilughlings  .lackson  first  called  attention— unilateral  hemi-alntphy 
of  the  tongue,  loss  of  power  in  the  palate  muscle,  with  paralysis  of  the 
hiryn.x  on  the  same  side.  When  the  disease  is  bilateial,  the  tongue  lies 
almost  motionless  in  the  lloor  of  the  mouth;  it  is  atrophied,  and  can- 
not be  protruded.  Speech  and  maslicatitui  are  extremely  dillicidt  and 
deglutition  nuiy  be  ini|)aired.  If  the  seat  of  the  disease  is  above  the 
nuclei,  there  may  be  little  or  no  wasting.  The  condilion  is  seen  in 
progressive  bulbar  jiaralysis  and  occasionally  in  progressive  muscular 
atrophy. 

The  (lidfpiosis  is  readily  nuule  and  the  ;  itualion  of  the  lesion  can  usu- 
ally be  determined,  since  when  supra-nuclear  there  is  associated  hemi- 
plegia and  no  wasting  of  the  muscles  of  the  tongue.  Xucdear  disease  is 
oidy  occasionally  unilateral;  most  comnu)nly  bilateral  and  part  of  a  bulbar 
])aralysis.  Jt  should  be  borne  in  miiul  that  the  fibres  of  the  hy|)oglossal 
may  be  involved  within  the  nu'duUa  after  leaving  their  nuclei.  In  such 
a  case  there  may  be  ])aralysi8  of  the  tongue  on  one  side  and  )»aralysis  of 
the  limbs  on  the  o])posite  side,  and  the  tongue,  when  protruded,  is  pushe(l 
toward  the  sound  side. 

Spnsvi. — This  rare  affection  may  be  imilateral  or  bilateral.  It  is  most 
fre(piently  a  ])art  of  some  other  convulsive  disorder,  such  as  epilepsy, 
chorea,  or  sjjasm  of  the  facial  muscles.  In  some  cases  of  stuttering,  spasm 
of  the  tongue  precedes  the  ex])losive  utterance  of  the  words.  It  may  occur 
in  hysteria,  and  is  said  to  follow  reflex  irritation  in  the  fifth  nerve,  '^i'he 
nu>st  remarkable  cases  are  those  of  paroxysmal  clonic  si)asm,  in  which  the 
tongue  is  rapidly  thrust  in  and  ou*-.  as  many  as  f(»rty  or  fifty  tinu's  a  minute. 
In  the  case  re])ortcd  by  Gowers  the  attacks  occurred  during  sleep  and  con- 
tinued for  a  year  and  a  half.  The  spasm  is  xisually  bilateral.  Wendt  has 
reported  a  case  in  which  it  was  unilateral.    The  prognosis  is  usually  good. 


IV.    DISEASES    OF   THE    SPINAL    NERVES. 

Cervical  Plexus. 

(1)  Occipito-cervical  Neuralgia. — This  involves  the  nerve  territory  sup- 
jilied  by  the  second,  the  occipitalis  major  and  minor,  and  the  auricularis 
ningnv.s  nerves.  The  iiains  are  chiefiy  in  the  back  of  the  head  and  neck 
and  in  the  oar.  The  condition  may  follow  cold  and  is  sometimes  associated 
with  stiffness  of  the  neck  or  torticollis.  Unless  connected  with  it  there 
exists  disease  of  the  bones  or  due  to  pressure  of  tumors,  the  outlook  is  usu- 
ally good.  There  are  tender  points  midway  between  the  mastoid  process 
and  the  spine  and  just  above  the  parietal  eminence,  and  between  the  sterno- 
mastoid  and  the  trapezius.  The  affection  may  be  due  to  direct  pressure,  in 
j  ersons  who  carry  very  heavy  loads  on  the  neck. 


10G8 


DISEASES  OF  THE  NERVOUS  SYSTEJI. 


/' 


(2)  Affections  of  the  Phrenic  Nerve. — Paralyfeis  may  follow  a  lesion  in 
the  anterior  horns  at  the  level  of  tlie  third  and  fourth  cervical  nerves,  or 
may  he  due  to  compression  of  tlic  nerve  hy  tumors  or  aneurism.  !More 
rarely  j)aralysis  results  from  neuritis. 

It  may  be  part  of  a  diphtheritic  or  load  palsy  and  is  usually  bilateral. 
"When  the  diaj)hrngm  is  ])aralyzed  respiration  is  carried  on  by  the  inter- 
costal and  accessory  muscles.  When  the  patient  is  quiet  and  at  rest  little 
may  1)C  noticed,  hut  the  abdomen  retracts  in  ins})iration  and  is  forced  out 
in  expiration.  On  exertion  or  even  on  attempting  to  move  there  may  l)e 
dyspniea.  If  the  paralysis  sets  in  suddenly  there  may  he  dyspnoea  and 
lividity,  whicl'  usually  temjMjrary  (W.  I'asteur).  Intercurrent  attacks  of 
bronchitis  seriously  aggravate  the  condition.  Dilficulty  in  coughing,  owing 
t(>  the  impossibility  of  drawing  a  full  breath,  adds  greatly  to  the  danger 
of  this:  complication,  as  the  mucus  accumulates  in  the  tuljos. 

When  the  phrenic  nerve  is  paralyzed  on  one  side  the  paralysis  may  bo 
scarcely  noticeal)le,  but  careful  inspection  shows  that  the  descent  of  the 
dia])hragm  is  much  less  on  the  all'ected  side. 

Tlie  diagnosis  of  paralysis  is  not  always  easy,  particularly  in  women, 
wlio  ha1)itually  use  this  muscle  less  than  men,  and  in  whom  the  diaphrag- 
matic l)rcathing  is  less  conspicuous.  Immobility  of  the  diaphragm  is  not 
uncommon,  particu''^rly  in  diaphragmatic  pleurisy,  in  large  effusions,  and 
in  extensive  emphysema.  The  muscle  itself  may  be  degenerated  and  its 
power  impaired. 

Owing  to  the  lessened  action  of  the  diajihragm,  there  is  a  tendency  to 
accumulation  of  blood  at  the  bases  of  the  lungs,  and  there  may  be  im- 
paired resonance  and  signs  of  oedema.  As  a  rule,  however,  the  paralysis  is 
not  confined  to  this  muscle,  but  is  part  of  a  general  neuritis  or  an  anterior 
polio-myelitis,  and  there  are  other  symptoms  of  value  in  determining  its 
presence.  The  outlook  is  usually  serious.  Pasteur  states  that  of  15  cases 
following  diphtheria,  only  8  recovered.  The  treatment  is  that  of  the  neuri- 
tis or  polio-myelitis  with  Avhich  it  is  associated. 

Hiccough. — Here  may,  perhai)s,  best  be  considered  this  remarkable  symp- 
tom, caused  l)y  intermittent,  sudden  contraction  of  the  diaphragm.  The 
mechanism,  however,  is  complex,  and  while  the  afferent  impressions  to  the 
resi)iratory  centre  may  be  peripheral  or  central,  the  efFcrent  are  distributed 
through  the  phrenic  nerve  to  the  diaphragm,  causing  the  intermittent 
spasm,  and  through  the  laryngeal  branches  of  the  vagus  to  the  glottis,  caus- 
ing sudden  closure  as  the  air  is  rapidly  inspired. 

Obstinate  hiccough  is  one  of  the  most  distressing  of  all  symptoms,  and 
may  tax  to  the  uttermost  the  resources  of  the  physician.  W.  Langford 
Symes  in  a  recent  study  groups  the  cases  into: 

(a)  Inflammatory,  seen  particularly  in  affections  of  the  abdominal  vis- 
cera, gastritis,  peritonitis,  hernia,  internal  strangulation,  appendicitis,  sup- 
purative pancreatitis,  and  in  the  severe  forms  of  typhoid  fever. 

(b)  Irritative,  as  in  the  direct  stimulus  of  the  diaphragm  in  the  swal- 
lowing of  very  hot  substances,  local  disease  of  the  oesophagus  near  the 
diaphragm,  and  in  many  conditions  of  gastric  and  intestinal  disorder,  more 
particularly  those  associated  with  flatus. 


a  lesion  in 
al  nerves,  or 
risni.     !More 

Hy  bilateral. 
»y  the  inter- 
at  rest  little 
is  forced  out 
liero  may  be 
yspnooa  and 
it  attacks  of 
filing,  owing 
•  the  danger 

lysis  may  l)o 
scent  of  the 

'  in  women, 
le  diaphrag- 
ragm  is  not 
fusions,  and 
ited  and  its 

tendency  to 

pay  be  im- 
paralysis  is 
an  anterior 

rmining  its 
of  15  cases 

f  the  neuri- 

cable  symp- 
agm.  The 
sions  to  the 
distributed 
ntermittent 
lottis,  caus- 

ptoms,  and 
Langford 

ominal  vis- 
licitis,  su[)- 

i  the  swal- 
s  near  the 
»rder,  more 


DISEASES  OP  TUE  SPINAL  NERVES. 


lOOO 


(c)  Specific,  or,  perhajjs  more  properly,  idiopathic,  in  which  no  evident 
causes  are  present.  Jn  these  cases  tiiere  is  usually  some  constitutional  taint, 
a.  gout,  diabetes,  or  chronic  I5right's  disease.  1  have  seen  several  instances 
of  obstinate  hiccouj^li  in  the  later  stages  of  chronic  interstitial  nephritis. 

(d)  Keurc'tic,  cases  in  which  the  ]u-imary  cause  is  in  the  nervous  system; 
hysteria,  e])ilepsy,  shock,  or  cerebral  tumors.  Of  these  cases  the  hysterical 
are,  ])erhaps,  the  most  obstinate. 

The  treatment  is  often  very  unsatisfactory.  Sometimes  in  the  milder 
forms  a  sudden  reflex  irritation  will  check  it  at  once.  Headers  of  I'lato's 
Symposium  will  remember  that  the  ])hysician  Eryximachus  recommended 
to  Aristophanes,  who  had  hiccough  from  eating  too  much,  either  to  hold 
his  breath  (which  for  trivial  forms  of  hiccough  is  very  satisfactory)  or  to 
gargle  with  a  little  water;  but  if  it  still  continued,  "  tickle  your  nose  with 
something  and  sneeze;  and  if  you  sneeze  once  or  twice  even  the  most  vio- 
lent hiccough  is  sure  to  go."  The  attack  must  have  been  of  some  severity, 
as  it  is  stated  subsequently  that  the  hiccough  did  not  disappear  until  Aris- 
toi)hanes  had  resorted  to  the  sneezing. 

Ice,  a  teaspoonfv.i  of  salt  and  lemon-juice,  or  salt  and  vinegar,  or  a  tea- 
s])Oonful  of  raw  spirits  may  be  tried.  When  the  hiccough  is  due  to  gas- 
tric irritation,  lavage  is  sometimes  promptly  curative.  I  saw  a  case 
of  a  week's  duration  cured  by  a  hy])odermic  injection  of  gr.  I  of  apomor- 
}>hia.  In  obstinate  cases  the  various  antispasmodics  have  been  used  in  suc- 
cession. Pilocarpine  has  been  recommended.  One  has  sometimes  to  resort 
to  hypodermics  of  morphia,  or  to  iidialations  of  chloroform.  The  nitrite 
of  amyl  and  nitroglycerin  have  been  beneficial  in  some  cases.  Galvanism 
over  the  phrenic  nerve,  or  ])ressure  on  the  nerves,  applied  between  the  heads 
of  the  sterno-cleido-mastoid  muscles  may  be  used.  Strong  retraction  of  the 
tongue  nuiy  give  immediate  relief. 

Brachial  Plexus, 

(1)  Combined  Paralysis. — The  plexus  may  be  involved  in  the  supra- 
clavicular region  by  com])ression  of  the  nerve  trunks  as  they  leave  the  spine, 
or  by  tumors  and  other  morbid  processes  in  the  neck.  Below  the  clavicle 
lesions  are  more  connnon  and  result  from  injuries  following  dislocation 
or  fracture,  L.mctimes  from  neuritis.  The  most  common  cause  of  lesion  of 
the  brachial  plexus  is  luxation  of  the  humerus,  particularly  the  subcoracoid 
form.  If  the  dislocatio.  is  quickly  reduced  the  symptoms  are  (juite  tran- 
sient, and  disappear  in  a  few  days.  In  severe  cases  all  the  branches  of  the 
]ilexus,  or  only  one  or  two,  may  be  involved.  The  most  serious  cases  are 
those  in  which  the  dislocation  is  imdetected  or  unreduced  for  some  time, 
when  the  prolonged  pressure  on  the  nerves  may  cause  com]i]ete  and  ])erma- 
nent  paralysis  of  the  arm.  The  muscles  waste,  the  reaction  of  degeneration 
is  present,  and  trophic  changes  in  the  skin  are  apt  to  occur.  The  medico- 
legal bearings  of  these  cases  are  im])ortant,  and  may  be  thus  briefly  sum- 
marized: Direct  injury,  as  by  a  fall  or  blow  on  the  shoulder,  resulting  in 
great  bruising  of  the  nerves  without  dislocation,  is  occasionally  followed  by 
complete  jiaralysis  of  the  arm.    A  dislocation  may  be  set  immediately  and 


loro 


DISEASES  OP   THE  NERVOL'S  SVSTEM. 


.  I 
/ 


yet  the  lesion  of  the  braeliial  plexus  may  bo  such  as  to  oaiiso  permanent 
paralysis  of  the  nerves.  The  dislocation  may  be  reduced  and  the  joint  in 
subsecpient  movements  &ii]>s  out  again.  It  lias  hnpi)ened  tiuit  by  the  tinii 
tlie  surgeon  sees  the  patient  again,  the  damage  has  become  irreparable. 

Injuries  and  blows  on  the  Jieck  may  cause  i)artial  paralysis  of  the  arm, 
involving  the  deltoid,  supraspinatus,  infraspinatus,  biceps,  brachialis  an- 
ticus,  and  the  supinator.  The  injury  may  occur  to  the  child  during  do- 
livery. 

A  primary  neuritis  of  the  brachial  plexus  is  rare.  More  commonly  the 
process  is  an  ascending  neuritis  from  a  lesion  of  a  perii)heral  branch,  involv- 
ing first  the  radial  or  ulnar  nerves,  and  spreading  upward  to  the  plexus, 
producing  gradually  complete  loss  of  power  in  tlie  arm. 

(2)  Lesions  of  Individual  Nerves  of  the  Plexus. — (n)  Long  Thonuir 
'Nerve  {Serratus  ralsij). — This  occurs  chiefly  in  men.  The  nerve  is  injured 
in  the  posterior  triangle  of  the  neck,  usually  by  direct  pressure  in  the  carry- 
ing of  loads;  cold  may  cause  neuritis.  It  may  l}e  involved  also  in  pro- 
gressive muscular  atrophy  and  in  polio-myelitis  anterior.  When  paralyzed 
the  scapula  on  the  affected  side  looks  winged,  which  results  from  tlie  pro- 
jection of  the  angle  and  posterior  border.  This  is  particularly  noticeable 
wjien  the  arm  is  moved  forward,  when  the  serratus  no  longer  holds  the 
scapula  against  tlie  thorax.  It  is  a  well-defined  and  readily  recognized 
form  of  i)aralysis.  The  onset  is  associated  with,  sometimes  preceded  by, 
neuralgic  pains.  The  course  is  dubious,  and  many  months  may  elapse 
before  there  is  any  improvement. 

(h)  Circiunflcx  Nerve. — This  supplies  the  deltoid  and  the  teres  minor. 
Tlie  nerve  is  apt  to  be  involved  in  injuries,  in  dislocations,  bruising  by  a 
crutch,  or  sometimes  by  extension  of  inflammation  from  the  joint.  Occa- 
sionally the  paralysis  arises  from  a  pressure  neuritis  during  an  illness.  As 
a  consequence  of  loss  of  ^lower  in  the  deltoid,  the  arm  cannot  be  raised. 
Tlie  wasting  is  usually  marked  and  changes  the  shape  of  the  shoulder. 
Sensation  may  also  be  impaired  in  the  skin  over  the  muscle.  The  ]oint 
may  be  relaxed  and  there  may  be  a  distinct  space  between  the  head  of  the 
humerus  and  the  acromion.  In  other  instances  the  ligaments  are  thick- 
ened, and  a  condition  not  unlike  ankylosis  may  be  produced,  but  which  is 
readily  distinguished  on  moving  the  arm. 

(c)  Mnscnlo-spiral  Paralysis;  Eadial  Paralysis. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  position 
of  the  musculo-spiral  nerve.  It  is  often  bruised  in  the  use  of  the  crutch, 
by  injuries  of  the  arm,  blows,  or  fractures.  It  is  frequently  injured  when 
a  person  falls  asleep  with  the  arm  over  the  liack  of  a  chair,  or  by  ])ressure 
of  the  body  upon  the  arm  when  a  person  is  sleeping  on  a  bench  or  on  the 
ground.  It  may  be  paralyzed  by  sudden  violent  contraction  of  the  triceps. 
It  is  sometimes  involved  in  a  neuritis  from  cold,  but  this  is  uncommon  in 
comparison  with  other  causes.  In  the  subcutaneous  injection  of  ether  tlic 
nerve  may  be  accidentally  struck  and  temporarily  paralyzed.  The  paraly- 
sis of  lead  poisoning  is  the  result  of  involvement  of  certain  branches  of 
this  nerve. 

A  lesion  when  high  up  involves  the"  trice])s,  the  brachialis  anticus,  and 


iS3  pormancm 
1  tlie  joint  ill 
t  by  the  tiim 
|)arable. 
is  of  the  arm. 
brachialis  au- 
Id  during  dc- 

eommoniy  the 
•ranch,  involv- 
to  the  plexus, 

Long  Thoractr 
3rve  is  injured 
e  in  the  carry- 
1  also  in  pro- 
lien  paralyzed 
from  the  pro- 
irly  noticeable 
'.ger  holds  the 
ily  recognized 
5  preceded  by, 
lis  may  elapse 

e  teres  minor. 

bruising  by  a 
!  joint.  Occa- 
\n  illness.  As 
mot  be  raised. 

the  shoulder, 
le.  The  ]oint 
lie  head  of  the 
'nts  are  thick- 
,  but  which  is 

is  one  of  the 
posed  position 
of  the  crutch, 

injured  when 

or  liy  ])ressure 

3ncli  or  on  the 

of  the  triceps. 

uncommon  in 
»n  of  ether  the 
The  paraly- 
in  branches  of 

is  anticus,  and 


DISEASES  OF  THE  SPINAli  NERVES. 


1071 


the  supinator  longus,  as  well  as  the  extensors  of  the  wrist  and  fingers. 
Xaturally,  in  lesions  just  above  the  elbow  the  arm  muscles  and  tlie  sujjinator 
longus  are  si)ared.  The  most  characteristic  feature  of  the  })aralysis  is  the 
wrist-drop  and  the  inability  to  extend  the  first  phalanges  of  the  lingers  and 
thumb.  In  the  pressure  palsies  the  supinators  are  usually  involved  and 
the  movements  of  supination  cannot  be  accomplished.  The  sensations  may 
lie  im})aired,  or  there  may  lie  marked  tingling,  but  the  loss  of  sensation  is 
rarely  so  jji-onounced  as  that  of  motion. 

The  all'ection  is  readily  recognized,  but  it  is  sometimes  dillicult  to  say 
upon  what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a  rule,  uni- 
lateral and  involve  the  su})inator  longus.  The  paralysis  from  lead  is  bi- 
lateral and  the  supinators  are  unalfected.  Bilateral  wrist-drop  is  a  very 
common  symptom  in  many  forms  of  multi])lc  neuriti.s,  i)articularly  the 
alcoholic;  but  the  mode  of  onset  and  the  involvement  of  the  legs  and  arms 
are  features  which  make  the  diagnosis  easy.  The  duration  and  course 
(tf  the  inusculo-si)iral  })aralyses  are  very  variable.  The  pressure  palsies  may 
(lisai)pear  in  a  few  days.  Recovery  is  the  nde,  even  when  the  all'ection  lasts 
for  many  weeks.  The  electrical  examination  is  of  importance  in  the  prog- 
nosis, and  the  rules  laid  down  under  paralysis  of  the  facial  nerve  hold  good 
liore. 

The  treatment  is  that  of  neuritis. 

((/)  Ulnar  Nerve. — The  motor  branches  su])i)ly  the  ulnar  halves  of  the 
deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the  interossei, 
the  adductor  and  the  inner  head  of  the  short  flexor  of  the  thumb,  and  the 
idnar  flexor  of  the  wrist.  The  sensory  branches  supply  the  ulnar  side  of 
the  hand — two  and  a  half  fingers  on  the  back,  and  one  and  a  half  fingers 
t)n  the  front.  Paralysis  may  result  from  pressure,  usually  at  the  elbow- 
joint,  although  the  nerve  is  here  protected.  Possibly  the  neuritis  in  the 
ulnar  nerve  in  some  cases  of  acute  illness  may  be  due  to  this  cause.  Gowers 
mentions  the  case  of  a  lady  who  twice  had  ulnar  neuritis  after  confinement. 
Owing  to  paralysis  of  the  ulnar  flexor  of  the  wrist,  the  hand  moves  tt^ward 
the  radial  side;  adduction  of  the  thumb  is  impossible;  the  first  phalanges 
cannot  be  flexed,  and  the  others  cannot  be  extended.  In  long-standing 
cases  the  first  phalanges  are  overextended  and  the  others  strongly  flexed, 
])roducing  the  claw-hand;  but  this  is  not  so  marked  as  in  the  progressive 
nmscular  atrophy.  The  loss  of  sensation  corresponds  to  the  sensory  dis- 
tribution just  mentioned. 

(e)  Median  Nerve. — This  supplies  the  flexors  of  the  fingers  except  the 
ulnar  half  of  the  deep  fiexors,  the  abductor  and  the  flexors  of  the  thumb, 
the  two  radial  lumbric?1es,  the  pronators,  and  the  radial  flexor  of  the  wrist. 
The  sensory  fibres  sup]dy  the  radial  side  of  the  palm  and  the  front  of  the 
thumb,  the  first  two  fingers  and  half  the  third  finger,  and  the  dorsal  sur- 
faces of  the  same  three  fingers. 

This  nerve  is  seldom  involved  alone.  Paralysis  results  from  injury  and 
occasionally  from  neuritis.  The  signs  are  inability  to  ]ironate  the  forearm 
beyond  the  mid-position.  The  wrist  can  only  be  flexed  toward  the  ulnar 
side;  the  thumb  cannot  be  opposed  to  the  tips  of  fingers.  The  second 
phalanges  cannot  be  flexed  on  the  first;  the  distal  phalanges  of  the  first 


1072 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


and  seccind  fiii^'crs  cannot  be  tlexcd;  but  in  tho  third  and  fourth  fin<;c'rs 
this  action  can  he  pcrt'ornicd  hy  the  uhiar  hall'  of  the  Ik'xor  i)rol'uii(lus.  Tiio 
loss  of  sensation  is  iu  the  rej;iou  eorrespoiuhn^'  to  the  sensory  distribution 
ah'eady  mentioned.  The  wasting  of  the  tluinil)  muscles,  which  is  usually 
inaria'd  in  this  jjaralysis,  gives  to  it  a  characteristic  apjiearauce. 


T.IMUAH    AM)    SacUAL   PlKXUSES. 

The  liiiiihar  plexus  is  sometimes  involved  in  growths  of  the  lym})h- 
glands,  in  psoas  abscess,  and  in  disease  of  the  bones  of  the  vertelnw.  Of 
its  branches  tlie  ohhirdlor  iirrrr  is  occasionally  injured  during  ])arturili()n. 
When  paralyzed  the  power  is  lost  over  the  atlductors  of  the  thigh  and  one 
leg  cannot  be  crossed  over  the  other.  Outward  rotation  is  also  disturbed. 
The  aiilcrior  crural  nerre  is  sometimes  involved  in  wounds  or  in  disloca- 
tion of  the  hip-joint,  less  commonly  during  ])arturiti(M,  and  sometimes 
by  disi'ase  of  the  bones  and  in  psoas  abscess.  The  specia'  symi)t()nis  of  alfee- 
tion  of  this  nerve  arc  ]>aralysis  of  the  extensors  of  the  knee  with  wasting 
of  the  muscles,  ana'sthesia  of  the  autero-lateral  parts  of  the  thigh  and  of  the 
inner  side  of  the  leg  to  the  big  toe.  This  nerve  is  sometimes  involved  early 
in  growths  about  the  s])ine,  and  there  nuiy  be  i)ain  in  its  area  of  distribu- 
tion. Loss  of  tlie  i)ower  of  abducting  the  thigh  results  from  ])aralysis  of 
the  gluteal  nerve,  which  is  distributed  to  tho  gluteus,  medius,  and  minimus 
muscles. 

The  sacral  phwus  is  frequently  involved  in  tumors  and  inflammations 
within  the  jjclvis  and  may  be  injured  during  parturition.  Xeuritis  is  com- 
mon, usually  an  extension  from  the  sciatic  nerve. 

Of  the  branches,  the  sciatic  nerre,  when  injured  at  or  near  the  notch, 
causes  paralysis  of  the  flexors  of  the  legs  and  the  muscles  below  tho  knee, 
but  injury  below  the  middle  of  the  thigh  involves  only  tho  latter  muscles. 
There  is  also  anaesthesia  of  the  outer  half  of  the  leg,  the  sole,  and  the  greater 
]H)rtion  of  the  dorsum  of  the  foot.  Wasting  of  the  muscles  frequently  fol- 
lows, and  there  may  be  trophic  disturljances.  In  paralysis  of  one  sciatic 
the  leg  is  fixed  at  the  knee  by  the  action  of  the  quadricojjs  extensor  and  the 
patient  is  able  to  walk. 

Paralysis  of  the  siuall  sciatic  iierre  is  rarely  seen.  The  gluteus  maximus 
is  involved  and  there  may  be  diflhculty  in  rising  from  a  seat.  There  is  a 
strip  of  anaesthesia  along  the  back  of  the  middle  third  of  the  thigh. 

E.rtenidl  Popliteal  Xerve. — Paralysis  involves  the  peronan,  the  long  ex- 
tensor of  the  toes,  tibialis  anticus.  and  the  extensor  brevis  digitorum.  The 
ankle  cannot  be  flexed,  resulting  in  a  condition  known  as  foot-drop,  and 
as  the  toes  cannot  be  raised  the  whole  leg  must  be  lifted,  producing  the 
characteristic  steppage  gait  seen  in  so  many  forms  of  peripheral  neuritis. 
In  long-standing  cases  the  foot  is  permanently  extended  and  there  is  wasting 
of  the  anterior  tibial  and  peroneal  muscles.  The  loss  of  sensation  is  in  tho 
outer  half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Infernal  Popliteal  Nerve. — When  paralyzed,  plantar  flexion  of  the  foot 
and  flexion  of  the  toes  are  impossible.  The  foot  cannot  be  adducted,  nor 
can  the  patient  rise  on  tiptoe.     In  long-standing  cases  talipes  calcaneus 


DISEASES  OF  THE  Sl'lNAL   NKUVES. 


1073 


urth  fingcTd 
mid  us.  Tlio 
(listriljutioii 
h  is  usually 


follows  aiul  the  toes  nssuiuf  ii  claw-like  position  from  secondary  contracture, 
(hie  to  oN'erextension  of  thf  |ii'o.\iiiiid  and  Jlcxion  of  the  s^ccoiid  and  third 


ilialanges. 


the  lyniph- 
jrtebne.     Of 

l)ar(uriti()n. 
i^di  and  one 
;o  disturbed. 

•  in  disloca- 
1  sometimes 
>ms  of  all'ec- 
iith  wasting 
h  and  of  the 
volved  early 

of  distribu- 
paralysis  of 
ud  uiiuijnus 

flammations 
ritis  is  coni- 

•  the  notch, 
w  the  knee, 
ter  innscles. 

the  greater 
inently  fol- 

one  sciatic 
isor  and  the 

us  maximns 
There  is  a 
ligh. 

he  long  ex- 
lornm.  The 
t-drop,  and 
xlucing  the 
ral  neuritis, 
e  is  wasting 
on  is  in  the 

of  the  foot 
ducted,  nor 
s  calcaneus 


SCIATICV. 


This  is,  ns  n  rule,  a  neuritis  either  of  the  sciatic  nerve  or  of  its  cords 
of  origin,    it  may  in  some  instances  be  a  functional  neurosis  or  Jieuralgia. 

It  occurs  most  commonly  in  adult  males.  A  history  of  rheumatism  or 
<d'  gout  is  present  in  numy  cases.  Exposure  to  cold,  particularly  after 
lieavy  muscular  exertion,  or  a  severe  wetting  are  not  uncommon  causes. 
Within  the  pelvis  the  nerves  may  be  compressed  by  large  ovarian  or  uterine 
tuuKtrs,  l)y  lympliadenomata,  by  the  fcetal  head  during  lal)or;  occasion- 
ally lesions  of  the  hip-joint  induce  a  secondary  sciatica.  The  condition 
of  the  nerve  has  been  examined  in  a  few  cases,  and  it  has  often  lieen  seen 
in  the  operation  of  stretching.  Jt  is,  as  a  rule,  swollen,  reddened,  and  in  a 
ciindition  of  interstitial  neuritis.  '^I'he  alfection  may  i)e  most  intense  at  the 
sciatic  notch  or  in  the  nerve  about  the  middle  of  the  thigh. 

Of  the  s!/niplt)nis,  \)n\n  is  the  most  constant  and  troublesome.  The 
onset  may  be  severe,  with  slight  ])yrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  time  there  is  only  slight  pain  in  the  back  of  the  thigh,  particularly 
in  certain  positions  or  after  exertion.  Soon  the  jiain  becomes  more  intense, 
and  instead  of  being  limited  to  the  upper  ])ortion  of  the  nerve,  extends 
down  the  thigh,  reaching  the  foot  and  radiating  o\t'r  the  entire  distribu- 
tion of  the  nerve.  The  ])atient  can  often  ])oint  (uit  the  most  sensitive  spots, 
usually  at  the  notch  or  in  the  middle  of  the  thigh;  and  on  ])ressure  these 
are  exquisitely  ])ainful.  The  pain  is  described  as  gnawing  or  burning,  and 
is  usually  constant,  but  in  some  instances  is  paroxysmal,  and  often  worse 
at  night.  On  Avalking  it  may  be  >ery  great;  the  knee  is  bent  and  the  pa- 
tient treads  on  the  toes,  so  as  to  relieve  the  tensioii  on  the  nerve.  Jn  ]»ro- 
tracted  cases  there  may  be  much  wasting  of  the  muscles,  but  the  reaction  of 
degeneration  can  seldom  be  obtained.  In  these  clironic  cases  cramp  may 
occur  and  fibrillar  contractions.  Herpes  may  develo]),  but  this  is  unusual. 
In  rare  instances  the  neuritis  ascends  and  involves  the  spinal  cord. 

The  duration  and  course  are  extremely  variable.  As  a  rule  it  is  an  ob- 
stinate affection,  lasting  for  months,  or  even,  with  slight  remissions,  for 
years.  Kelapses  are  not  uncommon,  and  the  disease  may  be  relieved  in  one 
nerve  only  to  appear  in  the  other.  In  the  severer  forms  the  patient  is  hed- 
ridden,  and  such  cases  ])rove  among  the  most  distressing  and  trying  which 
tlie  ])hysician  is  called  u])on  to  treat. 

In  the  (liaf/iiosis  it  is  important,  in  the  first  place,  to  determine  whether 
tlie  disease  is  primary,  or  secondary  to  some  alfection  of  the  pelvis  or  of 
the  spinal  cord.  A  careful  rectal  examination  should  he  made,  and,  in 
women,  ])elvic  tumor  should  be  excluded.  Lumbag(j  may  he  confounded 
with  it.  Affections  of  the  hip-joint  are  easily  distinguished  by  the  absence 
of  tenderness  in  the  course  of  the  nerve  and  the  sense  of  pain  on  movement 
of  the  hip-joint  or  on  pressure  in  the  region  of  the  trochanter.  There  are 
instances  of  sacro-iliac  disease  in  which  the  patient  complains  of  ])ain  in 
the  upper  part  of  the  thigh,  which  may  sometimes  radiate;  but  careful 
•67 


1074 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


cxaminntinn  will  rondily  distinjruisli  between  the  afTeetions.  ProssiirG  on 
the  nerve  trunks  ol'  the  eaiuhi  equina,  I's  a  rule,  causes  l)ijateral  pain  and 
disturbances  of  sensation,  and,  as  double  sciatica  is  rare,  these  eircumstancis 
always  suggest  lesion  ol'  the  nerve  roots.  JJetween  the  severe  lightnin<: 
pains  of  tabes  and  sciatica  the  dilferences  are  usually  well  defined. 

Treatment. — Tlie  pelvic  organs  should  be  carefully  and  systematically 
examined.  Constitutional  conditions,  such  as  rheumatism  and  gout,  should 
receive  appropriate  treatment.  In  a  few  cases  with  pronounced  rheumatic 
history,  which  come  on  acutely  with  fever,  the  salicylates  seem  to  do  good. 
]n  other  instances  they  are  (juite  useless.  Jf  tliere  is  a  suspicion  of  sy])hilis, 
the  iodide  of  ])otassium  should  be  emjjloyed,  and  in  gouty  cases  salines. 

Kest  in  bed  with  fixation  of  the  limb  by  means  of  a  long  splint  is  a 
most  valuable  method  of  treatment  in  many  cases,  one  upon  which  Weir 
Mitchell  has  specially  insisted.  I  have  known  it  to  relieve,  and  in  some 
instances  to  cure,  obstinate  and  jjrotracted  cases  which  had  resisted  all 
other  treatment.  Hydrotherapy  is  sometimes  satisfactory,  particularly  the 
warm  baths  or  the  mud  baths.  Many  eases  are  relieved  by  a  prolonged 
residence  at  one  of  the  thermal  springs. 

Antipyrin,  antifebrin,  and  quinine,  are  of  doubtful  benefit. 

Local  api)lications  are  more  beneficial.  The  hot  iron  or  the  thermo- 
cautery or  blisters  relieve  the  pain  temporarily.  Deep  injections  into  the 
nerves  give  great  relief  and  may  be  necessary  for  the  pain.  It  is  best  to  use 
cocaine  at  first,  in  doses  of  from  an  eighth  to  a  quarter  of  a  grain.  If  the 
pain  is  imbearable  morphia  may  be  used,  but  it  is  a  dangerous  remedy  in 
sciatica  and  should  be  withheld  as  long  as  possible.  The  disease  is  so  pro- 
tracted, so  liable  to  relapse,  and  the  patient's  morale  so  undermined  by 
the  constant  worry  and  the  sleepless  nights,  that  the  danger  of  coniiacting 
the  morphia  habit  is  very  great.  On  no  consideration  should  the  patient 
be  permitted  to  use  the  hypodermic  needle  himself.  It  is  remarkable  how 
promptly,  in  some  cases,  the  injection  of  distilled  water  into  the  nerve  will 
relieve  the  pain.  Acupuncture  may  also  be  tried;  the  needles  should  be 
thrust  deeply  into  the  most  painful  spot  for  a  distance  of  about  2  inches, 
and  left  for  from  fifteen  to  twenty  minutes.  The  injection  of  chloroform 
into  the  nerve  has  also  been  recommended. 

Electricity  is  an  uncertain  remedy.  Sometimes  it  gives  prompt  relief; 
in  other  cases  it  may  be  used  for  weeks  without  the  slightest  benefit.  Tt 
is  most  serviceable  in  the  chronic  eases  in  which  there  is  wasting  of  the 
legs,  and  should  be  combined  with  massage.  The  galvanic  current  should 
be  used;  a  flat  electrode  should  be  placed  over  the  sciatic  notch,  and  ;i 
smaller  one  used  along  the  course  of  the  nerve  and  its  branches.  In  very 
obstinate  cases  nerve-stretching  may  be  employed.  It  is  sometimes  success- 
ful; but  in  other  instances  the  condition  recurs  and  is  as  bad  as  ever. 


ACUTK   DELIRIUM. 


1075 


rrcssiiro  on 
nil  i)aiii  mill 
'ircumsliiiiccs 
ire  lightning 
'lined, 
ysteniatically 

gont,  sliould 
jd  rlu'uniatic 
1  to  do  good. 
n  of  syi)liilis, 
?s  salinos. 
g  splint  is  a 

which  Weir 
and  in  sonic 
I  resisted  all 
"ticnlarly  the 

a  prolonged 

t. 

the  tliermo- 
ions  into  the 
is  best  to  nso 
rain.  If  the 
iS  remedy  in 
ise  is  so  pro- 
clerniined  hy 
'  eon  1 1  acting 
[  the  patient 

arkable  how 
le  nerve  will 

s  should  Ik' 
)ut  2  inches, 

'  chlorofonu 

ompf  relief; 
benefit.  It 
sting  of  the 
rrent  should 
otch,  and  a 
es.  In  very 
mes  success- 
s  ever. 


YII.   GENEPwAL  AND   FUNCTIONAL   DISEASES. 

I.    ACUTE   DELIRIUM   (/W/'a  Mania). 

Definition. — Acide  delirium  running  a  rapidly  fatal  course,  with 
slight  lever,  and  in  which  jiost  mortem  no  lesions  aie  found  sullieient  to 
account  for  the  disease. 

Cases, are  reported  by  many  old  writers  under  the  term  lira  in  fever  or 
phrenitis.  J5ell,  at  the  time  Superintendent  of  the  ^IcLean  Asylum,  de- 
scribed it  *  accurately  under  the  designation,  "  a  form  of  disease  resembling 
some  advanced  stages  of  mania  and  fever." 

The  disease  may  set  in  abruptly  or  be  preceded  by  a  period  of  irrita- 
bility, restlessness,  and  insomnia.  The  mental  symptoms  develop  with 
rapidity  and  may  ([uickly  reach  a  grade  of  the  most  intense  frenzy.  There 
are  the  wildest  hallucinations  and  outbreaks  of  great  violence.  The  pa- 
tient talks  incessantly,  but  incoherently  and  unintelligibly.  No  sleep  is 
obtained,  and  at  last,  worn  out  with  the  intensity  of  the  muscular  move- 
ments, the  ])atient  becomes  utterly  prostrated  and  assumes  the  sitting  or 
recumbent  posture.  There  may  sometimes  be  definite  salaam  movements, 
and  in  a  case  which  I  saw  at  Westphal's  clinic  the  patient  incessantly  made 
motions  as  if  working  a  pump  handle.  After  a  period  of  intense  bodily 
excitement,  lasting  for  from  twenty-four  to  thirty-six  hours  or  longer,  the 
patient  can  be  examined,  and  presents  the  conditions  which  liell  described 
as  typho-mania.  The  temperature  ranges  from  10:<}°  to  104:°,  or  even 
higher.  The  tongue  is  dry,  the  pulse  rai)id  and  feeble;  sometimes  there 
are  seen  on  the  skin  bulla}  and  pustules,  and  freiiuently  sores  from 
abrasion  and  self-inflicted  injuries.  Toward  the  close-  or,  according  to 
Spitzka,  even  during  the  development  of  the  disease  there  may  be  lucid 
intervals.  There  may  be  petechia;  on  the  skin,  and  often  there  is  marked 
congestion  of  the  face  and  extremities.  The  duration  of  the  disease  is 
variable.  Very  acute  cases  may  terminate  within  a  week;  others  persist 
for  two  or  even  three  weeks.  The  course  of  the  disease  is  almost  uniformly 
fatal.  The  anatomical  condition  is  practically  negative,  or  at  any  rate 
l)resents  nothing  distinctive.  There  is  great  venous  engorgement  of  the 
vessels  of  the  meninges  and  of  the  gray  cortex.  In  two  cases  in  which  I 
made  a  careful  microscoi)ical  examination  of  the  gray  matter  there  were 
perivascular  exudation  and  leucocytes  in  the  lymph  sheaths  and  peri- 
gangliar  s])accs.  In  the  inspection  of  fatal  cases  of  acute  delirium  care- 
ful examination  should  be  made  of  the  lungs  and  ileum.  It  should  bo 
l)orne  in  mind  that  in  a  majority  of  the  cases  dying  in  this  manner, 
there  is  engorgement  of  the  bases  of  the  lungs  or  even  deglutition  pneu- 
monia. 

The  nature  of  the  disease  is  quite  unknown.  Some  of  the  cases  sug- 
gest acute  infection.  Spitzka  thinks  that  it  is  due  to  an  autochthonous 
nerve  poison. 


*  American  Journal  of  Insanitv,  18-19. 


pip 


1070 


DISKASKS  OF  THE  NKIIVOUS  SYSTEM. 


/ 


Diagnosis.  Thon  nro  scvcriil  discuses  wliidi  may  present  ideiiliciil 
s_viii[it()iiis.  As  I'ell  reiiiarkri  in  his  paper,  (lie  lirsl  ^ulaiiee  in  iiiaiiv  eases 
siij-'^^'sls  l_vpii(»i(l  fever,  parlieiilarly  when  the  patient  is  seen  niter  the  vio- 
lence iA'  the  mania  lias  suhsided.  He  gives  two  instances  ol'  this  which  were 
admitted  Irom  a  jiciicral  hospital,  l-'-nlai'^cmeiit  of  llii'  sph'cii,  the  occiir- 
rcni'C  uf  spots,  and  the  history  give  clews  for  the  separation  of  (ho  cases; 
l)ii(  tlieie  ari'  instances  in  which  it  is  at  firs(  inipossihle  to  deciih'.  Mdre- 
over,  t\plioid  fevi'r  may  set  in  with  the  most  intense  delirium,  'i'lie  exist- 
ence of  fever  is  the  must  dece]itive  synip(t)m,  and  its  comhination  with 
dcliriiim  and  drv  tongue  so  I'onimoiily  means  typhoid  fever  that  it  is  very 
ditlicult   to  avoid  error. 

Ai'titi"  [meiinioiiia  may  come  on  with  violent  maniacal  delirium  and  the 
])ulmoiiary  symptoms  may  he  entirely  masked. 

Occasionally  acute  iii'U'inia  sets  in  suddi'iily  with  intense  mania,  and 
linally  suhsides  into  a  fatal  coma.  The  condition  of  the  urine  and  the  ah- 
sence  of  fevi'r  would  he  important  diagnostic  features. 

'1  he  chai'actcr  of  the  delirium  is  (piite  dilVercul  from  that  of  iiidiiid  a 
pitlu.  It  may  he  extremely  dillicult  to  did'erentiate  acute  delirium  from 
certain  cases  of  cortical  meningitis  occurring  in  coiinecdon  with  j)iicu- 
monia,  ulceradve  eii(h»carditis  or  tuhcrt'ulosis,  or  due  to  extension  from 
disease  of  (he  I'ar.  Tliis  sets  in  more  I'requeiidy  with  a  chill,  and  there 
may  he  I'oin  ulsions. 

TreatJient. — Kvi'ii  though  ]n)dily  i)rostratioii  is  ajit  to  como  on  early 
and  he  profound,  in  the  case  of  a  roluist  man  i'ree  venesection  might 
be  tried.  1  have  heen  criticised  for  this  advice,  Imt  repeat  it.  It  is 
not  at  all  improhahle  that  some  of  tlu'  many  cases  of  mania  in  Mhich 
JU'iijamin  Ixiisli  let  blood  with  such"  benetit  belonged  to  this  class  of  alTcc- 
tions.  Considering  its  remarkable  calming  inlliience  in  febrile  delirium, 
the  cold  bath  or  the  cold  pack  should  bi'  employed,  ^[orjihia  and  chloro- 
form may  be  administered  and  liyoscine  and  the  bromides  may  be 
tried.  l\rall't-I''bing  states  that  Solivetti  has  obtained  good  results  by 
the  use  of  ergotin.  Fnfortnnately,  as  asylum  reports  show,  the  disease 
is  almost  iinil'ormlv  fatal. 


II.    PARALYSIS    AGITANS 


(Parkinson's  Disease  :  Shaki)i(j  Ai/.^iy). 

Definition. — A  chronic  affection  of  the  nervous  system,  characterized 
by  muscular  weakness,  tremors,  and  rigidity. 

Etiology. — ^len  are  more  frequently  affected  than  Avonion.  It  rarely 
occurs  under  forty,  but  instances  have  been  reported  in  which  the  disease 
began  about  the  twentieth  year.  It  is  by  no  means  an  uncommon  affec- 
tion. Direct  heredity  is  rare,  but  the  patients  often  belong  to  families  in 
■which  there  are  other  nervous  affections.  Among  exciting  causes  may  be 
mentioned  e.\"])osure  to  cold  and  wet,  and  business  worries  and  anxieties. 
In  some  instances  the  disease  has  followed  directly  upon  severe  mental  shock 
or  trauma.     Cases  have  been  described  after  the  specific  fevers.     Malaria 


<i'iit  idciiticjil 
II  iiiiiny  cast's 
iiltiT  till'  vio- 
ls wliicli  ufi'c 
n,  lilt.'  oi'ciir- 
(if  the  ciist's; 
'cidc.  Morc- 
Tlii'  I'xisf- 
)iniiti()n  with 
lilt  il  is  vciT 

rium  and  (lu- 

'  mania,  and 
'  and  the  al»- 

ol"  mil II ill  II 
.dirinni   IVoin 

willi  i>n('ii- 
onsion  rroin 
II,  and  tiu'iv 

jnic  on  early 
ction  mi.ylit 
it  it.  it  is 
ia  in  wliich 
ass  of  allVc- 
le  dolirinni, 

and  c'liloro- 

I's    may    Itc 

rt'sults   l)y 

the  disease 


I'AIIA LYSIS  AOITANS. 


107T 


liaracterized 

It  rarely 
the  disease 
nmon  afTcc- 
fainilies  in 
ises  may  hv 
d  anxieties, 
ental  shock 
s.     Malaria 


is  helievod  by  some  to  he  an  important  factor,  hnt  of  this  there  is  no  Butis- 
I'iictnry  cvidt'iice. 

Morbid  Anatomy.  —  No  constant  lesions  have  hem  found,  'i'hu 
-imilarity  hetwccn  certain  of  the  features  of  rarkinson's  disease  and  those 
of  old  age  su<,'gest  that  the  allVction  may  depend  upon  a  premature  seidl- 
ity  of  certain  regions  of  the  hrain.  Our  organs  do  not  age  uniformly,  hut 
in  some,  owing  to  hereditary  disposition,  the  proc(;ss  may  he  more  rapi(l 
than  in  others.  "Parkinson's  disease  has  no  chiiracteristic  lesions,  iiut  on 
the  other  hand  it  is  not  a  neurosis.  It  has  for  an  anatomical  hasis  the 
lesions  of  cerehro-spinal  senility,  and  which  only  dilVer  from  those  of  true 
senility  in  their  early  onset  and  greater  intensity"  (hiiiiicf).  The  im- 
portant changes  are  douhtle.ss  in  the  cerebral  corte.v. 

Symptoms. — The  disease  begins  gradually,  usually  in  one  or  other 
hand,  and  the  tremor  may  be  either  constant  or  intermittent.  With  this 
may  bo  associated  weakness  or  still'ness.  x\t  first  these  symptoms  may  ho 
present  only  after  ex(;rtion.  Although  th<!  onset  is  slow  and  gradual  in 
nearly  all  eases,  there  are  instances  in  which  it  sets  in  abruptly  after  fright 
or  trauma.  When  well  established  the  disease  is  very  characteristic,  and 
the  diagnosis  can  he  nnide  at  a  glance.  The  four  prominent  symptoms 
are  tremor,  weakness,  rigidity,  and  the  attitude. 

Tremor. — 'J'his  may  be  in  the  four  extremities  (jr  conline(l  to  hands  or 
feet;  the  head  is  not  so  commonly  all'ected.  'V\w.  tremor  is  usually  marketl 
in  the  haixls,  and  the  thumb  and  forefinger  display  the  motion  made  in  tho 
act  of  rolling  a  |)ill.  At  the  wrist  there  are  movements  of  pronation  and 
supination,  and,  though  less  mai'ked,  of  flexion  and  extension.  The  nppcr- 
arm  muscles  are  riirely  involved.  Jn  the  legs  the  movement  is  most  evident 
at  the  aqkle-joint,  and  less  in  the  toes  than  in  the  fingers.  Shaking  of  the 
head  is  less  fretpient,  l)ut  does  occur,  and  is  usually  vertical,  not  rotatory. 
The  rate  of  oscillation  is  about  five  per  second.  Any  emotion  exaggei'ates 
the  movement.  The  attem|)t  at  a  voluntary  mo  nent  may  check  the 
triMnor  (the  patient  may  be  able  to  thread  a  needle),  but  it  retiirns  with 
increased  intensity.  Tho  tremors  cease,  as  a  rule,  during  sleej),  but  persist 
when  the  muscles  are  at  rejjose.  The  writing  of  the  i)atient  is  tremulous 
and  zigzag. 

\ycakncsH. — Loss  of  ])ower  is  present  in  all  eases,  and  may  occur  even 
before  the  tremor,  but  is  not  very  striking,  as  tested  by  the  dynamometer, 
until  the  late  stages.  The  weakness  is  greatest  where  the  tremor  is  most 
developed.  The  movements,  too,  are  remarkably  slow.  There  is  rarely 
complete  loss  of  power. 

liifjidih/  may  early  l)e  expressed  in  a  slowness  and  stiffness  in  the  vol- 
untary movements,  which  are  performed  with  some  effort  and  difficulty, 
and  all  the  actions  of  the  patient  are  deliberate.  This  rigidity  is  in  all  tho 
muscles,  and  leads  nltimately  to  the  characteristic 

Attitude  and  Gait. — The  head  is  bent  forward,  the  back  is  bowed,  and 
the  arms  are  held  away  from  the  body  and  are  somewhat  flexed  at  tho 
ell)ow-joints.  The  face  is  expressionless,  and  the  movements  of  the  lips 
are  sIoav.  The  eyebrows  are  elevated,  and  the  whole  ox]ircspion  is  immobile 
or  mask-like,  the  so-called  Parkinson's  mask.     The  voice,  as  pointed  out 


w 


1078 


DISEASES  OF  THE  NEUV(JUS  SYSTEM. 


1)}'  l)iiz/,nr(l,  is  apt  to  l)o  slirill  and  pipin",',  and  tlicro  U  oftcMi  n  hcsitaiuy  in 
Ix'iiinniii^'  a  sentence;  (lien  the  wiirds  ai'e  nttered  witii  rapidity,  as  if  tlie 
l»atic'nt  was  in  a  liiirry.  'I'liis  is  sometimes  in  sti'ii\in;;'  euntrasl  to  tlie  siaii- 
iiing  spi'ech  of  insular  sclerosis.  The  lingers  are  lie.ved  und  in  the  jiosilion 
assumed  when  the  hand  is  at  rest;  in  tlie  iati'  stages  they  cannot  bo  ex- 
tended. Occasionally  there  is  overc.\ten>ion  of  the  termiiud  phalanges. 
The  hand  is  usually  turned  toward  the  ulnar  side  and  llu'  attitude  some- 
what resend)les  that  of  advanced  cases  of  rheumatoid  arthritis.  In  the 
late  stages  there  are  contractures  at  the  elhows,  knees,  and  ankli's.  'J'h(> 
movements  of  the  patient  are  charat-terized  hy  great  delihenUion.  lie  rises 
from  the  chair  slowly  in  the  stooping  altitude,  with  the  head  projecting 
forward.  In  atli'mpling  to  walk  the  steps  are  short  and  hurried,  and,  as 
Trousseau  renuirks,  ho  ai)pear8  to  ho  running  after  his  centre  of  gravity. 
This  is  termed  festination  or  projtulsion,  in  contradistinction  to  a  i)eculiar 
gait  observed  when  the  patient  is  pulled  backward,  when  he  makes  a  num- 
ber of  steps  and  would  fall  over  if  not  prevented — retrojiulsion. 

The  rellexes  are  normal  in  most  cases,  but  in  a  few  they  are  exaggerated. 

Of  sensory  disturbances  Charcot  has  noted  ahnormal  alterations  in  the 
temperature  sense.  'J'he  ])atient  may  complain  of  subjective  sensations  of 
heat,  either  general  or  local — a  i)henonu'non  which  may  be  present  on  one 
side  oidy  ami  associated  witli  an  actual  increase  of  the  surface  temi)ei'ature, 
as  much  as  0°  V.  ((Jowers).  In  other  instances,  patients  complain  of  cold. 
Localized  sweating  nuiy  be  present.  The  mental  condition  rarely  shows  any 
change. 

Variatitnis  in  the  Si/inplonis. — The  tremor  may  be  ahscnt,  hut  ;he  rigid- 
ity, weakness,  and  attitude  arc  sullicient  to  make  the  diagnosis.  The  dis- 
ease may  he  homii)legic  in  character,  involving  only  one  side  or  Qven  one 
liml).     Usually  these  are  hut  stages  of  the  disease. 

Diagnosis.' — In  well-develoi)ed  cases  the  disease  is  recognized  at  a 
glance.  The  attitude,  gait,  stilfness,  and  nuisk-like  expression  are  points 
of  as  much  imjjortance  as  the  oscillations,  and  usually  serve  to  separate 
the  cases  from  senile  and  other  forms  of  tremor.  Disseminated  sclerosis 
develops  earlier,  and  is  characterized  l)y  the  nystagmus,  and  the  scanning 
speech,  and  does  not  present  the  attihide  so  constant  in  paralysis  agitans. 
Yet  Schultzo  and  Sachs  have  reported  cases  in  which  the  signs  of  multiple 
sclerosis  have  heen  associated  with  those  of  paralysis.  The  hemiplegie 
form  might  he  confounded  with  post-hemiplegic  tremor,  hut  the  history, 
the  mode  of  onset,  and  the  greatly  increased  reflexes  would  he  sufficient  to 
distinguish  the  two.  The  Parkinsonian  face  is  of  great  importance  in  the 
diagnosis  of  the  ohscure  and  anomalous  forms. 

The  disease  is  incurahle.  Periods  of  improvement  may  occur,  hut  the 
tendency  is  for  the  affection  to  proceed  progressively  downward.  It  is  a 
slow,  degenerative  ])rocess  and  the  cases  last  for  years. 

Treatment.' — There  is  no  method  which  can  he  recommended  as  satis- 
factory in  any  respect.  Arsenic,  opium,  and  hyoscyamine  may  he  tried,  hut 
the  friends  of  the  patient  should  he  told  frankly  that  the  disease  is  incur- 
ahle, and  that  nothing  can  he  done  except  to  attend  to  the  physical  com- 
forts of  the  patient. 


ACUTE  (niORKA. 


luTl) 


I  hositaiicy  in 
ity,  lis  if  till- 

t    to    tllC   SfMll- 

1  the  jiosiUun 
iimiot  be  t'x- 
il  jiliJiIiin^'cH. 
ttididc  s<tiiie- 
itis.  ill  iho 
iinklcs.  Tlu! 
»n.  Ho  rises 
ul  iJi'djoctiii}^ 
ric'd,  iuul,  jis 

0  of  gravily. 
to  a  i)t'fuliar 
lakes  a  nuni- 
1. 

exafr^'c  rated, 
itions  in  the 
sensations  ot" 
L'sent  on  one 
temperature, 
lain  of  cold, 
y  eliows  any 

lit  llie  riffid- 
s.  Tlic  dis- 
or  Qvcn  one 

gnized  at  a 

1  are  points 
to  se])arate 

;ecl  sclerosis 
tie  scanninj,' 
>'sis  ajritans. 
of  multiple 
hemiplegic 
the  history, 
sufficient  to 
ance  in  the 

ur,  but  the 
•d.     It  is  a 

led  as  satis- 
e  tried,  hut 
36  is  incur- 
ysical  com- 


OtIIICU    ToIIMS   ok   'I'llKMOIl. 

(a)  Simple  Trntior. — This  is  occasionally  found  in  persons  in  whom  it 
is  impossii)h!  to  assi;,Mi  any  cause.  Jt  may  he  transient  or  persist  for  an 
indellnite  time.  It  is  often  extremely  sli},'iit,  and  is  agj^'ravateil  hy  all  causes 
which  lower  the  vitality. 

(h)  Jlcrcililiiri/  Tirnior. — ('.  L.  Dana  has  r('pf)rted  romarkahh^  cases  of 
hereditary  tremor.  Jt  occurred  in  all  the  members  of  one  family,  and  be- 
;,Mnning  in  infancy  continued  without  producing  any  serious  changes. 

(c)  Senile  Tremor. — With  advancing  age  tremulousness  during  muscular 
Miovements  is  extremely  common,  but  is  rarely  seen  imder  seventy.  It  is 
always  a  line  trenutr,  which  begins  in  the  hands  and  often  extends  to  the 
muscles  of  the  neck,  causing  slight  movement  of  the  head. 

{(I)  Toxic  tremor  is  seen  chielly  as  an  effect  of  tobacco,  alcohol,  lead,  or 
mercury;  more  rarely  in  arsenical  or  opium  j)oisoning.  Jn  elderly  nu-n 
who  smoke  much  it  may  be  entirely  due  to  the  tohac-co.  One  of  the  com- 
monest forms  of  this  is  the  alcoholic  tremor,  which  occurs  only  on  move- 
ment and  has  considerable  range.  Lead  tremor  is  considered  under  lead 
poisoning,  of  which  it  constitutes  a  very  important  symptom. 

{e)  Ihjslerical  tremor,  which  usiuilly  occurs  uiuler  circumstances  which 
make  the  diagnosis  easy,  will  be  considered  in  the  section  on  hysteria. 


III.    ACUTE   CHOREA 

{Sijdenham'a  Chorea  ;  St.  Viius^a  Dance). 

Definition. — \  disease  chiefiy  affecting  children,  characterized  by 
irregular,  involuntary  contraction  of  the  muscles,  a  variable  amount  of 
psychical  disturbance,  and  a  remarkable  liability  to  acute  eiuh)carditis. 

We  shall  speak  here  only  of  Sydenham's  chorea.  Senile  chorea,  chronic 
chorea,  the  prehemiplegic  and  post  hemi})legic  forms,  and  rhythmic  chorea 
are  totally  different  aft'ecHons. 

Etiology. — Sex. — Of  554  cases  which  I  liave  analyzed  from  the  Phila- 
delphia Infirmary  for  Diseases  of  the  Nervous  System,  71  per  cent  were  in 
females  and  29  per  cent  in  males.  After  puberty  the  percentage  in  females 
increases. 

A(]e. — The  disease  is  most  common  between  the  ages  of  five  and  fifteen. 
C)f  'i'l'l  cases,  380  occurred  in  this  period.  It  is  more  common  in  the  lower 
classes,  and  is  rare  among  the  negroes  and  native  races  of  this  continent, 
^forris  J.  Lewis  has  shown  that  the  cases  are  most  numerous  when  the 
mean  relative  humidity  and  barometric  pressure  are  low. 

Blieiimafism. — A  causal  relationship  between  rheumatism  and  chorea 
has  been  claimed  by  many  since  the  time  of  Bright.  The  English  and 
French  writers  maintain  the  closeness  of  this  connection;  on  the  other 
hand,  German  authors,  as  a  rule,  regard  the  connection  as  by  no  means  very 
close.  Of  554  cases  which  I  have  analyzed,  in  15.5  per  cent  there  was  a 
history  of  rheumatism  in  the  family.  In  88  cases,  15.8  per  cent,  there 
was  a  history  of  articular  swelling,  acute  or  subacute.     In  33  cases  there 


1080 


DISKASKS  «>F   TIIK   NKlfVOUS  HYSTK.M. 


were  pains,  somcf inii-s  (Icscrilii'd  as  ilu'iiiiiatic,  in  various  parts,  l)iil  imt 
assdciali'd  witli  jniut  trniildc  If  we  rc^iard  all  siicli  casi'S  as  rlu'iimatic  and 
add  tlii'rii  to  tliowe  with  niainfcst  niticular  trould*',  the  iifi-ccnta;,'*'  is  nii-rd 
(o  nrarly  '.M. 

W'v  find  Iwo  ^'I'oiipH  of  cnscH  in  which  acute  arthritis  is  present  in 
chorea.  In  <tne,  the  arthritis  antedates  \\\  >nine  months  ur  years  the  (in>et 
of  till'  chori-a,  and  does  not  recur  hefore  or  (hirinj:  the  attack.  In  the 
other  K'roup,  the  chorcn  sets  in  with  or  lidlows  iinniediately  upon  thu  acute 
ai'tliritis.  In  Home  instances  it  is  im|tossihle  to  (h'cide  whether  tlu'  joint 
symptoms  or  the  movements  havo  appeared  lirst.  It  \*  dillienlt  to  dill'er- 
eiitiate  the  cases  of  irre^Milar  |)ains  without  (h'linite  joint  all'ection.  It  is 
proliahh'  that  (uany  of  tlu'ni  arc  rheumatic,  and  yet  I  think  it  would  he  a 
mistake  in  re^fard  as  such  all  cases  in  children  in  whicii  there  are  complaints 
of  va-iiie  pains  in  the  hones  or  museh's — ,'^o-ealled  <,M'owin;,'  pains.  It  should 
never  he  for^^otteii,  however,  that  a  sli^dit  articular  swelling'  nuiy  he  the 
.sole  nuinifestation  of  rheunuitism  in  a  child — so  8li|j;ht,  indeed,  that  the 
disease  may  he  entirely  overlooked. 

Ift'drl-iliscdse. —  Endocarditis  is  helieved  hy  some  writers  to  l)e  the  cause 
of  the  disease.  The  particles  of  (ihrin  and  ve^'etations  from  the  valves 
pass  as  endxtli  t<t  the  cerehral  vessels.  On  this  view,  \vhi"h  we  shall  discuss 
later,  chorea  is  the  result  (d"  an  emholie  process  occurring  in  the  course  of 
a  riieumatic  endocarditis. 

I iifciliniis  Dlsnisrs. — Scai'let  fever  with  arthritic  manifestation.-!  may 
he  a  direct  antecedent.  Stur^'cs  states  that  a  history  of  previous  whoopin^'- 
coujfh  occurs  more  frecpiently  in  choreic  than  in  other  chihlrcn,  l)ut  1  lind 
no  evidence  (d"  this  in  the  Infirnuiry  records.  With  the  excejjtion  of  riieu- 
matic fever,  there  is  no  intimate  rclationsliip  Ix'tween  cliorea  and  the  acute 
diseases  incident  to  childhood.  Jt  may  lie  iu)ted  in  contrast  to  this  that 
the  so-called  canine  chorea  is  a  common  secjuel  of  distemper.  Chorea  has 
been  known  to  develop  in  the  course  of  an  acute  pyivnnia,  and  to  follow 
gonorrluea  and  pueri)eral  fever. 

AiKOiiia  is  less  often  an  antecedent  than  a  sequence  of  chorea,  and 
though  cases  develoj)  in  cliildren  who  are  anivmic  and  in  i)oor  liealth,  this 
is  by  no  means  tlie  rule.     Chorea  may  develop  in  chlorotie  girls  at  i)ul)erty. 

rrcgnaiicy. — A  choreic  patient  may  become  i)regnant;  more  frequently 
the  disease  occurs  during  ])regiumcy;  sometimes  it  develops  i)ost  partum. 
Ihiist,  of  Dundee  (Trans.  Kdin.  ()I)s.  Soc,  LSD,")),  has  tabulated  carefully 
the  recorded  cases  to  that  date.  Of  2'3()  cases,  in  G  the  chorea  preceded 
the  pregnancy;  in  105  it  occurred  during  the  ])regnancy;  in  'M  in  recur- 
rent pregnancies;  45  cases  terminated  fatally,  and  in  1(5  cases  the  chorea 
develojH'd  post  partum.  The  alleged  frequency  in  illegitimate  primii^ara?  is 
not  borne  out  by  his  figures,  lieginning  in  the  first  three  months  were 
108  cases,  in  the  second  three  months  70  cases,  in  the  last  three  months 
25  cases.  The  disease  is  often  severe,  and  maniacal  symptoms  may  de- 
velop. 

A  tendency  to  the  disease  is  found  in  certain  families.  In  80  eases 
tbere  was  a  history  of  attacks  of  chorea  in  other  members.  In  one  instance 
both  mother  and  grandmother  had  been  affected.     High-strung,  excitable. 


ACUTE  niOUEA. 


1081 


irtH,  hilt    iKit 

It'llMllltic  iltnl 

n^'  i.s  raiM'tl 

■^  |ti'cs('ii|  ill 
UN  I  lie  oiiscl 
ick.       Ill    111.' 

1)11     IIU!    llClltc 

nT  llio  joint 
lit  fo  (lill',.r- 
ftion.  It  is 
\v<»iil(l  l)(>  a 
'  (•'•niiiliiinls 

i.      It  Sll.llll.l 

iiiiiy  lie  the 
'([,  that   th.' 

)e  the  cause 

tlio  valves 

Oiall  (lisfuss 

le  course  of 

atioiis   iiiiiy 

wllnopiii^-- 

.  but  1  (iiid 
on  of  rlu'u- 
(1  the  acute 
(>  this  that 
(-"hori'a  has 
1  to  follow 

horea,  autl 
lealth,  this 
lit  i)ul)erty. 
frequently 
st  jwrtuni. 
1  carefully 
I  in-eceded 
in  reeur- 
the  cliorea 
inii])ara2  is 
'Uths  were 
ee  months 
3  may  de- 

1  80  cases 

e  instance 

excitable. 


nervous  cliildren  nro  especially  liable  to  the  dixeatie.  Friijld  is  considered 
ii  freiiucnt  causi'.  Iiut  in  a  lar<r<'  ninjnrity  of  the  cases  no  close  connection 
exista  between  the  i'riglit  and  the  onsiet  of  the  disease.  Uceabionully  the 
attack  setH  in  at  orue.  Mental  worry,  trouble,  a  sudden  j;rief,  or  u  scold- 
in;;  may  apparently  be  the  j-xcilinj;  cause.  The  strain  of  ctlncalum,  par- 
ticularly ill  ^drls  durin>(  the  third  hemidecade,  is  a  most  iinportaiit  factor 
in  the  el  lo^^y  (d'  the  disease.  Uri;,dit,  intelligent,  active-minded  ;;irls 
li'oiii  ten  Ml  fourteen,  aniltitious  to  do  well  at  school,  often  stimulated  in 
their  ell'ortrt  by  tenehers  and  jiarents,  form  a  large  contingent  of  tho  easea 
of  chorea  in  hospital  and  private  practice.  Sturges  has  called  special  at- 
tention to  this  .srlitKil-ininlr  chorea  as  one  sei'ious  evil  in  our  modern  method 
of  forced  education.  I mihtlinii,  which  is  mentiiuu'il  as  an  exciting  causi', 
is  extrenu'ly  rare,  and  does  iu)t  ap[)ear  to  have  inllueiiced  the  onset  in  a 
single  case  in  the  Inlirmary  records. 

'V\w  diseast!  may  ra|)idly  follow  an  injury  or  a  slight  surgical  operation. 
Ifellex  irritation  was  believecl  to  play  an  important  n'lli'  in  the  disease, 
particularly  the  preseiu'c  of  worms  or  genital  iri'italion;  but  J  have  met  with 
no  instaiu'c  in  which  the  disease  could  lie  attributed  to  either  of  these 
causes.  Local  spasm,  particularly  of  the  face — the  habit  chorea  of  .Mitclu-ll 
— may  be  associated  with  irritation  in  the  nostrils  and  aih'Uoid  growths  in 
the  vault  of  the  i)harynx.  as  |)ointed  out  by  .Jacobi. 

It  has  been  claimed  by  Stevens  that  ocular  di'fvclx  lie  at  the  basis  of 
many  cases  of  chorea,  and  that  with  the  correction  of  these  the  irregular 
movements  disappear.  The  investigations  of  JJe  Schweinitz  show  that 
ocular  defects  (h)  not  occur  in  greater  ])ro|»ortion  in  choreic  than  in  other 
children.  A  majority  of  the  cases  in  which  operation  has  been  followed  by 
relief  have  been  instances  of  //V,  local  or  general. 

Morbid  Anatomy  and  Pathology. — No  (onstant  lesions  have 

been  f.nind  in  the  lu'rvous  system  in  acute  chorea.  \'ascular  changes, 
such  as  hyaline  transfornuition,  exudation  of  leucocytes,  minute  luemor- 
rhages,  and  thrombosis  of  the  smaller  arteries,  have  been  described. 

Embolism  of  the  smaller  cer';bral  vessels  has  been  found,  as  might  be 
expected  in  a  disease  with  which  eiuhicarditis  is  so  fre(|uently  associated: 
and,  based  Ujion  this  fact,  Kirkes  and  others  have  sup[)orted  what  is  known 
as  the  end)olic  theory  of  the  disease.  Endocarditis  is  by  far  the  nH)st 
frecinent  lesion  in  Sydenham's  chorea.  "With  no  disease,  not  excepting  rheu- 
nuitism,  is  it  so  constantly  associated.  I  have  collected  from  the  literature 
(to  July,  1894)  the  records  of  73  auto])sies;  there  were  iVi  with  endocarditis.* 
The  endocarditis  is  usually  of  the  simple  variety,  but  the  ulcerative  fm-ni 
has  occasionally  been  described. 

We  are  still  far  from  a  solution  of  all  the  problems  connected  with 
chorea.  Unfortunately,  the  word  has  been  used  to  cover  a  series  of  totally 
diverse  disorders  of  movement,  so  that  there  are  still  excellent  obsc/vers 
who  hold  that  chorea  is  only  a  symptom,  and  is  not  to  be  regarded  as  an 
etiological  unit.  The  chorea  of  childhood,  the  disease  Avhich  Sydenham 
described,  presents,  however,  characteristics  so  unmistakable  that  it  must 


*  Osier,  Chorea  and  Choreiform  Affections,  1894. 


1082 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


.  \ 
/ 


1)0  regarded  as  a  defiiiito,  substantive  aU'ection.  AVo  eannot  discuss  fully, 
but  only  indicate  briefly,  certain  of  the  theories  which  have  been  advanced 
with  regard  to  it.  The  most  generally  accepted  view  is  that  it  is  a  func- 
tional hrinn  disorder  ad'ecting  the  nerve-centres  controlling  the  motor  ap- 
])aratus,  an  insta'oility  (>f  the  nerve-cells,  brought  about,  one  supposes  by 
liyi)erieniia,  another  by  ana-mia,  a  third  by  psychical  influences,  a  fourth 
by  irritation,  centric  or  perii)heric.  Of  the  actual  nature  of  this  derange- 
ment we  km)W  nothing,  nor,  indeed,  whether  the  changes  are  primary  and 
the  result  of  a  faulty  action  of  the  co.tical  cells  or  wiiether  the  impulses 
are  secondarily  disturbed  in  their  course  down  the  motor  ])atb.  The  pre- 
dominance of  the  disease  in  females,  and  its  onset  at  a  time  when  the 
education  of  the  brain  is  rapidly  developing,  are  etiological  facts  which 
iSturges  has  urged  in  favor  of  the  view  that  chorea  is  an  expression  of 
functional  instability  of  the  nerve-centres. 

The  embolic  theory  originally  advanced  l)y  Kirkes  has  a  solid  basis  of 
fact,  but  it  is  not  comprehensive  enough,  as  all  of  the  cases  cannot  be 
brought  within  its  limits.  There  are  instances  without  endocarditis  and 
without,  so  far  as  can  be  ascertained,  plugging  of  cerebral  vessels;  and 
there  are  also  cases  with  extensive  endocarditis  in  which  the  histological 
examination  of  the  brain,  so  far  as  embolism  is  concerned,  was  negative. 
In  favor  of  the  embolic  view  is  the  experimental  production  in  animals  of 
chorea  by  Rosenthal,  and  later  by  Money,  by  injecting  fine  particles  into 
the  carotids. 

Lately,  as  indeed  might  be  expected,  chorea  has  been  regarded  as  an 
infectious  disease.  Nothing  definite  has  yet  been  determined.  In  favor  of 
this  view  it  has  been  urged,  as  it  is  impossible  to  refer  the  chorea  to  endo- 
carditis or  the  endocarditis  in  all  cases  to  rheamatism,  that  both  have  their 
origin  in  a  common  cause,  some  infectious  agent,  which  is  capable  also, 
in  persons  predisposed,  of  exciting  articular  disease.  Cases  have  been  re- 
ported in  scarlet  fever  with  arthritic  manifestations,  in  puerperal  fever,  and 
rheumatism,  also  after  gonorrlura,  and  such  facts  are  suggestive  at  least 
of  the  association  of  the  disease  with  infective  processes.  Possibly,  as  has 
been  suggested  by  some  writers,  the  paralytic  conditions  associated  with 
chorea  may  be  analogous  to  those  which  occur  in  typhoid  and  certain  of 
the  infectious  diseases.  On  the  other  hand,  there  are  conditions  extremely 
difficult  to  harmonize  with  this  view.  The  prominent  psychical  element 
is  certainly  one  of  the  most  serious  objections,  since  there  can  be  no  doubt 
that  ordinary  chorea  may  rapidly  follow  a  fright  or  a  sudden  emotion. 

Symptoms. — Three  groups  of  cases  may  be  recognized — the  mild, 
severe,  and  maniacal  chorea. 

Mild  Chorea. — In  this  the  affection  of  the  muscles  is  slight,  the  speech 
is  not  seriously  disturbed,  and  the  general  health  not  impaired.  Premoni- 
tory symptoms  are  cbriwn  in  restlessness  and  inability  to  sit  still,  a  condi- 
tion well  characterized  by  the  term  "  fidgets."  There  are  emotional  dis- 
turbances, such  as  crying  spells,  or  sometimes  night-terrors.  There  may 
be  ]>ains  in  the  limbs  and  headache.  Digestive  disturbances  and  ana>mia 
may  be  present.  A  change  in  the  temperament  is  frequently  noticed,  and 
a  docile,  quiet  child  may  become  cross  and  irritable.     After  these  symp- 


ACUTE  CHOREA. 


10S3 


discuss  fully, 
)eeii  advanced 
;  it  is  a  fitiic- 
he  motor  ap- 
j  supposes  hy 
icos,  a  fourth 
this  derango- 

prinmry  and 

the  impulses 

h.     The  pre- 

110  when  the 

facts  which 
expression  of 

solid  basis  of 
es  cannot  be 
ocarditis  and 
vessels;  and 
3  histological 
vas  negative, 
n  animals  of 
)articles  into 

yarded  as  an 
In  favor  of 
rea  to  endo- 
h  have  their 
apable  also, 
ive  been  rc- 
d  fever,  and 
ive  at  least 
;ibly,  as  has 
)ciated  witli 
1  certain  of 
s  extremely 
eal  element 
30  no  doubt 
lotion, 
—the  mild, 

the  speech 
Premoni- 
11,  a  condi- 
:)tional  dis- 
There  may 
nd  anjvmia 
ttticed,  and 
lose  symp- 


toms have  persisted  for  a  week  or  more  the  cliaractcristic  involuntary 
iiioveinents  begin,  aiul  are  often  first  noticed  at  the  table,  when  the  child 
spills  a  tumbler  of  water  or  upsets  a  plate.  There  may  be  only  awkwardness 
(ir  slight  incoordination  of  voluntary  movements,  or  constant  irregular 
(Ionic  spasms.  The  jerky,  irregular  character  of  the  movements  diU'eren- 
tiates  them  from  almost  every  other  disorder  of  motion.  In  the  mild  cases 
only  one  hand,  or  the  hand  and  face,  are  aifected,  and  it  may  not  spread 
to  the  other  side. 

In  the  second  grade,  the  severe  fnn.i,  the  movements  bocon.c  generM 
and  the  ])atient  may  be  unable  to  get  about  or  to  feed  or  undress  herself, 
(iwing  to  the  constant,  irregular,  clonic  contractions  of  the  various  muscle 
gr()U})s.  The  speecli  is  also  aifected,  and  for  days  the  child  may  jiot  be 
able  to  talk.  Often  with  the  onset  of  the  severer  symptoms  there  is  loss 
of  power  on  one  side  or  in  the  limb  most  aifected. 

The  third  and  most  extreme  form,  the  so-called  maniacal  chorea,  or 
chorea  iiisdnicns,  is  truly  a  terrible  disease,  and  may  develop  out  of  the 
ordinary  form.  These  cases  are  more  common  in  adult  women  and  may 
develop  during  pregnancy. 

Chorea  begins,  as  a  rule,  in  the  hands  and  arms,  then  involves  ihe  face, 
and  subsequently  the  legs.  The  movements  may  be  confined  to  one  sido 
— hemiehoroa.  The  attack  begins  oftencst  on  the  right  side,  though  oc- 
casionally it  is  general  from  the  outset.  One  arm  and  the  opposite  leg 
may  bo  involved.  In  nearly  one  fourth  of  the  cases  speech  is  affected; 
this  may  amount  only  to  an  embarrassment  or  hesitancy,  but  in  other  in- 
stances it  becomes  an  incoherent  jumble.  In  very  severe  cases  the  child 
will  make  no  attempt  to  speak.  The  inability  is  in  articidation  rather  than 
in  phonation.  Paroxysms  of  panting  and  of  hard  expiration  may  occur, 
or  odd  sounds  may  be  produced.  As  a  rule  the  movements  cease  during 
sleep. 

A  prominent  symptom  is  muscular  weakness,  usually  no  more  than  a 
condition  of  paresis.  The  loss  of  power  is  slight,  but  the  weakness  may 
be  shown  by  an  enfeebled  grip  or  by  a  dragging  of  the  leg  or  limj)ing.  In 
his  original  account  Sydenham  refers  to  the  "  unsteady  movements  of  one 
of  the  legs,  which  the  patient  drags."  There  nuiy  be  extreme  paresis  with 
but  few  movements — the  paralytic  chorea  of  Todd.  Occasionally  a  local 
])aralysis  or  weakness  remains  after  the  attack. 

It  is  doubtful  whether  choreic  s])asms  extend  to  the  muscles  of  organic 
life.  The  rapid  action  and  disturbed  rhythm  of  the  heart  present  nothing 
peculiar  to  the  disease,  and  there  is  no  sujiport  for  the  view  that  irregular 
contractions  occur  in  the  pajtiiKiry  muscles. 

Heart  Symptoms. — Neurotic. — As  so  nuniy  of  the  subjects  of  chorea  are 
nervo  s  girls,  it  is  not  surprising  that  a  common  symptom  is  a  ra])idly  acting 
heart.  Irregularity,  however,  is  not  so  special  a  feature  in  chorea  as  ra- 
pidity.   The  patients  seldom  complain  of  pain  about  the  heart. 

Ilu'inic  Murmurs. — AVith  anannia  and  debility,  not  uncommon  assoc- 
ciates  of  chorea  in  the  third  or  fourth  week,  we  find  a  corresponding 
cardiac  condition.  The  impulse  is  diffuse,  perhaps  wavy  in  thin  children. 
The  carotids  throb  visibly,  and  in  the  recumbent  posture  there  may  be 


1084 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


])ulsati()ii  in  llic  cervical  veins.  On  jniscultiition  ,;  systolic  ninrmiir  is 
Jieard  at  the  base,  porhaps,  too.  at  the  apex,  soft  and  l)h)\\in^f  in  (piality. 

EmhwariUtis. — As  in  rlieiiinatisni,  so  in  chorea,  acute  valvulitis  rarely 
gives  evidence  of  its  presence  by  8ynii)tonis.  It  must  be  soujiht,  and  clin- 
ical experieiu-e  has  shown  that  it  is  usually  associated  with  nuirniurs  at 
one  or  other  of  the  cardiac  oritices. 

Fur  the  guidance  of  the  practitioner  the  following  statements  may  he 
made: 

(1)  In  tliin,  nervous  children  a  systfilic  murmur  of  soft  quality  is  ex- 
tremely couMuon  at  the  1)ase,  jjarticularly  at  the  second  left  costal  cartilage, 
and  is  probably  of  no  nu)ment. 

{'i)  A  systolic  murmur  of  maximum  intensity  at  the  apex,  and  beard 
also  along  the  left  sternal  margin,  is  not  uiu'ommon  in  amemic,  en- 
feebled states,  and  does  not  necessarily  indicate  either  endocarditis  or  insuf- 
liciency. 

(;{)  A  murnuir  of  maximum  intensity  at  apex,  witb  rough  quality,  ami 
transmitted  to  axilla  or  angle  of  scai)ula,  indicates  an  organic  le.«ion  of 
the  mitral  valve,  ami  is  usually  associated  with  signs  of  enlargement  of  the 
heart. 

(4)  When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of  eye 
and  hand  than  to  that  of  the  ear.  if  the  apex  beat  is  in  the  normal  posi- 
tion, and  the  area  of  dulness  not  increased  vertically  or  to  the  right  of  the 
sternum,  there  is  probably  no  serious  valvular  disease. 

(5)  The  endocarditis  of  chorea  is  almost  invariably  of  the  simple  or 
warty  form,  ami  in  itself  is  not  dangerous;  but  it  is  ai)t  to  lead  to  those 
sclerotic  changes  in  the  valve  which  produce  incompetency.  01  1-10  pa- 
tients examined  more  than  two  year  after  the  attack,*  I  found  the  heart 
nornud  in  51;  in  17  there  was  func  .onal  distu'-ljance,  and  T-J  presented 
signs  of  organic  heart-disease. 

(C)  Pericarditis  is  an  occasional  complication  of  chorea,  usually  in  cases 
with  well-marked  rheumatism. 

Scusonj  Disturhaiircs. — Pain  in  the  alTected  limbs  is  not  common.  Oc- 
casionally there  is  soreness  on  ])rcssure.  There  are  cases,  usually  of  he.u- 
chorea,  in  which  pain  in  the  limbs  is  a  marked  symptom.  Weir  Mitchell 
has  spoken  of  these  as  painful  choreas.  Tender  ])oints  along  the  lines  of 
emergence  of  the  spinal  nerves  or  along  the  course  of  the  nerves  of  the 
lind)s  are  rare. 

Psychical  disturhances  are  common,  though  in  a  majority  of  the  cases 
slight  in  degree.  Irritability  of  temi)er,  marked  wilfulness,  and  emotional 
outbreaks  may  indicate  a  com])lete  change  in  the  character  of  the  child. 
There  is  deficiency  in  the  powers  of  concentration,  the  memory  is  en- 
feebled, aiul  the  ajjlitiule  IV.r  study  is  lost.  Parely  there  is  ])rogressive 
impairment  of  the  intellect  with  termination  in  actual  dementia.  Acute 
melancholia  has  been  described  (Edes).  Hallucinations  of  sight  and  hear- 
ing may  occur.  Patients  may  behave  in  an  odd  and  strange  manner  and 
do  all  sorts  of  meaningless  acts.     By  far  the  most  serious  manifestation  of 


*  Monograph  on  Chorea,  1894. 


e  TminTinr  is 
in  (|iiality. 
Ivulitis  I'arcly 
k^ht,  and  cliii- 
:  niu  rill  Ill's  at 

iK'iits  may  ho 

quality  is  cx- 
stal  cartilage, 

X,  and  heard 

aiia'iiiic,    c'li- 

litis  or  insuf- 

qnality,  and 
nie  legion  of 
emont  of  the 

denco  of  eye 
normal  posi- 
rigiit  of  the 

!io  simple  or 
ead  to  those 
Of  MO  pu- 
nd  the  heart 
"i'l  presented 

tally  in  cases 

minon.  Oc- 
lly  of  he.ii- 
Y'ir  Mitchell 
the  lines  of 
erves  of  the 

of  the  cases 
id  emotional 
f  the  child, 
nory  is  en- 
progressive 
itia.  Acute 
d  and  liear- 
inanner  and 
festation  of 


ACUTE  criOKEA, 


1085 


lliis  character  is  the  maniacal  delirium,  occasionally  associated  with  the 
very  severe  cases — chovvd  iiisaiiinis.  I'siially  the  motor  di^turhance  in 
these  cases  is  aggravated,  but  it  has  been  overlooked  and  patients  liave 
been  sent  to  an  asylum. 

The  iisychical  element  in  chori-a  is  apt  to  he  neglected  by  the  practi- 
tioner. Jt  is  always  a  got)d  plan  to  tell  the  parents  that  it  is  not  the 
iiiiiscles  alone  of  the  eiiild  which  are  aifected,  but  th.it  the  general  irrita- 
bility and  change  of  disposition,  so  ftften  found,  really  form  part  of  the 
disease. 

The  condition  of  the  rr/lcves  in  chorea  is  usually  normal.  Trophic 
lesions  rarely  occur  in  chorea  unless,  as  some  writers  have  done,  we  regard 
the  joint  troubles  as  arthropathies  occurring  in  the  course  of  a  cerebro- 
spinal disease. 

Ferrr  is  not,  as  a  rule,  ])resent  in  chorea  unless  complications  exist. 
There  may  be  the  most  intense  and  violent  movements  without  any  rise 
()(  temperature.  1  have  seen  instances,  however,  in  which  without  appar- 
ently any  visceral  or  articular  disturljances  there  was  slight  daily  fever. 
II.  A.  llare  states  that  in  monochorea  the  temperature  on  the  affected 
side  may  be  elevated;  but  this  is  not  an  invariable  rule.  Fever  is  found 
with  an  acute  arthritis,  when  there  is  marked  endocarditis  or  jiericarditis, 
though  the  former  may  certainly  occur  with  little  if  any  rise  in  temj)era- 
ture,  and  in  the  cases  of  maniacal  chorea,  in  which  the  fever  may  range 
from  10'<}°  t(j  104°. 

Culaiu'uiis  Affections. — The  ])igmentatioii,  which  is  not  uncommon,  is 
due  to  the  arsenic.  Herpes  zoster  occasionally  occurs.  Certain  skin  erup- 
tions, usually  regarded  as  rheumatic  in  character,  are  not  uncommon. 
Erythema  nodosum  has  been  described  and  I  have  seen  several  cases  with 
a  purpuric  urticaria.  There  may,  indeed,  be  the  more  aggravated  condi- 
tion of  rheumatic  jiurpura,  known  as  Schonlein's  peUosis  rhcumatica.  Sub- 
cutaneous fibrous  nodules,  which  have  been  noted  by  English  observers  in 
many  cases  of  chorea,  associated  with  rheumatism,  are  extremely  rare  in 
this  country. 

Duration  and  Termination. — From  eight  to  ten  weeks  is  the  av- 
erage duration  of  an  attack  of  moderate  severity.  Chronic  chorea  rarely 
follows  the  minor  disease  which  we  have  been  considering.  The  cases  de- 
scribed under  this  designation  in  children  are  usually  instances  of  cerebral 
sclerosis  or  Friedreich's  ataxia;  but  occasionally  an  attack  which  has  come 
on  in  the  ordinary  way  ])ersists  for  months  or  years,  and  recovery  ulti- 
mately takes  place.  A  slight  grade  of  chorea,  particularly  noticeable  under 
excitement,  may  persist  for  months  in  nervous  children. 

The  tendency  of  chorea  to  recur  has  been  noticed  by  all  writers  since 
tSydenliam  first  made  the  observation.  Of  410  cases  analyzed  for  this  pur- 
pose, 240  had  one  attack,  110  had  two  attacks,  35  three  attacks,  10  four 
attacks,  12  five  attacks,  and  3  six  attacks.  The  recurrence  is  apt  to  be 
vernal. 

Recovery  is  the  rule  in  children.  The  statistics  of  out-patients'  depart- 
ments are  not  favorable  for  determining  the  mortality.  A  reliable  esti- 
mate is  that  of  the  Collective  Investiization  Committee  of  the  British  Medi- 


1086 


DISEASES  OP  THE  NEUVOUS  SYSTEM. 


cal  Association,  in  wliicli  9  deatlis  were  reported  among  439  cases,  about 
2  per  cent. 

The  paralysis  rarely  persists.  Mental  dulness  may  be  present  for  n 
time,  but  usually  jjasses  away;  pernument  imi)airment  of  tiie  mind  is  an 
exceptional  secpienee. 

Diagnosis. — There  are  few  diseases  which  present  more  characteristic 
features,  and  in  a  majority  of  instances  the  nature  of  the  trouble  is  recog- 
nized at  a  glance;  but  there  are  several  affections  in  children  which  may- 
simulate  and  be  mistaken  for  it. 

((/)  Multiple  and  ditl'iisc  cerebral  sclerosis.  The  cases  are  often  mis- 
taken for  ordinary  chorea,  and  have  been  described  in  the  literature  as  chorea 
spastica. 

There  are  doubtless  chronic  changes  in  the  cortex.  As  a  rule,  the 
movements  are  readily  distinguishable  from  those  of  true  chorea,  but  the 
simulation  is  sometimes  very  close;  the  onset  in  infancy,  the  impaired  in- 
telligence, increased  reflexes  and  in  some  instances  rigidity,  and  the  chronic 
course  of  the  disease,  separate  them  sharply  from  true  chorea. 

(h)  Friedreich's  ataxia.  Cases  of  this  well-characterized  disease  were 
formerly  classed  as  chorea.  The  slow,  irregular,  incoordinate  nlovement^^, 
the  scoliosis,  the  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the 
family  character  of  the  disease  are  points  which  should  render  the  diag- 
nosis easy. 

(c)  In  rare  cases  the  paralytic  form  of  chorea  may  be  mistaken  for 
polio-myelitis  or,  when  both  legs  are  affected,  for  paraplegia  of  spinal 
origin;  but  this  can  only  be  the  case  when  the  choreic  movements  are  very 
slight. 

((/)  Hysteria  may  simulate  chorea  minor  most  closely,  and  unless  there 
are  other  manifestations  it  may  be  impossible  to  make  a  diagnosis.  Most 
commonly,  however,  the  movements  in  the  so-called  hysterical  chorea  are 
rhythmic  and  differ  entirely  from  those  of  ordinary  chorea. 

(e)  As  mentioned  above,  the  mental  symptoms  in  maniacal  chorea  may 
mask  the  true  nature  of  the  disease  and  patients  have  even  been  sent  to 
the  asylum. 

Treatment. — Abnormally  bright,  active-minded  children  belonging 
to  families  with  pronounced  neurotic  taint  should  be  carefully  watched 
from  the  ages  of  eight  to  fifteen  and  not  allowed  to  overtax  their  mental 
powers.  So  frequently  in  children  of  this  class  does  the  attack  of  chorea 
date  from  the  worry  and  stress  incident  to  school  examinations  that  the 
competition  for  prizes  or  places  should  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic 
measures,  with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Par- 
ents should  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic 
children.  The  psychical  element,  strongly  developed  in  so  many  cases, 
is  best  treated  by  quiet  and  seclusion.  The  child  should  be  confined  tn 
bed  in  the  recumbent  posture,  and  mental  as  well  as  bodily  quiet  enjoined. 
In  private  practice  this  is  often  impossible,  but  wdth  well-to-do  patients 
the  disease  is  always  serious  enough  to  demand  the  assistance  of  a  skilled 
nurse.     Toys  and  dolls  should  not  be  allowed  at  first,  for  the  child  should 


39  cases,  about 

I)rosent  for  h 
;he  mind  is  an 


ACUTE  CHOREA. 


10S7 


c  cliaraeteristie 
■oublo  is  reco<r- 
•on  which  niav 


are  often  niis- 
iture  as  cliurea 

^s  a  rule,  the 
horea,  but  the 
e  impaired  in- 
iid  the  chronic 
I. 

[  disease  were 
te  movements, 
^mus,  and  the 
ider  the  diasj- 

mistaken  for 
gia  of  spinal 
lents  are  very 


I  unless  there 
gnosis.  Most 
al  chorea  are 


d  chorea  may 
been  sent  to 

en  belonging 
ully  watched 
their  mental 
ck  of  chorea 
ons  that  the 
den. 

.  to  hygienic 
jcover.  Par- 
ss  of  choreic 

many  cases, 
!  confined  to 
iet  enjoined. 
)-do  patients 

of  a  skilled 
child  should 


be  kept  amused  without  excitement.  The  rest  allays  the  hyper-excitabil- 
ity and  reduces  to  a  minimum  the  possibility  of  danuige  to  the  valve  seg- 
ments should  endocarditis  exist.  Time  and  again  have  I  seen  very  severe 
cases  which  had  resisted  treatment  for  weeks  outside  a  hospital  become 
quiet  and  the  movements  subside  after  two  or  three  days  of  absolute  rest 
in  bed. 

The  child  should  be  kejjt  apart  from  other  children  and,  if  possible, 
from  other  members  of  the  family,  and  should  see  only  those  persons 
directly  concerned  with  the  nursing  of  the  case.  Though  irksome  and 
troublesome  to  carry  out,  this  is  an  important  part  of  the  treatment.  In 
the  latter  period  of  the  disease  daily  rubbings  may  be  resorted  to  with 
great  benefit. 

The  medical  treatment  of  the  disease  is  unsatisfactory;  with  the  ex- 
ception of  arsenic,  no  remedy  seems  to  have  any  influence  in  controlling 
the  progress  of  the  affection.  Without  any  specific  action,  it  certainly 
does  good  in  many  cases,  probably  by  improving  the  general  nutrition. 
Jt  is  conveniently  given  in  the  form  of  Fowler's  solution,  and  the  good 
effects  are  rarely  seen  until  maximum  doses  are  taken.  It  may  be  given 
as  Martin  originally  advised  (1813);  he  began  "with  five  drops  and  in- 
creased one  drop  every  day,  until  it  might  begin  to  disagree  with  the  stom- 
ach or  bowels."  When  the  dose  of  15  minims  is  reached,  it  nuiy  be  con- 
tinued for  a  week,  and  then  again  increased,  if  necessary,  every  day  or  two, 
until  physiological  effects  are  manifest.  On  the  occurrence  of  these  the 
drug  should  be  stopped  for  three  or  four  days.  The  practice  of  resuming 
the  administration  with  snuiller  doses  is  rarely  necessary,  as  tolerance  is  usu- 
ally established  and  we  can  begin  with  the  dose  which  the  child  was  taking 
when  the  symptoms  of  saturation  occurred.  I  have  frequently  given  as 
much  as  25  minims  three  times  a  day.  Usually  the  signs  of  saturation  are 
trivial  but  plain,  and  I  have  never  seen  any  ill  effects  from  the  large  doses, 
although  I  have  heard  recently  of  a  case  of  arsenical  neuritis  due  to  the  ad- 
ministration of  Fowler's  solution  in  chorea. 

Of  other  medicines,  strychnine,  the  zinc  compounds,  nitrate  of  silver, 
bromide  of  potassium,  belladonna,  chloral,  and  especially  cimicifuga,  have 
been  recommended,  and  may  be  tried  in  obstinate  cases. 

For  its  tonic  effect  electricity  is  sometimes  useful;  but  it  is  not  neces- 
sary as  a  routine  treatment.  The  question  of  gymnastics  is  an  important 
one.  Early  in  the  disease,  when  the  movements  are  active,  they  are  not  ad- 
visable; but  during  convalescence  carefully  graduated  exercises  are  un- 
doubtedly beneficial.  It  is  not  well,  however,  to  send  a  choreic  child  to  a 
school  gymnasium,  as  the  stimulus  of  the  other  children  and  the  excite- 
ment of  the  romping,  violent  play  is  very  prejudicial. 

Other  points  in  treatment  may  be  mentioned.  It  is  important  to  regu- 
late the  bowels  and  to  attend  carefully  to  the  digestive  functions.  For  the 
anaemia  so  often  present  preparations  of  iron  are  indicated. 

In  the  severe  cases  with  incessant  movements,  sleeplessness,  dry  tongue, 
and  delirium,  the  important  indication  is  to  procure  rest,  for  which  pur- 
pose chloral  may  be  freely  given,  and,  if  necessary,  morphia.  Chloroform 
inhalations  may  be  necessary  to  control  the  intensity  of  the  paroxysms. 


lObS 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


but  tlie  high  rate  of  mortality  in  this  chiss  of  cases  illustrates  liow  oflen 
our  l)cst  endeavors  are  rniitless.  TJie  wet  paek  is  sonietinies  very  soothinj,' 
and  should  be  tried.  As  these  paiients  are  apt  to  sink  rai>idly  into  a  low 
typhoid  state  with  heart  weakness,  a  sujjporting  treatiuuut  is  reciuirud  from 
the  outset- 
Cases  are  found  now  and  then  which  dra<:  on  from  numth  to  month 
witluiut  jiettintf  cither  better  or  worse  and  resist  all  modes  of  treatment. 
('han<;e  of  air  and  scene  is  sometimes  followed  by  ra])id  improvement,  and 
in  these  eases  the  treatment  by  rest  and  seclusion  should  always  bo  given  a 
full  trial. 

In  all  cases  care  should  he  taken  to  examine  tiie  nostrils,  and  <;laring 
ocular  defects  shoiihl  be  properly  corrected  eitiicr  by  glasses  or,  if  neces- 
sary, by  operation. 

After  the  child  has  recovered  from  the  attack,  the  parents  should  bo 
warned  that  return  of  the  disease  is  by  no  means  infretpient.  and  is  par- 
ticularly liaide  to  follow  overwork  at  school  or  debilitating  inlluences  of 
any  kind.  These  relai)ses  are  apt  to  occur  in  the  spring.  Sydenham  ad- 
vised purging  in  order  to  prevent  the  vernal  recurrence  of  the  disease. 


IV.    OTHER    AFFECTIONS    DESCRIBED    AS    CHOREA. 

(^/)  Chorea  Major;  Pandemic  Chorea. — The  common  name,  St.  Vitus's 

dance,  applit'd  to  ciiorea  has  come  to  us  from  the  middle  ages,  when  under 
the  inlUience  of  religious  fervor  there  were  e|)idemics  characterized  l)y  great 
excitement,  gesticulations,  and  dancing.  For  the  relief  of  these  symjjtoms, 
when  excessive,  i)ilgrimagcs  were  made,  and  in  the  Klienish  provinces,  par- 
ticularly to  the  C'hapi'l  of  St.  A'itus  in  Zebern.  Kpidemics  of  this  sort 
have  occurred  also  during  this  century,  and  (lescri}itions  of  them  among  the 
early  settlers  in  Kentucky  have  been  given  by  Kobertson  and  Yandell. 
It  Avas  unfortunate  that  Sydenham  applied  the  term  chorea  to  an  affection 
in  children  totally  distinct  from  this  chorea  major,  which  is  in  reality  an 
hysterical  manifestation  under  the  influence  of  religious  excitement. 

(b)  Habit  Spasm  (Habit  Cliorea) ;  Convulsive  Tic  (of  the  French). 

Two  groups  of  cases  may  bo  recognized  under  the  designation  of  habit 
s])asm — one  in  which  there  are  simply  localized  s{)asmodic  movements,  and 
the  other  in  which,  in  addition  to  this,  there  are  explosive  utterances  and 
psychical  symptoms,  a  condition  to  which  French  writers  have  given  the 
name  tic  convulsif. 

(1)  Ilahit  Spasm. — This  is  found  chiefly  in  childhood,  most  frequently 
in  girls  from  seven  to  fourteen  years  of  age  (]\ritchell).  In  its  simplest 
form  there  is  a  sudden,  rpiick  contraction  of  certain  of  the  facial  muscles, 
such  as  rapid  winking  or  drawing  of  the  mouth  to  one  side,  or  the  neck 
muscles  are  involved  and  there  are  unilateral  movements  of  the  head. 
The  head  is  given  a  sudden,  quick  shake,  and  at  the  same  time  the  eyes 
wink.  A  not  infre(|uent  form  is  the  shrugging  of  one  shoulder.  The 
grimace  or  movement  is  repeated  at  irregular  intervals,  and  is  much  aggra- 
vated by  emotion.     A  short  inspiratory  snilf  is  not  an  uncommon  symp- 


's  liow  oft«'n 
fry  soothing 
y  into  11  low 
'(^uiri'd  I'i'oiii 

III  to  month 
if  trcatnu'iit. 
vcniont,  und 
s  ho  given  a 

iuul  ghiring 
or,  if  nocos- 

ts  sliould  ho 
,  iind  is  par- 
inihiencos  of 
ph'nham  ad- 
discase. 


iOREA. 

',  St.  Vitns's 

when  under 

ized  l)y  great 

se  symi)tonis, 

rovinoes,  par- 

of  this  sort 

in  among  the 

and  Yandell. 

)  an  alTection 

in  reality  an 

L'ment. 

rench). 

ition  of  habit 
vements,  and 
tt  era  noes  and 
ve  given  the 

ist  frequently 
its  simplest 

icial  muscles. 

.  or  the  neck 

of  the  head. 

iriu'  the  eyes 

oulder.  The 
much  aggra- 

mmon  symp- 


OTHER  AFFECTIONS  DESCRIBED  AS  CIIORKA. 


1089 


torn.  The  cases  are  found  most  frecjueiilly  in  children  who  are  "out  of 
sorts,"  or  wIkj  liave  been  growing  rapidly,  or  who  have  inherited  a  tend- 
emy  to  neurotic  disorders.  Allied  to  or  associated  with  this  are  sonic  of 
the  curious  tricks  t)f  children.  A  boy  at  my  clinic  was  in  the  habit  every 
few  moments  of  i)utting  the  middle  linger  into  the  mouth,  biting  it,  and 
at  the  same  time  pressing  his  nose  with  the  forefinger.  Hartley  (\)\i;- 
I'idge  is  said  to  have  had  a  somewhat  similar  trick,  oidy  he  bit  his  arm. 
In  all  these  eases  the  habits  of  the  child  should  be  examined  carefully,  the 
nose  and  vault  of  the  pharynx  thoroughly  inspected,  and  the  eyes  accurately 
tested.  As  a  rule  the  condition  is  transient,  and  after  {)ersisting  for  a  few 
months  or  longer  gradually  disappears.  Occasionally  a  local  spasm  persists 
— twitching  of  the  eyelids,  or  the  facial  grimace. 

(2)  Tic  Convuhif  {(lilks  de  la  Tuurelle's  Disease). — This  remarkable 
affection,  often  mistaken  for  chorea,  more  frccjuently  for  habit  spasm,  is 
really  a  |)sychosis  allied  to  hysteria,  though  in  certain  of  its  aspects  it  has 
the  features  (jf  monomania.  The  disease  hegins,  as  a  rule,  in  young  chil- 
dren, occurring  as  early  as  the  sixth  year,  though  it  nuiy  develop  after  pu- 
berty. There  is  usually  a  markedly  neurotic  family  history.  The  special 
features  of  the  complaint  are: 

(a)  Invohmtary  muscular  movements,  usually  affecting  the  facial  or 
brachial  muscles,  but  in  aggravated  cases  all  the  muscles  of  tiic  body  may 
be  involved  and  the  nu)vements  nuiy  be  extremely  irregular  ami  violent. 

(b)  Explosive  utterances,  which  may  resemble  a  bark  or  an  inarticulate 
cry.  A  word  heard  may  be  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.  To  this  the  term  crho- 
Inlia  has  been  applied.  A  much  more  distressing  disturbance  in  these 
cases  is  coprolalia,  or  the  use  of  bad  language.  A  cliild  of  eight  or  ten 
may  shock  its  mother  and  friends  by  constantly  using  the  word  damn 
when  making  the  involuntary  movements,  or  by  uttering  all  sorts  of  ob- 
scene words.     Occasionally  actiojis  are  mimicked — echokiiiesis. 

(c)  Associated  with  some  of  these  cases  are  curious  mental  disturbances; 
the  patient  becomes  the  subject  of  a  form  of  obsession  or  a  fixed  idea.  In 
other  cases  the  fixed  idea  takes  the  form  of  the  impulse  to  touch  objects, 
or  it  is  a  fixed  idea  about  words — onomatomania — or  the  patient  may  feel 
compelled  to  count  a  number  of  times  before  doing  certain  actions — arith- 
momania. 

The  disease  is  well  marked  and  readily  distinguished  from  ordinary 
chorea.  The  movements  have  a  larger  range  and  are  explosive  in  charac- 
ter. Tourette  regards  the  coprolalia  as  the  most  distinctive  feature  of  the 
disease.  The  prognosis  is  doubtful.  I  have,  however,  known  recovery  to 
follow. 

(c)  Saltatory  Spasm  (La tali ;  Myriarhil;  Jumpers). — T^amberger  has  de- 
scribed a  disease  in  which  when  the  patient  attempted  to  stand  there  were 
strong  contractions  in  the  leg  muscles,  which  caused  a  jumping  or  s})ring- 
ing  motion.  This  occurs  only  when  the  patient  attempts  to  stand.  The 
affection  has  occurred  in  both  men  and  women,  more  frequently  in  the 
former,  and  the  subjects  have  usually  shown  marked  ncuroti.;  tendencies. 

In  many  cases  the  condition  has  been  transitory;  in  others  it  has  persisted 
68 


lODU 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


for  years,  I?etnarkal>lo  airt'cliuiis  similar  tu  thia  in  certain  points  occur 
us  a  sort  of  cndcniit;  neurosJH.  One  of  tiu;  most  striking;  of  tlii'so  oc(;urrt 
amon^f  the  "jiim|iinf^  Froncliiiien  "  of  Maine  and  Canada.  As  (l(!S(!ril)c'd 
by  Heard  and  Tliornton,  the  Hubjtiets  are  liahlo  on  any  sudden  emotion  to 
jump  vioU'iitly  and  utter  a  loud  cry  or  sound,  and  will  olx-y  any  (tommaiKl 
or  imitate  any  action  without  rej^ard  to  its  nature,  'i'he  condition  of 
ediolalia  is  present  in  a  nuirked  degree.  The  "jumping"  prevails  in  cer- 
tain families. 

A  very  similar  disease  prevails  in  parts  of  Russia  and  in  Java,  where  it  is 
known  by  the  names  of  myriachit  and  latah,  the  chief  feature  of  which  is 
mimicry  by  the  |»atient  of  everything  he  sees  or  liears. 

{(l)  Chronic  Chorea  {llnnliiuilons  Cluirea). — An  all'eetion  characterized 
by  irregular  movements,  disturbance  of  speech,  and  gradual  dementia.  It 
is  frequently  hereditary.  The  diseases  has  no  connection  with  Sydenham's 
chorea,  and  it  is  unfortunate  that  the  term  was  a[)plied  to  it.  It  was  be- 
s(!ribed  by  Huntington,  of  Pomeroy,  Ohio,  at  the  time  a  practitioner  on 
Long  Island,  and  he  gave  in  three  brief  i)aragraphs  the;  salient  points  in 
connection  with  the  disease — namely,  the  hereditary  natnre,  the  associa- 
tion witti  psychical  troubles,  and  the  late  onset — between  tin?  thirtieth  and 
fortieth  years.  The  disease  seems  conunon  in  this  country,  and  many 
cases  liave  been  reported  by  Clarence  King,  Sinkler,  and  others.  I  have 
seen  it  in  two  iMaryland  families  within  the  past  few  years.  Under  the 
term  chronic  chorea  may  be  grouped  the  hereditary  form  and  the  cases 
which  come  (tn  without  family  disposition,  either  at  middle  life  or,  more 
commonly,  in  the  aged — senile  chorea.  It  is  doubtful  whether  the  cases 
in  children  with  chronic  choreiform  movements,  (>ften  with  mental  weak- 
ness and  si)asfic  condition  of  the  legs,  should  go  into  this  category. 

The  hereditary  character  of  the  disease  is  very  striking;  it  has  been 
traced  through  four  or  five  generations.  Huntington's  father  and  grand- 
father, also  [)hysieians,  had  treated  the  disease  in  the  family  which  he  de- 
scribed. Osborn,  of  East  Ham])ton,  L.  I.,  writes  (Jan.  iiiSth,  18!)8)  that  the 
disease  still  continues  to  recur  in  certain  families  described  by  Huntington, 
as  it  has  done,  so  it  is  said,  for  fully  two  centuries.  An  identical  aU'ection 
occurs  without  any  hereditary  disposition.  The  age  of  onset  is  late,  rarely 
before  the  thirtieth  or  the  thirty-fifth  year. 

The  sym])toms  are  very  characteristic.  The  irregular  movements  are 
usually  first  seen  in  the  hands,  and  the  patient  has  slight  difficulty  in  per- 
forming delicate  manipulations  or  in  writing.  When  well  estahlislied  the 
movements  are  disorderly,  irregular,  incoordinate  rather  than  choreic,  and 
have  not  the  sharp,  brusque  motion  of  Sydenham's  chorea.  In  the  face 
there  are  slow,  involuntary  grimaces.  In  a  well-developed  case  the  gait 
is  irregnlar,  swaying,  and  somewhat  like  that  of  a  drunken  man.  The 
sj)eech  is  slow  and  difficult,  the  syllables  are  badly  pronounced  and  indis- 
tinct, but  not  definitely  staccato.  The  mental  impairment  leads  finally  to 
dementia. 

Very  few  post  mortems  have  been  made.  No  characteristic  lesions  have 
been  found.  Atrophy  of  the  convolutions,  chronic  meningo-encejdialitis, 
and  vascular  changes  have  usually  been  present,  the  conditions  which  one 


)()iiils  occur 
Llicsc!  occiirn 
U  (Icscrilu'd 
1  eniotioti  to 
ly  coiumand 
•oiidition  ol' 
viiils  in  ciT- 

.,  where  it  \h 
ol'  vviiich  i« 

Imrnclerizcd 

'Micntiii.     It 

Sydenliain's 

Jt  WllH  bo- 

ctitioner  on 

it  points  in 

the  associu- 

hirtietli  and 

and   many 

MS.     I  have 

Under  the 

d  the  cases; 

fe  or,  more 

r  the  cases 

ental  weak- 

ory. 

t  has  been 
and  grand- 
lie  h  he  de- 
8)  that  the 
luntington, 
!al  atl'ection 
bite,  rarely 

ements  are 
Lilty  in  per- 
blished  th(! 
horeic,  and 

n  the  face 
se  tlie  gait 
man.     The 

and  indis- 
s  finally  to 

esions  have 

ncejjhalitis, 

which  one 


INFANTILE  CONVULSIONS. 


1091 


would  expect  to  find  in  chronic  dementia.  The  recent  study  of  two  cases 
by  l''a(l<bin  (Arch.  I'.  Psycliiatrie,  .'{(»)  conliriiiH  the  view  e\|)r('sscd  in  former 
editions  tiiat  the  diseast'  is  a  chronic  meningo-enccphaiilis  with  atrophy  of 
the  convolutions.  The  cord  and  peripheral  nerves  he  found  perfectly 
bcaltliy.  The  alTection  is  evidently  a  neuro-dcgenerative  disorder,  and  has 
MO  connection  with  the  simple  chorea  of  ciiildlio»»(l. 

{(')  Rhythmic  or  Hysterical  Chorea. — This  is  readily  recognized  by  the 
rliythmical  character  of  the  movements.  It  may  alfcct  the  muscles  of  the 
ai»doiiu'u,  producing  tlie  salaam  convulsion,  or  involv(!  tim  sterno-uuistoid, 
producing  a  rhythmical  movement  of  the  head,  or  the  psoas,  or  any  group, 
of  juuscles.     In  its  orderly  rhythm  it  resembles  the  canine  chorea. 


V.     INFANTILE    CONVULSIONS  (Echimpsia). 

Convulsive  seizures  similar  to  those  of  epilepsy  are  not  infre(iuent  in 
children  and  in  adults.  The  lit  may  indeed  be  idi-nlical  with  epilepsy, 
from  which  the  condition  differs  in  that  when  the  cause  u  removed  there 
is  no  tendency  for  the  fits  to  recur.  Occasionally,  however,  the  convul- 
sions in  children  continue  and  develo])  into  true  epilepsy. 

£tiolO{^y. — A  convulsion  in  a  child  may  be  due  to  many  causes,  all 
of  which  lead  to  an  unstable  condition  of  the  nerve-centres,  ])eriiutting  of 
sudden,  excessive,  and  temporary  nervous  discharges.  The  following  are 
the  most  important  of  them: 

(1)  Debility,  resulting  usually  from  gastro-intestinal  disturbance.  Con- 
vulsions fre(iuently  supervene  toward  the  close  of  an  attack  of  entero- 
colitis and  recur,  sometimes  proving  fatal.  Morris  J.  Lewis  has  shown 
that  the  death-rate  in  children  from  eclampsia  rises  steadily  with  that  of 
gastro-intestinal  disorders. 

{"l)  lVri[)heral  irritation.  Dentition  alone  is  rarely  a  cause  of  convul- 
sions, but  is  often  one  of  several  factors  in  a  feeble,  uidundthy  infant.. 
The  greatest  mortality  from  convulsions  is  during  the  first  six  months,  be- 
fore the  teeth  have  really  cut  through  the  gums.  Other  irritative  causes  arc 
the  overloading  of  the  stomach  with  indigestible  food.  It  has  been  sug- 
gested that  some  of  these  cases  are  toxic,  owing  to  the  absorption  of  poi- 
sonous ptomaines.  Worms,  to  which  convulsions  are  so  frequently  attrib- 
uted, probably  have  little  influence.  Among  other  sources  possible  are 
])himosis  and  otitis. 

(3)  Kickets.  The  observation  of  Sir  William  Jenner  upon  the  associa- 
tion of  rickets  and  convulsions  has  been  amply  confirmed.  The  spasms 
may  be  laryngeal,  the  so-called  child-crowing,  which,  though  convulsive  in 
nature,  can  scarcely  be  reckoned  under  eclampsia.  The  influence  of  this 
condition  is  more  apparent  in  Europe  than  in  this  country,  although  rickets 
is  a  common  disease,  particularly  among  the  colored  people.  Spasms,  local 
or  general,  in  rickets  are  probably  associated  with  the  condition  of  debility 
and  malnutrition  and  with  cranio-tabes. 

(4)  Fever.  In  young  children  the  onset  of  the  infectious  diseases  is  fre- 
quently with  convulsions,  which  often  take  the  place  of  a  chill  in  the  adult. 


(  1 


1092 


DISKASKS  OK  TMK  NKllVOUS  SYSTKM. 


It  is  not  known  upon  wlnit  they  (li'iu'iid.  Scarlet  fovcr,  incaslcp,  nnd  pnoii- 
iiioiiia  arc  niont  often  preceded  by  convulsions. 

(.">)  ('uii;^'es(i(»n  of  llie  liraiii.  That  extreiiie  ciij,'or>,fcinciit  (d*  the  hhxid- 
vos.scls  may  produce  convulsions  is  shown  hy  (heir  occasional  occurrence 
in  Bt'vere  whoopin^'-cou^h,  hut  their  rarity  in  this  disi-ase  really  indicates 
how  small  a  part  mechanical  con^fcstiou  |)lays  in  the  producttion  <tf  fits. 

(0)  Severe  convulsions  usher  in  or  accompany  many  of  the  serious  dis- 
eases of  the  nervous  system  in  children.  In  more  than  TjO  per  cent  of  the 
cases  of  infantile  heniiplej;ia  the  all'cction  follows  severe  convulsions.  They 
less  frecjucntly  precede  a  spiiuil  paralysis.  They  occur  with  mcnin^Mlis. 
tuberculous  or  simple,  and  with  tumors  and  other  lesions  of  the  brain. 

And,  lastly,  convulsions  may  occur  immediately  after  birth  and  persist 
for  weeks  or  nu)nths.  In  such  instances  there  has  probably  Iteen  meniji- 
geal  ha-morrhagc  or  serious  injury  to  the  corto.x. 

The  most  important  question  is  the  relation  of  convulsions  in  children 
to  true  epilepsy.  In  (lowers'  fl«:ures  of  1,-100  cases  of  epilepsy,  the  attacks 
bejfan  in  ISO  durinjf  the  lirst  three  years  of  life.  Of  UiO  cases  of  epilepsy 
in  children  which  1  have  aiudyzed,  in  187  the  fits  bepin  within  the  first 
three  years.  Of  the  total  list  the  ffreatest  number,  74,  was  in  the  first 
year.  In  nearly  nil  these  instances  there  was  no  interru])ti()n  in  the  con- 
vulsions. That  convulsions  in  early  infancy  arc  necessarily  followed  by 
ei)ilei)sy  in  after  life  is  certainly  a  mistake. 

Symptoms. — The  attack  may  come  on  suddenly  without  any  warn- 
ing; more  conmionly  it  is  preceded  by  a  stage  of  restlessness,  accomi)anied 
hy  twitching  and  ])erhai)S  grinding  of  the  teeth.  It  is  rarely  so  complete 
in  its^^tages  as  true  epile|>sy.  The  s|)asm  begins  usually  in  the  haiuls,  most 
connnonly  in  tlu'  right  hand.  Tlie  eyes  are  fixed  and  staring  or  are  rolled 
u]).  The  body  becomes  still"  and  breathing  is  suspended  for  a  moment  or 
two  hy  tonic  spasm  of  the  respiratory  muscles,  in  consecpience  of  which 
the  face  becomes  congested.  Clonic  convulsions  follow,  tin.'  eyes  are  rolled 
about,  the  hands  and  arms  twitch,  or  are  Hexed  and  extended  in  rhythmical 
movements,  the  face  is  contorted,  and  the  head  is  retracted.  The  attack 
gradually  subsides  and  the  child  slee])s  or  passes  into  a  state  of  stujjor. 
Following  indigestion  the  attack  may  be  single,  but  in  rickets  and  intestinal 
disorders  it  is  a])t  to  be  re])cat(-d.  Sometimes  the  attacks  follow  each  other 
with  great  rapidity,  so  that  the  child  never  rouses  but  dies  in  a  deep  coma. 
If  the  convulsion  has  been  limited  chiefly  to  one  side  there  may  be  slight 
])aresis  after  recovery,  or  in  instances  in  which  the  convulsions  usher  in 
infantile  hemi])]cgia,  when  the  child  arouses,  one  side  is  com])letely  para- 
lyzed. During  the  fit  the  temperature  is  often  raised.  Death  rarely  occurs 
from  the  convulsion  itself,  except  in  debilitated  children  or  when  the  at- 
tacks recur  with  great  frequency.  In  the  so-called  hydrocephaloid  state  in 
connection  with  protracted  diarrhoni  convulsions  may  close  the  scene. 

Diagnosis. — Coming  on  when  the  subject  is  in  full  health,  the  atts^ck 
is  prohably  due  either  to  an  overloaded  stomach,  to  some  peripheral  irrita- 
tion, or  occasionally  to  trauma.  Setting  in  with  high  fever  and  vomiting, 
it  may  indicate  the  onset  of  an  exanthem,  or  occasionally  be  the  primary 
symptom  of  cncejihalitis,  or  whatever  the  condition  is  which  causes  infan- 


ti 
o 


EPIT.RPSY. 


109.T 


nnd  pncu- 

llu!  blodd- 
ot'curreiU'c 
y  iiidicuti's 
I'  (its. 

■serious  dis- 
rciit  of  till' 
oMS.  'IMicy 
meningitis, 
I  rain. 

iind  pcMsist 
uen  nionin- 

in  childri'n 
the  iittiul<H 
of  cpiU'psy 
in  tho  lirst 
ill  tlic  first 
in  tlu'  c'oii- 
L'ollowed  by 

any  warn- 
ccompanitMl 
so  coinpK'to 
hands,  most 
ir  arc  rolli'd 

moment  or 
:^c  of  wliifli 
L'S  arc  rolled 
I  rhythmical 

The  attack 

0  of  stupor, 
id  intestinal 
V  each  other 

1  deep  coma. 
lay  he  slight 
)ns  usKer  in 
[)letely  para- 
rarcly  occurs 
vhcn  the  at- 
iloid  state  in 
ic  scene. 

h,  the  attack 
ihcral  irrita- 
nd  vomiting, 
the  primary 
causes  infan- 


lile  honiiplegia.  Wlu-n  ili(>  attaclc  is  nssociiited  with  dehility  and  with 
rickets  llie  diagnosis  is  easily  nnide.  The  earpopedal  s|)asins  and  pseudo- 
pundytie  rigidity  which  are  often  a.^soeiated  with  rickets,  la;yiigisnuis  stridii- 
liis,  iind  the  hydroeephaloid  stiite  are  u.'^iiidly  ((Hiiined  to  tlie  hands  and 
iiinis  and  are  intcriiiittt'iit  and  UHUally  tonic.  The  cDiivnlsionH  associated 
with  tninor  or  which  follow  iiifiuitilc  hemiplegia  are  usually  at  first  tJack- 
siinian  in  eluinicter.  After  the  second  year  cdnvidsivc  seiznres  which  conn! 
on  iricgnlaily  without  apparent  cause  and  recur  while  the  child  is  appai- 
eiitiy  ill  good  health  arc  liki'ly  to  pi()v<'  true  epilepsy. 

Prognosis. — ('onvulsionH  play  an  inipoitant  part  in  infantile  mor- 
tality, ill  Morris  , I.  Lewi.s's  table  of  dealhs  in  ciiildicii  under  ten,  8.5  per 
cent  were  ascribed  to  convulsions.  West  states  thai  2'2.:i:}  per  cent  of  deaths 
under  one  year  arc  caused  by  eoiivulsioiis,  but  thin  is  too  high  an  estimiite 
lor  this  country.  In  chronic  diurrlKcu  convulsions  ure  usually  of  ill  oineii. 
'I'ho.'^o  ushering  in  fevers  are  rarely  serious,  and  the  same  iniiy  be  said  of 
the  lits  associated  with  indigestion  and  |)eriplieiid  irritation. 

Treatment.— Mvery  source  of  irritation  should  be  removed.  If  as- 
sociated with  indigestible  food,  a  prompt  emetic  should  be  given,  followed 
by  an  enema.  The  teeth  should  be  examined,  and  if  the  gum  is  swollen, 
hot,  and  tense,  it  may  be  lanced;  but  never  if  it  looks  normal.  When 
seen  at  first,  if  the  paroxysm  is  severe,  no  time  should  be  lost  by  giving 
a  hot  bath,  but  chloroform  should  be  given  at  once,  and  repeated  if  neces- 
sary. A  child  is  so  readily  put  under  chloroform  and  with  such  a  small 
(juaiitity  that  this  preccdiire  is  (piite  harmless  and  saves  much  valuable 
time.  The  i)ractice  is  almost  universal  of  ])utting  the  child  into  a  warm 
bath,  and  if  there  is  fever  the  head  may  be  d(niclicd  with  cold  water.  The 
tem])erature  of  the  bath  should  not  be  above  95°  or  !)()°.  The  very  hot 
bath  is  not  suitable,  particularly  if  the  fits  are  due  to  indigestion.  After 
the  attack  an  ice-cap  may  be  ])Iaccd  upon  the  head.  If  there  is  much  irri- 
tability, jiarticularly  in  rickets  and  in  severe  diarrluea,  small  doses  of 
opium  will  be  found  clhcacious.  When  the  convulsions  recur  after  the 
child  conies  from  under  the  influence  of  chloroform  it  is  best  to  jilaee  it 
rapidly  under  the  inducncc  of  opium,  which  may  be  given  as  morphia 
bypodcrmically,  in  doses  of  from  one  twenty-fifth  to  one  thirtieth  of  a  grain 
for  a  child  of  one  year.  Other  remedies  recommended  are  chloral  by  enema, 
in  S-grain  doses,  and  nitrite  of  amyl.  After  the  attack  has  passed  the 
bromides  are  useful,  of  which  5  to  8  grains  may  be  given  in  a  day  to  a  child 
a  year  old.  Recurring  convulsions,  ]>articularly  if  they  come  on  without 
s])ecial  cause,  should  receive  the  most  thorough  and  careful  treatment 
with  lu'omides.  When  associated  with  rickets  the  treatment  should  be 
directed  to  improving  the  general  condition. 


VI.    EPILEPSY. 

Definition. — An  affection  of  the  nervous  system  characterized  by  at- 
tacks of  unconsciousness,  with  or  without  convulsions. 

The  transient  loss  of  consciousness  without  convulsive  seizures  is  known 


1(H»4 


DISKASKS  OK  TFIK  NKUVol'S  SVSTKM. 


nrt  /)«7i7  /;/(//;  llif  loss  of  coiiscioustu'SH  with  gcncnil  i'nnviilsiv<'  ncizuroii  is 
known  lit*  i/rainl  niitl.  Lociili/cd  ((iiiviilsKins,  ()('i'iii'i'iii<,'  iisiinlly  witlioul 
loHH  of  conscioiistU'SH,  iij-f  kiKiwii  us  i>|iil('|itir(ii'iii,  or  mori'  lri't[ii('ii(l)'  as 
•lacksoiiiiin  or  cotticiil  (>|)il(>|iHy. 

iEtiolotJ^y.  .1,'/''.  In  a  lar)^'(>  proportion  of  all  cases  llic  disctiM'  li('<riiis 
lu'l'oit'  piilu'.ly.  (M'  Ilif  UTdl  cases  oltscivcd  l)y  (iowcrs,  in  i".".'  llic  «Iis(Mm' 
Itcpin  licforc  (he  tenth  year,  and  three  r«tiirths  ol'  the  cases  hcfran  hel'ori' 
the  twentieth  yeai'.  01'  l<!l>  cases  of  epilepsy  in  chililri'ii  which  I  have 
jiniilyzed  till'  ii;,'e  of  onset  in  I'i'i  was  us  I'ollows:  I'irst  year.  71;  Hccond 
year,  (I?:  third  year,  M;  fourth  year,  :J  I ;  lirih  year.  17;  sixth  year.  IS; 
K'venth  year.  ll»;  I'ijihih  year.  J.';{;  ninth  year,  17;  lenlh  year,  >7;  eleventh 
year,  17;  twellth  year,  18;  thirteenth  your,  15;  fonrteeiith  year,  v*l;  lif- 
tci'iith  year,  HI.  Arranged  in  lieinideeiKleH  the  ligiires  an'  as  lollows:  Kioni 
tin-  liisi  lo  the  lil'lh  year,  i,"v'!»;  I'roin  the  lil'tli  to  the  tenth  year.  KM;  I'r.un 
the  tenth  to  the  littecnth  year,  \K).  These  li<;nres  ilhisiiatt'  in  a  sirikinu 
manner  the  early  onset  of  the  disease  in  a  large  ]>roporfion  of  the  eases. 
It  is  well  always  to  ho  nnspicionH  of  epilepsy  developing  in  the  adult,  for  in 
«  majority  of  such  cases  the  eonvnlsions  are  due  to  a  local  K'sion. 

>'r.r. — No  special  inlliience  appears  to  he  discovcrahlc  in  this  relation, 
certainly  not  in  children.  Of  I'A'A  cases  in  my  tahhs,  v';>'J  wcr*'  males  and 
yo.M  were  females,  showing  a  slight  predominance  of  the  male  sex.  After 
jiuherty  niuiuestionnhly,  if  a  large  nunil)er  of  cases  are  taken,  the  males 
are  in  excess.  The  (igiircs  of  Sicveking  and  Heymdds  show  that  the  dis- 
ease is  rather  more  |)revalcnt  in  females  than  in  males. 

Ilnrdih/. — Much  stress  has  heen  laid  upon  this  hy  many  authors  as  an 
important  predisposing  cause,  and  the  statistics  collected  give  from  !>  to  over 
40  per  cent,  (lowers  gives  ^5  per  cent  for  his  eases,  which  have  special 
value  apart  from  other  statistics  emhracing  large  numhcrs  of  epiU-ptics  in 
that  they  were  collected  hy  him  in  his  own  practice.  In  oiir  tiguivs  it  ap- 
pears to  jday  a  minor  nVr.  In  ^'  Infirmary  list  there  were  only  'M  cases 
in  which  there  was  a  history  of  marked  neurotic  taint,  and  only  I?  in  which 
the  mother  herself  had  heen  epileptic.  Tn  the  l\lwyn  cases,  as  might  he 
expected,  the  percentage  is  larger.  Of  the  !:;.*(>  there  was  in  '.Vi  a  family  his- 
tory of  nervous  derangement  of  some  sort,  either  paralysis,  epilepsy,  marked 
liystoria,  or  in.«anity.  It  is  interesting  to  note  that  in  this  group,  in  which 
the  question  of  heredity  is  carefully  looked  into,  there  were  only  two  in 
which  the  mother  had  had  epilejjsy,  and  not  one  in  which  the  father  had 
l)een  atfectcd.  Indeed,  I  was  not  a  little  surprised  to  find  in  the  list  of  my 
cases  that  hereditary  influences  ])layed  so  small  a  part.  I  have  lieard  this 
ojiinion  cxjircssed  by  certain  French  ])hysicians,  notal)ly  ilarie,  who  in  writ- 
ing also  upon  the  question  takes  strong  grounds  against  heredity  as  an  im- 
])ortant  factor  in  c[)ilepsy. 

While,  then,  it  may  he  said  that  direct  inheritance  is  comparatively  nn- 
'coninion.  yet  the  children  of  neurotic  families  in  which  neuralgia,  insanity, 
and  hysteria  jirovail  are  more  liahle  to  fall  victims  to  the  disease. 

Chronic  alcoholism  in  the  ])arents  is  regarded  hy  many  as  a  potent  ]>re- 
dis]iosing  factor  in  the  ])roduction  of  epilepsy.  Fcheverria  has  analyzed 
572  cases  hearing  upon  tliis  point  and  divided  them  into  three  elasscSj  of 


KIMLKPSY. 


1005 


Kl'l/.Uri'C    IH 

llv   \vithi»ui 
ftliii'ntly  as 

m'H>K'  lu'fiins 

I   llir  (llSi'ilSf 

fpiu  lti't\>ri' 

llirll     I    lliivr 

r  I ;  sc'iniid 
III  vi-ar.  IS; 
il;  oU'Vi'iilli 
rar.  '^1;  lif- 
llows:  Krom 
r,  in  I;  t'riim 
n  a  iilrikiiiii 
iif  tlu'  casi'S. 
adult.  fiM-  ill 
(111. 

ihis  n-Iation. 
w  inaU's  aiul 

80X.       Al'tl'V 

n.  tlio  lutili's 
tliat  tho  (lis- 

uitl\(irs  as  an 

roui  !>  \o  (UiT 

havi'  spoc'ial 

('j)ili'ptics  in 

titruivr-'  it  aji- 

(uily  lU  ('a^iOs 

ly  ;{  in  whicli 

as  ini<:ht  l>«' 

a  family  liis- 

k'psy,  marki'd 

)U|i,  in  wliich 

'  only  two  in 

IP  father  liad 

I  lie  list  of  my 

ve  heard  this 

.  who  in  writ- 

lity  as  an  im- 

[niratively  nn- 

Ifria,  inganity, 

aso. 

a  potont  prc- 

hns  analyzed 

ree  classes,  of 


wliiili  8r»7  I'MHCH  conld  ])v  trared  directly  to  alcohol  aB  ft  eanso;  l'v'<I  canon 
in  which  there  were  asHMciatcd  conditions,  such  as  syphilis  and  trannialisni; 
|S!»  cases  in  which  the  alcolmlisni  was  proliahly  the  result  of  the  epilepsy. 
I'i^Mircs  eijuaily  strong  are  ^'ivcii  hy  Martin,  who  fuiiud  m  I. Ml  iii>aiic  epi- 
leptics H',\  with  a  marked  history  <d'  parental  intcni|»eranec.  Of  llie  I'-ii't 
I'Jwyn  (;iiscs,  in  which  the  family  history  on  this  point  was  carefully  inves- 
tigated, a  deliiiile  stateini'til  was  fiuiiid  in  only  I  of  the  cases. 

t^Hliliilis.  This  ill  the  parents  is  prohaltly  less  a  predisposing'  than  an 
actual  cause  (d'  epilepsy,  which  is  tlie  direct  outcome  of  local  cerchral  mani- 
festations. 'I'liere  is  no  reason  for  rccoj^Miiziiif,'  ii  special  form  of  syphilitic 
epilepsy.  On  the  other  hand,  convulsive  siiixures  due  to  a*  ipiired  .syphilitic; 
ilisease  of  the  liraiii  are  very  common. 

Alriiliiil. — Severe  epileptic  cdiiviilsions  may  occur  in  steady  drinkers. 

Of  exciting;  canscs  fri;,dil  is  helieved  to  lie  ini|Mirtant,  hiit  is  less  so.  I 
til  ink,  than  is  nsiially  staled,  'rraiima  is  present  in  u  certain  numlicr  of 
inslances.  An  important  },M'(iup  depends  npon  a  local  disease  of  the  hrain 
•  'xistin;^  from  childhood,  as  seen  in  the  ]iosl-lieniipIe^nc  epilepsy.  Occa- 
sionally ca.ses  follow  the  infections  fevers.  Maslnrhation  has  hceii  stated 
to  lie  a  special  cause,  hiit  its  inllnenee  is  prohahly  overrated.  .\  lar^^e  j^roiip 
of  c<inviilsive  sei/.ures  allied  to  epilepsy  are  diK;  to  some  toxic  a;;enl,  as  in 
lead  poisoning'  and  in  nra'iiiia.  (Jrcat  stress  was  laid  ii|ion  rellex  causes, 
such  as  dentition  and  wornis,  the  irritation  of  a  cicatrix,  some  local  all'ee- 
li<tn,  such  as  adherent  prepuce,  or  a  forcij^n  hody  in  tlii'  ear  or  the  nosc!. 
In  many  of  these;  cases  th"  fits  cease  after  the  removal  of  the  cause,  so  that 
there  can  he  no  (jiieslion  of  the  association  helwccn  tli(>  two.  In  others  the 
attacks  jiersist.  'Jeiiuine  eases  of  rellex  epilepsy  are,  I  helieve.  rare.  A 
remarkahle  instance  of  it  ocenrred  at  the  I'hiladelphia  Iiilirmary  i'ov  his- 
eases  of  the  Nervoxis  System  in  the  case  of  a  man  with  a  t<'stis  in  the  in;:iiinal 
canal,  ])rcssiire  njxin   which  would  cause  a  typical   fit.      Hemoval   of  the 


oi'<i;an  was  followed  hy  enr(>. 


I'^pilepsy  has  heen  thouj,dit  to  ho  associated  with  distnrhance  of  the 
heart's  action,  and  some  have  spoken  of  a  special  cardiac  ejiilcp.'iy,  particu- 
larly in  cases  in  which  there  is  jialiiilation  or  slowinjf  of  the  action  prior 
to  the  on.^et.  l'!pile])tie  seizures  may  occnr  durinj^  the  pussajfe  of  a  fiall- 
stone  or  occasionally  dnrin<,'  the  removal  of  pleuritic  lluid.  Indigestion 
and  i^astric  tronhles  are  extremely  common  in  epilejisy,  and  in  many  in- 
stances the  eating  of  indijfcstihle  articles  seems  to  preeijiitatc  an  attack. 

An  attempt  to  associate  gennine  epilepsy  with  eye-strain  has  sijiiially 
failed. 

Symptoms. — (1)  Grand  Mai. — Preceding  the  fits  there  is  usually  a 
localized  sensation,  known  as  an  nvrn,  in  some  part  of  the  hody.  This 
may  he  somatic,  in  which  the  feelin};  comes  from  some  particnlar  re^^ion 
in  the  y)eri])hory.  as  from  the  finfj^er  or  hand,  or  is  a  sensation  felt  in  the 
stomach  or  ahont  the  heart.  The  peri]»hcral  sensations  ]irecedinff  tlie  fit 
are  of  <jreat  valne,  particidarly  those  in  which  the  anra  always  occnrs  in  a 
definite  re^xion,  as  in  one  fin<:fer  or  toe.  It  is  the  eqnivalent  of  the  si^rnal 
symptom  in  a  fit  from  a  hrain  tnnior.  The  varieties  of  these  sensations 
are  nnmerons.    The  e])igastric  sensations  are  most  common.    In  these  the 


lOUO 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


11 : 


|)atii'iit  coinpliiiiis  of  an  uneasy  sensation  in  the  epigastrium  or  distress  in 
tlic  intestines,  or  tiie  sensation  may  not  be  unlilve  that  of  heart-l)iirn  and 
may  he  assoeiated  with  palpitation.  These  groups  are  sometimes  known 
as  pneumogastric  aura)  or  warnings. 

Of  jtsyehieal  aura;  one  of  the  nu)st  common,  as  described  by  Ifuglilings 
Jackson,  is  the  vague,  dreamy  state,  a  sensation  of  strangeness  or  some- 
times of  terror.  'I'lie  anra>  may  l)e  associated  with  S])ecial  senses;  of  these 
tiie  most  common  are  the  visual,  consisting  of  flashes  of  light  or  sensa- 
tions o!"  color;  less  commonly,  distinct  objects  are  seen.  The  audi- 
tory aura'  consist  of  iu)ises  in  the  ear,  odd  louiuls,  musical  tones,  or  occa- 
sionally vt)ices.  Olfactory  and  gustatory  aura',  unpleasant  tastes  and  odors, 
are  rare. 

Occasionally  the  fit  may  be  preceded  not  by  an  aura,  but  hy  certain 
movements;  the  |)atient  may  turn  round  ra[)idly  or  run  with  great  sj)eed 
lor  a  few  minutes,  the  so-called  epilepsia  i)rocursiva.  In  one  of  the  Klwyn 
cases  the  lad  stood  on  his  toes  and  twirled  with  extraordinary  rapidity,  so 
that  his  features  were  scarcely  recognizable.  At  the  onset  of  the  attack 
the  i)atient  may  give  a  loud  scream  or  yell,  the  so-called  epileptic  cry.  The 
])atient  drops  as  if  shot,  making  no  ell'ort  to  gua.'d  the  fall.  In  consequence 
of  this  epileptics  frequently  injure  themselves,  cutting  the  face  or  head 
or  burning  themselves.  In  the  attack,  as  described  by  Hippocrates,  "the 
])atient  loses  his  speech  and  chokes,  and  foam  issues  from  the  mouth,  the 
toL'th  are  fixed,  the  hands  are  contracted,  the  eyes  distorted,  he  becomes 
insensible,  and  in  some  cases  the  bowels  are  affected.  And  these  symptoms 
occur  sometimes  on  the  left  side,  sometimes  on  the  right,  and  sometimes  on 
l)otli.'*    The  fit  may  be  described  in  three  stages: 

(a)  Tonic  Spasm. — The  head  is  drawn  back  or  to  the  right,  and  the 
jaws  are  fixed.  The  liands  are  clinched  and  the  kgs  extended.  This  tonic 
contraction  atl'ects  the  muscles  of  the  chest,  so  that  respiration  is  impeded 
and  the  initial  pallor  of  the  face  changes  to  a  dusky  or  livid  hue.  The 
muscles  of  the  two  sides  are  unequally  affected,  so  that  the  head  and  neck 
are  rotated  or  the  si)ine  is  twisted.  The  arms  are  usually  flexed  at  the 
elbows,  the  hand  at  the  wrist,  and  the  fingers  are  tightly  clinched  in  the 
palm.    This  stage  lasts  only  a  few  seconds,  and  then  the 

(h)  Clonic  Stage  begins.  The  muscular  contractions  become  intermit- 
tent; at  first  tremulous  or  vibraiory,  they  gradually  heconie  more  ra])id 
and  the  limbs  are  jerked  and  tossed  about  violently.  The  muscles  of  the 
face  are  in  constant  clonic  spasm,  the  eyes  roll,  the  eyelids  are  opened  and 
closed  convulsively.  The  movements  of  the  muscles  of  the  jaw  are  very 
forcible  and  strong,  and  it  is  at  this  time  that  the  tongue  is  a])t  to  be  caught 
Vctween  the  teeth  and  lacerated.  The  cyanosis,  marked  at  the  end  of  the 
tonic  sHge,  gradually  lessens.  A  frothy  saliva,  which  may  be  blood-stained, 
escapes  from  the  mouth.  The  faeces  and  urine  may  be  discharged  involun- 
tarily. The  duration  of  this  stage  is  variable.  It  rarely  lasts  more  than 
one  or  two  minutes.  The  contractions  become  less  violent  and  the  patient 
2;radually  sinks  into  the  condition  of 

(r)  Coma.  The  breathing  is  noisy  or  even  stertorous,  the  face  con- 
gested, but  no  longer  intensely  cyanotic.     The  limbs  arc  relaxed  and  the 


lislrcss  in 
burn  and 
C8  known 

Iiighlings 
or  sonio- 
;  of  these 
or  sensa- 
Mk!  aiuli- 
;,  or  occa- 
ind  odors, 

)y  certain 
roat  sjjeed 

10  I'llwyn 
i|)idity,  «o 
ho  attack 
cry.    The 

isequence 
or  head 
ites,  "  the 
louth,  the 
becomes 
symptoms 
letimes  on 

:,  and  the 
riiis  tonic 
s  impeded 
me.  Tlie 
and  neck 
ed  at  tlie 
led  in  the 

intermit- 
lore  ra])id 
les  of  tlie 
lened  and 
'  are  very 
be  cau<i;ht 
nd  of  tlie 
d-stained, 
1  involun- 
nore  than 
16  patient 

face  con- 
1  and  the 


EPILKPSY. 


101)7 


unconscionsncss  is  profound.  After  a  variable  time  the  patient  can  be 
aroused,  but  if  left  aloi^.e  he  sleeps  for  some  hours  and  then  awakes,  com- 
j)laining  only  of  slight  headache  or  mental  confusion. 

In  some  cases  one  attack  follows  the  other  with  great  rajjidity  and 
consciousness  is  not  regained.  This  is  termed  the  slalus  cpUvplicus, 
an  exceptional  condition,  in  which  the  patient  may  die  of  exiiaustion, 
consequent  upon  the  repeated  attacks.  In  it  tlie  temperature  is  usually 
elevated. 

Aft'  the  attack  the  reflexes  are  sometimes  absent;  more  frc(iueiitly  they 
are  increased  and  the  ankle  clonus  can  usually  be  obtained.  The  state  of 
the  urine  is  variable,  particularly  as  regards  the  solids.  The  (juantity 
is  usually  increased  after  the  attack,  and  albumin  is  not  infrequently 
})resent. 

Poat-cinleplic  sijiiiploiiis  are  of  groat  inii)ortance.  The  ])atient  may  be 
in  a  trance-like  condition,  in  which  he  performs  actions  of  which  subse- 
quently he  has  no  recollection.  More  serious  are  the  attacks  of  mania,  in 
which  the  patient  is  often  dangerous  and  sometinus  homicidal.  It  is  held 
by  good  authorities  that  an  outbreak  of  mania  may  be  substituted  for  tlie 
fit.  And,  lastly,  the  mental  condition  of  an  epilejitic  patient  is  often  seri- 
ously imi)aired,  and  i)roi'ound  defects  are  common. 

I'aralysis,  which  rarely  follows  the  epile})tic  fit,  is  usually  liemiplegic 
and  transient. 

Slight  disturbances  of  speech  also  may  occur;  in  some  instances  forms 
of  sensory  aphasia. 

The  attacks  may  occur  at  night,  and  a  jierson  may  be  epileptic  for  years 
without  knowing  it.  As  Trousseau  truly  remarks,  when  a  person  tells  us 
that  in  the  night  he  has  incontinence  of  urine  and  awakes  in  the  morning 
with  headache  and  mental  confusion,  and  comjiliins  of  ditliculty  in  speech 
owing  to  the  fact  that  he  has  bitten  his  tongue;  if,  also,  there  are  on  the 
skin  of  the  face  and  neck  purjiuric  spots,  the  iirobability  is  very  strong  in- 
deed that  he  is  subject  to  <  octurnal  epilepsy. 

(2)  Petit  Mai. — This  is  cjiilepsy  without  the  convulsions.  The  attack 
consists  of  transient  unconsciousness,  which  may  come  on  at  any  time,  ac- 
com])anicd  or  unaccompanied  by  a  feeling  of  faintness  and  vertigo.  Sud- 
denly, for  example,  at  the  dinner  table,  the  subject  stojis  talki  nnd  eating, 
the  eyes  become  fixed,  and  the  face  slightly  psile.     Anythi  '.licli  may 

have  been  in  the  hand  is  usually  dropped.  In  a  moment  or  two  conscious- 
ness is  regained  and  the  patient  resumes  conversation  as  if  nothing  had 
happened.  In  other  instfuc":  there  is  slight  incolieroncy  or  the  patient 
performs  some  almost  automatii?  action.  lie  may  begin  to  undress  himself 
and  on  returning  to  consciousness  find  that  be  has  ])artially  disrobed.  lie 
n  ";-  lb  his  beard  or  face,  or  may  spit  about  in  a  careless  way.  In  other 
a  _Ks  the  patient  may  fall  without  convulsive  seizures.  A  definite  aura 
is  rare.  Though  transient,  unconsciousness  and  giddiness  are  the  most 
constant  manifestations  of  petit  mat ;  thee  are  many  other  equivalent  mani- 
festations, such  as  siidden  jerkings  in  the  limbs,  sudden  tremor,  or  a  sudden 
visual  sensation.  Gowers  mentions  no  less  than  seventeen  difTerent  mani- 
festations of  pdit  mal.    Occasionally  there  are  cases  in  which  the  patient 


& 


^ 


1098 


DISEASES  op  THE  NERVOUS  SYSTEM. 


lias  a  sensation  of  losing  liis  breath  and  may  even  get  red  in  the  face.  T 
luive  seen  such  attacks  also  in  children. 

After  the  attack  the  patierjt  may  be  dazed  for  a  few  seconds  and  }ior- 
form  certain  automatic  actions,  which  may  seem  to  be  volitional.  As  men- 
tioned, undressing  is  a  common  action,  but  all  sorts  of  odd  actions  may  be 
performed,  some  of  which  are  awkward  or  even  serious.  One  of  my  pa- 
tients after  an  attack  was  in  the  habit  of  tearing  anything  he  could  lay 
hands  on,  particularly  books.  Violent  actions  have  been  committed  and 
assaults  made,  frecjuently  giving  rise  to  (juestions  which  come  before  the 
courts.  This  condition  has  been  termed  masked  epilepsy,  or  epilepsia 
larvaia. 

In  a  majority  of  the  cases  of  pcHt  mal  convulsions  finally  occur,  at  first 
slight,  bxit  ultimately  the  grand  mal  becomes  well  developed,  and  the  attacks 
may  then  alternate. 

(3)  Jacksonian  Epilepsy. — This  is  also  known  as  cortical,  symptomitic, 
or  partial  ejjilejjsy.  Jt  is  distinguished  from  the  ordinary  epilepsy  by  tiie 
important  fact  that  consciousness  is  retained  or  is  lost  late.  The  attacks 
are  usually  the  result  of  irritative  lesions  in  the  motor  zone,  though  there 
are  probably  also  sensory  ecjuivalonts  of  this  motor  form.  In  a  typical 
attack  the  spasm  begins  in  a  limited  muscle  grouj)  of  the  face,  arm,  or  leg. 
The  zygomatic  muscles,  for  instance,  or  the  tlnuub  may  twitch,  or  the  toes 
may  first  be  moved.  Prior  to  the  twitching  the  patient  nuiy  feel  a  sensation 
of  numbness  or  tingling  in  the  part  affected.  The  spasm  extends  and  may 
involve  the  muscles  of  one  limb  only  or  of  the  face.  The  patient  is  con- 
scious throughout  and  watches,  often  with  interest,  the  march  of  the  spasm. 

The  onset  may  be  slow,  and  there  may  be  time,  as  in  a  case  which  I 
have  reported,  for  the  ])atient  to  j)lace  a  ])illow  on  the  floor,  so  as  to  be 
as  comfortable  as  possible  during  the  attack.  The  spasms  may  be  local- 
ized for  years,  but  there  is  a  great  risk  that  the  partial  epilepsy  may  become 
general.  The  condition  is  due,  as  a  rule,  to  an  irritative  lesion  in  the  motor 
zone.  Thus  of  107  cases  analyzed  by  Koland,  there  were  48  of  tumor,  21 
instances  of  intlfrmmatory  softening,  1-4  instances  of  acute  and  chronic 
meningitis,  and  8  cases  of  trauma.  The  remaining  instances  were  due  to 
haemorrhage  or  abscess,  or  were  associated  with  sclerosis  cerebri.  Two 
other  conditions  may  be  mentioned,  which  may  cause  typical  Jacksonian 
cj  ilepsy — namely,  ura-mia  and  progressive  paralysis  of  the  insane.  A  con- 
siderable number  of  the  cases  of  Jacksonian  epilepsy  are  found  in  children 
following  hemiplegia,  the  so-called  post-hemiplegic  epilepsy.  The  con- 
vulsions usually  begin  on  the  affected  side,  either  in  the  arm  or  leg,  and  the 
fit  may  be  nnilateral  and  without  loss  of  consciousness.  Ultimately  they 
become  more  severe  and  general. 

Diagnosis. — In  major  epilepsy  the  suddenness  of  the  attac"  the 
abrupt  loss  of  consciousness,  the  order  of  the  tonic  and  clonic  spasm,  and 
the  relaxation  of  the  sphincters  at  the  height  of  the  attack  are  distinctive 
features.  The  convulsive  seizures  due  to  uraemia  are  epi^  ;  tic  in  charuj^er 
and  usually  readily  recognized  by  the  existence  of  grcf  ,  increased  ten- 
sion and  the  condition  of  the  urine.  Pract'cally  in  young  adults  hysteria 
causes  the  greatest  difhculty,  and  may  closely  simulate  true  epilepsy.    The 


EPILEPSY. 


1099 


le  face.    T 

3  and  per- 
Ah  nu'ii- 
ns  may  bo 
of  my  pa- 
could  liiy 
iiittod  and 
1)0 fore  the 
:•   epilepsia 

uY,  at  first 
the  attacks 

nptomitic, 
|)sy  hy  the 
'he  attacks 
iugli  there 
I  a  typical 
rm,  or  leg. 
or  the  toes 
a  sensation 
Is  and  may 
L'nt  is  con- 
the  spasm. 
5e  which  I 
,0  as  to  be 
y  be  local- 
lay  l)ccome 
the  motor 
tumor,  21 
id  chronic 
ere  due  to 
)ri.  Two 
Facksonian 
e.  A  con- 
n  children 
The  con- 
!g,  and  the 
lately  they 

ttac'  tlie 
pasm,  and 
distinctive 
1  chara  ;^cr 
eased  ten- 
ts hysteria 
3psy.    The 


following  table  from  Gowers'  work  draws  clearly  the  chief  differences  be- 
tween them: 


Epileptic. 

HVSTBROID. 

Apparent  cause 

\V  urniiig 

none. 

any,  hut  especially  unilateral 
or  epigastric  aunt'. 

always  sudden. 

at  (rnsct. 

ligidity  followed  hy  "jerk- 
ing," rarely  rigidity  alone. 

tcngue. 

frequent. 

occasional. 

never. 

a  few  minutes. 

to  prevent  accident 
spontaneous. 

einotiiin. 

IMilpilatidU.  malaise,  choking,  bi- 
lateral foot  aura. 

often  gradual. 

during  course. 

rigidity  or  "struggling,"  throwing 
al)out  of  limbs  or  head,  arching 
of  back. 

lips,  hands,  or  other  people  and 
things. 

never. 

Onset 

Screuin 

C\>uvulsion 

Bitiiiff 

Micturition 

Di.'feciition 

Taliviiig 

never. 

frequent. 

more  than  ten  minutes,  often  much 

longer, 
to  control  violence, 
spontaneous    or    induced    (water, 

etc.). 

Duration 

Restraint  neces>.sary. . . 
Termination 

Recurring  epileptic  seizures  in  a  person  over  thirty  who  has  not  had 
previous  attacks  is  always  suggestive  of  organic  disease.  According  to  II. 
C.  Wood,  whose  opinion  is  sujijiorted  by  that  of  Fournier,  in  \)  cases  out  of 
10  the  condition  is  due  to  syphilis. 

Petit  mal  must  be  distinguished  from  attacks  of  syncope,  and  the  ver- 
tigo of  ^leniere's  disease,  of  a  cardiac  lesion,  and  of  indigestion.  In  these 
cases  there  is  no  actual  loss  of  consciousness,  which  forms  a  characteristic 
though  not  an  invariable  feature  of  petit  mal. 

Jacksonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is 
at  once  recognized.  It  is  by  no  means  easy,  however,  always  to  determine 
upon  what  the  spasm  depends.  Irritation  in  the  motor  centres  may  be  due 
to  a  great  variety  of  causes,  among  which  tumors  and  localized  meningo- 
encephalitis are  the  most  frequent;  but  it  must  not  be  forgotten  that  in 
uramiia  localized  epilepsy  may  occur.  The  most  typical  Jacksonian  spa.^^ms 
also  are  not  infrequent  in  general  paresis  of  the  insane. 

Prognosis. — This  may  be  given  to-day  in  the  words  of  Hippocrates: 
"  The  prognosis  in  epilepsy  is  unfavorable  when  the  disease  is  congenital, 
and  when  it  endures  to  manhood,  and  when  it  occurs  in  a  grown  person 
without  any  previous  cause.  .  .  .  The  cure  may  be  attempted  in  young 
persons,  but  not  in  old." 

Death  during  the  fit  rarely  occurs,  but  it  may  happen  if  the  patient 
falls  into  the  water  or  if  the  fit  comes  on  while  he  is  eating.  Occasionally 
the  fits  seem  to  stop  spontaneously.  This  is  particularly  the  case  in  the 
epilepsy  in  children  which  has  followed  the  convulsions  of  teething  or  of 
the  fevers.  Frequency  of  the  attacks  and  marked  mental  di'^-turbanc"  arc 
unfavorable  indications.  Hereditary  predisposition  is  ap'iarently  of  no 
moment  in  the  prognosis.  The  outlook  is  better  in  males  than  in  females. 
The  post-hemiplegic  epilepsy  is  rarely  arrested.     Of  the  cases  coming  on 


1100 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


in  adults,  those  due  to  pypliilis  and  to  local  aflections  of  tlio  brain  allow  a 
more  favorable  jji-ognosis. 

Treatment. — ilciirral. — In  the  case  of  cliildren  (he  parents  should 
he  made  to  understand  from  the  ontset  that  epilejjsy  in  the  great  majority  of 
cases  is  an  incurable  all'ection,  so  that  the  disease  may  interfere  as  little  us 
l)ossible  with  the  I'ducation  of  the  child.  The  su])jects  need  iirm  but  kind 
treatment.  Indulf^cnce  and  yielding  to  caprices  and  whims  are  followed 
by  weakening  of  the  moral  control,  which  is  so  necessary  in  these  cases. 
The  disease  does  not  ineai)acitate  a  jjcrson  for  all  occupation.  It  is  much 
better  for  epileptics  to  have  some  definite  pursuit.  There  are  many  in- 
stances in  which  they  have  been  persons  of  extraordinary  mental  and  bodily 
vigor;  as,  for  e.\ami)Ie,  Julius  Cicsar  and  Napoleon.  One  of  the  most  dis- 
tressing features  in  ei)ilei)sy  is  the  gradual  mental  imi)airnient  which  fol- 
lows in  a  certain  number  of  cases.  If  such  patients  become  extremely  irri- 
table or  show  signs  of  violence  they  should  be  ])laced  under  su])ervision  in 
an  asylum.  JMarriage  should  be  forbidden  to  epileptics.  During  the  attack 
a  cork  or  bit  of  rublier  should  be  })laced  between  the  teeth  and  the  clothes 
should  be  loosened.  The  patient  should  be  in  the  recumbent  i)osture.  As 
the  attack  usually  passes  off  with  rapidity,  no  special  treatment  is  necessary, 
but  in  cases  in  which  the  convulsion  is  prolonged  a  few  whiffs  of  chloro- 
form or  nitrite  of  amyl  or  a  hypodermic  of  a  quarter  of  a  grain  of  morphia 
may  be  given. 

Dietetic. — The  old  authors  laid  great  stress  upon  regimen  in  epilepsy. 
The  important  jjoint  is  to  give  the  patient  a  light  diet  at  fixed  hours,  and 
on  no  account  to  permit  overloading  of  the  stomach.  Meat  should  not  be 
given  more  than  once  a  day.  There  are  cases  in  which  animal  food  seems 
injurious.  A  strict  vegetalde  diet  has  been  wamdy  recommended.  The 
patient  should  not  go  to  sleep  until  the  completion  of  gastric  digestion. 

Medicinal. — The  bromides  are  the  only  remedies  which  have  a  special 
influence  upon  the  disease.  Kitlier  the  sodium  or  potassium  salt  may  be 
given.  Sodium  bromide  is  probably  less  irritating  and  is  better  borne  for 
a  long  period.  It  may  be  given  in  milk,  in  which  it  is  scarcely  tasted.  In 
all  instances  the  dilution  shoidd  be  considerable.  In  adults  it  is  well  taken 
in  soda  water  or  in  some  mineral  water.  The  dose  for  an  adult  should  be 
from  half  a  drachm  to  a  drachm  and  a  half  daily.  As  Seguin  recommends, 
it  is  often  best  to  give  but  a  single  dose  daily,  about  four  to  six  hours  before 
the  attacks  are  most  likely  to  occur.  Fo^  instance,  in  the  case  of  nocturnal 
eiiileppy  a  drachm  should  be  given  an  hour  or  two  after  the  evening  meal. 
If  the  attack  occurs  early  in  the  morning,  the  patient  shoidd  take  a  full 
dose  when  he  awakes.  When  given  three  times  a  day  it  is  best  given  after 
meals.  Each  ease  should  be  carefully  studied  to  determine  how  much 
1)romide  should  be  used.  The  individual  susceptibility  varies  and  some 
patients  recpiii'e  more  than  others.  FortuTiately,  cliildren  take  the  drug 
well  and  stand  proportionately  larger  doses  than  adults.  Saturation  is 
indicated  by  certain  unpleasant  effects,  particularly  drowsiness,  mental 
torpor,  and  gastric  and  cardiac  distress.  Loss  of  palate  reflex  is  one  of  the 
earliest  indications  that  the  system  is  under  the  influence  of  the  bromides, 
and  is  a  condition  which  should  be  attained.     A  very  unpleasant  feature 


X 


EPILEPSY. 


1101 


in  allow  a 

its  should 
liijority  of 
IS  littlo  us 

but  kind 
3  I'ollowod 
icse  cases, 
t  is  much 

many  in- 
md  bodily 

most  dis- 
ivhich  fol- 
'uicly  irri- 
rvision  in 
the  attack 
he  clothes 
sture.  As 
necessary, 
of  chloro- 
f  morphia 

1  epilepsy, 
lours,  and 
dd  not  be 
ood  seems 
led.  The 
estion. 
a  special 
it  may  be 
borne  for 
asted.  In 
veil  taken 
should  be 
ommends, 
urs  before 
nocturnal 
ing  meal. 
d<:e  a  full 
iven  after 
ow  much 
and  some 
the  drug 
iration  is 
s,  mental 
»ne  of  the 
bromides, 
it  feature 


is  the  development  of  acne,  which,  however,  is  no  indication  of  broniisni. 
Seguin  states  that  the  tendency  to  this  is  much  diminished  by  giving  the 
driig  largely  diluti'd  in  alkaline  waters  and  administering  frcun  time  to  time 
full  doses  of  arsenic.  To  be  eU'eclual  the  treatment  should  be  continued 
for  a  prolonged  jjcriod  and  the  cases  should  be  incessantly  watched  in  oidcr 
to  i)revent  bromism.  The  medicine  should  be  continued  for  at  least  two 
years  after  the  cessation  of  the  fits;  indeed,  Seguin  reconnueuds  that  the 
reduction  of  the  bromides  should  not  be  begun  until  the  jtatient  has  been 
three  years  without  any  manifestations.  Written  directions  should  be  given 
to  the  mother  or  to  the  friends  of  the  patient,  and  he  should  iu)t  liiTuself 
be  held  responsible  for  the  administration  of  the  nu'dieine.  A  book  should 
he  provided  in  which  the  daily  number  of  attacks  and  the  amount  of  medi- 
cine taken  should  be  noted.  The  addition  of  belladonna  to  the  bromide  is 
warmly  recommended  by  Black,  of  Glasgow.  In  very  obstinate  cases  Flech- 
sig  uses  oi)ium,  5  or  6  grains,  in  three  doses  daily;  then  at  the  end  of  six 
weeks  opium  is  stopped  ami  the  bromides  in  large  anu)unts,  75  to  100  grains 
daily,  are  used  for  two  months. 

Among  other  remedies  which  liavc  been  recommended  as  controlling 
epilepsy  arc  chloral,  cannabis  indica,  zin?,  nitroglycerin,  and  bora.x.  Nitro- 
glycerin is  sometimes  advantageous  in  petit  vial,  but  is  not  of  much  service 
in  the  major  form.  To  be  beneficial  it  must  be  given  in  full  doses,  from  2 
to  5  minims  of  the  1-per-cent  solution,  and  increased  until  the  physiological 
niTects  are  produced.  Counter-irritation  is  rarely  advisable.  When  the 
aura  is  very  definite  and  constant  in  its  onset,  as  from  the  hand  or  from  the 
toe,  a  blister  about  the  part  or  a  ligature  tightly  ap])lied  nuiy  stop  the  on- 
coming fit.  In  children,  care  should  be  taken  that  there  is  no  source  of 
peripheral  irritation.  In  boys,  adherent  ])re])nce  may  occasionally  be  the 
cause.  The  irritation  of  teething,  the  presence  of  worms,  and  foreign  bodies 
in  the  cars  or  nose  have  been  associated  with  epileptic  seizures. 

The  snbjects  of  a  chronic  and,  in  most  cases,  a  ho])elessly  incurable 
disease,  e])ileptic  patients  form  no  small  portion  of  the  unfortunate  victims 
of  charlatans  and  quacks,  who  prescribe  to-day,  as  in  the  time  of  the  father 
of  medicine,  "  purifications  and  spells  and  other  illiberal  practices  of  like 
kind." 

Surgical. — In  Jacksonian  epilejisy  the  ])ro]n'iety  of  surgical  interfer- 
ence is  universally  granted.  It  is  questionable,  however,  whether  in  the 
epilepsy  following  hemi])legia,  considering  the  anatomical  condition,  it  is 
likely  to  be  of  any  benefit.  In  idiopathic  e]n]e])sy,  when  the  fit  starts  in 
a  certain  region — the  thumb,  for  instance — and  the  signal  sym])tom  's  in- 
variable, the  centre  controlling  this  ])art  may  be  removed.  This  pre  cdure 
has  been  practised  by  Macewen,  Ilorsley,  Keen,  and  others,  but  time  alone 
can  determine  its  value.  The  traumatic  epilepsy,  in  which  the  fit  follows 
fracture,  is  much  more  hopeful. 

The  operation,  per  se,  appears  in  some  cases  to  have  a  curative  cfTcct. 
Thus  of  50  cases  of  tre])hining  for  epilepsy  in  which  nothing  abnormal  was 
found  to  account  for  the  sym])toms,  25  were  reported  as  cured  and  18  as  im- 
proved. The  o]icrations  have  not  been  always  on  the  skidl,  and  White 
has  collected  an  interesting  series  in  which  various  surgical  procedures  have 


^ 


t^^l  p 


1102 


DISKASES  OF  THE  NERVOUS  SYSTEM. 


been  resorted  to,  oflcii  witli  curative  elTcct,  sucli  as  lif,'ati()n  of  the  carotid 
artery,  castration,  tnidicotoniy,  excision  of  tlie  superior  cervical  ganglia, 
incision  of  the  scalp,  circumcision,  etc. 


VII.    MIGRAINE   {Ilemicmnia;  Sick  Headache). 

Definition. — A  paroxysmal  affection  cliaractorized  by  severe  headache, 
usually  unilateral,  and  often  associated  with  disorders  of  vision. 

Etiology. — The  disease  is  frequently  hereditary  and  has  occurred 
through  several  generations.  Women  and  the  members  of  neurotic  fami- 
lies are  most  freiiucnlly  attacked.  Jt  is  an  alTectiou  from  which  many  dis- 
tinguished men  have  suH'cied  and  have  left  on  record  an  account  of  the  dis- 
ease, notably  the  astronomer  Airy.  Kdward  Liveing's  work  is  the  standard 
authority  upon  which  most  of  the  subsequent  articles  have  been  based.  A 
gouty  or  rheumatic  taint  is  present  in  many  instances.  Sinkler  has  called 
special  attention  to  the  frecpiency  of  rellex  causes.  Migraine  has  long  been 
known  to  be  associated  with  uterine  and  menstrual  disorders.  Nutritive 
disturbances  are  common,  and  attempts  have  been  made  by  Ilaig  and  others 
to  associate  the  attacks  with  disturbed  uric-acid  outjjut.  Certainly  the 
amount  of  uric  acid  excreted  just  prior  to  and  during  an  attack  is  reduced. 
Others  regard  the  disease  as  a  toxa'mia  from  disordered  intestinal  digestion. 
JIany  of  the  headaches  from  eye-strain  are  of  the  hemicranial  type.  IJrun- 
ton  refers  to  caries  of  the  teeth  as  a  cause  of  these  headaches,  even  when 
not  associated  with  toothache.  Cases  have  been  described  in  connection 
with  adenoid  growths  in  the  pharynx,  and  particularly  with  abnormal  con- 
ditions of  the  nose.  ]\lany  of  the  attacks  of  severe  headaches  in  children  are 
of  this  nature,  and  the  eyes  and  nostrils  should  be  examined  with  great 
care.  Sinkler  refers  to  a  case  in  a  child  of  two  years,  and  Gowers  states  that 
a  third  of  all  the  cases  begin  between  the  fifth  and  tenth  years  of  age.  The 
direct  influences  inducing  the  attack  are  very  varied.  Powerful  emotions 
of  all  sorts  are  the  most  potent.  IMental  or  bodily  fatigue,  digestive  dis- 
turbances, or  the  eating  of  some  particular  article  of  food  may  be  followed 
by  the  headache.  The  paroxysmal  character  is  one  of  the  most  striking 
features,  and  the  attacks  may  recur  on  the  same  day  every  week,  every  fort- 
night, or  every  month.  Headaches  of  the  migraine  type  may  recur  for 
years  in  connection  with  chronic  Bright        ;ease. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the 
patient  can  tell  when  an  attack  is  coming  on.  Remarkable  prodromata 
have  been  described,  particularly  in  connection  with  vision.  Ap])aritions 
may  appear — visions  of  animals,  such  as  mice,  dogs,  etc.  Transient  hemi- 
anopia  or  scotoma  may  be  present.  In  other  instances  there  is  spasmodic 
action  of  the  pupil  on  the  affected  side,  which  dilates  and  contracts  alter- 
nately, the  condition  known  as  hippnfi.  Frequently  the  disturbance  of 
vision  is  only  a  blurring,  or  there  are  balls  of  light,  or  zigzag  lines,  or  the 
so-called  fortification  spectra  (teichopsia),  which  may  be  illuminated  with 
gorgeous  colors.  Disturbances  of  the  other  senses  are  rare.  Numbness  of 
the  tongue  and  face  and  occasionally  of  the  hand  may  occur  with  tingling. 


MIGRAINE. 


ic  cnrf)ti(l 
1  ganglia, 


I 


1103 


headache, 

occurred 
jtic  fanii- 
miiny  dis- 
)i'  the  d;s- 
!  staii(hu'd 
l)ased.     A 
has  called 
long  heen 
Nutritive 
md  others 
tainly  the 
s  reduced, 
digestion. 
)e.     IJrun- 
!ven  when 
onnection 
irnial  con- 
ildren  are 
vith  great 
■•tates  that 
ge.    The 
emotions 
L'stive  dis- 
followed 
t  striking 
;very  fort- 
recur  for 

i,  and  the 
rodromata 
])l)aritions 
lent  heiui- 
spasmodic 
acts  altcr- 
rhance  of 
les.  or  the 
lated  with 
mhness  of 
1  tingling. 


More  rarely  there  are  crajniis  or  .^ipasnis  in  the  muscles  of  the  affected  side. 
Transient  aphasia  has  also  been  noted.  Some  patients  sliow  marked  psy- 
chical (lislnrl)an((',  either  exiMlcmcnt  or,  more  commonly,  mental  confusion 
or  great  depression.  Dizziness  occ-urs  in  some  ciises.  The  headache  follows 
a  short  time  after  the  prodnimid  symptoms  have  a|)pcared.  It  is  cumulative 
iind  t'X|)ansiI('  in  character,  beginning  as  a  localized  small  spot,  which  is 
generally  constant  cither  on  the  tcmjtle  or  forehead  or  in  the  eyeball.  It 
is  usually  described  as  of  a  peiu'trating,  sharp,  boring  (;haracter.  At  first 
unilateral,  it  gradually  spreads  ami  involves  the  side  of  the  head,  sometimes 
ihe  neck,  and  the  pains  may  pass  into  the  arm.  In  other  cases  both  sides 
are  all'ected.  Nausea  and  vomiting  are  common  symptoms.  If  the  attack 
conies  on  when  the  stomach  is  full,  vomiting  usually  gives  relief,  ^'aso- 
niotor  symptoms  may  he  present.  The  face,  for  instance,  may  be  pale,  and 
there  may  be  a  marked  dill'erenco  between  the  two  sides.  Subsequently  the 
face  and  ear  on  the  affected  side  may  become  a  hurning  red  from  the  vaso- 
dilator influences.  The  pulse  may  be  slow.  The  temporal  artery  on  the 
all'ected  side  may  be  iirm  ami  hard,  and  in  a  condition  of  artcrio-sclerosis — 
a  fact  which  has  heen  confirmed  anatomically  by  Tlioma.  Few  all'ectiona 
iire  more  prostrating  than  migraine,  and  during  the  luiroxysm  the  patient 
niny  scarcely  he  able  to  raise  the  head  from  the  pillow.  The  slightest  noise 
or  light  aggravates  the  condition. 

The  duration  of  the  entire  attack  is  variable.  The  severer  forms  usually 
incajmcitate  the  jjcrson  for  at  least  three  days.  In  other  instances  the  en- 
tire attack  is  over  in  a  day.  The  disease  recurs  for  years,  and  in  cases  with 
a  marked  hereditary  tendency  may  ])ersist  throughout  life.  In  women  the 
attacks  often  cease  after  the  clinuiteric,  and  in  men  after  the  age  of  fifty. 
Two  of  the  greatest  sufferers  I  have  known,  who  had  recurring  attacks 
every  few  weeks  from  early  boyhood,  now  have  complete  freedom. 

The  nature  of  the  disease  is  unknown.  Liveing's  view,  that  it  is  a 
nerve  storm  or  form  of  periodic  discharge  from  certain  sensory  centres  and 
is  related  to  epilepsy,  has  found  much  favor.  According  to  this  view,  it 
is  the  sensory  CHjuivalent  of  a  true  epile))tic  attack.  Mollendorf,  Latham, 
and  others  regard  it  as  a  vaso-motor  neurosis,  and  hold  that  the  early  symp- 
toms are  due  to  vaso-constrictor  and  the  later  symptoms  to  vaso-dilator 
influences.  The  fact  of  the  development  of  arterio-sclerosis  in  the  arteries 
of  the  affected  side  is  a  point  of  interest  hearing  upon  this  view. 

Treatment. — The  patient  is  fully  aware  of  the  causes  which  precipi- 
tate an  attack.  Avoidance  of  excitement,  regularity  in  the  meals,  and 
moderation  in  diet  are  important  rules.  I  have  known  cases  greatly  hene- 
fitted  by  a  strict  vegetahle  diet.  The  treatment  should  he  directed  toward 
the  removal  of  the  conditions  upon  which  the  attacks  depend.  In  children 
much  may  he  done  hy  watchfulness  and  care  on  the  part  of  the  mother  in 
regulating  the  howels  and  watching  the  diet  of  the  child.  Errors  of  re- 
fraction should  l)e  adjusted.  On  no  account  should  such  children  he  allowed 
to  compete  in  school  for  prizes.  A  prolonged  course  of  hromides  sometimes 
proves  successful.  If  auirmia  is  present,  iron  and  arsenic  should  be  given. 
When  the  arterial  tension  is  increased  a  course  of  nitroglycerin  may  he 
tried.    Not  too  much,  however,  sh-^uld  he  expected  of  the  preventive  treat- 


WW^'V 


1104 


DISEASES  OF  TDK  NERVOUS  SYSTEM. 


nicnt  of  inigniine.  It  imii-t  1)0  confessed  Hint  in  a  very  larpe  proportion  of 
the  capes  the  liendaehes  recur  in  spite  of  nil  we  can  do.  I  Idler  advises,  so 
soon  as  the  patient  has  any  intimation  of  llie  attack,  to  wash  out  the  stoin- 
uch  witii  water  at  10.5°,  and  to  j,dve  u  l)risiv  saline  cathartic.  Durini,'  the 
paroxysm  the  patient  should  he  kept  in  hed  and  ahs(dutely  (piiet.  If  the 
jmtient  feels  faint  and  nauseated,  a  snudl  cup  of  hot,  strong  coffee  or  5J(> 
drops  of  chloroform  give  relief.  Caunahis  iiulicu  is  prol)al)ly  the  most  satis- 
factory remedy.  Seguin  recoiunu'uds  a  prolonged  course  of  the  drug. 
Antipyrin,  jintifehrin,  and  i)lienacetin  have  heen  much  used  of  late.  When 
given  early,  at  the  very  outset  of  the  paroxysm,  they  are  sometimes  efTective. 
The  doses  which  have  heen  recommended  of  antifehrin  and  antipyrin  are 
often  dangerous,  and  1  have  seen  in  a  case  of  migraine  uni)leasant  collapse 
symptoms  follow  a  2r)-grain  dose  of  antipyrin  which  the  patient  had  taken 
on  her  own  rcsponsihility.  Smaller,  repeated  doses  are  more  satisfactory. 
Of  other  remedies,  caffeine,  in  Tj-grain  doses  of  tfie  citrate,  nu.x  vomica, 
and  ergot  have  been  recommended.     Electricity  does  not  ai)pear  to  he  of 


mucli  service. 


VIII.    NEURALGIA. 

Definition. — A  painful  affection  of  the  nerves,  due  either  to  function:il 
disturbance  of  their  central  or  peripheral  extremities  or  to  neuritis  in  their 
course. 

Etiology. — ^FtMnbors  of  neuropathic  families  arc  most  subject  to  the 
disease.  It  alfects  women  more  than  men.  Children  are  rarely  attacked. 
Of  all  causes,  debility  is  the  most  frequent.  It  is  often  the  first  indication 
of  an  enfeebled  nerv  is  system.  The  various  forms  of  antcmia  are  fre- 
quently associated  with  neuralgia.  It  may  be  a  prominent  feature  at  the 
onset  of  certain  acute  diseases,  particularly  typhoid  fever.  Malaria  is  be- 
lieved to  be  a  potent  cause,  but  it  has  not  been  shown  that  neuralgia  is 
more  frequent  in  malarial  districts,  and  the  error  has  probably  arisen  from 
regarding  periodicity  as  a  special  manifestation  of  paludism.  It  occasion- 
ally occurs  in  malarial  cachexia.  Exposure  to  cold  is  a  cause  in  very  sus- 
ceptible persons.  Keflex  irritation,  particularly  from  carious  teeth,  may 
induce  nenralgia  of  the  fifth  nerve.  The  disease  occurs  sometimes  in  rheu- 
matism, gout,  lead  poisoning,  and  diabetes.  Persistent  neuralgia  may  be 
a  feature  of  latent  Bright's  disease. 

Symptoms. — Before  the  onset  of  the  pain  there  may  be  nneasy  sen- 
sations, sometimes  tingling  in  the  part  which  will  be  affected.  The  pain 
is  localized  to  a  certain  group  or  division  of  nerves,  nsnally  affecting  one 
side.  The  pain  is  not  constant,  but  paroxysmal,  and  is  described  as  stab- 
bing, burning,  or  darting  in  character.  The  skin  may  be  exquisitely  ten- 
der in  the  affected  region,  particularly  over  certain  points  along  the  course 
of  the  nerve,  the  so-called  tender  points.  ^Movements,  as  a  rule,  are  pain- 
ful. Trophic  and  vaso-motor  changes  may  accompany  the  paroxysm;  the 
skin  may  be  cool,  and  subseqnently  hot  and  burning;  occasionally  local 
oedema  or  erythema  occurs,  ^fore  remarkable  still  are  the  changes  in  the 
hair,  which  may  become  blanched  (canities),  or  even  fall  out.    Fortunately, 


NEURALGIA. 


1106 


iportion  of 
iidviHcs,  ^o 

llic  stoMi- 
)uriii{,'  tlic 
et.  If  the 
)ir('o  or  2i) 
most  Hiitis- 

Uio  (lrii;x- 
lie.  Wlu'ii 
}s  efTcctive. 
tipyi'in  arc 
nt  collapse 

liad  taki'ii 
iitisl'at'tory. 
iix  vomica, 
ir  to  be  of 


functionil 
tis  in  their 

ijcct  to  the 

y  attacked. 

indication 

lia  are  fre- 

ture  at  the 

laria  is  be- 

leviralgia  is 

irisen  from 

t  occasion- 

n  very  sns- 

teeth,  may 

es  in  rhen- 

^ia  may  be 

measy  sen- 
The  pain 
fecting  one 
led  as  stab- 
lisitely  ten- 
the  conrsc 
L',  are  pain- 
oxysm;  tlie 
)na]]y  local 
ngos  in  the 
fortunately, 


Buoh  alterations  are  rare.  Twitchings  of  the  ninpclcs,  or  oven  spasms, 
may  be  jjresent  during  the  paroxysm.  After  lasting  a  variable  time — from 
u  few  minutes  to  many  hours — the  attack  subsides.  ]{ccurrence  may  be 
at  dclinite  intervals — every  day  at  the  same  Jiour,  or  at  intervals  of  two, 
t]ire(;,  or  even  seven  days.  Oci-asionally  tlu;  j)ar<).\ysni.s  develop  only  at  the 
catamenia.  This  periodicity  is  (piite  as  marked  in  non-mularinl  as  in  ma- 
larial regions. 

Clinical  Varieties,  depending  on  the  Nerve  Groups  affected.— (1)  Tri- 
facial NenraUjia;  Tic  Doiilmirviix ;  Trosopdltjia. — All  the  branches  are 
rarely  involved  together.  The  ophthalmic  is  most  often  airected,  but  in 
severe  attacks  the  pain.s,  though  more  intense  in  one  division,  radiate  over 
the  other  branches.  At  the  out.^et  there  may  be  hypera'sthesia  of  the  skin 
and  sensitiveness  of  the  mucous  membrane.  Pressure  is  i)ainful  at  the  |)ointH 
of  emergence  of  the  nerve  trunk,  and  where  the  nerves  enter  the  muscles. 
Sometimes  in  addition,  as  Trousseau  pointed  out,  there  are  i)ains  nt  the 
occipital  ])rotu])erance  and  in  the  upper  cervical  spines.  When  the  oph- 
thalmic division  is  all'ected  the  eye  may  weep  and  the  conjunctivic  are  in- 
jected and  i)ainful.  In  the  uj>per  maxillary  division  there  is  a  teiuler  j)()int 
where  the  nerve  leaves  the  infraorbital  canal,  and  the  pain  is  specially 
marked  along  tlie  upper  teeth.  In  the  lower  brandies,  which  are  more 
fre(iuently  involved,  tlu're  are  painful  ])oints  along  the  auriculo-temporal 
nerve  and  the  pain  radiates  in  the  region  of  the  ear  along  the  lower  jaw 
and  teeth.  The  movements  of  mastication  and  speaking  may  be  painful. 
Salivation  is  not  uncommon.  Herpes  may  occur  about  the  eye  or  the  lips. 
In  pi  "^racted  cases  there  may  be  atro])hy  or  induration  of  the  skin.  Sonu' 
of  the  forms  of  facial  neuralgia  are  of  frightfid  intensity  and  the  recurring 
attacks  render  the  patient's  life  almost  insupportable. 

(2)  Cervico-occipital  ncvralt/ia  involves  the  posterior  branches  of  the 
first  four  cervical  nerves,  particularly  the  inferior  occii)ital,  at  tiie  emer- 
gence of  which  there  is  a  painful  jioint  a])out  half-way  between  the  mastoid 
process  and  the  first  cervical  vertebra.  It  may  be  caused  by  cold,  and  tliese 
nerves  are  often  affected  in  cervical  caries. 

(3)  Ccrvico-hracMal  ticvrah/ia  involves  the  sensory  nerves  of  the  brachial 
])lexus,  particularly  in  the  cubital  division.  When  the  circumflex  nerve  is 
involved  the  pain  is  in  the  deltoid.  The  pain  is  most  commonly  about  the 
shoulder  and  doAvn  the  course  of  the  ulnar  nerve.  There  is  usually  a 
marked  tender  point  upon  this  nerve  at  the  elbow.  This  form  rarely  fol- 
lows cold,  but  more  frequently  results  from  rheumatic  affections  of  the 
joints,  and  trauma. 

(t)  Neuralgia  of  the  phrenic  nerve  is  rare.  It  is  sometime^:  found  in 
]ileurisy  and  in  pericarditis.  The  pain  is  chiefly  at  the  lower  part  of  the 
thorax  on  a  line  with  the  insertion  of  the  diaphragm,  and  here  may  be 
]iainfu]  points  on  deep  pressure.  Full  inspiration  is  painful,  and  there  is 
great  sensitiveness  on  coughing  or  in  the  performance  of  any  movement  by 
which  the  diaphragm  is  suddenly  depressed. 

(5)  Intercostal  Neuralgia. — Next  to  the  tic  donloureiix  this  is  the  most 
important  form.  It  is  most  frequent  in  women  and  very  common  in  hys- 
teria and  an.Tmia.  The  pain  in  caries  and  aneurism  is  felt  in  the  intercostal 
C9 


vw 


1100 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


nerves.  Tlicy  arc  alno  the  Hcut  of  tlio  iiitoiisc  pain  in  inllaiiiiiialioii  (if  tlit> 
pleura.  Tlii'  pain  is  often  conwlant  and  cxag^jerated  by  movements.  I'leii- 
rodynia  is  siippo.sed  hy  Home  to  be  loeul  intercostal  iiciiralf^ia,  tonlined  to 
one  s|)ot,  usually  alon<f  the  course  or  at  the  exit  of  llie  nerves.  Herpes 
/ostci'  or  zona  occurs  with  the  most  a^^^ravatt'd  form  (d'  intercostal  lU'ural- 
f;ia.  'J'he  pain  usually  pre(!e(le«  the  eruption,  which  consists  of  a  series  of 
pearly  vesicles,  which  take  two  or  three  days  to  develop  and  gradually  dis- 
appear, 'j'he  eruption  may  occur  without  much  pain,  'i'he  most  distressin;^; 
featuic  in  the  complaint  is  tlu'  persistence  in  the  pain  aftt-r  the  eruption 
has  subsided.  'J'he  eruption  and  the  neural^da  are  in  reality  manircsta- 
tions  of  neuritis.  Changes  have  been  found  in  the  nerves  and  in  the  gan- 
glia of  the  dorsal  roots.  The  pain  of  zona  may  persist  indelinitely,  and  it 
has  been  known  to  be  so  intractable  that  in  di'spair  the  |)erson  has  com- 
mitted suicide. 

(())  Lvinhar  Ncnrahjia. — The  alTecled  lu-rves  are  the  posterior  fibres  of 
the  lundiar  ]tlexus,  particularly  the  ilio-scrotal  branch.  The  pain  is  in 
the  region  of  the  iliac  crest,  along  the  inguinal  canal,  in  the  s|)ermatic 
cord,  and  in  the  scrotum  or  labium  majus.  The  aifection  known  as  irritable 
testis,  probal)ly  a  neuralgia  of  this  nerve,  nuiy  be  very  severe  and  accom- 
panied l)y  syncojial  sensations. 

(7)  Cnrrydijiiio. — This  is  regarded  as  a  neuralgia  of  the  coccygeal  jilexus. 
It  is  most  common  in  women,  and  is  aggravated  by  the  sitting  posture.  Jt 
is  very  intractable,  and  may  necessitate  the  removal  of  the  coccyx,  an  opera- 
tion, however,  which  is  not  always  successful.  Neuralgias  of  the  nerves 
of  the  leg  have  already  been  considered. 

(H)  Ncurdhjias  of  the  No'ves  of  the  Feet. 

Pa  ill  flit  J I  eel. — lioth  in  women  and  men  there  may  l)e  about  the  heel 
severe  pains  which  interfere  seriously  with  walking — the  pododynia  of  S. 
D.  Gross.  There  may  be  little  or  no  swelling,  no  discoloration,  and  no 
affect  ion  of  the  joints. 

riaiilar  Xciinihjid. — This  is  often  associated  with  a  definite  neuritis, 
such  as  fidlows  typhoid  fever,  and  has  been  seen  in  an  aggravated  form 
in  caiss<ni  disease  (Hughes).  The  i)ain  may  he  linnted  to  the  tips  of  the 
toes  or  to  the  hall  of  the  great  toe.  Numbness,  tingling,  and  hypera^sthosia 
or  sweating  may  occur  with  it.  Following  the  cold-bath  treatment  in  ty- 
phoid fever  it  is  not  uncommon  for  patients  to  comi)lain  of  great  sensi- 
tiveness in  the  toes. 

Mctatarsohjin. — Morton's  (Thomas  G.)  "painful  affection  of  the  fourth 
mctatarso-]ihalangeal  articulation  "  is  a  ]ieculiar  and  very  trying  disorder, 
seen  most  frequently  in  women,  and  usually  in  one  foot.  Morton  regards 
it  as  due  to  a  pinching  of  the  metatarsal  nerve.  The  disease  rarely  gets  well 
without  o]ieration.  The  red,  painful  neuralgia — erythromelalgia — is  de- 
scribed under  the  vaso-motor  and  trophic  disturbances. 

(9)  Yisrernl  Neuralgias. — The  more  important  of  those  have  already 
hcen  referred  to  in  connection  with  the  cardiac  and  the  gastric  neuroses. 
They  arc  most  frequent  in  women,  and  are  constant  accompaniments  of 
neurasthenia  and  hysteria.  The  pains  are  most  common  in  the  pelvic 
region,  particularly  about  the  ovaries.    Nephralgia  is  of  great  interest,  for, 


PUOI'KSSION'AL  SPASMS;  OCCUPATION   NKl'ROSRS. 


1107 


lion   (tf  tllO 

Ills.  I'K'U- 
'olililH'd  to 
s.  Il('r|ii's 
itiil  lu'iiral- 
11  Kcrit'H  of 
i(lii;illy  (lis- 
(listrcssiii^f 

IC    (M'llptioll 

manircstii- 

iii  llic  fillll- 
Icly,  iiikI  it 
II   lias  c'oiii- 

or  ril)re8  of 

pain   is  in 

■  spcrniatic 

as  irritahii! 

ind  acc'om- 

i^cal  ])k'xus. 

)osturo.     It 

«,  an  openi- 

the  nerves 


lit  the  heel 
(lyiiia  of  S. 
on,  ami  no 

ite  nenritis, 
ivated  form 
tips  of  the 
q)era^st]icsia 
mont  in  ty- 
groat  scnsi- 

'  tlie  fourth 
ig  disorder, 
ton  regards 
)ly  gets  well 
Igia — is  de- 

avc  already 
ic  nenroses. 
iniments  of 
tlie  pelvic 
nterest,  for, 


ns  has  already  l)ei'n  mentioned,  (he  symptoms  may  closely  simulate  those 
of  stone. 

Treatment. — Causes  of  rellex  irritation  should  he  carefully  removed. 
The  neuralgia,  as  a  rule,  recurs  unlc,>-s  the  gcnei'al  liealtli  improves;  so  that 
tonic  and  hygienic  nu-asures  of  all  sorts  should  he  employed.  Often  a 
change  of  air  or  surroundings  will  relieve  a  severe  neuralgia.  1  have 
known  olistinate  ca.^es  to  he  cured  hy  a  pr(»longcd  resi  leiice  in  tlu'  moun- 
tains, will)  an  out-of-door  life  and  plenty  of  exercise.  A  strict  vegetahle 
diet  will  sometimes  relieve  the  neuralgia  or  headache  of  a  gouty  person.  Of 
general  remedies,  iron  in  often  a  speeifle  in  the  eases  associated  with  chloro- 
sis and  ana'niia.  Arsenic,  too,  is  very  heneticial  in  these  forms,  and  should 
he  given  in  ascending  doses.  The  value  of  (piiuine  has  heen  much  over- 
rated. It  prohahly  has  no  more  iniluence  than  any  other  hitter  tonic,  ex- 
ce|>t  in  the  rare  instances  in  which  the  neuralgia  is  definitely  associated  with 
malarial  poisoning.  Strychnine,  eod-liver  oil,  au<l  jihosphorus  are  also  ad- 
vantageous. Of  remeilies  for  the  pain,  the  new  analgesics  should  first  he 
tried — aiitipyrin,  antifehrin,  and  phenacetin — for  they  are  somclinu's  of 
servic(\  .Morphia  should  he  given  with  great  ciiiition,  and  only  after  otlu'r 
remedies  have  heen  tried  in  vain.  On  no  consideration  should  the  patient 
he  allowed  to  WHU  the  hy])odermie  syringe.  Oelsemium  is  highly  recom- 
mended. Of  nervine  stinndants,  valerian  and  ether,  wliicli  often  act  well 
together,  may  he  given.  Alcohol  is  a  valuahle  though  dangerous  remedy, 
and  should  not  he  ordered  for  women.  In  the  trifacial  neuralgia  nitro- 
glyeorin  in  large  doses  may  he  tried.  Aeonitia  in  doses  of  from  one  two- 
hundredth  to  one  one-lumdri'd-and-fiftieth  of  a  grain  may  he  tried.  In 
gouty  and  rheumatic  suhjects  cnnnahis  indica  and  eimieifuga  are  recom- 
mended with  the  lithium  salts. 

Of  local  a])plieations,  the  therrno-cautery  is  invaluahle,  ]iartieularly  in 
zona  and  the  more  chronic  forms  of  neuralgia.  Acupuncture  may  he  used, 
or  a(pia])unctiire,  the  injection  of  distilled  water  hencath  the  skin.  Chloro- 
form liniment,  cam))hor  and  chloral,  menthol,  the  oleat(>s  of  morphia,  atro- 
pia,  and  hcHadonna  used  with  lanolin  may  he  tried.  Freezing  over  the 
tender  point  with,  ether  R])ray  is  sometimes  successful.  The  continuous 
current  may  he  ihckI.  The  sponges  should  he  warm,  and  the  positive  ])ole 
shoidd  he  placed  near  the  seat  of  the  pain.  The  strength  of  the  current 
shoidd  he  such  as  to  cause  a  slight  tingling  or  hurning,  hut  not  pain. 

The  surgical  treatment  of  intractahlc  neuralgia  emliraccs  nerve  stretch- 
ing and  excision.  The  latter  is  the  more  satisfactory,  hut  too  often  the 
pain  returns. 


IX.    PROFESSIONAL  SPASMS;    OCCUPATION   NEUROSES. 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  cer- 
tain movement  may  he  followed  hy  an  irregular,  involuntary  spasm  or 
cramp,  which  may  completely  check  the  performance  of  the  action.  The 
condition  is  found  most  frequently  in  writers,  hence  the  term  writer's  cramn 
or  scrivener's  palsy;  but  it  is  also  common  in  piano  and  violin  players  and 


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1108 


DISEASES  OF  TEE  NERVOUS  SYSTEM. 


ii  I 


in  telegraph  operators.  The  spasms  occur  in  many  other  personj,  such  a." 
milkmaids,  weavers,  and  cigarette-rollers. 

The  most  common  form  is  writer's  cramp,  which  is  much  more  fre- 
quent in  men  than  in  women.  Of  75  cases  of  impaired  writing  power  re- 
ported by  Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in 
men.  Morris  J.  Lewis  states  that  in  this  country,  in  tlie  telegrapher's 
cramp,  women,  who  are  employed  a  great  deal  in  telegrai)hy,  are  much 
less  frequently  all'ected  (only  4  out  of  43  eases).  Persons  of  a  nervous 
temperament  are  more  liable  to  the  disease.  Occasionally  it  follows  slight 
injury. 

(jowers  states  that  in  a  majority  of  the  eases  a  faulty  method  of  writing 
has  been  emi)loyed,  using  either  the  little  finger  or  the  wrist  as  the  fixed 
l)oint.  Persons  who  write  from  the  middle  of  the  forearm  or  from  the  elbow 
are  rarely  affected. 

No  anatomical  changes  have  been  found.  The  most  reasonable  ex- 
planation of  the  disease  is  that  it  results  from  a  deranged  action  of  the 
nerve  centres  presiding  over  the  muscular  movements  involved  in  the  act 
of  writing,  a  condition  Avhich  has  been  termed  irritable  weakness.  "  The 
education  of  centres  which  may  be  widely  separated  from  each  other  for  the 
performance  of  any  delicate  movement  is  mainly  accomplished  by  lessen- 
ing the  lines  of  resistance  between  them,  so  that  the  movement,  which  was 
at  first  produced  by  a  considerable  mental  effort,  is  at  last  executed  almost 
unconsciously.  If,  therefore,  through  prolonged  excitation,  this  lessened 
resistance  be  carried  too  far,  there  is  an  increase  and  irregular  discharge 
of  nerve  energy,  which  gives  rise  to  spasm  and  disordered  movement.  Ac- 
cording to  this  view, the  muscular  weakness  is  explained  by  an  im])airment  of 
nutrition  accompanying  that  of  function,  and  the  diminished  faradic  excita- 
bility by  the  nutritional  disturbance  descending  the  motor  nerves  "  (Gay). 

Symptoms. — Tliese  may  be  described  under  five  heads  (Lewis). 

(a)  Cramp  or  Spasm. — This  is  often  an  early  symptom  and  most  com- 
monly affects  the  forefinger  and  thumb;  or  there  may  be  a  combined  move- 
ment of  flexion  and  adduction  of  the  thumb,  so  that  the  pen  may  be  twisted 
from  the  grasp  and  thrown  to  some  distance.  Weir  Mitchell  lias  described 
a  lock-spasm,  in  which  the  fingers  beccme  so  firmly  contracted  upon  the 
pen  that  it  cannot  be  removed. 

{b)  Paresis  and  Paralysis. — This  may  occur  with  the  spasm  or  alone. 
The  patient  feels  a  sense  of  weakness  and  debility  in  the  muscles  of  the 
hand  and  arm  and  holds  the  pen  feebly.  Yet  in  these  circumstances  the 
grasp  of  the  hand  may  be  strong  and  there  may  be  no  paralysis  for  ordinary 
acts. 

(c)  Tremor. — This  is  moit  commonly  seen  in  the  forefinger  and  may 
be  a  premonitory  symptom  of  atrophy.  It  is  not  an  important  symptom, 
and  is  rarely  sufficient  to  produce  disability. 

(r')  Pain. — Abnormal  sensations,  particularly  a  tired  feeling  in  the 
muscles,  are  very  constantly  present.  Actual  pain  is  rare,  but  there  may 
be  irregular  shooting  pains  in  the  arm.  Numbness  or  soreness  may  exist. 
If,  as  sometimes  happens,  a  subacute  neuritis  develo])s,  there-  may  be  pain 
over  the  nerves  and  numbness  or  tingling  in  the  fingers. 


mj,  such  113 

I  more  fre- 
g  power  ri.'- 
ju})  wevc  in 
L;legra|)lu,'i"s 
,  are  much 
a  nervous 
Hows  sliglit 

1  of  Avriting 
IS  the  fixed 
[u  the  elbow 

sonable  cx- 
tion  of  the 
I  in  the  act 
less.  '^  The 
ther  for  the 
1  by  lease  n- 
,  which  was 
uted  almost 
his  lessened 
ir  discharge 
nient.  Ac- 
pairnient  of 
adic  excita- 
^•cs  "  (Gay), 
wis), 
most  com- 
)ined  move- 
)e  twisted 
IS  described 
d  upon  the 

n  or  alone. 
3cles  of  the 
stances  the 
or  ordinary 

T  and  may 
t  symptom, 

ing  in  the 
there  may 
may  exist. 

lay  be  pain 


TETANY. 


1109 


(e)  Vaso-molor  Drdurhances. — These  may  occur  in  severe  cases.  There 
may  be  hypenvsthcsia.  Occasionally  the  skin  becomes  glossy,  or  there  is 
a  condition  of  local  asj)hyxia  reseml)ling  chilblains.  In  attempting  to 
write,  the  hand  and  arm  may  become  flushed  and  hot  and  the  Vc-ins  in- 
creased in  size.  ]*]arly  in  the  disease  the  electrical  reactions  are  nojnnil,  but 
in  advanced  cases  there  may  be  diminution  of  faradic  and  v;Oiiietimes  in- 
crease in  the  galvanic  irritability. 

Diagnosis. — A  well-marked  case  of  writer's  cramp  or  palsy  could 
scarcely  be  mistaken  for  any  other  affection.  Care  must  be  taken  to  ex- 
clude the  existence  of  any  cerebro-spinal  disease,  such  as  j)rogressive  mus- 
cular atrophy  or  hemii)lcgia.  The  physician  is  sometimes  consulted  by 
nervous  persons  v,ho  fancy  they  are  becoming  subject  to  the  disease  and 
complain  of  stiffness  or  weakness  without  disjjlaying  any  characteristic 
features. 

Prognosis. — The  course  of  the  disease  is  usually  chronic.  If  taken 
in  time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  im- 
])rove  rai)idly,  but  too  often  there  is  a  strong  tendency  to  recurrence.  The 
]»atient  may  learn  to  write  with  the  left  hand,  but  this  also  may  after  a 
time  be  attacked. 

Treatment. — Various  prophylactic  measures  have  been  advised.     As 
mentioned,  it  is  important  that  a  proper  method  of  writing  ])e  adopted, 
(iowers  suggests  that  if  all  persons  wrote  from  the  shoulder  writer's  cramp' 
would  practically  not  occur.     A'arious  devices  have  been  invented  for  re- 
lieving the  fatigue,  but  none  of  them  are  very  satisfactory.    The  use  of  the' 
type-writer  has  diminished  very  much  the  frequency  of  scrivener's  palsy. 
Hcst  is  essential.     No  measures  are  of  value  without  this.     Massage  and 
manipulation,  when  combined  with  systematic  gymnastics,  give  the  best 
rosulfs.     Poore  recommends  the  galvanic  current  applied  to  the  muscles,, 
which  are  at  the  same  time  rhythmically  exercised.    In  very  obstinate  cases 
the  condition  remains  incurable.     I  saw  a  few  years  ago  a  distinguished' 
gynaecologist  who  had  had  writer's  cram])  twenty  years  before,  and  who  had' 
all  sorts  of  treatment,  including  the  Wolff's  method,  without  any  avail.. 
He  still  has  it  in  aggravated  form,  but  he  can  do  all  the  finer  manipulations 
of  operative  work  without  any  diflficulty. 

The  nutrition  of  the  ])atients  is  apt  to  be  much  impaired,  and  cod-liver 
oil.  strychnia,  and  other  tonics  will  be  found  advantageous.  Local  appli- 
cations are  of  little  benefit.  Tenotomy  and  nerve-stretching  have  been 
abandoned. 

X.   TETANY. 

Definition. — An  affection  characterized  by  peculiar  bilateral  tonic 
spasms,  either  paroxysmal  or  continued,  of  the  extremities. 

Etiology. — The  disease  occurs  under  very  different  conditions,  of 
which  the  following  may  be  recognized: 

(a)  Epidemic  tetany,  also  known  as  rheumatic  tetany.  In  certain 
parts  of  the  continent  of  Europe  the  disease  has  prevailed  widely,  particu- 
larly in  the  winter  season.     Von  Jaksch,  who  has  described  an  epidemic 


1110 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


form  occurring  in  young  men  of  the  working  classes,  sometimes  with  slight 
fever,  regards  the  disease  as  infectious.  Thib  form  is  acute,  lasting  only 
two  or  three  weeks  and  rarely  proving  fatal. 

(b)  A  majority  of  the  cases  are  found  in  association  witli  debility  fol- 
lowing lactation  and  chronic  diarrhcea,  or  ii;  the  malnutrition  of  rickets. 
From  its  occurrence  in  nursing  women  Trousseau  called  it  nurse's  con- 
tracture. It  nuiy  also  develop  during  pregnancy  or  recur  in  successive 
pregnancies.  It  has  been  found  as  a  sequence  of  the  acute  fevers,  and  in 
some  typhoid  epidemics  many  cases  have  occurred. 

(c)  Tetany  nuiy  follow  removal  of  the  thyroid  gland.  Thirteen  cases, 
for  example,  followed  78  operations  on  enlarged  thyroid  in  Billroth's  clinic, 
and  6  of  them  proved  fatal.  James  Stewart  has  reported  an  instance  in 
which  with  the  tetany  there  were  symptoms  of  myxedema,  and  no  trace  of 
the  thyroid  gland.    Kemoval  of  the  thyroid  in  dogs  is  followed  by  tetany. 

(d)  Ami,  lastly,  there  is  a  form  of  tetany  which  is  associated  with  dila- 
tation of  the  stomach,  particularly  after  the  organ  has  been  washed  out. 

On  this  ?ontinent  true  tetany  is  an  extremely  rare  disease.  Griffith 
has  collected  71^  cases,  among  which,  however,  cases  of  carpo-pedal  spasm 
are  included. 

The  nature  of  the  disease  is  unknown;  certain  forms  depend  undoubt- 
edly on  loss  of  the  function  of  the  thyroid  gland. 

Symptoms. — In  cases  associated  with  general  debility  or  in  children 
with  rickets  the  spasm  is  limited  to  the  hands  and  feet.  The  fingers  are 
bent  at  the  metacar])o-})halangeal  joint,  extended  at  the  terminal  joints, 
pressed  close  together,  and  the  thumb  is  contracted  in  the  palm  of  the 
hand.  The  wrist  is  flexed,  the  elbows  are  bent,  and  the  arms  are  folded 
over  the  chest.  In  the  lower  limbs  the  feet  are  extended  and  the  toes  ad- 
ducted.  The  muscles  of  the  face  and  neck  are  less  commonly  involved, 
but  in  severe  cases  there  may  be  trismus,  and  the  angles  of  the  mouth  are 
■drawn  out.  The  skin  of  the  hands  and  feet  is  sometimes  tense  and  cedem- 
;atous.  The  spasms  are  usually  paroxysmal  and  last  for  a  variable  time. 
In  children  the  attack  may  i)ass  ofi  in  a  few  hours.  In  some  of  the  severer 
chronic  cases  in  adults  the  stiffness  and  contracture  may  continue  or  even 
increase  for  many  days,  and  the  attack  may  last  as  long  as  two  weeks.  In 
the  acute  cases  the  temperature  may  be  elevated  and  the  pulse  quickened. 
In  the  severe  paroxysms  +here  may  be  involvement  of  the  muscles  of  the 
back  and  of  the  thorax,  inducing  dyspnoea  and  cyanosis.  Certain  addi- 
tional features,  valuable  in  diagnosis,  are  present. 

Trousseau's  symjitom:  "  So  long  as  the  attack  is  not  over,  the  parox- 
ysms may  be  reproduced  at  will.  This  is  effected  by  sim])ly  compress- 
ing the  affected  parts,  either  in  the  direction  of  their  principal  nerve 
trunks  or  over  their  hlood-vessels,  so  as  to  impede  the  venous  or  arterial 
circulation." 

Chovstek's  symptom  is  shown  in  the  remarkable  increase  in  the  me- 
chanical excitahility  of  the  motor  nerves.     A  slight  tap,  for  example,  in 
the  course  of  the  facial  nerve  will  throw  the  muscles  to  which  it  is  dis- 
tributed into  active  contraction.     Erb  has  shown  that  the  electrical  irrita 
bility  of  the  nerves  is  also  greatly  increased,  and  Hofmann  has  demon- 


with  slight 
istiiig  only 

ohility  fol- 
of  rickets. 

urso's  con- 
succossive 

crs,  and  in 

rtocn  cases, 
otli's  clinic, 
instance  in 
no  trace  of 
y  tetany. 
1  witli  dila- 
shed  out. 
ic.  Griffith 
)edal  spasm 

id  undoubt- 

in  children 
lingers  are 
linal  joints, 
lalm  of  the 
s  are  folded 
the  toes  ad- 
ly  involved, 
e  mouth  are 
!  and  oodem- 
iriable  time, 
f  the  severer 
mue  or  even 
3  weeks.  In 
e  quickened, 
iscles  of  the 
Certain  addi- 

•,  the  parox- 
ly  compress- 
ncipal  nerve 
IS  or  arterial 

!  in  the  me- 

example,  in 

ieh  it  is  dis- 

ctrical  irrita 

has  demon- 


HYSTERIA. 


nil 


strated  the  heightened  excitability  of  the  sensory  ncrvc.«,  the  sligiitcst 
pressure  on  which  may  cause  partcsthesia  in  tlie  region  of  distriltution. 

Diagnosis. — The  disease  is  readily  recognized.  It  is  a  mistake  to  call 
instances  of  carpo-pedal  spasm  of  children  true  tetany.  It  is  common  to 
find  in  rickety  children  or  in  cases  of  severe  gastro-intestinal  catarrji  a 
transient  spasm  of  the  fingers  or  even  of  the  arms.  J3y  many  authors  these 
are  considered  cases  of  mild  tetany,  and  tliero  are  all  grades  in  rickety  chil- 
dren between  tlie  simple  carpo-pedal  spasm  and  the  condition  in  which 
the  four  extremities  are  involved;  but  it  is  well,  I  think,  to  limit  the  iterm 
tetany  to  the  severer  affection. 

With  true  tetanus  the  di.sease  is  scarcely  ever  confounded,  as  the  com- 
mencement of  the  spasm  in  tl.e  extremities,  the  attitude  of  the  hands,  and 
the  etiological  factors  are  very  different.  Hysterical  contractures  are  usually 
unilateral. 

Treatment. — In  the  case  of  children  the  condition  with  which  the 
tetany  is  associated  should  be  treated.  Baths  and  cold  sponging  are  recom- 
mended and  often  relieve  the  spasm  as  promptly  as  in  child-crowing,  liro- 
mide  of  ])otassium  may  be  tried.  In  severe  cases  chloroform  inhalations 
may  be  given.  Massage,  electricity,  and  the  spinal  ice-bag  have  also  been 
used  with  siiccess.  Cases,  however,  may  resist  all  treatment,  and  the  spasms 
recur  for  many  years.  The  thyroid  extract  should  be  tried.  Ciottstein  re- 
ports relief  in  a  case  of  long  standing,  and  Bramwell  reports  one  case  of 
operative  tetany  and  one  of  the  idiopathic  form  successfully  treated  in 
this  way. 

XI.    HYSTERIA. 

Definition. — A  state  in  which  ideas  control  the  body  and  produce 
morbid  changes  in  its  functions  (Mobius). 

Etiology. — The  affection  is  most  common  in  women,  and  usually  ap- 
pears first  about  the  time  of  puberty,  but  the  manifestations  may  continue 
until  the  menopause,  or  even  until  old  age.  Men,  however,  are  by  no  means 
exempt,  and  of  late  years  hysteria  in  the  male  has  attracted  much  attention. 
It  recurs  in  all  races,  but  is  much  more  prevalent,  particularly  in  its 
severer  forms,  in  members  of  the  Latin  race.  In  this  country  the  milder 
grades  are  common,  but  the  graver  forms  are  rare  in  comparison  with  the 
frequency  with  which  they  are  seen  in  France. 

Children  under  twelve  years  of  age  are  not  very  often  affected,  but  the 
disease  may  be  well  marked  aa  early  as  the  fifth  or  sixth  year.  One  of 
the  saddest  chapters  in  the  history  of  human  deception,  that  of  the 
Salem  witches,  might  be  headed  hj/sterk  in  children,  since  the  tragedy 
resulted  directly  from  the  hysterical  pranks  of  girls  under  twelve  years 
of  age. 

Of  predisposing  causes,  two  are  important — heredity  and  edncation. 
The  former  acts  by  endowing  the  child  with  a  mobile,  abnormally  sensi- 
tive nervous  organization.  We  see  eases  most  frequently  in  families  with 
marked  neuropathic  tendencies,  the  members  of  which  have  suffered  from 
neuroses  of  various  sorts.    Education  at  home  too  often  fails  to  inculcate 


1112 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


habits  of  self-control.  A  child  grows  to  girlhood  with  an  entirely  errone- 
ous idea  of  her  relations  to  others,  and  accustomed  to  have  every  whim 
gratilied  and  abundant  sympathy  lavished  on  every  woe,  liowever  trilling:, 
she  readies  womanhood  with  a  moral  organization  iinlitted  to  withstaud 
the  cares  and  worries  of  every-day  life.  At  school,  between  the  ages  of 
twelve  and  fifteen,  the  most  imi)o/tant  [)eri()d  in  her  lii'e,  when  the  vital 
energies  are  absorbed  in  the  rai)id  develrjpment  of  the  body,  she  is  often 
cramming  for  examinations  and  coo])ed  in  close  school-rooms  for  six  or 
eight  hours  daily.  The  result  too  frequently  is  an  active,  bright  mind  in 
an  enfeebled  body,  ill  adapted  to  subserve  the  functions  for  which  it  wa. 
framed,  easily  disordered,  and  prone  to  react  abnormally  to  the  ordinary 
stimuli  of  life.  Among  the  more  direct  inlluences  are  emotions  of  various 
kinds,  fright  occasionally,  more  frequently  love  affairs,  grief,  and  domestic 
worries.  Physical  causes  less  often  bring  on  hysterical  outbreaks,  but  they 
may  follow  directly  upon  an  injury  or  develop  during  the  convalescence 
from  an  acute  illness  or  be  associated  with  disease  of  the  generative  organs. 
The  name  hysteria  indicates  how  important  was  believed  to  he  the  part 
played  by  the  uterus  in  the  causation  of  the  disease.  Opinions  differ  a 
good  deal  on  this  question,  but  undoubtedly  in  many  cases  tiiere  are  ova- 
rian and  uterine  disorders  the  rectification  of  which  sometimes  cures  the 
disease.  Sexual  excess,  particularly  nuisturbation,  is  an  important  factor, 
both  in  girls  and  boys. 

Symptoms. — A  useful  division  is  into  the  convulsive  and  non-convul- 
sive varieties. 

Convulsive  Hysteria. — (a)  Minor  Forms. — The  attack  most  commonly 
follows  emotional  disturbance.  It  may  set  in  suddenly  or  be  preceded  by 
symptoms,  called  by  the  laity  "  hysterical,"  such  as  laughing  and  crying 
alternately,  or  a  sensation  of  constriction  in  the  neck,  or  of  a  ball  rising  in 
the  throat — the  yhihus  hystericus.  Sometimes,  preceding  the  convulsive 
movements,  there  may  be  painful  sensations  arising  from  the  pelvic,  ab- 
dominal, or  thoracic  regions.  From  the  description  these  sensations  re- 
send)le  aurae.  They  become  more  intense  with  the  rising  sensation  of 
choking  in  the  neck  and  difficulty  in  getting  breath,  and  the  patient  falls 
into  a  more  or  less  violent  convulsion.  It  will  be  noticed  that  the  fall  is 
not  sudden,  as  in  epilepsy,  but  the  subject  goes  down,  as  a  rule,  easily,  often 
picking  a  soft  spot,  like  a  sofa  or  an  easy-chair,  and  in  the  movements 
apparently  exercises  care  to  do  herself  no  injury.  Yet  at  the  same  time 
she  appears  to  be  quite  unconscious.  The  movements  are  clonic  and  dis- 
orderly, consisting  of  to-and-fro  motions  of  the  trunk  or  pelvic  musclesy 
while  the  head  and  arms  are  thrown  about  in  an  irregular  manner.  TTie 
paroxysm  after  a  few  minutes  slowly  subsides,  then  the  patient  becomes 
emotional,  and  gradually  regains  consciousness.  When  questioned  the 
patient  may  confess  to  having  some  knowledge  of  the  events  which  have 
taken  place,  but,  as  a  rule,  has  no  accurate  recollection.  During  the  at- 
tack the  abdomen  may  be  much  distended  with  flatus,  and  subsequently  a 
large  amount  of  clear  urine  may  be  passed.  These  attacks  vary  greatly  in 
character.  There  may  be  scarcely  any  movements  of  the  limbs,  but  pftcr 
a  nerve  storm  the  patient  sinks  into  a  torpid,  semi-unconscious  condition, 


HYSTERIA. 


1113 


ily  errone- 
ory  whim 
u-  trilliiij.T, 
withstaiid 
le  ages  of 
tlie  vital 
e  id  oi'tun 
for  six  or 
t  mind  in 
ich  it  wa. 
3  ordintiry 
of  various 
I  domestic 
,  but  they 
valoscence 
ve  organs. 
!  the  part 
i8  differ  a 
e  are  ova- 
cures  the 
,nt  factor, 

)n-convul- 

commonly 
ecoded  by 
nd  crying 
[  rising  in 
convulsive 
)elvic,  ab- 
ations  re- 
isation  of 
tient  falls 
the  fall  is 
sily,  often 
lorements 
fame  time 
3  and  dis- 
;  muscles^ 
tier.  TTie 
t  becomes 
ioned  the 
hich  have 
ig  the  at- 
iquently  a 
greatly  in 
but  pfter 
condition, 


from  which  she  is  roused  with  great  dilliculty.  In  some  cases  from  this 
.slate  the  patient  passes  into  a  condition  of  catalepsy. 

{!))  Mdjor  Furnis;  I[ijslrro-cpileiisi/. — This  condition  has  been  especially 
studied  by  Charcot  and  his  pupils.  Typical  instances  ])assing  through  the 
various  phases  are  very  rare  in  this  country.  The  attack  is  initiated  by 
certain  prodromata,  chiefly  minor  hysterical  manifestations,  cither  foolish 
or  unsecndy  behavior,  excitement,  sometimes  dyspeptic  symptoms  with 
lympanites,  or  frecjuent  micturition.  Areas  of  hvpcraisthcsia  may  at  this 
time  be  marked,  the  so-called  hysterogenic  spots  so  elaborately  described 
by  Kichet.  These  are  usually  symmetrical  and  situated  over  the  upi)er 
dorsal  vertebra,  and  in  front  in  a  series  of  symmetrically  placed  spots  on 
the  chest  and  abdomen,  the  most  nuirked  being  those  in  the  inguinal  re- 
gions over  the  ovaries.  Painful  sensations  or  a  feeling  of  oppression  and  a 
globus  rising  in  the  throat  may  be  complained  of  prior  to  the  onset  of  the 
convulsion,  which,  according  to  French  writ(  rs,  has  four  distinct  stages: 
(1)  Epileptoid  condition,  which  closely  simulates  a  true  epileptic  attack 
with  tonic  sjiasm  (often  leading  to  opisthotonos),  grinding  of  the  teeth, 
congestion  of  the  face,  followed  by  clonic  convulsions,  gradual  relaxation, 
and  coma.  This  attack  lasts  rather  longer  than  a  true  epileptic  attack.  (2) 
Succeeding  this  is  the  period  which  Charcot  has  termed  clownism,  in  which 
there  is  an  emotional  display  and  a  remarkable  series  of  contortions  or  of 
cataleptic  poses.  (3)  Then  in  typical  cases  there  is  a  stage  in  which  the 
])atient  assumes  certain  attitudes  expressive  of  the  various  passions — ecstasy, 
fear,  beatitude,  or  erotism.  (1)  Finally  consciousness  returns  and  the  pa- 
tient enters  upon  a  stage  in  which  she  m.ay  display  very  varied  symp- 
toms, chiefly  manifestations  of  a  delirium  with  the  most  extraordinary 
hallucinations.  A'isions  are  seen,  voices  heard,  and  conversations  held  with 
imaginary  persons.  In  this  stage  patients  will  relate  with  the  utmost 
solemnity  imaginary  events,  and  make  extraordinary  and  serious  charges 
against  individuals.  This  sometimes  gives  a  grave  aspect  to  these  seizures, 
for  not  only  will  the  patient  at  this  stage  make  and  believe  the  state- 
ments, but  when  recovery  is  complete  the  hallucination  sometimes  per- 
sists. We  seldom  see  in  this  country  attacks  having  this  orderly  se- 
quence. Much  more  commonly  the  convulsions  succeed  each  other  at 
intervals  for  several  days  in  succession.  Here  is  a  striking  difference 
between  hystero-epilepsy  and  true  epilepsy.  In  the  latter  the  status 
epilepticus,  if  persistent,  is  always  serious,  associated  wdth  fever,  and  fre- 
quently fatal,  while  in  hystero-epilepsy  attacks  may  recur  for  days  with- 
out special  danger  to  life.  After  an  attack  of  hystero-epilepsy  the  pa- 
tient may  sink  into  a  state  of  trance  or  lethargy,  in  which  she  may  remain 
for  days. 

Non-convulsive  Forms. — So  complex  and  varied  is  the  clinical  picture  of 
hysteria  that  various  manifestations  are  best  considered  according  to  the 
systems  Avhich  are  involved. 

(1)  Disorders  of  Motion. — (a)  Farah/ses. — These  may  he  hemiplegic, 
paraplegic,  or  monoplegic.  Hysterical  diplegia  is  extremely  rare.  The 
paralysis  cither  sets  in  abruptly  or  gradually,  and  may  take  weeks  to  attain 
its  full  development.     There  is  no  type  or  form  of  organic  paralysis  which 


IIU 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


/ 


may  not  he  simiilolcd  in  hystcrid.  Acconlinfif  to  Weir  Mitclicll,  ilio  homi- 
jilc-jfias  are  most  I'rcciiu'iit  in  the  mtio  of  four  on  tlio  left  t<t  oiu;  on  tlio 
li^dit  side.  '^I'lio  face  is  not  alTcctcd;  the  neck  niiiy  be  involved,  l/ut  the 
lej,'  suH'ers  most.  Sensation  is  either  lessened  or  lost  on  the  affected  side. 
The  hyoterical  paraplejfia  is  more  comnnm  than  hemi]»legiii.  'J'he  loss  of 
power  is  not  absolute;  the  lej^s  can  usually  bo  moved,  but  do  not  support 
the  patient.  The  retle.xes  may  be  increased,  thouj,di  the  knee-jerk  is  often 
normal.  A  spuriouLi  ankle  clonus  may  sometimes  be  present.  The  feet 
are  usually  extended  and  turned  inward  in  the  ecjuino-varus  position.  The 
muscles  do  not  waste  and  the  electrical  reactions  are  normal.  Other  mani- 
festations, such  as  paralysis  of  the  bladder  or  aphonia,  are  usually  associ- 
ated with  the  hysterical  ])araple<,na.  Hysterical  monople;^ias  may  be  facial, 
crural,  or  brachial.  A  condition  of  ataxia  sometimes  occurs  with  paresis. 
The  incoordination  may  be  a  nuirked  feature,  and  there  are  usually  sensory 
manifestations. 

(/>)  Contractures  and  Spasms. — An  extraordinary  variety  of  spasmodic 
alfections  occurs  in  hysteria,  of  which  the  most  common  are  the  follow- 
ing: The  hysterical  contractures  may  attack  almost  any  j,m-()U|)  of  volun- 
tary muscles  and  be  of  the  hemii)legic,  ])araplegie,  or  monoplegic  type. 
They  may  come  on  suddenly  or  slowly,  persist  for  months  or  years,  and 
disaj)pear  rapidly.  The  contracture  is  most  commonly  seen  in  the  arm, 
which  is  flexed  at  the  elbow  and  wrist,  while  the  fin<;'ers  tij;htly  grasp  the 
thumb  in  the  palm  of  the  hand;  more  rarely  the  terminal  i)halanges  are 
hyperextended  as  in  athetosis.  It  may  occur  in  one  or  in  both  legs,  more 
commonly  the  former.  The  ankle  clonus  is  present;  the  foot  is  inverted 
and  the  toes  are  strongly  flexed.  These  cases  may  be  mistaken  for  lateral 
sclerosis  and  the  difficulty  in  diagnosis  may  really  be  very  great.  The 
spastic  gait  is  very  typical,  and  with  the  exaggerated  knee-jerk  and  ankle 
clonus  the  picture  may  be  characteristic.  In  1879  I  frequently  showed 
such  a  case  at  the  Montreal  General  Hospital  as  a  typical  example  of  lat- 
eral sclerosis.  The  condii'on  persisted  for  more  than  eighteen  months  and 
then  disappeared  completely.  Other  forms  of  contracture  may  be  in  the 
muscles  of  the  hip,  shoulder,  or  neck;  more  rarely  in  those  of  the  jaws — 
hysterical  trismus — or  in  the  tongue.  Eemarkable  indeed  are  the  local  con- 
tractures in  the  diaphragm  and  abdominal  muscles,  producing  a  phantom 
tumor,  in  which  just  below  and  in  the  neighborhood  of  tiie  umbilicus  is  a 
firm,  aj^^parently  solid  growth.  According  to  Gowers,  this  is  produced  by 
relaxation  of  the  recti  and  n  spasmodic  contraction  of  the  diaphragm,  to- 
gether with  inflation  of  the  intestines  with  gas  and  an  arching  forward  of 
the  vertebral  column.  They  are  apt  to  occur  in  middle-aged  women  about 
the  menopause,  and  are  frequently  associated  with  the  symptoms  of  s])u- 
rious  pregnancy — psendo-cyesis.  The  resemblance  to  a  tumor  may  be  strik- 
ing, and  I  have  known  skilful  diagnosticians  to  be  deceived.  The  only 
safeguard  is  to  be  found  in  complete  anaesthesia,  when  the  tumor  entirely 
disappears.  Some  years  ago  I  went  by  chance  into  the  operating-room  of 
a  hospital  and  found  a  patient  on  the  table  under  chloroform  and  the  sur- 
geon prepared  to  perform  ovariotomy.  The  tumor,  however,  had  com- 
pletely disappeared  with  full  anaesthesia.    Mitchell  has  reported  an  instance 


IIYSTKHIA. 


1115 


llio  liomi- 
itiu'  on  tilt' 

(1.    I,ut    till' 

'('(■ti'd  sick'. 
I' ho  loss  ol' 
lot  support 
■rk  is  often 
The  foL-t 
tioii.  The 
)th('r  mani- 
iiliy  assoei- 
y  \ii\  facial, 
itli  paresis, 
illy  sensory 

siiasmodic 
the  foUow- 
)  of  volun- 
)k'j,Mc  typo, 
voars,  and 
n  tho  arm, 
y  ^irasp  tho 
alangos  are 
legs,  more 
is  inverted 
I  for  lateral 
,a-eat.     Tho 
:  and  ankle 
itly  showed 
nplo  of  lat- 
moutlis  and 
f  be  in  the 
the  jaws — 
e  local  con- 
a  phantom 
ihilicus  is  a 
roducod  by 
)hragm,  to- 
forward  of 
omen  about 
ims  of  s])u- 
ay  be  strik- 
The  only 
lor  entirely 
ng-room  of 
nd  the  siir- 
,  had  com- 
an  instance 


of  a  ))liantoni  Imnor  in  the  left  pectoral  region  just  above  tho  breast,  which 
was  tender,  hard,  and  dense. 

I'luiiir  siDisins  are  nmro  coiiiinon  in  hysteria  in  this  country  than  coti- 
Iracturos.  'i'lie  following  are  tho  important  forms:  Jiln/lliiuiv  liiislcrical 
s/Kistn.  This,  unfortunately,  is  sometiiiios  known  as  rhythmic  chorea  or 
hysterical  chorea.  The  movements  may  ho  of  the  arm,  cither  llexion  and 
exleiision.  or,  more  rarely,  pronation  and  su[)ination.  Clonic  contractions 
of  tho  storno-cleido-masloid  or  of  the  muscles  of  the  jaws  or  of  the  rota- 
tory muscles  of  the  head  may  produce  rhythmic  movements  of  these  parts. 
Tho  s))asm  may  ho  in  one  or  both  psoas  muscles,  lifting  the  log  in  a  rhythmic 
inannor  eight  or  ten  times  in  a  minute.  In  other  instances  the  muscles 
of  the  trunk  are  affoctod,  and  every  few  moments  there  is  a  bowing  move- 
ment— salaam  convulsions — or  tho  muscles  of  the  back  iiui}  contract,  caus- 
ing strong  arching  of  the  vortol)ral  column  and  retraction  of  tho  head. 
These  movements  may  often  alternate,  as  in  a  case  in  my  wards,  in  which 
the  patient  on  fine  days  had  regular  salaam  convulsions,  while  on  wet  days 
the  rhythmic  spasm  was  in  tho  muscles  of  the  back  and  nock.  j\Iitchell 
has  described  a  rotatory  .spasm  in  wbicl'"  the  patient  r(»tated  involuntiirily, 
usually  to  the  left.  More  unusual  cases  are  those  in  which  the  contractions 
clo.sely  simulate  paramyoclonus  niultiiilox.  Hysterical  athetosis  is  a  rare 
form  of  spasm.  Tnnnor  may  bo  a  ])urely  hysterical  man  i  festal  ion,  occur- 
ring either  alone  or  with  ])aralysis  and  contracture.  It  most  commonly  in- 
volves the  hands  and  arms;  more  rarely  the  head  and  legs.  The  move- 
ments are  small  and  quick.  In  the  ty  o  licndu  the  tremor  may  or  may 
not  persist  during  ro])ose,  but  it  is  increased  or  provoked  by  volitional  move- 
ments. Volitional  or  intentional  tremor  may  exist,  simnhiting  closely 
the  movements  of  insular  sclerosis,  liuzzard  states  that  many  instances 
of  this  disease  in  young  girls  arc  mistaken  for  hysteria. 

(3)  Disorders  of  Sensation. — Ana'sthesia  is  most  common,  and  usually 
confined  to  one  half  of  the  body.  It  may  not  be  noticed  by  the  patient. 
Usually  it  is  accurately  limited  te  the  middle  line  and  involves  the  mucous 
surfaces  and  deo])er  parts.  Tho  conjunctiva,  however,  is  often  spared. 
There  may  be  honiianopia.  This  symiitom  may  come  on  slowly  or  follow 
a  convulsive  attack.  Sometimes  the  various  sensations  are  dissociated  and 
the  anaesthesia  may  be  oidy  to  pain  and  to  touch.  Tho  skin  of  the  affected 
side  is  usually  pale  and  cool,  and  a  pin-])rick  may  not  bo  folhnved  by  blood. 
AVith  the  loss  of  feeling  there  may  be  loss  of  muscular  power.  Curious 
trophic  changes  may  be  present,  as  in  an  interesting  case  of  Weir  Mitchell's, 
in  which  there  was  unilateral  swelling  of  the  hemiplogic  side. 

A  phenomenon  to  which  much  attention  has  been  paid  is  that  of  trans- 
ference. By  metallotherapy,  tho  ap]dication  of  certain  metals,  the  anaes- 
thesia or  analgesia  can  be  transferred  to  the  other  side  of  the  body.  It 
has  been  shown,  however,  that  this  phenomenon  may  be  caused  by  the 
electro-magnet  and  by  wood  and  various  other  agents,  and  is  ])robably  en- 
tirely a  mental  effect.  The  subject  has  no  practical  importance,  but  it 
remains  an  interesting  and  instructive  chapter  in  Gallic  medical  history. 

Hj/pern'sthcsin. — Increased  sensitiveness  and  pains  occur  in  various  parts 
of  the  body.     One  of  the  most  frequent  complaints  is  of  pain  in  the  head. 


1116 


DISKASES  OP  THE  NERVOUS  SYSTRM. 


iisiijilly  over  tlio  snj,'i(lal  siilnro,  less  frcciiicntly  in  the  occiput.  Thi«  is 
described  as  ngoniziii^',  and  is  ((Uiipared  lo  (lie  driving,'  nl'  a  iiiul  into  the 
})art;  hcnco  the  iiaiiio  rlaruH  hi/sli'rirus.  N('iiralj:ias  mv  common.  Jlyper- 
a'sllictie  areas,  the  hysterofreiiie  points,  exist  on  the  skin  (»!'  the  thorax  and 
al/(h)men,  pressnre  upon  wiiicii  may  cause  minor  manifestations  or  even 
a  convulsivo  attack.  Increased  sensitiveness  exists  in  the  ovarian  rejfion, 
bnt  is  not  i)e(;idiar  to  hysteria.  J'ain  in  tiio  l)ack  is  an  almost  constant 
complaint  oi"  hysterical  patients.  The  sensitiveness  may  he  Umiled  to  cer- 
tain spinous  processes,  or  it  may  l)e  did'use.  Jn  hysterical  women  the  pains 
in  the  al)domen  may  simulate  thos"  of  <fastra|i,na  and  of  <>astric  nicer,  or 
the  condition  may  be  almost  identical  with  that  of  peritonitis;  more  rarely 
the  ahdoniinal  i)ains  closely  resemble  those  of  a])pendix  disease. 

Special  Senses. —  Disturbances  of  taste  and  smell  are  not  uncoinnum 
and  may  cause  a  good  deal  of  distress.  Of  ocular  symptoms,  retinal  hyper- 
R'sthesia  is  tlic  most  common,  and  the  ])atients  always  ])refer  to  be  in  a 
darkened  room.  Retraction  of  the  field  of  vision  is  common  and  usually 
follows  a  convulsive  seizure.  It  may  ])ersist  for  years.  The  color  i)ercei)- 
tion  nuiy  be  normal  even  with  complete  ana'sthesia,  and  in  this  country 
the  achr()mato])sia  does  not  seem  to  be  nearly  so  common  an  hysterical 
manifestation  as  in  Europe.  Hysterical  deafness  may  be  complete  and 
may  alternate  or  come  on  at  the  same  time  with  hysterical  ])lindness. 
Hysterical  amaurosis  may  occur  in  children.  One  must  carefully  distin- 
gui-^li  between  functional  loss  of  jjower  and  simulation. 

(3)  Visceral  Manifestations. — Respiratory  Apparatus. — Of  disturbances 
in  the  respiratory  rhythm,  the  most  frequent,  pcrha])s,  is  an  cxajj^geration 
of  the  deeper  l)reatli,  which  is  taken  normally  every  fifth  or  fixth  inspira- 
tion, or  there  nuiy  bo  a  "  catching  "  breathing,  such  as  is  seen  when  cold 
water  is  poured  over  a  person.  ITystcrical  dyspnaui  is  readily  recognized, 
as  there  is  no  special  distress  and  the  pulse  is  usually  normal.  I  have  met 
with  a  remarkable  case  following  trauma  in  which  the  respirations  rose 
above  1P>0  in  the  minute.  Among  laryngeal  manifestations  aphonia  is  tlie 
most  fre([uent  and  may  persist  for  nmnths  or  even  years  vt'ithout  other  spe- 
cial symptoms  of  the  disease.  Spasm  of  the  muscles  may  occur  with  violent 
inspiratory  efforts  and  great  distress,  and  may  even  lead  to  cyanosis.  Hic- 
cough, or  sounds  rcsemT)ling  it,  may  be  present  for  weeks  or  months  at  a 
time.  Among  tlie  most  remarkable  of  the  respiratory  manifestations  are 
the  hysterical  cries.  These  may  mimic  the  sounds  produced  by  animals, 
such  as  barking,  mewing,  or  grunting,  and  in  France  epidemics  of  them 
have  been  repeatedly  observed.  Extraordinary  cries  may  be  produced, 
either  mspiratory  or  expiratory.  I  saw  at  Wagner's  clinic  at  Leipsic  a  girl 
of  thirteen  or  fourteen,  wlio  had  LjX  many  weeks  given  \xtterance  to  a  re- 
markable inspiratory  cry  somewhat  like  the  whoop  of  whooping-cough,  but 
so  intense  that  it  was  heard  at  a  long  distance.  It  was  incessant,  and  the 
girl  was  worn  to  a  skeleton.  Attacks  of  gaping,  yawning,  and  sneezing 
may  also  occur. 

The  hysterical  cough  is  a  frequent  symptom,  particularly  in  young 
girls.  It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  croaking 
cough,  extremely  monotonous  and  unpleasant  to  hear.     Sir  Andrew  Clark 


nYSTr<:RiA. 


1117 


TIUK    is 

il  into  tlic 
I.  llyiKT- 
liora.v  and 

IS    or    CVt'!! 

mil  rcjfioii, 
t,  coiistaiit 
led  to  ccr- 
1  the  pains 
('  ulcer,  or 
iioro  rarely 

niicoinnioii 

iiaj  liypcr- 

to  hv  ill  u 

11(1  usually 

lor  i)('rc('[)- 

lis  fount ry 

hysterical 

uplete  and 

hlindiiess. 

illy  distin- 

isturbanccs 
'cafi'j^eratiou 
:th  inspira- 

when  cold 
recoffiiized, 
I  have  met 
at  ions  roso 
onia  is  the 

other  spe- 
•ith  violent 
osis.  Ilic- 
lonths  at  a 
tations  are 
ly  animals, 
3S  of  them 

produced, 
ipsic  a  girl 
ce  to  a  re- 
eoiigh,  but 
it,  and  the 
1  sneezing 

in  young 
;,  croaking 
Irew  Clark 


haa  called  attention  to  a  loud,  hiirking  cougli  {njimhex  hchciica)  occurring 
about  the  lime  of  puberty,  chielly  in  boyH  belonging  to  neiuotic  families. 
Tlie  attacks,  which  last  about  a  niiiuile,  recur  friMpieiitly. 

Tlicre  is  u  (leculiar  form  of  lui'iiioptysis  which  may  bo  very  deceptive 
and  lead  to  the  diagnosia  of  pulmonary  disorders.  Wagner  describes  the 
sputum  as  u  pale-red  lluid — not  so  bright  in  color  as  in  ordinary  hicmop- 
tyHis;  on  si-ttling  it  presents  ii  red(lish-l)r()wii  Hcdiment.  It  contains  par- 
ticles of  food,  jiavement  epithelium,  red  cor|)uscles,  and  micrococci,  but 
no  cylindrical  or  ciliated  epithelium.  It  probably  comes  from  the  mouth 
or  pharynx. 

J)i(/cslirp  Si/slrm. — Disturbed  or  depraved  ajipetite,  dyspepsia,  and  gas- 
tric pains  are  comnion  in  hyst<'rical  patients.  The  patient  may  have  dilli- 
culty  in  swallowing  the  food,  apparently  from  spasm  of  the  gullet.  There 
are  instances  in  which  the  food  seems  to  be?  expelled  lu-fore  il  reaches  the 
stomach.  In  other  cases  there  is  iiuiessant  gagging.  In  tlie  hysterical 
vomiting  the  food  is  regurgitated  without  much  elfort  and  without  nausea. 
This  feature  may  jiersist  for  years  without  great  listiirliaiice  of  nutrition. 
'^Phe  most  striking  and  remarkable  digestive  disturbance  in  hvsteria  is  the 
nnorexia  ncrrond  described  by  Sir  William  (iull.  "To  call  it  loss  of  apjie- 
tite — anorexia — liut  feebly  characteri/es  the  symptom.  It  is  rather  an 
annihilation  of  a])petile,  so  complete  that  it  seems  in  some  cases  iiii[)ossibIe 
ever  to  eat  again.  CMit  of  it  grows  an  antagonism  to  food  which  results 
at  last  and  in  its  worst  forms  in  spasm  on  the  approach  of  food,  and  this  in 
turn  gives  rise  to  sc-nc  of  those  remarkable  cases  of  survival  for  long  peril uls 
without  food"  (^litchell).  As  this  goes  on  there  may  be  an  extreme  de- 
gree of  muscular  restlessness,  so  that  the  jiatients  wander  about  until  ex- 
hausted. Nothing  more  jiitiable  is  to  be  seen  in  practice  than  an  ad- 
vanced case  of  this  sort.  It  is  usually  in  a  young  girl,  sometimes  as  'y 
as  the  eleventh  or  twelfth,  more  commonly  between  the  fifteenth  and  I  .  n- 
tieth  years.  The  emaciation  is  frightful,  and  scarcely  exceeded  by  that  of 
cancer  of  the  (jesojihagiH.  The  jiatient  finally  takes  to  bed,  and  in  extreme 
cases  lies  ujjon  one  side  with  the  thighs  and  legs  flexed,  and  contractures 
may  occur.  Food  is  either  not  taken  at  all  or  only  u[)on  urgent  compul- 
sion. The  skin  becomes  wasted,  dry,  and  covered  with  bran-like  scales. 
No  food  may  he  taken  for  several  weeks  at  a  time,  and  attempts  to  feed 
may  bo  followed  by  severe  spasms.  Although  the  condition  looks  so  alarm- 
ing, these  cases,  when  removed  from  their  homo  surroundings  and  treated 
by  Weir  Mitchell's  method,  sometimes  recover  in  a  remarkable  way.  Death, 
however,  may  follow  with  extreme  emaciation.  In  a  fatal  case  under  my 
care  the  girl  weighed  only  49  pounds.     No  lesions  were  found  post  mortem. 

Amcmg  intestinal  symptoms  flatulency  is  one  of  the  most  distressing, 
and  is  usually  associated  with  the  condition  of  peristaltic  unrest  (Kuss- 
maul).  Fre(|uent  discharges  of  faeces  may  he  due  to  disturbance  in  either 
the  small  or  large  bowel.  An  obstinate  form  of  diarrhoea  is  found  in  some 
hysterical  patients,  which  proves  very  intractable  and  is  associated  espe- 
cially with  the  taking  of  food.  It  seems  an  aggravated  form  of  the  loose- 
ness of  bowels  to  which  so  many  nervous  people  are  subject  on  emotion 
or  the  tendency  which  some  have  to  diarrhoea  immediately  after  eating. 


1118 


IHSKASKS  OF  TIIR  NERVOUS  SYSTEM. 


All  ciitirclv  tlill'(  rt'iil  ruriii  is  (hut  prdduccd  by  wlial  Milclull  culls  llif  irri- 
liihlo  rcctmii,  ill  wliicli  hcvIhiIu  arc  passed  frccniciitly  (luriii;,'  llic  day.  soine- 
tiiiics  with  ^M'cat  vi(dciicc.  ('()iiHti|iati(»ii  is  iiioro  frtMjiicnt,  however,  and 
may  bo  due  t<i  a  h)<s  of  power  in  thct  iiiiis(  Ics  of  the  howcl,  or  in  the  ah- 
(hiiuiiial  iiuisch's.  In  extreme  cases  the  howels  may  lud  l)e  moved  for  two 
or  three  weeks,  h'adiii;;  to  ^Mvut  acciimuhition  of  fa-ces.  Other  disturhancos 
are  uno-spasm  or  intense  pain  in  the  rectum  apart  from  any  fissure. 

Cardio-rasntldr. — Jtapid  action  of  the  heart  on  tlio  8lij,'litest  emotion, 
witli  or  without  the  siil)jeetive  sensation  of  palpitation,  is  often  a  source 
(if  ^M'l'at  distress.  A  slow  |tulse  is  less  frcipii'iit.  Tains  about  the  heart 
may  simulate  angina,  the  so-called  hysterical  or  pseudo-angina,  which  has 
already  been  considered,  l-'liishes  in  various  parts  are  among  the  most 
common  symptoms.     Sweating  occasionally  occurs. 

Among  the  more  remarkal)le  vaso-motor  phenomena  are  the  so-called 
stigmata  or  luemonhages  in  llu!  skin,  such  as  were  present  in  the  cele- 
brated case  of  Louise  Jiateau.  lu  many  cases  these  are  undoubtedly  fraud- 
ulent, but  if,  as  appears  credible,  such  bleeding  may  exist  in  the  hypnotic 
trance,  there  seems  no  reason  to  doubt  its  occurrence  in  the  trance  of  pro- 
longed religious  ecstasy. 

Joint  A  If  eel  ions. — To  Sir  15enjamin  hrodie  and  Sir  James  Paget  wo 
owe  tl:e  recognition  of  these  extraordinary  manifestations  of  hysteria.  Per- 
haps no  single  alfection  has  brought  more  discredit  u[)on  the  profession, 
for  the  cases  are  very  refractory,  and  finally  fall  into  the  hands  of  a  char- 
latan or  faith-healer,  under  whose  touch  the  disease  may  disappear  at  once. 
Usually  it  affects  the  knee  or  the  hij).  and  may  follow  a  trilling  injury. 
The  joint  is  usually  fixed,  sensitive,  and  swollen.  The  siirface  may  be 
et)ol,  but  sometimes  the  local  temperature  is  increased.  To  the  touch  it 
is  very  sensitive  and  movement  causes  great  pain.  In  protracted  cases  the 
muscles  about  the  joint  are  somewhat  wasted,  and  in  consequence  it  looks 
larger.  The  ])ains  are  often  nocturnal,  at  which  time  the  local  tempera- 
ture may  be  much  increased.  AVhile,  as  a  rule,  neuromimetic  joints  yield 
to  jiroper  management,  there  are  interesting  instances  in  the  literature  in 
which  organic  change  has  succeeded  the  functional  disturbance.  In  the 
remarkable  case  reported  in  Weir  Mitchell's  lectures,  the  hysterical  fea- 
tures were  pronounced,  and,  on  account  of  the  chronicity,  the  disease  of 
the  knee-joint  was  considered  organic  by  such  an  authority  as  Billroth. 
Sands  found  the  joint  surfaces  normal,  and  the  thickening  to  be  due  to 
inflammatory  products  outside  the  capsule. 

Intermittent  hydrarthrosis  may  be  a  manifestation  of  hysteria,  occur- 
ring in  the  knee  or  other  joints,  sometimes  with  transient  paresis. 

Mental  Sjiniptnms. — The  psychical  condition  of  an  hysterical  patient 
is  always  abnormal,  and  the  disease  occupies  the  ill-defined  territory  be- 
tween sanity  and  insanity.  In  a  large  number  of  cases  the  patients  are 
really  insane,  particularly  in  the  ])erversion  witnessed  in  the  moral  sphere. 
Not  the  slightest  de]iendence  can  be  placed  upon  their  statements,  and 
they  will  for  months  or  years  deceive  friends,  relatives,  and  physician. 
This  appears  to  result  partly,  but  not  wholly,  from  a  morbid  craving  for 
sympathy.    It  is  really  due  to  an  entire  unhinging  of  the  moral  nature. 


U  llic  ii'i'!- 
lay.  soiiic- 
K'vcr,  ami 
in  llic  al)- 
(mI  for  two 
slurlmiU'iM 
mo. 

;t  cmotioti, 

11  a  sourt'O 

tli(!  heart 

whicli  lias 

;  the   most 

ic  so-calltMl 
1  till'  (•(•Ic- 
ed ly  I'nuid- 
le  liyi>noti(" 
nee  of  pro- 

I'aj^et   wo 
teria.     IVr- 

profcssion, 
s  of  a  char- 
lear  at  onee. 
ling  injury, 
ace  may  be 
he  touch  it 
ed  cases  the 
•nee  it  looks 
•al  tempera- 
joints  yiehl 
literature  in 
ice.  In  the 
sterical  fea- 
le  disease  of 

as  Billroth. 
.0  be  due  to 

iteria,  occur- 
?sis. 

rical  patient 
territory  be- 
patients  are 
noral  sphere. 
;ements.  and 
id  physician. 
[  craving  for 
\\  nature. 


nV.STRRIA. 


1110 


TTyHterical  ]»iitieiits  may  become  insane  and  display  porsistont  hallu- 
cinations and  (leliriuni,  alternating  perhaps  with  emotional  oiithursts  of 
an  aggravated  cliaiacter.  I'nr  weeks  or  months  tliey  may  he  eonlined  to 
lied,  entirely  oblivious  to  their  surroundings,  with  a  delirium  which  may 
simulate  Miat  of  delirium  tremens,  particularly  in  being  as.sociated  with 
loathsome  and  unpleasant  animals.  The  mitr'ion  may  be  maintaine<l, 
but  in  these  cases  there  is  alvays  a  very  heavy,  foul  breath.  With  seclu- 
sion and  care  i'ec(»very  usually  takes  place  within  three  or  four  months. 
At  the  onset  of  these  attacks  and  during  convalescence  tlu!  patients  must 
be  incessantly  watched,  as  a  suicidal  tendency  in  by  no  means  uncommon. 
1  have  been  accustnincd  to  speak  of  this  condition  as  the  shiliis  lii/slcrinis. 

Of  hysterical  manifestations  in  the  higher  centres  that  oi'  trane(!  is  the 
most  remarkaltlc.  This  may  develop  spontaneously  without  any  convul- 
sive seizure,  but  more  fre(pieiitly,  in  this  coiuitry  at  least,  it  follows  hys- 
lerold  attacks.  Catalepsy,  a  condition  in  which  the  limbs  are  plastic  and 
remain  in  any  position  in  which  they  are  placed,  may  be  present. 

The  Mi'luhi.lisin  in  II yslerid. — The  studies  of  (iilles  de  la  Tourette  and 
Cathelineau,  under  Charcot's  direction,  have  shown  that  in  the  ordinary 
forms  of  hysteria  the  urine  does  not  show  quantitativ(^  or  (|ualiiativo 
changes,  but  in  the  severer  types,  characterized  l»y  convulsions,  etc.,  there 
are  important  modilications:  reduction  in  the  urates  and  phos|)liates;  the 
ratio  of  the  earthy  to  tiie  alkaline  |)hosphates,  normally  1  : ;{,  is  1  :  2,  or 
even  1:1.  The  urine  is  also  reduced  in  amount.  They  think  that  these 
chiinges  might  sometimes  serve  to  dilferentiate  convulsive  hysteria  from 
epilepsy,  in  which  there  is  always  an  increase  in  the  solid  constituents  after 
a  seizure. 

Ifyslrriail  Fern'. — In  hysteria  the  tcnijierature,  as  a  rule,  is  normal. 
The  cases  with  fever  may  be  gro  .ped  as  follows:  (a)  Instances  in  which 
the  fever  is  the  sole  manifestation.  These  are  rare,  but  I  have  seen  at 
least  two  cases  in  which  the  chronic  course,  the  retention  of  the  nutrition, 
and  the  entirely  negative  condition  of  the  organs  left  no  otl  er  diagnosis 
possible.  In  a  case  recently  under  observation  the  patient  has  had  for  four 
or  five  years  an  afternoon  rise  of  temperature,  reaching  usually  to  102°  or 
103°.  She  was  well  nourished  and  ])resented  no  ])ronounccd  hysterical 
syni])toins.  but  there  was  a  marked  neurotic  history  on  one  side  and  a  form 
of  interrui)ted  sighing  respiration  so  often  seen  in  hysteria. 

(/;)  Cases  of  hysterical  fever  with  spurious  local  manifestations.  These 
are  very  troublesome  and  decei)tive  cases.  The  ])atient  may  be  suddenly 
taken  ill  with  pain  in  various  regions  and  elevation  of  temperature.  The 
case  may  simulate  meningitis.  There  may  be  pain  in  the  h'^ad,  vomiting, 
contracted  jnipils,  and  retraction  of  the  neck — symptoms  which  may  per- 
sist for  weeks — and  some  anomalous  manifestation  during  convalescence 
may  alone  indicate  to  the  physician  that  he  has  had  to  deal  with  a  case  of 
hysteria,  and  has  not.  as  he  ])crhaps  flattered  himself,  cured  a  case  of  men- 
ingitis. ]\lary  Putnam  Jacobi,  in  a  recent  article  on  hysterical  fever,  men- 
tions a  case  in  the  service  of  Cornil  which  was  admitted  with  dysjUKcn, 
slight  cyanosis,  and  a  temperature  of  39°  C.  The  condition  ])rovcd  to  be 
hysterical.     There  is  also  an  hysterical  pseudo-phthisis  with  pain  in  the 


1120 


DISEASKS  OP  THE  NERVOUS  SYSTEAf. 


/ 


f 


chost,  sliglit  fever,  and  (lie  oxpctoration  of  a  Ijlood-stained  inneus.  The 
cases  of  liyslerical  j)erilonitis  may  also  show  fever. 

{(•)  Ih/slrrinil  H i/pcrpi/rcriti. —  It  is  a  su<ij;estive  fact  that  the  eases  of 
j)ara(h)xieal  teir.peralures  re|>orte(l  of  hite  years,  in  whieli  tlu^  tliennonieter 
lias  registeri'd  11:;J"  to  I2U°  or  nioie,  have  heen  in  women.  !''raud  has  heeii 
l)raetised  in  some  of  these,  hut  others  have  to  he  accepted,  thouj^li  their 
explanation  is  impossihle  under  our  knowti  laws.  Jacohi  has  reported  a 
ease  in  wliich  the  temperature  rose  to  1  1S°  F.  ((I.'')..'")"  ('.).  Tiie  Onuiha 
ease,  in  which  the  temperature  was  recorded  at  170°  F.,  has,  1  am  informed 
on  «food  authority,  provetl  a  fraud. 

Diagnosis. — ln([uiry  into  the  occurrence  of  previous  manifestations 
and  the  mental  conditions  nuiy  give  important  information.  'IMiese  ques- 
tions, as  a  rule,  should  not  he  asked  the  mother,  wiio  of  all  others  is  least 
likely  to  give  satisfactory  information  ahout  the  patient's  condition.  The 
occurrence  of  the  glohus  hystericus,  of  emotional  attacks,  of  weeping  and 
crying,  are  always  suggestive.  The  points  of  difference  hetweeu  the  con- 
vulsive attacks  and  true  e})ilepsy  were  referred  to  in  their  description, 
and  as  a  rule  little  dilli(.'ulty  is  experienced  in  distinguishing  hetween  the 
two  conditions.  The  hysterical  jjaralyses  are  very  variahle  and  apt  to  he 
associated  with  anaesthesia.  The  contractures  may  at  times  he  very  decep- 
tive, but  the  occurrence  of  areas  of  ana>sthesia,  of  retraction  of  the  visual 
field,  and  the  development  of  minor  hysterical  manifestations,  give  valua- 
ble indications.  The  contractures  disa])pear  under  full  antesthesia.  Spe- 
cial care  must  be  taken  not  to  confound  the  spastic  paraplegia  of  hysteria 
with  lateral  sclerosis. 

The  visceral  manifestations  arc  usually  recognized  without  much  difli- 
culty.  The  practitioner  has  constantly  to  bear  in  mind  the  strong  tendency 
in  hysterical  patients  to  practise  deception. 

Treatment. — The  prophylaxis  in  hysteria  may  be  gathered  from  the 
remarks  on  the  relation  of  education  to  the  disease.  The  successful  treat- 
ment of  hysteria  demands  qualities  possessed  by  few  physicians.  The  first 
element  is  a  due  appreciation  of  the  nature  of  the  disease  on  the  part  of 
the  physician  and  friends.  It  is  pitiable  to  think  of  the  misery  which  has 
been  inliicted  on  these  unhappy  victims  by  the  harsh  and  unjust  treat- 
ment which  has  resulted  from  false  views  of  the  nature  of  the  trouble; 
on  the  other  hand,  worry  and  ill-health,  often  the  wrecking  of  mind, 
body,  and  estate,  are  entailed  npon  the  near  relatives  in  the  nursing  of  a 
protracted  case  of  hysteria.  The  minor  manifestations,  attacks  of  the 
vapors,  the  crying  and  weeping  spells,  are  not  of  much  moment  and  rarely 
require  treatment.  The  physical  condition  should  be  carefully  looked  into 
and  the  mode  of  life  regulated  so  as  to  insure  system  and  order  in  every- 
thing. A  congenial  occupation  offers  the  best  remedy  for  many  of  these 
manifestations.  Any  functional  disturbance  should  be  attended  to  and  a 
course  of  tonics  prescribed.  Special  attention  should  be  paid  to  the  action 
of  the  bowels. 

Valerian  and  asafcetida  are  often  of  service.  For  the  pains  in  various 
parts,  particularly  in  the  back,  the  thermo-cautery  and  static  electricity 
will  be  found  invaluable.    Morphia  should  be  withheld.    In  the  convulsive 


HYSTRRIA. 


1121 


icus.    The 

10  casoR  of 
crnionuitcr 
(1  has  been 
DUj^h  their 
reported  a 
lu!  Omaha 
1  iiil'ormed 

lifestations 
'hese  (jues- 
ers  is  least 
tion.  The 
Hoping  and 
n  tiie  con- 
lescriptioii, 
:!twccn  the 

apt  to  be 
'ery  decep- 

the  visual 
jivo  vahia- 
osia.  Spe- 
of  hysteria 

iiuch  difli- 
g  tendency 

1  from  the 
^sful  treat- 

Tho  first 

he  part  of 

which  has 

just  treat- 

le  trouble; 

of  mind, 
irsing  of  a 
;ks  of  the 
and  rarely 
ooked  into 
r  in  every- 
y  of  these 
1  to  and  a 
the  action 

in  various 
electricity 
convulsive 


j;('!xures,  ])articularly  in  tlio  minor  fonns,  A  is  often  best,  after  settling  (he 
piilient  comfortably,  to  Jeiive  her.  W'Ula  slic  comes  to,  and  tinds  herself 
alone  ami  without  sympathy,  the  attacks  are  less  likely  to  be  repeated, 
'i'licrc  is,  as  a  rule,  no  cure  for  the  hysterical  maiiirestat iotis  of  women, 
otherwise  in  good  health,  who  are,  as  Mitchell  says,  "Cat  and  ruddy,  with 
sound  organs  and  good  a[»pctitcs,  but  ever  complain  of  pains  and  aches, 
;ind  ever  liable  on  the  least  emotional  disturbance  to  exhibit  a  (juaint  vari- 
ety ol'  hysterical  phenomena." 

To  treat  liysti'riu  as  a  physical  disorder  is,  at'tm-  all,  radically  wrong.  It 
is  essentially  a  mental  and  emotional  anomaly,  and  the  important  element 
in  the  treatment  is  moral  control.  At  home,  surrounded  by  loving  relatives 
who  nusinterpret  entirely  the  symptoms  and  have  no  apfireciation  of  the 
nature  of  the  disease,  the  severer  forms  of  hysteria  can  rarely  be  cured.  The 
necessary  control  is  impossible;  hence  the  s|tecial  value  of  the  method  in- 
troduced by  Weir  Mitchell,  which  is  particularly  applicable  to  the  advamed 
cases  which  have  become  chronic  and  bedridden.  The  treatment  consists 
in  isolation,  rest,  diet,  massage,  and  electricity.  Separation  from  friends 
and  sym[)atlietic  relatives  must  l>e  absolute,  and  can  rarely,  if  ever,  be 
obtained  in  the  individual's  home.  An  essential  element  in  tiie  treatment 
is  an  intelligent  nurse.  No  small  share  of  the  success  which  has  attended 
the  author  of  this  j)lan  has  been  duo  to  tiie  fact  that  he  has  pcn-sistently 
chosen  as  his  allies  bright,  intelligent  women.  The  details  of  the  plan  are 
as  follows:  The  ])atient  is  confined  to  bed  and  not  allowed  to  get  i\\),  nor, 
at  first,  in  aggnivated  cases,  to  read,  write,  or  even  to  feed  herself,  ilassage 
is  used  daily,  at  first  for  twenty  minutes  or  half  an  hour,  subseciuently  for 
a  longer  period.  Jt  is  essential  as  a  substitute  for  exercise.  The  induction 
current  is  applied  to  the  various  muscles  and  to  the  spine.  Its  use,  how- 
ever, is  not  so  essential  as  that  of  massage.  The  diet  may  at  first  be  entirely 
of  milk,  4  ounces  every  two  hours.  It  is  better  to  give  skimmed  milk, 
and  it  may  be  diluted  with  soda  water  or  barley  water  and,  if  necessary, 
pej)toiiized.  After  a  week  or  ten  days  the  diet  may  be  increased,  the 
amount  of  milk  still  being  ke])t  up.  A  chop  may  be  given  at  midday,  a  cup 
of  coffee  or  cocoa  with  toast  or  bread  and  butter  or  a  biscuit  with  the  milk. 
The  patients  usually  fatten  rapidly  as  the  solid  food  is  added,  and  with 
the  gain  there  is,  as  a  rule,  a  diminution  or  cessation  of  the  nervous  symp- 
toms. The  milk  is  the  essential  element  in  the  diet,  and  is  in  itself  amply 
sulficient. 

The  I'cmarkable  results  obtained  by  this  method  are  now  universally 
recognized.  The  plan  is  more  applicable  to  the  lean  than  to  fat,  flabby 
hysterical  patients.  Not  only  is  it  suitable  for  the  more  obstinate  varieties 
of  hysteria  with  bodily  manifestations,  but  in  the  cases  with  mental  symp- 
toms the  seclusion  and  separation  from  relatives  and  friends  are  particu- 
larly advantageous.  In  the  hysterical  vomiting  Debove's  method  of  forced 
feeding  may  be  used  with  benefit.  For  the  innumerable  minor  manifesta- 
tions of  hysteria  and  for  the  simulations  the  indications  for  treatment  are 
usually  clear.  Of  late,  hypnotism  has  been  extensively  nsed  in  the  treat- 
ment of  hysteria.  Occasionally  in  cases  of  hysterical  contractions  or  paraly- 
sis it  is  of  benefit,  bnt  any  one  who  has  seen  the  development  of  this  method 
70 


•■     '!i 


1122 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Rs  practised  at  present  in  France  must  feel  that  it  is  a  two-edged  sword  and 
that  the  constant  repetition  in  the  same  patient  is  fraught  with  danger. 
In  tlie  cases  in  which  we  have  tried  it  here  the  success  has  not  heen  marked. 


XII.    NEURASTHENIA. 

Definition. — A  condition  of  weakness  or  exhaiistion  of  the  nervous 
system,  giving  rise  to  various  forms  of  mental  and  hodily  inefFiciency. 

The  term,  an  old  one,  but  first  popularized  by  Beard,  covers  an  ill-de- 
fined, motley  group  of  symptoms,  which  may  be  either  general  and  the  ex- 
pression of  derangement  of  the  entire  system,  or  local,  limited  to  certain 
organs;  hence  the  terms  cerebral,  spinal,  cardiac,  and  gastric  neurasthenia. 

Etiology. — The  causes  may  be  grouped  as  hereditary  and  acquired. 

(a)  Hereditary. — We  do  not  all  start  in  life  with  the  same  amount  of 
nerve  capital.  Parents  who  have  led  irrational  lives,  indulging  in  excesses 
of  various  kinds,  or  who  have  been  the  subjects  of  nervous  complaints  or 
of  mental  trouble,  may  transmit  to  their  children  an  organization  which  is 
defective  in  what,  for  want  of  a  better  term,  we  must  call  "  nerve  force." 
Such  individuals  start  handicapped  with  a  neuropathic  predisposition,  and 
furnish  a  considerable  proportion  of  our  neurasthenic  patients.  As  van 
Gieson  sonorously  puts  it,  "  the  potential  energies  of  the  higher  constelLi- 
tions  of  their  association  centres  have  been  squandered  by  their  ancestors." 

Besides  such  forms  of  hereditary  neuropathy,  which  we  have  to  look 
upon  as  instances  of  injury  to  the  germ-plasm  derived  from  one  or  botli 
of  the  parents,  there  have  to  be  considered  those  cases  in  which  durini^ 
intra-uterine  life  there  have  been  conditions  which  interfered  with  the 
proper  development  and  nutrition  of  the  embryo.  So  long  as  these  indi- 
viduals are  content  to  transact  a  moderate  business  with  their  life  capital, 
all  may  go  well,  but  there  is  no  reserve,  and  in  the  exigencies  of  modern  life 
these  small  capitalists  go  under  and  come  to  us  as  bankrupts. 

(b)  Acquired. — The  functions,  though  nerverted  most  readily  in  persons 
who  have  inherited  a  feeble  organization,  may  also  be  damaged  in  persons 
with  no  neuropathic  predisposition  by  exercise  which  is  excessive  in  pro- 
portion to  the  strength — i.  e.,  by  strain.  The  cares  and  anxieties  attendant 
upon  the  gaining  of  a  livelihood  may  be  borne  without  distress,  but  in  many 
persons  the  strain  becomes  excessive  and  is  first  manifested  as  worry.  Tlie 
individual  loses  the  distinction  between  essentials  and  non-essentials,  trifles 
cause  annoyance,  and  the  entire  organism  reacts  with  unnecessary  readiness 
to  slight  stimuli,  and  is  in  a  state  which  the  older  writers  called  irritaljlf 
weakness.  If  such  a  condition  be  taken  early  and  the  patient  given  rest. 
the  balance  is  quickly  restored.  In  this  group  may  be  placed  a  large  pnt- 
portion  of  the  neurasthenics  which  we  see  in  this  country,  particularly 
among  business  men,  teachers,  and  journalists.  Neurasthenia  may  follow 
the  infectious  diseases,  particularly  influenza,  typhoid  fever,  and  syphilis. 
The  abuse  of  certain  drugs,  alcohol,  tobacco,  morphine  may  lead  to  a  high 
grade  of  neiTrasthenia,  though  the  drug  habit  is  more  often  a  result  rather 
than  a  cause  of  the  neurasthenia.    Other  causes  more  subtle,  yet  potent,  and 


NEURASTHENIA. 


1123 


I  sword  and 
ith  diiTigcT. 
3cn  markod. 


the  nervous 

cicney. 

rs  an  ill-do- 

and  the  ex- 

i  to  certain 

urastlienia. 

acquired. 

amount  of 
;  in  excesses 
mplaints  or 
on  which  is 
erve  force." 
osition,  and 
ts.  As  van 
21  constella- 
•  ancestors.'' 
ave  to  look 
me  or  botli 
lich  durinii; 
d  with  tlie 

these  indi- 
life  capital, 
modern  life 

^  in  persons 
I  in  persons 
sive  in  pro- 
?s  attendant 
jut  in  many 
worry.  Tlie 
itials,  trifles 
ry  readiness 
led  irritable 
given  rest. 
a  large  pro- 
particularly 
may  follow 
nd  syphilis. 
id  to  a  higli 
esult  rather 
potent,  and 


less  easily  dealt  with,  are  the  worries  attendant  upon  love  afl'airs,  religious 
doubts,  and  the  sexual  passion.  Hexual  excesses  have  undoubtedly  been 
exaggerated  as  a  cau.se  of  neurasthenia,  but  tliat  they  are  responsible  in  a 
number  of  instances  is  certain. 

The  traumatic  forms,  especially  those  following  upon  railway  accidents, 
will  be  separately  considered. 

Symptoms. — These  are  extremely  varied,  and  nuiy  be  general  or 
localized;  more  often  a  com])i'  ti(m  of  both.  T)  j  appearaneo  of  the  pa- 
tient is  suggestive,  sometimes  cnaracteristic,  but  ditlicult  to  (lescril)e.  Im- 
l)ortant  information  can  be  gained  by  the  jdiysician  if  he  observe  thci 
patient  closely  as  he  enters  the  room — the  way  he  is  clothed,  the  manner 
in  which  he  holds  his  body,  his  facial  expression,  and  the  humor  which  lu; 
is  in.  Ijoss  of  weight  and  slight  ana'uiia  may  be  present.  The  physical 
debility  may  reach  a  high  grade  and  the  patient  nuiy  be  conlined  to  bed. 
JMentally  the  ])atients  are  usually  low-spirited  and  despondent,  in  women 
frcijuently  emotional. 

The  local  symptoms  may  dominate  the  situation,  and  there  have  accord- 
ingly been  described  a  whole  series  of  types  of  the  disease — cerebral,  spinal, 
cardio-vascular,  gastric,  and  sexual.  In  all  forms  there  is  a  striking  lack  of 
accordance  between  the  symptoms  of  which  the  patient  complains  and  the 
objective  changes  discoverable  by  the  physician.  In  nearly  every  clinical  type 
of  the  disease  the  predominant  symi)toms  are  referable  to  pathological  sensa- 
tions and  the  psychic  efl'ects  of  these.  Imperfect  sleep  is  also  complained 
of  by  a  majority  of  patients,  or,  if  not  complained  of,  is  found  to  exist  on 
inquiry. 

In  the  cerebral  or  psychic  form  the  symptoms  are  chiefly  connected  with 
an  inability  to  perform  the  ordinary  mental  work.  Thus  a  row  of  figures 
cannot  be  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greatest  worry,  the  transaction  of  petty  details  in  business  is 
a  painful  effort,  and  there  is  loss  of  power  of  fixed  attention.  With  this 
condition  there  may  be  no  headache,  the  a])petite  may  be  good,  and  the 
])atient  may  sleep  well.  As  a  rule,  however,  there  are  sensations  of  fulness 
and  weight  or  flushes,  if  not  actual  headache.  Sleeplessness  is  a  frequent 
concomitant  of  the  cerebral  form,  and  may  be  the  first  manifestation. 
Some  of  these  patients  are  good-tempered  and  cheerful,  but  a  majority  are 
moody,  irritable,  and  depressed. 

ITypera'sthesia,  especially  to  sensations  of  ])ain,  is  one  of  the  main  char- 
acteristics of  almost  all  neurasthenic  individuals.  The  sensations  are  nearly 
always  referred  to  some  special  region  of  the  body — the  skin,  eye  muscles, 
the  joints,  the  blood-vessels,  or  the  viscera.  It  is  frequently  possible  to 
localize  a  number  of  points  painfiil  to  pressure  (Valleix's  points).  In  some 
patients  there  is  marked  vertigo,  occasionally  even  resembling  that  ui  Meni- 
ere's disease. 

If  such  pathological  sensations  continue  for  a  long  time  tlie  mood  and 
character  of  the  patient  gradually  alter.  The  so-called  "  irritable  humor  " 
develops.  Many  obnoxiously  egoistic  individuals  met  with  in  daily  life  are 
in  reality  examples  of  psychic  neurasthenia.  Everything  is  complained  of. 
The  individual  demands  the  greatest  consideration  for  his  condition;  feels 


1124 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


.  i 
/ 


Slip  i 

m 
ill 


that  lie  has  been  deeply  insulted  if  his  desires  arc  not  always  immediately 
granted.  He  may  at  tiie  same  time  have  hut  little  consideration  for  otluTs. 
Indeed,  in  the  severer  forms  of  the  disease  he  may  show  a  malicious  j)lcas- 
urc  in  attempting  to  make  people  who  seem  happier  tluiu  himself  uncom- 
fortnhle.  Sueh  i)atients  complain  frequently  that  they  are  "  misunder- 
ttood  "'  liy  their  fellows. 

In  many  eases  the  so-called  ''anxiety  conditions"  p'adually  develop; 
one  scarcely  ever  sees  a  case  of  advanced  neurasthenia  without  the  existciu-c 
of  some  form  of  "anxiety."  In  the  sim|)ler  forms  of  anxiety  (nosophohic) 
tliere  may  he  only  a  fear  of  impendin>.f  insanity  or  of  approachin<,'  death 
or  of  a})oplexy.  More  frequently  the  anxious  feeling  is  localized  somewhere 
in  the  body — in  the  i)ra'cordial  region,  in  the  head,  in  the  abdomen,  in  the 
thorax,  or  more  rarely  in  the  extremities. 

In  some  cases  the  anxiety  becomes  intense  and  the  patients  are  restless, 
and  declare  that  they  do  not  know  what  to  do  with  themselves.  They  may 
throw  themselves  upon  a  'id,  crying  and  comi)laining,  and  making  con- 
vulsive nu)vements  with  tii''  hands  and  feet.  Suicidal  tendencies  are  not 
uncommon  in  such  cases,  a  '  patients  may  in  desi)eration  actually  take 
their  own  lives. 

Involuntary  mental  activity  may  be  very  troublesome;  the  patient  com- 
])lains  that  when  he  is  overtired  thoughts  which  he  cannot  stop  or  control 
run  through  his  head  with  lightning-like  ra])idity  ^n  other  cases  there  is 
marked  absence  of  mind,  the  individual's  mind  .jt-ing  so  filled  up  owing 
to  the  ovfcvexcitability  of  latent  memory  pictures  that  he  is  unable  to  form 
the  proper  associations  for  ideas  called  up  by  external  stimuli.  Sometimes 
a  i)aiient  complains  that  a  definite  word,  a  name,  a  number,  a  melody,  or  a 
song  kee])s  running  in  his  .  v.id  in  spite  of  all  he  can  do  to  abolish  it. 

In  the  severer  cases  of  psj'cliic  neiirasthenia  the  so-called  "  phobias  " 
are  common.  The  most  frequent  form  perhaps  is  agoraphobia,  in  which 
patients  the  moment  they  come  into  an  open  space  are  oppressed  by  an 
exaggerated  feeling  of  anxiety.  They  seem  "  frightened  to  death,"  and 
connnence  to  trend)le  all  over;  they  complain  of  compression  of  the  thorax 
and  palpitation  of  the  heart.  They  may  break  into  profuse  pers])iration  and 
assert  that  they  feel  as  though  chained  to  the  ground  or  tliat  they  cannot 
move  a  ste]).  It  is  remarkable  that  in  some  such  cases  the  open  space  can 
be  crossed  if  the  individual  be  accompanied  oy  some  one,  even  by  a  child, 
or  if  he  carry  a  stick  or  an  umbrella!  Other  people  are  afraid  to  be  left 
alone  (mono])hobia),  especially  in  a  closed  compartment  (claustrophobia). 

The  fear  of  people  and  of  society  is  known  as  anthropopiiobia.  A  whole 
series  of  other  jihobias  have  been  descrilied — bnto]ihobia,  or  the  fear  that 
high  things  will  fall;  pathophobia,  or  fear  of  disease;  siderodromophobia, 
or  fear  of  a  railway  journey;  siderophobia  or  astrophobia,  fear  of  thunder 
and  lightning.  Occasionally  we  meet  with  individuals  who  are  afraid  of 
everything  and  every  one — victims  of  the  so-called  pantophobia. 

The  special  senses  may  lie  disturbed,  ])articularly  vision.  An  aching  or 
^A•ca^iness  of  the  eyeT)alls  after  reading  a  few  minutes  or  flashes  of  light  are 
common  symptoms.  The  "  irritalde  eye,"  the  so-called  nervous  or  neu- 
rasthenic asthenopia,  is  familiar  to  every  family  physician.    According  to 


iinmedijitt'ly 
>  for  others, 
icioiis  pk'iis- 

SC'lf    lIllCOIll- 

"  niisiuKlfr- 

lly  develop; 
he  existence 
nosophohic) 
c'liiii^f  death 
I  somewhere 
men,  in  the 

are  restless, 

They  may 

naking  eoii- 

eies  are  not 

dually  take 

latient  com- 
[)  or  control 
ises  there  is 
d  up  owing 
ible  to  form 

Sometimes 
nelody,  or  a 
ish  it. 

"  phobias  " 
a,  in  which 
essed  by  an 
death,"  and 
f  the  thorax 
piration  and 
they  cannot 
in  space  can 

by  a  child, 
d  to  be  left 
tropliobia). 
a.  A  whole 
he  fear  that 
romophobia. 
■  of  thunder 
re  afraid  of 
a. 
.n  aching  (»r 

of  light  are 
ons  or  neu- 
Lecording  to 


NEURASTHENIA. 


112r> 


Binswangor,  the  cs.sonce  of  the  asthenoi)ie  distrrhance  consists  in  patho- 
logical sensations  of  fatigue  in  the  ciliary  muscles  or  tiio  medial  recti. 

There  may  be  acoustic  disturbances — hyperalgesia  and  oven  true  hyper- 
acusia. 

One  of  tiu'  most  common  of  all  the  symptoms  of  neurasthenia  is  the 
pressure  in  the  head  ''oinplained  of  by  these  i)atieiits.  This  symptom,  vari- 
ously described,  may  he  dilfuse,  but  is  more  frtniuently  referred  to  some  one 
ix'gion — frontal,  temporal,  parietal,  or  occipital.* 

When  the  spinal  sympioins  ])redominate — spinal  irritation  or  spinal 
neurasthenia — in  addition  to  many  of  the  features  just  mentioned,  the 
patients  comi)lain  of  weariness  on  the  least  exertion,  of  weakness,  i)ain  in 
the  hack,  intercostal  neuralgiform  pains,  and  of  aching  pains  in  the  legs. 
Tliere  may  be  spots  of  local  tenderness  on  the  spine.  The  rachialgia  may 
he  s[)ontaneous,  or  may  be  noticed  only  on  pressure  or  movement.  Occa- 
sionally there  may  be  disturbances  of  sensation,  jjarticularly  a  feeling  of 
nund)ness  and  tingling,  and  the  reflexes  may  be  increased.  Visceral  neural- 
gias, especially  in  connection  with  the  genital  organs,  are  frequently  met 
with.  The  aching  pain  in  the  back  or  in  the  back  of  the  neck  is  the  most 
constant  com])laint  in  these  cases.  In  women  it  is  often  impossible  to  say 
whether  this  condition  is  one  of  neurasthenia  or  hysteria.  It  is  in  these 
cases  that  the  disturbances  of  muscular  activity  are  most  pronounced,  and 
in  the  French  writings  anii/oslheiiia  particularly  i)lays  an  important  role. 
The  symptoms  may  be  irritative  or  paretic,  or  a  combination  of  both.  Dis- 
turbances of  coordination  are  not  uncommon  in  the  severer  forms.  These 
are  particularly  prone  to  involve  the  associated  movements  of  the  eye  mus- 
cles leading  to  astheno]nc  lack  of  accommodation.  Drooping  of  one  eyelid 
is  very  common,  probably  owing  to  insuificient  innervation  on  the  part  of 
the  sympathetic  rather  than  to  paresis  of  the  nervus  oculomotorius.  Oc- 
casionally Honibcrg's  symptom  may  be  present,  and  the  patient,  or  even  his 
physician,  may  fear  a  beginning  tabes.  More  rarely  there  is  disturbance  of 
such  finely  coordinated  acts  as  writing  and  articulation,  not  unlike  those 
seen  at  the  onset  of  general  paresis.  Such  sym])toms  are  always  alarming, 
and  the  greatest  care  mnst  be  taken  in  establishing  a  diagnosis.  That  they 
may  be  the  symptoms  of  pure  neurasthenia,  liowever,  can  no  longer  be 
doubted. 

The  reflexes  in  neurasthenia  are  usually  increased,  the  deep  reflexes 
especially  never  '  ng  absent.  The  condition  of  the  superficial  reflexes  is 
less  constant,  though  these,  too,  are  usually  increased.  The  i)Ui)ils  are  often 
dilated,  and  the  reflexes  are  nsnally  normal.  There  may  be  inequality  of  the 
])upils  in  nenrasthenia,  a  ])oint  which  Pclizaeus  has  especially  em|)hasized. 

In  another  ty])e  of  cases  the  musculo  weakness  is  extreme,  and  may  go 
on  even  to  complete  motor  hel]dcssness.  Very  thorough  examination  is 
necessary  before  deciding  as  to  the  nature  of  the  affection,  since  in  some 

*  For  an  exhaustive  consideration  of  the  mentenl  symptoms  of  neurasthenia,  see  the 
Shattuck  Lecture,  by  Cowles  (Fioston  Medical  and  Surgical  Journal.  18!)1),  as  avoII  ns  two 
Herman  monographs,  that  of  Binsvvanirer  (ISflfi),  and  that  of  Lowciifflil.  The  T-^ri'nch 
tivatise  of  Bouveret  (1891)  is  also  valuable.  F.  C.  Miiller's  Handbuch  der  Xourastlicnie 
(Leipzig,  1893)  contains  an  excellent  bibliography  of  this  subject. 


1120 


DISEASES  OF  THE  NKRVOUS  SYSTEM. 


/' 


instances  serious  misiiikcs  have  l)eeii  inadi".  ]I(>re  Itelonf,'  tlio  nliriiild  oT 
Kellel,  tlie  dUiivsia  ali/era  of  ^Mol)iiis,  and  the  neurasthenic  Torni  of  n.slasid 
(ihasia  doscrihed  hy  IJinswaiiger. 

In  other  eases  the  ranlio-vdsrnlar  syin])toins  arc  the  most  distrossinji;, 
and  may  occur  with  oidy  slif^lit  disturbance  of  the  cerel)ro-s|>inal  functions, 
thougli  the  conditions  are  nearly  always  conil)ined.  ralpitation  of  tiie  heart, 
irreguhir  and  very  rapid  action  (neurasthenic  tachycardia),  and  ])ains  and 
opjjressive  i'eelin{i;s  in  the  cardiac  rej^Mon  are  the  most  common  symjitoms. 
The  slightest  excitement  may  be  followed  by  increased  action  of  the  heart, 
sometimes  associated  with  sensations  of  dizziness  and  anxiety,  and  the  ])a- 
tients  frequently  have  the  idea  that  they  suffer  from  serious  disease  of  this 
organ.    Attacks  of  pseudo-angina  may  occur. 

Vaso-violor  disturbances  constitute  a  special  feature  of  many  cases. 
Flushes  of  heat,  esjiecially  in  the  head,  and  transient  hyi)erivinia  of  the 
skin  may  be  very  distressing  symptoms.  Profuse  sweating  may  occur, 
<?ither  local  or  general,  and  sometimes  nocturnal.  The  pulse  may  show  inter- 
esting features,  owi)  j  to  the  extreme  relaxation  of  the  peripheral  arterioles. 
The  arterial  throbbing  may  be  everywhere  visible,  almost  as  much  as  in 
aortic  insufficiency.  The  i)\dse,  too,  may  under  these  circumstances  have 
a  somewhat  water-hammer  quality.  The  capillary  pulse  may  be  seen  in 
the  nails,  on  the  lips,  or  on  the  margins  of  a  line  drawn  upon  the  forehead, 
and  I  have  on  several  occasions  seen  pulsation  in  the  veins  of  the  back  of 
the  hand.  A  characteristic  symptom  in  some  cases  is  the  throbbing  aortd. 
This  "  ])reternatural  pulsation  in  the  epigastrium,"  as  Allan  Burns  calls 
it,  may  be  extremely  forcible  and  suggest  the  existence  of  abdominal  aneu- 
rism. The  subjective  sensations  associated  with  it  may  be  very  unpleasant, 
particularly  when  the  stomach  is  empty. 

In  women  especially,  and  sometimes  in  men,  the  peripheral  blood-ves- 
sels are  contracted,  the  extremities  are  cold,  the  nose  is  red  or  blue,  and  the 
face  has  a  pinched  expression.  These  patients  feel  much  more  comfortable 
when  the  cutaneous  vessels  are  distended,  and  resort  to  various  means  to 
favor  this  (wearing  of  heavy  clothing,  use  of  diffusible  stimulants). 

The  general  features  of  gastro-intestinal  neurasthenia  have  been  dealt 
Avith  under  the  section  of  nervous  dys])epsia.  The  connection  of  these  cases 
with  dilatation  of  the  stomach,  floating  kianey,  and  the  condition  which 
Glenard  calls  enteroptosis  has  already  been  mentioned. 

Scrital  neurasthenia  is  a  condition  in  which  there  is  an  irritable  weak- 
ness of  the  sexual  organs  manifested  by  nocturnal  emissions,  unusual  de- 
pression after  intercourse,  and  often  by  a  distressing  dread  of  impotence. 
The  mental  condition  of  these  patients  is  most  pitiable,  and  they  fall  an 
easy  ])rcy  to  quacks  and  charlatans  of  all  kinds. 

Sj)crmatorrho?a  is  the  bugbear  of  the  majority.  They  complain  of  con- 
tinued losses,  usually  without  accompanying  ])leasurable  sensations.  After 
defecation  or  micturition  there  may  be  seminal  discharges.  Microscopic  ex- 
amination sometimes  reveals  the  presence  of  spermatozoa.  Actual  nervous 
impotence  is  not  uncommon.  The  "  painful  testicle  "  is  a  well-known  neii- 
rasthcnic  phenomenon. 

In  the  severer  cases,  especially  those  bearing  the  stigmata  of  degenera- 


a:t\ 


NKUIIASTIIEXIA. 


1127 


0  ahrtnld  of 
111  of  (islasia 

{  (listrc'ssiiiff, 
ill  I'liiu'tions, 

of  the  heart, 
1(1  j)ain8  and 
III  syiiiptonis. 
of  the  heart, 

and  tlie  i)a- 
isease  of  this 

many  cases, 
wniia  of  the 
may  occur, 
ly  sliow  inter- 
ral  arterioles. 
I  much  as  in 
istances  have 
y  be  seen  in 
the  forehead, 
f  tlie  back  of 
robbing  aorta. 
I  Burns  calls 
ominal  aueu- 
■y  unpleasant, 

ral  blood-ves- 
blue,  and  the 
e  comfortable 
ous  means  to 
ants). 

i^e  been  dealt 
of  these  cases 
idition  which 

•ritable  weak- 

,  unusual  de- 

3f  impotence. 

they  fall  an 

iplain  of  con- 
itions.  After 
icroscopic  ex- 
ctual  nervous 
1-known  neu- 

of  degenera- 


tion, there  may  lie  evidence  of  se;aial  jiervcrsion.  The  "■  damnable  itera- 
tion" witii  which  writers  in  our  ranks  "dish  up"  this  uni>leasaiit  subject 
is  proof  positive  (liat  not  all  prophets  s|)('iik  to  edilicatioii. 

In  IViiiuk's  it  is  common  to  lind  a  tender  ovary,  and  painful  or  irregular 
menstruation. 

Jn  all  forms  of  neurasthenia  the  condition  of  the  urine  is  important. 
^Fany  cases  are  complicated  with  the  symptoms  of  the  condition  known 
as  litha>mia,  and  so  marked  may  this  be  that  some  have  indeed  made  a  s[)e- 
cial  form  of  litluemic  neurasthenia.  I'olyuria  may  l)e  present,  but  is  more 
common  in  hysteria.  AVitli  disturbed  digestion  the  urates  and  oxalates 
may  be  in  excess. 

Diagnosis. — While  in  the  majority  of  cases  the  diagnosis  can  readily 
be  made,  still  there  are  instances  in  which  it  is  very  dillicult.  Xeurasthenia 
overlaps  hypochondria  and  hysteria  on  the  one  hand,  and  the  jisychoses  and 
degenerative  diseases  of  the  nervous  system  on  the  other.  The  term  has 
in  the  jjast  been  altogether  too  loosely  used.  Simple  local  disturbances 
and  temporary  general  disturbances  the  result  of  sudden  overexertion  should 
scarcely  l)e  diagnosed  as  neurasthenia.  Only  when  we  have  before  us  a 
clinical  picture  indicating  general  weakness  of  the  nervous  system  in  addi- 
tion to  the  local  disturbances,  no  matter  how  pronounced  they  are,  is  the 
diagnosis  justifiable.  Cha  cot  has  designated  as  neurasthenic  stigmata  cer- 
tain fundamental  and  typical  symptoms,  such  as  the  pain  and  pressure  in 
the  head,  the  disturbances  of  sleep,  the  rhachialgia  and  spinal  hypera^s- 
thesia,  the  muscular  weakness,  the  nervous  dyspepsia,  the  disturbances  of 
the  genital  organs,  and  the  typical  mental  ])lienomena  (irritable  humor, 
psychic  de])ression,  feelings  of  anxiety,  intellectual  fatigue,  incapacity  of 
decision,  and  the  like).  In  addition  to  these  cardinal  symptoms  of  the  dis- 
ease, he  described  as  secondary  or  accessory  symjitoms  the  feelings  of  dizzi- 
ness and  vertigo,  the  neurasthenic  asthenojiia,  the  circulatory,  respiratory, 
secretory,  and  nutritive  disturbances,  disturbances  of  motility  and  sensa- 
tion, the  fever  of  neurasthenia,  and  neurasthenic  idiosyncrasies.  The  anxiety 
conditions  and  various  phobias,  as  well  as  the  different  varieties  of  tic  and 
the  occupation  neuroses  when  they  accompany  neurasthenia,  are  regarded 
as  comidications  dependent  in  the  majority  of  instances  ujion  faulty  hered- 
ity. I  must  agree  with  Binswanger  in  emphasizing  the  imjiortance  for  the 
diagnosis  of  the  peculiar  intellectual  and  emotional  condition  of  the  patient, 
as  well  as  the  disturbances  of  sleep. 

Neurasthenia  is  a  disease  above  all  others  which  has  to  1  diagnosed 
from  the  subjective  statements  of  the  patient,  and  from  an  observation  of 
his  general  behavior  rather  than  from  the  physical  examination.  The 
])hysical  examination  is  of  the  highest  importance  in  excluding  other  dis- 
eases likely  to  be  confounded  with  it.  That  somatic  changes  occur  and  that 
])hysical  signs  are  often  to  be  made  out  is  very  true,  and  we  owe  to  Liiwen- 
feld  especially  a  careful  discussion  of  these  points,  but  there  is  notliing 
typical  or  pathognomonic  in  these  objective  changes. 

The  hypochondriac  differs  from  the  neurasthenic  in  the  excessive  psychic 
distortion  of  the  pathological  sensations  to  which  he  is  subject.  He  is 
the  victim  of  actual  delusions  regarding  his  condition. 


i^^ 


1123 


niSKASES  OP  THE  NEIlVOrS  SYSTEM. 


The  confusion  of  nciirastlicnia  willi  liystcria  is  still  more  frcquont;  in 
women  c'K|H'C'ially  a  (lia{;nosis  of  hysteria  is  often  uuuU'  when  in  irality 
the  condition  is  one  of  neurasthenia.  In  tiie  nhsence  of  hysterical  par- 
oxysnis,  of  crises,  and  of  those  marked  emotional  and  intellectual  eliar- 
acteristies  of  the  hysterical  individual  the  dia^Miosis  of  hysteria  should  not 
l)e  nuide.  Of  course,  in  many  of  tlie  cases  of  hysteria  detinitc  hysterical 
stigmata  (hysterical  paralyses,  convxdsions,  contractures,  ana'sthesias, 
alterations  in  the  visual  field,  etc.)  are  present,  and  the  diaf,MU)si8  is  not 
dilhcult. 

Epilepsy  is  not  likely  to  be  confounded  with  neurasthenia  if  there  be 
definite  ei)ile])tic  attacks,  but  the  cases  of  petit  mat  may  be  puzzling. 

The  onpet  of  exoi)hthaImic  goitre  may  be  mistaken  for  neurasthenia, 
especially  if  there  be  no  exophthalmos  at  the  beginning.  The  einoti(mal 
disturljances  and  the  irritability  of  the  heart  nuay  mislead  the  jjhysician. 
In  i)ronounced  cases  of  nervous  prostration  the  ditrerential  diagnosis  from 
the  various  psychoses  may  be  extremely  difficult. 

The  two  forms  of  organic  disease  of  the  nervous  system  with  which  neu- 
rasthenia is  most  likely  to  be  confounded  are  tabes  and  general  paresis.  The 
syniptoms  of  the  spinal  form  of  neurasthenia  may  resemble  those  of  the 
former  disease,  while  the  symptoms  of  the  psychic  or  cerebral  form  of  neu- 
rasthenia may  be  very  similar  to  those  of  general  paresis.  The  diagnosis, 
as  a  rule,  ])resents  no  dilhculty  if  the  physician  be  careful  to  make  a  thor- 
ough routine  examination.  ]t  is  only  the  suj)erficial  study  of  a  case  that  is 
likely  to  lead  one  astray.  In  tabes  especially  a  consideration  of  the  sensory 
disturbances,  of  the  deep  reflexes,  and  of  the  ])Ui)illary  findings  will  alwaj'S 
establish  the  ])resence  or  absence  of  the  disease.  In  general  jiaresis  there  is 
sometimes  nmre  ditliculty.  I'hc  onset  of  general  ])aresis  is  often  character- 
ized by  the  ap])earance  of  symptoms  quite  like  those  of  ordinary  neu- 
rasthenia, and  the  family  ])hysician  may  entirely  overlook  the  grave  nature 
of  the  malady.  The  mistake  in  the  other  direction  is,  however,  perhaps  just 
as  common.  A  physician  who  once  or  twice  has  seen  a  case  of  general 
paresis  develop  out  of  what  a])]ieared  to  be  one  of  pronounced  neurasthenia 
is  too  prone  afterward  to  suspect  every  neurasthenic  to  be  developing  the 
malign  affection.  The  most  marked  symptoms,  however,  of  psychic  ex- 
haustion do  not  justify  a  diagnosis  of  general  paresis  even  when  the  his- 
tory is  sus])icious,  unless  along  with  it  definite  paresis  of  the  facial  or  mus- 
cles of  articulation  or  of  the  pupils  exist.  A  history  of  syphilis  or  of  chronic 
alcoholism  or  morphinism  associated  with  severe  psychic  exhaustion  should, 
of  course,  put  one  always  on  his  guard,  and  the  physician  should  be  sharply 
on  the  lookout  for  the  appearance  of  intellectual  defects,  paraphasia,  facial 
paresis,  and  sluggishness  of  the  pupils. 

Treatment.' — Prnphylnxis. — Many  patients  come  under  our  care  a 
generation  too  late  for  satisfactory  treatment,  and  it  may  be  impossible  to 
restore  the  exhausted  capital.  The  greatest  care  should  be  taken  in  the 
rearing  of  children  of  neuropathic  predisposition.  From  a  very  earlv  age 
they  should  be  submitted  to  a  process  of  "psychic  hardening,"  every  effort 
being  made  to  strengthen  the  bodily  and  mental  condition.  Even  in  in- 
fancy the  child  should  not  be  pampered.     Later  on  the  greatest  ciire  should 


NErRASTIIEKlA. 


1129 


rtupioiit;  in 
I  ill  reality 
tcrical  piir- 
iftual  ciiiir- 
shoiild  lint 
e  liystericjil 
iiriii'stlu'sias, 
iiosis  is  not 

if  there  be 
ling. 

eurastluniia, 
c  emotional 
3  physician, 
gnosis  I'roni 

wliic'h  ncii- 
aresis.    The 
hose  of  the 
orm  of  ncii- 
le  diagnosis, 
lake  a  thor- 
caso  that  is 
the  sensory 
will  ahvayf? 
•esls  there  is 
n  character- 
linary   neii- 
jrave  natnre 
perha])s  just 
3  of  general 
lenrastlienia 
k^eloping  the 
psychic  cx- 
len  the  his- 
cial  or  nins- 
)r  of  chronic 
tion  should, 
d  he  sharjily 
diasia,  facial 

our  care  a 
mpossible  to 
;aken  in  tlio 
Ty  early  age 
'  every  effort 
Even  in  in- 

care  should 


be  e.vcrciscd  with  regard  to  f(i<td,  sleep,  and  school  work.     Coinplaintd  of 
children  should  not  be  too  seriously  considered. 

Much  depends  uiion  the  example  set  by  the  parents.  A  restless,  emo- 
tional, constantly  complaining  mother  will  rack  the  nervctus  system  of  a 
delicate  child.  In  some  instance  ,  f(jr  the  welfare  of  a  develo[)ing  boy  or 
girl,  the  jjliysician  may  find  it  necessary  to  advise  its  reinovul  from 
home. 

Neurotic  children  are  especially  liable  during  develoi)ment  to  fits  of 
temper  and  of  emotional  disturbance.  These  should  not  be  too  lightly 
considered.  Above  all,  violent  chastisement  in  such  cases  is  to  be  avoidcil, 
and  loss  of  temper  on  the  part  of  the  parent  or  teacher  is  particularly  per- 
nicious for  the  nervous  system  of  the  child.  Wlu-re  possible,  in  such  in- 
stances, the  l)est  treatment  is  to  ])ut  the  ol)strei)er(»us  child  immediately  to 
bed,  and  if  the  excitement  and  temper  continue  a  warm  bath  followed  by 
a  cool  douch  may  be  elTective.  If  he  be  put  to  bed  after  the  bath  sleep  soon 
follows. 

Special  attention  is  necessary  at  puberty  in  both  boys  and  girls.  If 
there  be  at  this  period  any  marked  tendency  to  emotional  -listurbance  or  to 
intellectual  weakness  the  child  should  be  removed  from  school  and  every 
care  taken  to  avoid  unfavorable  influences. 

Personal  lly(jienc. — Throughout  life  individuals  of  neuro])athic  ])redis- 
position  should  oljcy  scrupulously  certain  hygienic  and  ])ro])hylactic  rules. 
Intellectual  work  especially  should  be  judiciously  limited  and  should  alter- 
nate fre([uently  with  ])eriods  of  repose.  Excitement  of  all  kinds  should  (jf 
course  be  avoided,  and  such  individuals  will  do  well  to  be  abstemious  in 
the  use  of  tobacco,  tea,  coffee,  and  alcohol,  if,  indeed,  they  be  permitted  to 
use  these  substances  at  all.  The  habit,  ha])pily  in  this  country  becoming 
very  common,  of  taking  at  least  once  a  year  a  prolonged  holiday  away  from 
the  ordinary  environment,  in  the  woods,  in  the  mountains,  or  at  the  sea- 
shore, should  be  urgently  enjoined  upon  every  neuro])atliic  individual.  In 
many  instances  it  is  found  to  be  the  greatest  relief  and  rest  if  the  ])atient 
can  take  his  holiday  av.-ay  from  his  relatives. 

During  ordinary  life  nervous  people  should,  during  some  ])ortion  of 
each  day,  pay  rational  attention  to  the  body.  Cold  baths,  swimming,  exer- 
cises in  the  gymnasium,  gardening,  golf,  lawn  tennis,  cricket,  hunting, 
shooting,  rowing,  sailing,  and  bicycling  are  of  value  in  maintaining  the 
general  nutrition.  Such  exercises  are,  of  course,  to  be  recommemh'd  only 
to  individuals  physically  ecpuil  to  them.  If  neurasthenia  be  once  well  (h;- 
veloped  the  greatest  care  must  be  observed  in  the  ordering  of  exercise. 
]Many  nervous  girls  have  been  completely  broken  down  by  following  injudi- 
cious advice  with  regard  to  long  walks. 

Treatment  of  the  Condition. — The  treatment  of  neurasthenia  when  onco 
established  presents  a  varied  problem  to  the  thoughtful  physician.  Every 
case  must  be  handled  upon  its  own  merits,  no  two,  as  a  rule,  requiring  ex- 
actly the  same  methods.  In  general  it  will  be  the  aim  of  the  medical 
adviser  to  remove  the  patient  as  far  as  possible  from  the  influences  wl'.ich 
have  led  to  his  downfall,  and  to  restore  to  normal  the  nervous  mechanisms 
which  have  been  Avcakened  by  injurious  influences.    The  general  character 


lino 


DISKASES  OK  THK   NHIlVOUS  SYSTKM. 


/ 


nl  the  iiidividuiil,  liis  physical  mid  social  slatuM  iiuist  uf  courHO  bo  consid- 
cR'd,  and  the  lhi'ra|»i'Utit'  incasurert  cart-'fuliy  adjusti'd  to  tlu'se. 

Ahovc  ail,  the  |tli_vsi(iaii  iiiiisl  (list  ^aiii  lln'  (•(HiddciU'c  of  his  patifiit, 
niid  this  he  will  not  do  it'  he  he  iiiattciitivo  to  the  coiiiiilaiiits  of  the  individ- 
ual, c'sjH'cially  at  lirst,  or  if  he  rudidy  tell  the  patient  before  he  has  care- 
fully examined  him  and  observed  him  for  some  time  that  his  troubles  an' 
ima^dnary.  As  has  been  said,  it  is  educalion  more  than  medicine  that 
these  patients  need,  but  the  patients  themselves  do  not  wish  to  be  educated; 
they  come  to  the  physician  to  be  treatecl,  and  the  educating  process  has  to 
be  dis^Miised. 

The  (liaj,Miosis  havinj^  been  settled,  the  physician  may  assure  the  patient 
that  with  pr(ilon<,'ed  treatment,  during'  which  his  coiiperation  with  the  physi- 
cian is  absolutely  essential,  he  nuiy  expi'ct  to  ^'ct  well.  Jle  must  be  told 
that  much  depends  upon  himself  and  that  he  must  make  a  vigorous 
effort  to  overcome  (c'rtain  of  his  tendencies,  and  that  all  his  strength 
of  will  will  be  needed  to  further  the  progress  t)f  the  cure.  In  the  case  of 
business  or  i)rofessional  nu-n,  in  whom  the  coiulition  develo])S  as  a  result 
of  overwork  or  overstudy,  it  nuiy  be  suflicient  to  enjoin  al)solute  rest  with 
change  of  scene  and  diet.  A  trip  abroad,  with  a  residence  for  a  month  or 
two  in  Switzerland,  or,  if  there  are  symptoms  of  nervous  dyspcjjsia,  a  resi- 
dence at  one  of  the  Spas  will  usually  prove  sulbcient.  The  excitement  of 
the  large  cities  abroad  should  be  avoided.  'J'he  longer  (lie  disease  has 
lasted  and  I  he  more  intense  the  symptoms  have  been,  the  longer  the  time 
necessary  for  the  restoration  of  hcallh.  In  cases  of  any  severity  the  patient 
must  be  told  that  at  least  six  months'  complete  absence  from  business,  under 
strict  medical  guidance,  will  be  necessary.  Shorter  periods  nuiy  of  course 
be  of  beiU'fit,  which,  however,  as  a  rule,  will  be  only  tem]>orary. 

It  will  be  wise  in  very  many  cases  to  treat  the  individual  for  a  fev 
weeks  at  least  in  a  hos])ital  or  other  institution  before  sending  him  away  on 
a  journey.  In  this  ])relimiiuiry  treatment  the  greatest  tact  is  rerpiired  on 
the  ])art  of  the  medical  attendant  and  nurse.  The  patient  should  not  see 
the  doctor  too  often  after  the  first  careful  examination,  although  he  should 
of  course  receive  regular  visits  from  him.  The  physician  will  make  a  mis- 
take if  he  responds  to  frequent  calls  on  the  part  of  the  i)atient  between 
the  periods  of  his  rogidar  visits.  The  choice  of  a  nurse  is  by  no  means  an 
easy  matter.  That  she  should  be  healthy,  strong,  and  by  no  means 
nervous  herself  are  among  the  first  considerations.  Sallow-faced,  emo- 
tional, emaciated  women  can  only  do  harm  if  detailed  to  the  care  of  a 
nervous  patient. 

It  will  often  be  foiind  advisable  to  make  out  a  daily  programme,  which 
shall  occnpy  almost  the  whole  time  of  the  patient.  At  first  he  need  know 
nothing  about  this,  the  ease  being  given  over  entirely  to  the  nurse.  As 
improvement  advances,  moderate  physical  and  intellectnal  exercises,  alter- 
nating frequently  with  rest  and  the  administration  of  food,  may  be  under- 
taken. Some  one  hour  of  the  day  may  be  left  free  for  reading,  correspond- 
ence, conversation,  and  games.  In  some  instances  the  writing  of  letters  is 
])articnlarly  harmful  to  the  patient  and  must  be  prohibited  or  limited.  Cul- 
tured individuals  may  find  benefit  from  attention  to  drawing,  painting,  mod- 


1)0  consid- 

lis  piiticiit, 
111'  iiidiviil- 
e  luiH  care- 
roiihlcrf  are 

llicilK!     tllilt 

0  I'diicati'il; 
iccss  lias  to 

tiic  patient 

1  llic  plivsi- 
iist  1)(!  told 
a  vigorous 
is  strength 
the  case  of 
as  a  result 
e  rest  with 
a  month  or 
)sia,  a  rosi- 
fitenuMit  of 

lisease  has 
cr  the  time 
the  patient 
Ticss,  under 
y  of  course 

I  for  a  fev 
ini  away  on 
ref|uired  on 
uld  not  see 
I  he  should 
nake  a  niis- 
'ut  between 
o  means  an 
no  means 
faced,  emo- 
e  care  of  a 

nme,  which 
need  know 
nurse.  As 
■cises,  alter- 
y  be  undor- 
eorrcspond- 
of  letters  is 
nited.  Cul- 
nting,  mod- 


NKURASTIIKNIA. 


11  :U 


filing,  translating  from  a  foreign  language,  the  making  of  abstracts,  etc, 
for  short  periods  in  the  day. 

in  not  a  few  cases,  including  a  large  proportion  of  neurasthenic  women, 
a  systenuitic  Weir  Mitchell  treatnu-nl  rigidly  carried  out  should  be  tried 
(see  llyst(ria).  l-'oi  obstinate  and  protracted  eases,  particularly  if  com- 
bined with  tlu'  chloral  or  morphia  habit,  no  other  plan  is  so  satisfactory. 
The  patient  must  b»'  isolated  from  his  friends,  and  any  regulations  under- 
taken must  be  strictly  adhered  to,  tlu'  consent  of  the  patient  and  his  fiimily 
having  lirst  been  gained.  If  the  case  resi)oii(ls  well  to  the  treatment  tliero 
should  be  a  gain  (d"  from  5i  to  4  jjounds  per  week.  The  benelit  is  often 
extraordimiry,  individuals  increasing  in  weight  as  much  as  frou\  ")()  to  SO 
pounds  in  the  course  of  twelve  weeks.  The  treatment  of  the  gastric  an<l  in- 
tcstimd  symptoms  so  important  in  this  condition  has  already  bi'cn  con- 
sidered. For  the  irregular  pains,  particularly  in  the  back  and  neck,  the 
thermo-cautery  is  invaluable. 

[!ydrothera|)y  is  indicated  in  nearly  every  case  if  it  can  be  properly 
a]iplie(l.  iMueh  can  be  done  at  home  or  in  an  ordinary  hospital,  but  for 
systematic  hydrotherapeutic  tn-atment  residenc.'  in  a  suitable  sanitarium  is 
lU'cessary.  1  have  found  the  wet  i)ack  of  especial  value.  Particularly  at 
night  in  cases  of  sleeplessness  it  is  ])erhaps  tlu;  best  renu'dy  against  in- 
somnia we  have.  Some  patieids  gain  rapidly  in  weight  throu}.h  the  sys- 
tematic WitQ  of  the  wet  pack.  Salt  baths  are  more  helpful  to  some  patients. 
The  various  forms  of  douches,  partial  ])acks,  foot  baths,  etc.,  may  be  valu- 
able in  individual  cases.  The  Scotch  douche  is  often  invigorating  in  the 
milder  cases. 

Electrotherapy  is  of  some  value,  though  only  in  cond)imition  with  psy- 
chic treatment  and  hydrotherai)y.  (Jeneral  and  local  faradization,  galvanic 
electricity,  and  Franklinization  may  be  used;  in  every  case,  however,  with 
great  caution  and  only  by  skilled  operators. 

Treatment  by  drugs  should  be  avoided  as  much  as  possible.  They  are 
of  benefit  ehielly  in  the  combating  of  single  symjjtoms.  A  jdacebo  is 
sometimes  necessary  for  its  psychic  cfTcct.  Alcohol,  morphia,  chloral,  or  co- 
caine should  never  be  given,  'i'lie  fami'"  physician  is  often  resi)onsible  for 
the  development  of  a  drug  habit.  I  have  ])een  repeatedly  shocked  ])y  the 
loose,  careless  way  in  which  jjliysicians  inject  morphia  for  a  simple  head- 
ache or  a  mild  neuralgia. 

General  tonics  may  be  helpful,  esjiecially  if  the  individual  be  ana;nuc. 
Arsenic  and  more  often  iron  are  then  indicated.  The  value  of  phosphorus 
has  been  exaggerated.  For  the  severer  ])ains  and  nervous  attacks  some 
sedative  may  occasionally  be  necessary,  especially  at  the  beginning  of  the 
treatment.  The  bromides,  especially  a  mixture  of  the  salts  of  ammonium, 
potassium,  and  sodium  may  here  be  given  with  advantage.  An  occasional 
dose  of  phcnacetin,  antipyrin,  or  salipyrin  may  ])e  recpiired,  but  the  less  of 
these  substances  Ave  can  get  along  with  the  better.  For  the  relief  of  sleep- 
lessness all  possible  measures  should  be  resorted  to  before  the  employment  of 
drugs.  The  wet  pack  will  usually  suffice.  If  absolutely  necessary  to  give 
a  drug,  sulphonal,  trional,  or  amylene  hydrate  may  bo  employed. 

In  cases  in  which  the  anxiety  conditions  are  disturbing,  the  cautious  use 


1132 


DIsriASRS  op  THE  NERVOUS  SYSTEM. 


(»f  opium  in  pill  form  iiuiy  l»<'  lu'ccssiiry,  Hinc**,  an  in  the  pHyclioHCK,  opium 
lu'iv  will  sonu'tiiiu'rt  yinld  permanent  relief.  A  prolonj,'e(l  treatment  with 
opium  i.s,  however,  lu-vcr  neceHsary  in  neuraHtlienia. 


XIII.    THE    TRAUMATIC    NEUROSES 

(Itailway  liraiii  ttnd  Jiuilwity  Spini' ;  Tiaiiinittii:  Ilyatfiiii). 

Definition. — A  inorl)i<l  con<lilion  following  nhoek  which  prenenls  the 
sym|)lom.s  of  neurasthenia  or  hysteria  or  of  hotii.  'J'lie  condition  is  known 
as  *'  niilway  brain  "  and  "  railway  Hpine." 

Krichsen  re«,'arded  the  condition  as  the  residt  of  inllnmmation  of  '" 
meniiijres  and  cord,  and  pive  it  the  name  railway  spine.  Walton  and 
.  .J.  Putnam,  of  Hoston,  were  the  lirst  to  rec(iji;ni/e  the  hysterical  nature 
of  many  of  the  cases,  and  to  Westphal's  pupils  we  owe  the  name  traumatic 
neurosis.  l''or  an  excellent  discussi(  .  of  the  whole  cpicstion  the  reader  is 
referred  to  I'earce  Uaily's  recent  work,  «)n  .\ccidcnt  and  Injury:  their  liela- 
ticn  t(/  Hiseases  of  the  .Nervous  Systeui. 

Etiology. — The  condition  follows  an  accident,  often  in  a  railway 
train,  in  which  injury  has  been  si:>*taiiu'd,  or  succcedj  a  shock  or  concus- 
sion, from  which  the  patient  may  a|>|tareutly  iH)t  have  sulTered  in  his  hody. 
A  man  may  appear  jtertecily  well  for  several  days,  or  even  a  week  or 
more,  and  then  dcvelo])  the  syuMitoms  of  the  lU'urosis.  Ilodily  shock  or 
concussion  'S  not  necessary.  The  ail'ection  uuiy  foliow  w  profound  mental 
impression;  thus,  an  engine-driver  ran  over  a  child,  and  received  therehy 
a  very  .'severe  shock,  suhsoquent  to  which  the  most  pronounced  sym|t|ouis 
of  neurasthenia  developed.  Severe  nu'utal  str;';n  cond)ined  with  horlily 
exposure  may  cause  it,  as  in  a  case  of  a  naval  ollicer  who  was  wrecked  in 
violent  storm  and  exjiosed  for  more  than  a  day  in  the  rigging  before 
he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage  or  on  the  stairs  nuiy 
sullice. 

Symptoms. — TIk*  cases  may  bo  divided  into  three  groups:  sim])le 
neurasthenia,  cases  with  marked  hysterical  manifestations,  and  cases  with 
severe  symptoms  indicating  or  simnlating  organic  disease. 

(a)  Simple  Trniiniatir  Xnira.^llirnin. — The  lirst  syin])toms  usually  de- 
velop a  few  weeks  after  the  accident,  which  may  or  may  not  have  been 
as.sociatcd  with  an  actual  trauma.  The  ])atient  complains  of  headache 
and  tired  feelings.  He  is  sleepless  and  finds  himself  unable  to  concentrate 
his  attention  properly  upon  his  work.  A  condition  of  nervous  irritaldlity 
develo[)s,  which  may  have  a  host  of  trivial  manifestations,  and  the  entire 
mental  attitude  of  the  person  may  for  a  time  be  changed.  lie  dwells  con- 
stantly upon  his  condition,  gets  very  despondent  and  low-spirited,  and  in 
extreme  cases  melancholia  may  develo]).  He  may  complain  of  numbness 
and  tingling  in  the  extremities,  and  in  some  cases  of  much  pain  in  the 
back.  The  bodily  functions  may  be  well  performed,  though  such  patients 
usually  have,  for  a  time  at  least,  disturbed  digestion  and  loss  in  weight. 
The  ]ihysical  examination  may  be  entirely  negative.  The  reflexes  are 
slightly  increased,  as  in  ordinary  neurasthenia.     The  pupils  may  be  un- 


THF,  TUAUMATIC  NKUIlOSi^. 


1133 


ii'rt,  opiiiin 
IR'Ut   witli 


c'St'nts  the 
is  known 

on  of  ' 
altoii  iiiid 
(ill  iintiirc 
tniiiniiitic 
>  reader  is 
heir  Kcla- 

a  railway 
itr  conciis- 
I  his  body. 
I   week   or 

shock  or 
nd  nu'iital 
'd  1  hereby 

;yiii|t(oiiis 
ith  bodily 
irecked  in 
in<(  l)efore 
stairs  may 

[>s:  simple 
cases  with 

snally  de- 
have  been 

hcadaelie 
onocntrate 
irritability 
ilie  entire 
wells  enn- 
3d,  and  in 

numbne.«s 
lin  in  the 
h  patients 
in  weiirht. 
'flexes  are 
ay  be  \m- 


C(|iial;  tho  cnrdin-vaseuiar  chan^^eH  already  deserilied  in  neurasthenia  may 
be  present  ill  ii  marked  (legrec.  Aecordiuj,'  us  tho  symptoms  are  more 
spimd  or  nioru  (.-erebral,  the  condition  is  known  as  railway  brain  or  rail* 
way  spine. 

(v')  Ciisfs  irilli  Miiiiril  II i/slnirdl  Fealinrs. —  Kollowin;,'  an  injury  of 
Bny  8(  •♦,  neurasthenic  symptoms,  like  those  described  aliove,  may  dev»'lr»p, 
ami  i'  addition  symptoms  repirded  as  characteristic  of  hysteria.  'I'he 
emolioiiai  element  is  prominent,  and  there  is  but  sli^^ht  control  over  tlu! 
iVelin^is.  'I'lie  patients  have  headailie,  backache,  and  vcrli;,n).  A  violent 
tremor  may  be  present,  and  indeed  constitutes  the  most  strikin;,'  feature  of 
the  ease.  I  have  n-ci-ntly  seen  an  engineer  who  developed  sid)se(pu'nt  to 
an  accident  a  series  of  nervous  plienonuMia,  but  the  most  marked  feature 
uas  an  excessive  tri'mor  of  the  entire  body,  which  was  specially  manifest 
during'  emotiomd  e.xcitcnu'nt.  'VUv  most  proniUiiwed  hysterical  symptoms 
are  the  sonsoiy  disturbances.  As  (irst  noted  by  J'ulmim  and  Walton,  hemi- 
ana'sthesia  may  occur  as  a  se(|Uence  <d'  traunuitism.  This  is  a  common 
symptom  in  !•' ranee,  but  rare  in  l'!n;^dand  and  in  this  country.  Achromnlop- 
sia  nuiy  exist  n  tlu'  ana'stlietic  side.  .\  secoiwl,  more  comnM>n,  manifesta- 
tion is  limitation  of  the  field  (jf  vision,  similar  to  that  which  occiirs  in 
hysteria. 

b'emarkal)le  distuibances  nuiy  develop  in  some  of  these  oases.  A  few 
months  a<j;o  I  saw  a  man  who  had  been  struck  by  nn  electric  car,  whose 
chief  symptom  was  an  extraordinary  increase  in  the  number  of  respira- 
tions, lie  was  a  stout,  powerfully  built  man,  and  i)resented  practically  no 
other  symptom  than  dyspmea  of  the  most  extreme  <,'rad(>.  At  the  tinu'  of 
obsei  'ion  his  respirations  were  over  i;{()  per  minute,  and  he  stateil  that 
they  had  been  counted  at  over  \'>',i. 

(3)  Cases  in  which  the  Syniptonis  siii/ni'st  On/nnir  Disrasr  of  llir  llniiit 
and  Cord. — As  a  resnlt  of  spinal  concussion,  without  fracture  or  external 
injury,  there  nuiy  subscMpu'utly  develop  symptoms  su;^'<,'estive  of  orpinic 
disease,  which  may  come  on  rapidly  or  at  a  late  date.  In  a  case  reported  by 
liCyden  the  symptoms  followin<f  the  commission  were  at  (irst  sli<,dit  and  the 
j)atient  was  rejxarded  as  a  simulator,  but  finally  the  condition  became  a<;<,'ra- 
vated  and  death  resulted.  The  ])ost  mortem  showed  a  chronic  pachy- 
nu'uin^itis,  which  had  doubtless  resulted  from  the  accident.  'J'he  cases 
in  this  ^rouj)  about  which  there  is  so  much  discussion  are  those  which  dis- 
])lay  marked  sensory  and  motor  chan^'es.  FoUowinj;  an  accident  in  which 
the  patient  has  not  received  external  injury  a  condition  of  excitemen  nay 
develop  within  a  week  or  ten  days;  he  complains  of  headache  and  back'iche, 
and  on  examination  sensory  distur])ances  are  found,  either  hemiaiiiesthesia 
or  areas  on  the  skin  in  which  the  sensation  is  much  l)enund)ed;  or  painful 
and  tactile  impressions  nuiy  he  distinctly  felt  in  certain  re<jnons.  and  the 
temi)erature  sense  is  absent.  The  distribution  may  be  l)ilateral  and  sym- 
metrical in  litnited  re<xions  or  liemiple<i:ic  in  type.  Tiimitation  of  tlie  field 
of  vision  is  usually  marked  in  these  cases,  and  there  may  be  disturl)ance 
of  the  senses  of  taste  and  smell.  The  snpcrficial  reflexes  may  be  diminished; 
usually  tho  de(>p  reflexes  are  pxpjrfrcrnted.  The  pu|)ils  may  he  unequal;  the 
motor  disturbances  are  variable.     The  French  writers  describe  cases   of 


1134 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


monoplegia  with  or  without  coiitructuro,  symptoms  upon  which  Charcot  lays 
great  stress  as  a  manil'cstatic..  of  profound  hysteria.  The  combination  of 
sensory  disturhances — ana-sthesia  or  hypenesthesia — with  i)aralysis,  i)articu- 
larly  if  mono])h>gic,  and  tiic  occurrence  of  contractures  witiiout  atrophy  and 
witii  normal  electrical  reactions,  nmy  be  regarded  as  distinctive  of  hyoteria. 

In  rare  cases  following  trauma  and  succeeding  to  sym})toms  which  may 
have  been  regarded  as  neurastiienic  or  hysterical,  there  are  organic  changes 
which  may  ])rove  fatal.  That  this  sequence  occurs  is  demonstrated  clearly 
by  recent  post-mortem  examinations.  The  features  upon  which  tlie  greatest 
reliance  can  be  placed  as  indicating  organic  change  are  optic  atrophy,  blad- 
der symptoms,  particularly  in  condjination  with  tremor,  paresis,  and  exag- 
gerated retlexes. 

The  anatomical  changes  in  this  condition  have  not  been  very  definite. 
"When  death  follows  spinal  concussion  within  a  few  days  there  may  be  no 
apparent  lesion,  but  in  some  instances  the  brain  or  cord  has  shown  punc- 
tiform  haemorrhages.  Edes  has  reported  -4  cases  in  which  a  gradual  degen- 
eration in  the  pyramidal  tracts  followed  concussion  or  injury  of  the  spine; 
hut  in  all  these  cases  there  was  marked  tremor  and  the  spinal  symptoms 
developed  early  or  followed  immediately  upon  the  accident.  Post  mortems 
upon  cases  in  which  organic  lesions  have  supervened  upon  a  traumatic 
neurosis  are  extremely  rare.  Bernhardt  reports  an  instance  of  a  man,  aged 
thirty-three,  who  in  1886  received  a  kick  from  a  horse  on  the  epigastrium 
and  subsequently  developed  the  symptom-complex  of  neurasthenia  and  hys- 
teria with  attacks  of  vertigo  and  great  psycliical  depression.  He  afterward 
had  more  marked  mental  symptoms  and  attacks  of  unconsciousness.  He 
committed  suicide  and  the  brain  and  cord  showed  a  beginning  multiple 
sclerosis  in  the  white  matter,  which  was  possibly  associated  with  an  ad- 
vanced grade  of  arterio-sclerosis.  In  a  second  case  a  man,  aged  forty-two, 
received  a  shock  in  a  railway  accident  in  July,  1884.  He  was  rendered 
unconscious  and  had  a  slight  injury  in  the  buttock  region.  In  a  few  weeks 
symptoms  of  traumatic  neurosis  developed,  particularly  great  depression 
of  spirits,  with  headache  and  sensory  disturbances  in  the  feet  and  hands. 
Tremor  and  great  weakness  were  complained  of  when  he  attempted  to 
work.  There  was  no  increase  in  the  reflexes.  The  case  was  regarded  as  an 
instance  of  simulation  and  a  defect  in  objective  symptoms  favored  this 
view.  Subsequently  this  judgment  was  reversed,  but  he  did  not  improve. 
He  died  in  January,  1889,  with  symptoms  of  cardiac  dyspnoea.  Macro- 
scopically  the  brain  and  cord  appeared  normal.  There  was  extreme  arterio- 
sclerosis, particularly  of  the  vessels  of  the  brain  and  cord.  In  the  latter 
there  were  scattered  areas  of  degeneration  in  the  white  substance,  and  de- 
generation in  the  sympathetic  ganglia. 

I  have  entered  somewhat  fidly  into  this  question  because  of  its  extreme 
importance  and  on  account  of  the  paucity  of  tlie  observations  upon  cases 
which  have  subsequently  developed  symptoms  of  organic  disease.  Exam- 
ples of  it  are  extremely  rare.  So  far  as  I  know  no  case  with  autopsy  has 
been  reported  in  this  country,  nor  have  I  seen  an  instance  in  which  the 
clinical  features  pointed  to  an  organic  disease  which  had  followed  upon  a 
traumatic  neurosis. 


THE  TRAUMATIC  NEUROSES. 


1135 


Cliarcot  lays 
ibination  oi' 
sis,  particu- 
atrophy  and 
of  hy;5teria. 
which  may 
nic  changes 
atcd  clearly 
the  greatest 
i-ophy,  blad- 
!,  and  exag- 

}ry  definite. 

may  be  no 
liown  punc- 
dual  degen- 
f  the  spine; 
1  symptoms 
)st  mortems 
I  traumatic 
I  man,  aged 
epigastrium 
lia  and  hys- 
e  afterward 
isness.  He 
ig  multiple 
r'ith  an  ad- 
1  forty-two, 
is  rendered 
I  few  weeks 

depression 
and  hands, 
tempted  to 
irded  as  an 
ivored  this 
)t  improve, 
a.  Macro- 
me  arterio- 
L  the  latter 
ce,  and  de- 
its  extreme 
upon  cases 
ie.  Exam- 
utopsy  has 
which  the 
^ed  upon  a 


Diagnosis. — A  condition  of  fright  and  excitement  following  an  acci- 
dent may  i)ersiat  for  days  or  even  weeks,  and  then  gradually  pass  away. 
The  symptoms  of  neurasthenia  or  of  hysteria  whicli  subsequently  develo[) 
l)resent  nothing  jjcculiar  and  are  identical  with  those  whicli  occur  under 
other  circumstances.  Care  must  be  taken  to  recognize  simulation,  and,  as  in 
these  cases  the  condition  is  largely  subjective,  this  is  sometimes  extremely 
difficult.  In  a  careful  examination  a  simulator  will  often  reveal  himself 
by  exaggeration  of  certain  symptoms,  })articularly  sensitiveness  of  the  spine, 
and  by  increasing  voluntarily  the  reflexes.  Maunkoplf  suggests  as  a  good 
test  to  take  the"  pulse-rate  before,  during,  and  after  ])ressure  upon  an  area 
said  to  be  painful.  If  tiie  rate  is  quickened,  it  is  held  to  be  proof  that  the 
pain  is  real.  This  is  not,  however,  always  the  case.  It  may  require  a  careful 
study  of  the  case  to  determine  whether  the  individual  is  honestly  sull'ering 
from  the  symptoms  of  which  he  complains.  A  still  more  important  ques- 
tion in  these  cases  is.  Has  the  patient  organic  disease?  The  symptoms  given 
under  the  first  two  groups  of  cases  may  exist  in  a  marked  degree  and  may 
persist  for  several  years  without  the  slightest  evidence  of  organic  change. 
Hemianesthesia,  limitation  of  the  field  of  vision,  monoplegia  with  con- 
tracture, may  all  be  present  as  hysterical  manifestations,  from  which  recov- 
ery may  be  complete.  In  our  present  knowledge  the  diagnosis  of  an  organic 
lesion  should  be  limited  to  those  cases  in  which  optic  atrophy,  bladder 
troubles,  and  signs  of  sclerosis  of  the  cord  are  well  marked — indications 
either  of  degeneration  of  the  lateral  columns  or  of  multiple  sclerosis. 

Prognosis. — A  majority  of  patients  with  traumatic  hysteria  recover. 
In  railway  cases,  so  long  as  litigation  is  pending  and  the  patient  is  in  the 
hands  of  lawyers  the  symptoms  usually  persist.  Settlement  is  often  the 
starting-point  of  a  speedy  and  perfect  recovery.  I  have  known  return  to 
health  after  the  persistence  of  the  most  aggravated  symptoms  with  com- 
plete disability  of  from  three  to  five  years'  duration.  On  the  other  hand, 
there  are  a  few  cases  in  which  the  symptoms  persist  even  after  the  litigation 
has  been  closed;  the  patient  goes  from  bad  to  worse  and  psychoses  develop, 
such  as  melancholia,  dementia,  or  occasionally  progressive  paresis.  And, 
lastly,  in  extremely  rare  cases,  organic  lesions  may  develop  as  a  sequence 
of  the  traumatic  neurosis. 

The  function  of  the  physician  acting  as  medical  expert  in  these  cases 
consists  in  determining  (a)  the  existence  of  actual  disease,  and  (b)  its  char- 
acter, wdiether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion. 
The  outlook  for  ultimate  recovery  is  good  except  in  cases  which  present  the 
more  serious  symptoms  above  mentioned.  Nevertheless,  it  must  be  borne 
in  mind  that  traumatic  hysteria  is  one  of  the  most  intractable  affections 
which  we  are  called  upon  to  treat.  In  the  treatment  of  the  traumatic 
neuroses  the  practitioner  may  be  guided  by  the  princi]iles  laid  down  in  the 
preceding  chapter,  in  which  the  treatment  of  neurasthenia  in  general  has 
been  described. 


113G 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


XIV.    OTHER    FORMS    OF    FUNCTIONAL   PARALYSIS. 


/ 


I.  Pkriodical  Paralysis. 

I  liave  already  referred  to  the  remarkable  periodical  paralysis  of  tlic 
ocular  iiuiscles,  which  may  recur  at  intervals  for  many  years.  There  is  a 
form  of  periodical  ])aralysis  involving  the  general  muscles,  which  may 
recur  with  great  regularity,  and  which  is  also  a  "  family  "  aitection.  Gold- 
flam  has  described  a  family  in  which  twelve  members  were  affected  with  this 
disease,  the  heredity  being  through  the  mother.  In  this  country  K.  W. 
Taylor  has  described  in  one  family  11  eases  in  five  generations. 

The  clinical  i)icture  is  very  much  alike  in  all  the  recorded  cases.  The 
paralysis  involves,  a*;  a  nde,  the  arms  and  legs.  It  comes  on  when  the 
l)atients  are  in  full  health,  and  without  any  apj)arent  cause,  ofteu  during 
sleep.  Sometimes  it  begins  with  weakness  in  the  limbs,  a  sensation  of  weari- 
ness and  sleepiness,  not  often  Avith  sensory  symptoms.  The  ])aralysis  is 
usually  com])lcte  within  the  first  twenty-four  hours,  beginning  in  the  legs, 
to  whicli  in  rare  instances  it  is  confined.  The  muscles  of  the  neck  are 
sonietin.es  involved,  and  occasionally  those  of  the  tongue  and  pharynx. 
The  cerebral  nerves  and  the  special  senses  are,  as  a  rule,  uninvolved.  The 
attacks  are  afebrile,  sometimes  vith  low  temperatures  and  slow  pulse.  The 
deep  reflexes  are  reduced,  sometimes  abolished,  and  the  skin  reflexes  may  be 
feeljle.  One  of  the  most  remarkal)le  features  is  the  extraordinary  reduction 
or  complete  abolition  of  the  farad ic  excitability,  both  of  muscles  and  of 
nerves. 

Improvement  begins  sometimes  in  the  course  of  a  few  hours  or  after  a 
day  or  two,  and  the  paralysis  disappears  comi)letely,  and  the  patient  is  ])er- 
fectly  well.  As  mentioned,  the  attacks  may  recur  every  few  weeks,  in  some 
instances  even  daily;  more  commonly,  an  interval  of  one  or  two  weeks 
elapses  between  the  attacks.  There  may  be  signs  of  acute  dilatation  of  the 
heart  during  the  attack.     After  the  fiftieth  year  the  attacks  usually  cease. 


II.  Astasia;  Abasia. 

These  terms,  indicating  respectively  inability  to  stand  and  inability  to 
walk,  have  been  applied  by  Charcot  and  Ulocq  to  diseased  conditions  char- 
acterized by  loss  of  the  power  of  standing  or  of  walking,  with  retention  of 
muscular  power,  coordination,  and  sensation.  Blocq's  definition  is  as  fol- 
lows: "A  morbid  state  in  which  the  im])ossibility  of  standing  erect  and 
walking  normally  is  in  contrast  with  tlie  integrity  of  sensation,  of  muscu- 
lar strength,  and  of  the  coordination  of  the  other  movements  of  the  lower 
extremities."  The  condition  forms  a  sym])tom  group,  not  a  morbid  entity, 
and  is  probalily  a  functional  neurosis.  Knajjp  in  his  monograph  analyzes 
the  50  cases  reported  in  the  literature.  Twenty-five  of  these  were  in  men, 
25  in  women.  In  21  cases  hysteria  was  ])resent;  in  3,  chorea;  in  2,  epi- 
lepsy; and  in  4,  intention  psychoses.  As  a  rule,  the  patients,  though  able 
to  move  the  feet  and  legs  perfectly  when  in  bed,  are  either  unable  to  walk 
properly  or  cannot  stand  at  all.     The  disturbances  have  been  very  varied. 


RAYNAUD'S  DISEASE, 


1137 


LYSIS. 


lysis  of  tlie 
Tliero  is  a 
which  iiiiiy 
ion.  Gohl- 
'(1  witli  this 
iitiy  ]<:.  W. 

cases.  The 
1  when  the 
Fton  during 
jii  of  weari- 
])aralysis  is 
in  the  legs, 
le  neck  are 
(1  pliarynx. 
ilved.  Tlio 
pulse.  The 
'xcs  may  Ije 
y  reduction 
cles  and  of 

3  or  after  a 
lent  is  ]ier- 
ks,  in  some 
two  weeks 
tion  of  the 
uallv  cease. 


inahility  to 

tions  char- 

etention  of 

1  is  as  fol- 

erect  and 

of  musen- 

f  the  lower 

'bid  entity, 

)li  analyzes 

're  in  men, 

in  2,  epi- 

liougli  able 

)le  to  walk 

ery  varied, 


and  dilTercnt  forms  have  been  recognized.  The  commonest,  according  to 
Knajip's  analysis  of  the  recorded  cases,  is  the  |)araiytic,  in  which  the  legs 
give  out  as  the  patient  attempts  to  walk  and  "  bend  under  him  as  if  made 
of  cotton."'  "  There  is  no  rigidity,  no  s^jasm,  no  incoiirdination.  In  bed, 
sitting,  or  even  while  suspended,  the  muscular  strength  is  found  to  be  good." 
Other  cases  are  associated  with  sjmsra  or  ataxia;  thus  there  may  be  move- 
ments which  stilfen  the  legs  and  give  to  the  gait  a  somewhat  spastic  char- 
acter. In  other  instances  there  are  sudden  flexions  of  the  legs,  or  even  of 
the  arms  a  saltatory,  spring-like  sjjasm.  In  a  majority  of  the  cases  it 
is  a  man.'        ition  of  a  neurosis  allied  to  hysteria. 

The  cases,  as  a  rule,  recover,  particularly  in  young  persons.  RelaiJses 
arc  not  uncommon.  The  rest  treatment  and  static  electricity  should  be 
employed. 


YIII.   YASO-MOTOE  AND  TEOPHIC   DISORDEES. 
I.    RAYNAUD'S    DISEASE. 

Definition. — A  vascular  disorder,  ]u-obably  dependent  upon  vaso- 
motor influences,  characterized  by  three  grades  of  intensity:  (a)  Local  syn- 
cope, (b)  local  asphyxia,  and  (c)  local  or  symmetrical  gangrene. 

Local  Syncope. — This  condition  is  seen  most  frequently  in  the  extremi- 
ties, producing  the  condition  known  as  dead  fingers  or  dead  toes.  It  is 
analogous  to  that  produced  by  great  cold.  The  entire  hand  may  be  affected 
with  the  fingers;  more  commonly  only  one  or  more  of  the  fingers.  This 
feature  of  the  disease  rarely  occurs  alone,  but  is  generally  associated  with 
local  asphyxia.  The  common  sequence  is  as  follows:  On  exposure  to  slight 
cold  or  in  consequence  of  some  emotional  disturbance  the  fingers  become 
white  and  cold,  or  both  fingers  and  toes  are  affected.  The  pallor  may  con- 
tinue for  an  indefinite  time,  though  usually  not  more  than  an  hour  or  so; 
then  gradually  a  reaction  follows  and  the  fingers  get  burning  hot  and  red. 
This  does  not  necessarily  occur  in  all  the  fingers  together;  one  finger  may 
be  as  white  as  marble,  while  the  adjacent  ones  are  of  a  deep  red  or  plum 
color. 

Local  Aspliyxia. — Chilblains  form  the  mildest  grade  of  this  condition. 
It  usually  follows  the  local  syncope,  l)ut  it  may  come  on  independently. 
The  fingers  and  toes  are  oftenest  affected,  next  in  order  the  ears;  more 
rarely  portions  of  the  skin  on  the  arms  and  legs.  During  an  attack  the 
fingers  alone,  sometimes  the  hands,  also  swell  and  become  intensely  con- 
gested. In  the  most  extreme  grade  the  lingers  are  perfectly  livid,  and  the 
capillary  circulation  is  almost  stagnant.  The  swelling  causes  stiffness  and 
usually  ])ain,  not  acute,  but  due  to  the  tension  and  distention  of  the  skin. 
Sometimes  there  is  marked  anicsthesia.  Pain  of  a  most  excruciating  kind 
mny  be  present.  Attacks  of  this  sort  may  recur  for  years,  and  be  brought 
on  by  the  slightest  exposure  to  cold  or  in  conseqiumce  of  disturbances,  either 
mental  or,  in  some  instances,  gastric.  Apart  from  this  unpleasant  symp- 
■     71 


1138 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


/ 


if'  '1 

I;  ■' 


1      I 


torn  the  general  health  may  he  very  good.  The  condition  is  always  worse 
during  the  winter,  and  may  he  present  only  when  the  external  temperature 
is  low. 

Local  or  Symmetrical  Gangrene. — The  mildest  grade  of  this  condition 
follows  the  local  asphyxia,  in  the  chronic  cases  of  which  small  uefcrotic 
areas  are  sometimes  seen  at  the  tips  of  the  fingers.  Sometimes  the  pads 
of  the  fingers  and  of  the  toes  are  quite  cicatricial  from  repeated  slight  los^ses 
of  this  kind.  So  also  when  the  ears  are  all'ected  there  may  he  superficial 
loss  of  siihstance  at  the  edge.  The  severer  cases,  which  terminate  in  ex- 
tensive gangrene,  are  fortunately  rare. 

In  an  attack  the  local  asphyxia  persists  in  the  fingers.  The  terminal 
phalanges,  or  perhaps  the  end  of  only  one  finger,  hecome  hlack,  cold,  and  in- 
sensihle.  The  skin  hegins  to  necrose  and  superficial  gangrenous  hleus  appear. 
Gradually  a  line  of  demarkation  shows  itself  and  a  portion  of  one  or  more  of 
the  fingers  sloughs  away.  The  resulting  loss  of  suhst  ince  is  much  less  than 
the  appearance  of  the  hand  or  foot  would  indicate,  and  a  condition  which 
looks  as  if  the  patient  would  lose  all  the  fingers  or  half  of  a  foot  may  result 
perhaps  in  only  a  slight  superficial  loss  in  the  phalanges.  In  severer  cases 
the  greater  portion  of  a  finger  or  the  tip  of  the  nose  may  be  lost.  Occa- 
sionally the  disease  is  not  confined  to  the  extremities,  but  affects  sym- 
metrical patches  on  the  limbs  or  trunk,  and  may  pass  on  to  rapid  gangrene. 
These  severe  types  of  cases  occur  particularly  in  young  children,  and  death 
may  result  within  three  or  four  days.  The  attacks  are  usually  very  pain- 
ful, and  the  motion  of  the  part  is  much  impaired.  In  some  cases  numbness 
and  tingling  persist  for  a  long  time. 

The  climax  of  this  series  of  neuro-vascular  changes  is  seen  in  the  re- 
markable instances  of  extensive  multiple  gangrene.  They  are  most  com- 
mon in  children,  and  may  progress  with  frightful  rapidity.  In  the  Medico- 
Chirurgical  Society's  Transactions,  vol.  xxii,  there  is  an  extraordinary  case 
reported,  in  which  the  child,  aged  three,  lost  in  this  way  both  arms  above 
the  elbow,  and  the  left  leg  below  the  knee.  There  also  had  been  a  spot 
of  local  gangrene  on  the  nose.  Spontaneous  amputation  occurred,  and  the 
child  made  a  complete  recovery.  The  cases  are  more  frequent  than  has 
been  supposed,  and  an  illustration  is  given  by  "Weeks,  of  Marion,  Ohio,  in 
which  the  boy  had  rheumatic  pains  in  the  legs,  and  purpuric  blotches  de- 
veloped before  the  gangrene  began  (Medico-Surgical  Bulletin,  July  1, 
1894). 

Therp  are  remarkable  concomitant  symptoms  in  Raynaud's  disease  to 
which  a  good  deal  of  attention  has  been  paid  of  late  years.  Haemoglobi- 
nuria  may  develop  during  an  attack,  or  may  take  the  place  of  an  outbreak. 
In  such  instances  the  affection  is  usually  brought  on  by  cold  weather.  In 
a  case  reported  by  H.  M.  Thomas  from  my  clinic,  Raynaud's  disease  occurred 
for  three  successive  winters  and  always  in  association  with  haimoglobinuria. 
The  attacks  were  sometimes  preceded  by  a  chill.  Several  cases  of  the  kind 
are  found  in  Barlow's  appendix  to  his  translation  of  Raynaud's  paper  for 
the  New  Sydenham  Society.  The  onset  with  a  chill,  as  in  the  case  just 
mentioned,  has  doubtless  given  rise  to  the  idea  that  the  disease  is  in  some 
way  associated  with  ague.     Cerebral  symptoms,  particularly  mental  torpor 


u :-;(::. 


ERYTHROMELALOIA. 


1139 


Iways  worse 
toiiiporatuie 

is  condition 
lall  uefcrotic 
les  the  pads 
slight  losses 
e  superficial 
inate  in  ex- 
he  terminal 
iold,  and  in- 
)lcijs  appear. 
e  or  more  of 
ch  less  than 
iition  which 
t  may  result 
severer  cases 
lost.  Occa- 
affects  sym- 
id  gangrene. 
I,  and  death 
{  very  pain- 
ts numbness 

in  the  re- 
most  com- 
the  Medico- 
'dinary  case 
arms  above 
been  a  spot 
ed,  and  the 
it  than  has 
)n,  Ohio,  in 
jlotches  de- 
in,   July    1, 

3  disease  to 
Ijemoglobi- 
n  oiitbreak. 
eather.  In 
ise  occurred 
3globinuria. 
of  the  kind 
's  paper  for 
le  case  just 
is  in  some 
ntal  torpor 


and  transient  loss  of  consciousness,  have  also  been  noticed  in  some  cases. 
Tiio  case  just  mentioned  with  luvmoglobinuria  had  opilej)sy  with  the  at- 
tacks. Exposure  on  a  cold  day  would  bring  on  an  epileptic  seizure  witli 
the  local  as})hyxia  and  bloody  urine.  Another  patient,  the  subject  for  years 
of  Raynaud's  disease,  has  had  many  attacks  of  transient  hemii)legia  on  one 
side  or  the  other,  when  on  the  right  side  with  aphasia.  Since  the  second 
edition  of  this  work  was  issued  she  died  in  an  attack.  Occasionally  joint 
affections  develop,  particularly  anchylosis  and  thickening  of  the  phalan- 
geal articulations.  Southey  has  reported  a  case  in  which  mania  developed, 
and  liarlow  an  instance  in  which  the  woman  had  delusions.  Peripheral 
neuritis  has  been  found  in  several  cases. 

The  pathology  of  this  remarkable  disease  is  still  obscure.  Raynaud 
suggested  that  the  local  syncope  was  produced  by  contraction  of  the  vessels, 
which  seems  likely.  The  asphyxiu  is  dependent  upon  dilatation  of  the 
capillaries  and  small  veins,  probably  with  the  persistence  of  some  degree 
of  spasm  of  the  smaller  arteries.  There  are  two  totally  dilTerent  forms  of 
congestion,  which  may  be  shown  in  adjacent  fingers;  one  may  be  swollen, 
of  a  vivid  rod  color,  extremely  hot,  the  capillaries  and  all  the  vessels  fully 
distended,  and  the  anaemia  produced  by  pressure  m.ay  be  instantaneously 
o])literated;  the  adjacent  finger  may  be  equally  swollen,  absolutely  cyanotic, 
stone  cold,  and  the  ana[>mia  produced  by  pressure  takes  a  long  time  to 
disappear.  In  the  latter  case  the  arterioles  are  probably  still  in  a  condition 
of  spasm. 

Treatment. — In  many  cases  the  attacks  recur  for  years  uninfluenced 
by  treatment.  Mild  attacks  require  no  treatment.  In  the  severer  forms 
of  local  asphyxia,  if  in  the  feet,  the  patient  should  be  kept  in  bed  with  the 
legs  elevated.  The  toes  should  be  wrap])ed  in  cotton-wool.  The  i)ain  is 
often  very  intense  and  may  require  morphia.  Carefully  applied,  systematic 
massage  of  the  extremities  is  sometimes  of  benefit.  Galvanism  may  be  tried. 
Barlow  advises  immersing  the  affected  limb  in  salt  water  and  placing  one 
electrode  over  the  spine  and  the  other  in  the  water.  Nitroglycerin  has  been 
warmly  recommended  by  Cates. 


II.    ERYTHROMELALOIA   (Red  Neuralgia). 

Definition. — "  A  chronic  disease  in  which  a  part  or  parts — usually  one 
or  more  extremities — suffer  with  pain,  flushing,  and  local  fever,  made  far 
worse  if  the  parts  hang  down  "  (Weir  Mitchell).  The  name  signifies  a  pain- 
ful, red  extremity. 

Symptoms. — In  1872  (Phila.  Med.  Times,  November  23d),  in  a  lec- 
ture on  certain  painful  affections  of  the  feet,  "Weir  ^Mitchell  described  the 
case  of  a  sailor,  aged  forty,  who  after  an  African  fever  began  to  have  "  dull, 
heavy  pains,  at  first  in  the  left  and  soon  after  in  the  right  foot.  There  was 
no  swelling  at  first.  When  at  rest  he  was  comfortable  and  the  feet  were 
not  painful.  After  walking  the  feet  were  swollen.  They  scarcely  pitted 
on  pressure,  but  were  purple  with  congestion;  the  veins  were  everywhere 
singularly  enlarged,  and  the  arteries  were  throbbing  visibly.     The  whole 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


■  I 


foot  was  said  to  be  aching  and  l)nmiiig,  but  above  the  ankle  there  was 
neither  swelling,  j)ain,  nor,  tlushing."  As  the  weather  grew  cool  he  got 
relief.  Notliing  seemed  to  benefit  him.  This  brief  summary  of  Mitcheirs 
iirst  Ciise  gives  an  aceurate  clinical  i)ic(ure  of  the  disease.  His  second  com- 
municalion,  On  a  Kare  N'aso-motor  Neurosis  of  tlie  Kxtremities,  a})peart'd 
in  the  Am.  .Four,  of  the  ^ledical  Sciences  for  July,  1878,  while  in  his  Clin- 
ical Ia'ssous  on  Nervous  iJiseases,  18!)7,  will  be  found  additional  observa- 
tions. 

The  disease  is  rare.  Rost  states  that  there  are  only  about  40  instances  in 
the  literature.  The  feet  are  much  more  often  att'ected  than  the  hands.  The 
]min  may  be  of  the  most  atrocious  character.  It  is  usually,  but  not  always, 
relieved  by  cool  weather;  in  one  of  my  cast's  the  winter  aggravate.?  tlie  trou- 
ble. Jn  n  few  ca.^^es  (Klsner,  Dehio,  KoUeston)  the  affection  has  been  com- 
j)licated  with  Raynaud's  disease. 

]\Iitchell  speaks  of  it  as  a  "  painful  nerve-end  neuritis."  Dehio  suggests 
that  there  may  be  irritation  in  the  cells  of  the  ventral  horns  of  the  cord 
at  certain  levels.  Excision  of  the  nerves  ])assing  to  the  parts  has  been  fol- 
lowed by  relief.  In  one  of  MitchelTs  cases  gangrene  of  .the  foot  followed 
excision  of  four  inches  of  the  musculo-cutaneous  nerve  and  stretching  of  the 
posterior  tibial.    Sclerosis  of  the  arteries  was  found. 


111.    ANGIO-NEUROTIC  CEDEMA. 


Definition. — An  affection  characterized  by  the  occurrence  of  local 
edematous  swellings,  more  or  less  limited  in  extent,  and  of  transient  dura- 
tion. Severe  colic  is  sometimes  associated  with  the  outbreak.  There  is  a 
marked  hereditary  disposition  in  the  disease. 

Symptoms. — The  (odema  a[)pears  suddenly  and  is  usually  circum- 
scribed. It  may  appear  in  the  face;  the  eyelid  is  a  common  situation;  or 
it  may  involve  the  li])s  or  cheek.  The  backs  of  the  hands,  the  legs,  or  the 
throat  may  be  attacked.  Usually  the  condition  is  transient,  associated  per- 
haps with  slight  gastro-intestinal  distress,  and  the  affection  is  of  little 
moment.  There  may  be  a  remarkable  periodicity  in  the  outbreak  of  the 
(edema.  In  ]\fatas'  case  this  ])eriodicity  was  very  striking;  the  attack  came 
on  every  day  at  eleven  or  twelve  o'clock.  The  disease  may  be  hereditary 
through  many  generations.  In  the  family  whose  history  I  reported,  five 
generations  had  ])een  affected,  including  twenty-two  members.  The  swell- 
ings apy)ear  in  various  parts;  only  rarely  arc  they  constant  in  one  locality. 
The  hands,  face,  and  genitalia  are  the  ])arts  most  frequently  affected.  Itch- 
ing, heat,  redness,  or  in  some  instances,  urticaria  may  ])recede  the  out- 
break. Sudden  (edema  of  the  larynx  may  prove  fatal.  Two  members  of 
the  family  just  referred  to  died  of  this  complication.  In  one  nuunber  of  this 
family,  whom  I  saw  repeatedly  in  attacks,  the  swellings  came  on  in  different 
parts;  for  example,  the  under  lip  would  be  swollen  to  such  a  degree  that 
the  month  could  not  be  opened.  The  hands  enlarge  suddenly,  so  that  the 
fingers  cannot  be  bent.  The  attacks  recur  every  three  or  four  weeks.  Ac- 
companying them  are  usually  gastro-intestinal  attacks,  severe  colic,  pain, 


FACIAL  HEMIATROPHY. 


1141 


!  there  was 
tool  he  got 
f  iMitcheira 
lOeond  com- 


!S 


,  appeared 
ill  his  Clin- 
lal  ohserva- 


instances  in 
lands.  The 
not  alway^i, 
e3  the  trou- 
i  been  eom- 

lio  suggests 
oi'  the  cord 
as  been  i'ol- 
x)t  followed 
ching  of  the 


nee  of  local 
nsient  dura- 
There  is  a 


nausea,  and  KomctimeR  vomiting.  It  is  <iiiite  |)ossible  iliat  some  of  the  cases 
of  Iveyden's  intermittent  vomiting  may  belong  to  this  group.  The  colic 
is  of  great  intensity  and  usually  reciuires  morphia.  Arthritis  apparently 
does  not  occur.  I'eriodic  attacks  of  eardialgia  have  also  been  met  with  dur- 
ing the  outbreak  of  the  oedema.  Jlienu)globimiria  has  occurred  in  several 
cases. 

The  disease  has  afinities  with  urticaria,  the  giant  form  of  which  is 
probably  tiie  same  disease.  There  is  a  form  of  severe  jturpura,  often  with 
urticarial  manifestations,  which  is  also  associated  with  marked  gastro- 
intestinal crises,  and  it  is  interesting  to  note  that  Schlesingcr  has  reported 
a  case  in  which  a  cond)ination  of  erythromelalgia,  Jiaymiud's  disease,  ami 
acute  a'dema  occurred.  Quincke  regards  the  condition  as  a  vaso-motor 
jieurosis,  under  the  influence  of  which  the  ])ermeal)ility  of  the  vessels  is 
suddenly  increased,  ^lilroy,  of  Omaha,  has  described  cases  of  hereditary 
cedema,  twenty-two  individuals  in  six  generations,  in  whicii  there  existed 
from  birth  a  solid  a'dema  «f  one  or  of  both  legs,  without  any  special  incon- 
venience or  any  ])rogres  ive  increase  of  the  disease. 

Some  years  ago  1  described  a  remarkable  vaso-motor  neurosis  chiirac- 
terized  by  stvcUing  and  tumefaction  of  the  whole  arm  on  exeiiioii.  My  ])atient 
was  a  man,  healthy  in  every  other  respect.  Kecently  in  l*hilad('l|)hia  a, 
similar  case  has  been  observed.  On  the  supposition  that  liiere  might  liC' 
pressure  on  the  axillary  vessels  these  were  exposed,  but  nothing  was  found. 

The  treatment  is  very  unsatisfactory.  In  the  cases  associated  with  aiue- 
mia  and  general  nervousness,  tonics,  i)articularly  large  doses  of  strychnia, 
do  good;  but  too  often  the  disease  resists  all  treatment.  I  have  seen  great 
improvement  follow  the  prolonged  use  of  nitroglycerin. 


ally  circum- 
situation;  or 
i  legs,  or  the 
sociated  per- 
is of  little 
break  of  the 
attack  came 
le  hereditary 
eported,  five 
The  swell- 
one  locality, 
ected.    Itch- 
ide  the  out- 
members  of 
unber  of  this 
1  in  different 
,  degree  that 
,  so  that  the 
weeks.    Ac- 
!  colic,  pain, 


IV.     FACIAL    HEMIATROPHY. 

An  affection  characterized  by  ])rogressive  wasting  of  the  bones  and  soft 
tissues  of  one  side  of  the  face.  The  atrophy  starts  in  childhood,  but  in  a 
few  cases  has  not  come  on  until  adult  life.  Perhaps  after  a  trilling  injury 
or  disease  the  process  begins,  either  diffusely  or  more  commonly  at  one  spot 
on  the  skin.  It  gradually  sjireads,  involving  the  fat,  then  the  bones,  more 
])articularly  the  ui)per  jaw,  and  last  and  least  the  muscles.  The  wasting 
is  sharply  limited  at  the  middle  line,  and  the  appearance  of  the  patient  is 
very  remarkable,  the  face  looking  as  if  made  u])  of  two  halves  from  dill'er- 
cnt  persons.  There  is  usually  change  in  the  color  of  the  skin  and  the  hair 
falls.  Owing  to  the  wasting  of  the  alveolar  processes  the  teeth  become  loose 
and  ultimately  drop  out.  The  eye  on  the  affected  side  is  sunken,  owing  to 
loss  of  orbital  fat.  There  is  usually  hemiatrophy  of  the  tongue  on  the  same 
side.  Disturbance  of  sensation  and  muscle  twitching  may  precede  or  ac- 
company the  atrophy.  In  a  majority  of  the  cases  the  atrophy  has  l)een 
confined  to  one  side  of  the  face,  but  there  are  instances  on  record  in  which 
the  disease  was  bilateral,  and  a  few  cases  in  which  there  were  areas  of  atro- 
phy on  the  back  and  on  the  arm  of  the  same  side,  The  disease  is  rare;  only 
about  100  cases  are  in  the  literature  (Mobius). 


1112 


disb:ases  op  the  nervous  system. 


/ 


Of  tlio  iiut()i)si('s,  ^londol's  alone  is  siitiHfactory.  There  was  tlie  terminal 
stage  ol'  an  interstitial  neuritis  in  all  the  branches  of  the  trigeminus,  from 
its  origin  to  the  jjeriphery,  most  marked  in  the  superior  maxillary  branch. 

The  disease  is  recognized  at  a  glance.  The  facial  asymmetry  associated 
with  congenital  wryneck  must  not  be  confounded  with  ])rogressive  facial 
hemiatrophy.  Otiier  conditions  to  be  distinguished  arc:  Facial  atrophy 
in  anterior  polio-myelitis,  and  more  rarely  in  the  hemiplegia  of  infants  and 
adults;  the  atrophy  following  nuclear  lesions  and  sympathetic  nerve  paraly- 
sis; acquired  facial  hemihypertroi)hy,  such  as  in  the  case  recorded  by  1), 
W.  ^Montgomery,  which  may  by  contrast  give  to  the  other  side  an  atroi)hic 
appearance;  and,  lastly,  scleroderma  (a  closely  related  affection),  if  conllned 
to  one  side  of  the  face.  The  precise  nature  of  the  disease  is  still  doubtful, 
but  it  is  a  suggestive  fact  that  in  many  of  the  cases  the  atrophy  has  followed 
the  acute  infections.    It  is  incurable. 


V.    ACROMEGALY. 

Definition. — A  dystrophy  characterized  by  abnormal  processes  of 
growth,  chiefly  in  the  bones  of  the  face  and  extremities. 

The  term  was  introduced  by  Marie,  and  signifies  large  extremities. 

Etiology. — It  occurs  rather  more  frequently  in  women.  '  'lie  affection 
usually  begins  about  the  twenty-fifth  year,  though  in  some  instances  as  late 
as  the  fortieth.  Kheumatism,  syphilis,  and  the  specific  fevers  have  pre- 
ceded the  development  of  the  disease,  but  probably  have  no  special  connec- 
tion with  it.    In  this  country  many  cases  have  now  been  reported. 

Symptoms. — In  a  well-marked  case  the  disease  presents  most  char- 
acteristic features.  The  hands  and  feet  are  greatly  enlarged,  but  are  not 
deformed,  and  can  be  used  freely.  The  hypertrophy  is  general,  involving 
all  the  tissues,  and  gives  a  curious  spade-like  character  to  the  hands.  The 
lines  on  the  palms  are  much  deepened.  The  wrists  may  be  enlarged,  but 
the  arms  are  rarely  affected.  The  feet  are  involved  like  the  hands  and  are 
uniformly  enlarged.  The  big  toe,  however,  may  be  much  larger  in  propor- 
tion. The  nails  are  usually  broad  and  large,  but  there  is  no  curving,  and  the 
terminal  phalanges  are  not  l)ulbous.  The  head  increases  in  volume,  but  not 
as  much  in  proportion  as  the  face,  which  becomes  much  elongated  and  en- 
larged in  consequence  of  the  increase  in  the  size  of  the  superior  and  inferior 
maxillary  bones.  The  latter  in  particular  increases  greatly  in  size,  and  often 
projects  beloAv  the  upper  jaw.  The  alveolar  processes  are  widened  and  the 
teeth  se])aratcd.  The  soft  parts  also  increase  in  size,  and  the  nostrils  are 
large  and  broad.  The  eyelids  are  sometimes  greatly  thickened,  and  the 
ears  enormously  hypertrophied.  The  tongue  in  some  instances  becomes^ 
greatly  enlarged.  Late  in  the  disease  the  spine  may  be  affected  and  the 
back  bowed — kyphosis.  The  bones  of  the  thorax  may  slowly  and  pro- 
gressively enlarge.  "With  this  gradual  increase  in  size  the  skin  of  the  hands 
and  face  may  appear  normal.  Sometimes  it  is  slightly  altered  in  color, 
coarse,  or  flabby,  but  it  has  not  the  dry,  harsh  appearance  of  the  skin  in 
niyxocdema.  .  The  muscles  are  sometimes  w'asted.     Changes  in  the  thyroid 


! 


I  the  torniiniil 
ominufl,  from 
illiiry  branch, 
try  assoc'iutt'il 
;rt'«sive  I'ac'iiil 
acial  atrophy 
)f  infants  and 
nerve  i)araly- 
icordcd  by  1), 
le  an  atrophic 
n),  if  confined 
still  doubtful, 
y  has  followfd 


ACROMEGALY. 


1143 


processes 


of 


trcmities. 
^  "he  affection 
stances  as  late 
rers  have  pre- 
pecial  connec- 
orted. 

its  most  char- 
1,  but  are  not 
!ral,  involving 
}  hands.  The 
enlarged,  but 
hands  and  are 
ger  in  propor- 
rving,  and  the 
)lurae,  but  not 
gated  and  en- 
)r  and  inferior 
size,  and  often 
dened  and  the 
\e  nostrils  are 
oncd,  and  the 
mces  becomes, 
ected  and  the 
)wly  and  pro- 
1  of  the  hands 
ered  in  color, 
of  the  skin  in 
in  the  thyroid 


Iiavo  been  found,  but  are  not  constant.  The  gland  has  been  normal  in 
some,  atrophied  in  others,  and  in  a  tiiinl  gr()ii|)  of  cases  enlarged.  Erb,  who 
has  nuule  an  elaborate  study  of  the  (hsease,  iuis  noticed  an  area  of  dulness 
over  the  manubrium  sterni,  which  he  tiiought  possibly  due  to  the  jjcrsist- 
ence  or  enlargement  of  the  thymus.  Headache  is  not  uiu'onnnon.  Somno- 
lence has  been  noted  in  many  cases.  Menstrual  (listurl)aMce  may  oceur 
early,  and  there  nuiy  be  suppression.  Ocular  tijjinploms  are  common.  Ilertel 
iias  analyzed  175  recorded  cases,  J)2  of  which  j)resented  eye  com{)lications. 
In  three  fourths  of  these  the  optic  nerves  were  aU'ected — usually  atrophy, 
rarely  neuritis.  Bitemporal  hemianopia  is  often  an  early  sign.  The  disease 
may  persist  for  fifteen,  twenty,  or  more  years. 

Patholixjical  Analomy. — Furnival  has  recently  analyzed  the  recorded  au- 
topsies, 34  in  number.  Changes  in  the  pituitary  gland  were  found  in  all, 
and  in  the  majority  there  was  hypertrophy  or  tumor.  In  5^4  cases  in  which 
it  was  examined  the  thyroid  was  normal  in  5,  hypertrophied  in  one  half;  the 
thymus  in  17  examined  was  absent  in  7,  hypertrophied  in  3,  and  persistent 
in  7.  In  Osborne's  case  the  heart  was  enormous,  weighing  2  pounds  U 
ounces. 

Owing  to  the  remarkable  changes  in  the  pituitary  gland  in  acromegaly, 
it  has  been  suggested  that  the  disease  is  a  nutritional  disturbance  analogous 
to  myxcedema,  and  caused  directly  by  disturbance  in  the  function  of  this 
organ.  The  evidence  from  comparative  anatomy  and  embryology  shows 
that  the  pituitary  body  is  a  very  "  comi)lex  organ,  consisting  of  an  anterior 
secreting  glandidar  organ;  a  water-vascular  duct;  a  ])osterior,  sensitive, 
nervous  lobe,  of  which  the  last  two — namely,  the  duct  and  the  nervous  lobe 
— were  morphologically  well  developed  and  functioned  in  ancestral  verte- 
brates, but  liave  become  obliterated  and  atrophied  in  structure  and  func- 
tion forever  above  larval  acraniatcs  "  (Andriezen,  British  Medical  Journal, 
1<S94,  i).  The  pituitary  body  continues  active,  but  the  duct  is  obliterated 
'•  and  the  gland  changed  into  a  ductless  gland;  the  secretion  becomes  an 
'  internal  secretion,' "  which  is  absorbed  by  the  lymphatics.  The  extraor- 
dinary frequency  with  whi^h  the  pituitary  is  involved  in  this  disease  lends 
weight  to  the  view  that  it  is,  in  the  words  of  Woods  Ihitchinson, 
the  growth  centre,  or  at  any  rate  the  proportion  regulator  of  the  skeleton. 

It  has  been  suggested  by  Massalongo  and  others  that  gigantism  and 
acromegaly  are  one  and  the  same  disease,  both  due  to  the  superfunction 
of  the  pituitary  gland.  Certain  persons  exhibited  as  giants,  or  who  have 
been  "  strong  men  "  and  wrestlers,  have  become  acromegalic,  and  the  skulls 
of  some  notable  giants  show  enormous  enlargement  of  the  sella  turcica. 

There  is  a  congenital  progressive  hypertrophy  of  one  extremity  or  of  a 
part  of  it  or  of  one  side  of  the  body — the  so-called  giant  growth,  which  docs 
not  appear  to  have  any  connection  with  acromegaly. 

The  treatment  does  not  appear  to  have  any  influence  upon  the  progress 
of  the  disease.  The  thyroid  extract  has  been  tried  in  many  cases,  without, 
so  far  as  my  personal  experience  goes,  any  benefit.  Extract  of  the  pituitary 
gland  has  also  been  used.  The  lung  extract  has  been  employed  in  some 
cases  of  pulmonary  osteo-arthropathy.  In  a  case  of  Caton's,  of  Liverpool, 
an  unsuccessful  attempt  was  made  to  extirpate  the  pituitary  body. 


1144 


DISKASKS  OP  THE  KEUVOUH  HYSTKM. 


OsTiMTis  Dkkoumank  {VdijcCs  Disease). 

In  lliis  romnrkablo  nfTcfliou  tlio  hlinfts  (tf  ili(?  Iniip;  l)(<nos  arc  chiefly 
involved,  iiiid  in  llic  liead  llu'  hones  of  the  criUiiiiin,  but  not  those  ol"  tlio 
face.  It  's  a  rare  disease.  The  hones  eniar^'e  and  sol'ten,  and  tliose  heav- 
ing weight  hecoine  unnaturally  curved  and  misshapen.  At  its  coninience- 
niont,  and  sonu'tinicH  throiigli  all  its  courrio,  it  is  attended  with  pains  in  the 
a  (reel  0(1  Ixines. 

The  hone  siructure  sIiowr  a  mixture  of  rarefying  osteitis,  with  the 
Haversian  canals  large  and  irregular,  and  of  forniative  osti;itis,  with  cer- 
tain Haversian  canals  narrowed  and  lamella;  of  recent  formation. 

Tiiere  is  an  intinuite  relation  hetwcen  ost-Mtis  deformans  and  the  fornui- 
tion  of  malignant  tumors.  Of  8  cases  traced  to  tlie  end,  5  died  with  cancer 
or  sarcoma. 

About  (iO  cases  liave  now  been  recorded,  most  of  tliem  in  England. 
Seven  have  been  reported  in  America.  'J'he  most  tyjjical  case  is  one  re- 
ported by  Watson  in  the  Johns  Jiojjkins  llos])ital  Hulletin  for  June,  1S!)8. 
T  saw  the  man  lirst  in  July,  1S!)7.  At  the  age  of  forty-two  he  was  strong 
and  healthy,  nu-asuring  5  feet  11:{  inches  in  height.  His  tibite  began  to 
enlarge  and  bow  forward  and  outward,  tiie  thoracic  s])inc  to  curve,  and  the 
cranial  hones  to  enlarge.  This  has  steadily  j)rogresse(l.  He  is  now  sixly-two 
years  of  age.  At  ])resent,  owing  to  the  bowing  of  the  sjjine  and  lower  ex- 
tremities, his  height  is  about  5  feet  2J  inches,  or  !J|  inches  less  than 
formerly.  The  circumference  of  his  head  has  increased  3^^  inches.  His 
thorax  is  almost  perfectly  quadrilateral.  ]Iis  intellect  is  imimpaired,  and 
his  general  health  is  fairly  good  (Watson). 

As  ]\laric  states,  in  Pagct's  disease  the  face  is  triangular  with  the  base 
upward;  in  acromegaly  it  is  oToid  or  ogg-shapcd  with  the  large  end  down- 
ward; while  in  niyx(cdema  it  is  round  and  full-moon-shapcd. 

Concerning  the  etiology  of  the  disease,  absolutely  nothing  is  known. 
No  method  of  treatment  has  had  the  slightest  influence  upon  its  progress. 

IIypeiitroi'iiic  I'uLMoxAitY  Artiihopatjiy. 

!Marie  has  given  the  name  hi/perfrophic  pnlnionary  ostco-arfhropalhy  to 
a  remarkable  disorder,  first  recognized  by  Baml)erger,  characterized  by  en- 
largement of  the  hands  and  feet,  and  of  the  ends  of  the  long  bones,  cliiefly 
of  the  lower  three  fourths  of  the  forearm  and  legs.  Unlike  acromegaly, 
the  bones  of  the  skull  and  of  the  face  are  not  involved.  The  terminal 
phalanges  arc  much  si)read  with  both  transverse  and  longitudinal  curves; 
the  nails,  too,  are  large  and  much  curved  over  the  ends  of  the  ])lialanges. 
Scoliosis  and  kyphosis  are  rarely  seen.  The  disease  is  very  chronic,  and  in 
nearly  all  cases  has  been  associated  with  some  long-standing  aiTt  ?tion  of 
the  bronchi,  lungs,  or  pleura  (hence  the  name  pnlmonory  odeo-arthropntlni), 
of  which  sarcoma,  chronic  bronchitis,  chronic  tuberculosis,  and  empyemn 
have  been  the  most  frequent.  There  are  several  instances  in  which  the 
aflPection  has  developed  in  the  subjects  of  syphilis.  It  occurs  usually  in 
adults  and  in  the  male  sex.     Thayer  has  reported  4  cases  from  my  clinic 


8CLKR0D  ^TlMA. 


1145 


arc  chiefly 

hosi'  of  tlio 

tliose  hcaf- 

coiniiieiK'u- 

[laiiis  in  the 

>(,  with  the 
s,  with  c'cr- 
1. 

the  fonim- 
with  cancer 

n  England. 
3  is  one  re- 
June,  1S!)8. 
was  stronfT 
a'  he<ian  to 
•ve,  and  the 
)w  sixLy-two 
d  h)wer  ex- 
s  less  than 
iiclies.  His 
l)aired,  and 

th  the  hase 
end  dowu- 

l  is  known, 
progress. 


nnd  has  collected  T)')  typical  cases  from  the  literuturr.  Forty-three  showed 
]ireceding  pulmonary  all'ection;  of  tlie  remaining?,  :i  followed  sypliilis,  3 
heart-disease,  I'  chronic  diarrlm-a,  1  spinal  curies,  U!id  3  unknown  causes. 

'i'lie  essential  patliolo^'y  of  the  disease  is  very  obscure.  Alarie  suf,'f,'('sls 
that  the  toxincs  of  llie  pidnionury  disease  are  absorbed  into  the  circulatiiui 
and  exercise  an  irritant  action  on  the  bony  and  articular  structures,  caus- 
ing,' an  ossifyiuff  jK-riostitis.  Thorbiirn  thinks  that  it  is  a  chronic  tubercu- 
lous aU'ection  of  a  larf;e  number  of  bones  and  joints  of  a  benign  type. 

Lhontlasis  Osska. 

Finally,  in  n  reniarkahlc  condition  known  as  lcoiill(tf<i's  nsttca,  there  is 
hyperostosis  of  the  l)oru's  of  the  (;raniuin,  and  sonu'tiiues  those  of  the  face. 
Tlu!  description  is  largely  leased  upon  the  skulls  in  uiuseuuis,  hut  Allen 
Starr  has  recently  reported  an  instance  in  a  woman,  who  presented  a  slowly 
])rogressing  increase  in  the  size  of  the  head,  face,  and  neck,  the  hard  and 
soft  tissues  both  Ix'ing  alVected.  He  has  a]»plie(l  to  the  condition  the  term 
vic</(tlu-<r/)li(ili/.  I'ulnam  states  that  the  disease  begins  in  eai'ly  life,  often 
as  a  result  of  injury.  There  may  be  osteophytic  growths  from  the  outer  or 
inner  tables,  which  in  the  lattei  situation  nuiy  give  the  symptoms  of  tumor. 

MlCnOMKOALY. 

A  reniarkahlc  condition,  the  antithesis  of  acromegaly,  has  been  de- 
scribed by  Jonathan  Hutchinson  and  Hastings  (Jilford  (Lancet,  18!)(!,  ii,  p. 
I::i:;i7)  as  "  mixed  prenuiture  and  immature  development."  The  name  viicro- 
mef/alij  is  suggested  by  (jlilford,  who  describes  it  as  a  disease  of  that  part  of 
the  nervous  system  presiding  over  nutrition,  which  manifests  itself  in  a 
smallness  and  inunaturity  of  some  parts  or  functions  and  a  relative  or 
actual  largeness  or  prematurity  of  others. 


hropatJiy  to 

ized  by  en- 

)nes,  chiefly 

acromegaly, 

16  terminal 

nal  curves; 

])lialanges. 

•nic,  and  in 

jfftction  of 

rthropnthi/), 

d  empyema 

which  the 

usually  in 

1  my  clinic 


VI.    SCLERODERMA. 

Definition. — A  condition  of  localized  or  diffuse  induration  of  the 
skin. 

Lewin  and  Heller  (Die  Sclerodermic,  Berlin,  1895)  have  recently  col- 
lected from  the  literature  508  cases. 

Two  forms  are  recognized:  the  circumscriljed,  which  corresponds  to 
the  keloid  of  Addison,  and  to  morph(ea;  and  the  diffuse,  in  which  large 
areas  are  involved. 

The  disease  affects  females  more  frequently  than  males.  The  oases 
occur  most  commonly  at  the  middle  period  of  life.  The  sclerema  neona- 
torum is  a  different  affection,  not  to  he  confounded  with  it.  The  disease  is 
more  common  in  this  country  than  statistics  indicate.  I  have  roi)orted  8 
cases  (Jour,  of  Genito-Urinary  and  Cutaneous  Diseases,  January,  1898), 
since  which  date  I  have  seen  3  additional  cases. 

In  the  circumscribed  form  there  are  patches,  ranging  from  a  few  centi- 


1140 


DISKASKS  OP  TFIK  NRIIVOUS  SYSTEM. 


iiu'tros  in  (liiuiicttT  to  tlic  size  of  the  liaml  or  larger,  in  wliitli  the  >ikiii  ]\;\< 
a  woxy  or  (Icad-uliito  appcaranco,  nnd  to  the  touch  iH  hrawny,  hard,  and 
inclaHtic.  SonictiinoH  there  iH  a  preliminary  hypera>inia  of  the  skin,  and 
Hults('(piciiliy  tlifre  are  chanj^'es  in  color,  either  areas  of  pi^Miienlalion  or  of 
coin|>U'tc  atrophy  of  (he  pi^nnent — h'ucoih'rina.  TIk'  Hi-nsory  ehangen  are 
rarely  marked.  The  neeretion  of  sweat  in  •limininhed  or  entirely  aholislud. 
The  diNcaHe  iH  more  common  in  women  than  in  men,  and  Ih  nituated  most 
frecpiently  ahont  the  hreastn  and  neck,  K(»metiineH  in  the  eoin-se  of  the 
nerves.  The  iiatehes  may  devehtp  with  ^'reat  rapidity,  and  may  persist  fur 
inonlliH  or  years;  Hometimes  they  disappear  in  a  few  weeks. 

The  diffuse  form,  though  less  common,  is  more  eerious.  It  develops 
firHt  in  the  extremiticH  or  in  the  face,  and  the  patient  notices  that  the  nkin 
is  nnuHually  hard  and  firm,  or  that  there  is  a  sense  of  HtilTness  or  tension 
in  m. iking  accustomed  movements.  (Jraduaily  a  dilfuse,  hrawny  induia- 
tion  developH  nnd  the  skin  hecomcs  firm  and  hard,  and  so  united  to  the 
Huhcutaneous  tissues  that  it  ennnot  he  picked  np  or  jtinehed.  The  skin 
nuiy  look  natural,  hut  more  commonly  is  glossy,  drier  th.in  normal,  and 
unusually  smooth.  With  reference  to  the  localization,  in  (!()  ohservations 
the  disease  was  universal;  in  'ZO'i,  regions  of  the  trunk  were  all'ccted;  in 
193,  parts  of  the  head  or  face;  in  287,  portions  of  one  or  other  of  the  upper 
extremities;  and  in  122,  portions  of  the  lower  extremities.  In  80  cases 
the^e  were  disturbances  of  sensation.  The  disease  nuiy  gradually  extend 
nnd  involve  the  skin  of  an  entire  limb.  When  universal,  the  face  is  ex- 
jiressionless,  the  lips  cannot  be  moved,  mastication  is  liindered,  and  it  may 
become  extremely  diHicult  to  feed  the  patient.  The  hands  become  fixed  and 
the  fingers  immobile,  on  account  of  the  extreme  induration  of  the  skin 
over  the  joints.  Remarkable  vaso-motor  disturbances  are  connnon,  as  ex- 
treme cyanosis  of  the  hands  and  legs.  In  one  of  my  cases  tachycardia  was 
present.  The  disease  is  chronic,  lasting  for  months  or  years.  There  are 
instances  on  record  of  its  persistence  for  more  than  twenty  years.  Recovery 
may  occur,  or  the  disease  may  be  arrested.  The  patients  arc  a])t  to  siu-- 
cumb  to  ])inmoiuiry  comidaints  or  to  nephritis.  Ilheumatic  troubles  have 
been  noticed  in  some  instances;  in  others,  endocarditis.  Raynaud's  disease 
may  be  associated  with  it,  as  in  2  cases  described  by  Stephen  ^Mackenzie.  I 
have  seen  an  instance  of  the  diffuse  form  in  wliich  the  primary  symptoms 
were  those  of  local  asphyxia  of  the  fingers,  and  in  which,  with  extensive 
scleroderma  of  the  arms  and  hands  and  face,  there  were  cyanosis  and  swell- 
ing of  the  skin  of  the  feet  without  any  brawny  induration.  The  pigmenta- 
tion of  the  skin  may  be  as  deep  as  in  Addison's  disease,  for  which  cases  have 
been  mistaken;  scleroderma  may  occur  as  a  complication  of  exophthalmic 
goitre. 

The  remarkable  dystrophy  known  as  schrodactylie  belongs  to  this  dis- 
order. There  are  symmetrical  involvements  of  the  fingers,  which  become 
deformed,  shortened,  and  atrophied;  tlio  skin  becomes  thickened,  of  a 
waxy  color,  and  is  sometimes  pigmented.  P.ulliie  and  ulcerations  have 
been  laet  with  in  some  instances,  and  a  great  deformity  of  the  nails.  The 
disease  has  usually  followed  exposure,  and  the  patients  are  much  worse 
during  the  winter,  and  are  '"riously  sensitive  to  cold.     There  may  be 


SCLEnoDEnMA. 


114T 


lie  skin  h:\^ 
,  hani,  lUid 
>  skin,  iiimI 
iiition  (tr  nt' 

y  al)olisli<  il. 
tuatt'il  iiioHt 
urnt!  of  tlu' 
,■  persist  f<»r 

It   (li'Vi'lnps 
Imt  the  fkin 
H  or  tension 
vny  ii\tlm'a- 
iiited  to  the 
.     The  skin 
normal,  and 
ohscrvations 
uircc'ted;  in 
of  the  uppor 
In  80  cases 
iially  extend 
0  I'aoe  is  cx- 
,  and  it  may 
me  fixed  and 
of  the  skin 
imon,  as  ex- 
lycardia  was 
There  are 
8.    Recovery 
a])t  to  sue- 
onbles  have 
aud's  disease 
ackcnzie.     I 
ry  symptoms 
th  extensive 
is  and  swell- 
le  pigmenta- 
ih  cases  liave 
xophthalmic 

to  this  dis- 
liicli  become 
koned,  of  a 
rations  have 
'  nails.    The 

much  worse 
lere  may  be 


olinnpcs  in  the  »kin  of  the  feet,  hut  the  (h'formity  simihir  to  that  uhieh 
oeeui'H  in  the  hand  has  not  been  noted.  Some  of  tlie  cases  present  in  addi- 
tion dilTuse  s(  lerodermalons  ehanj^es  of  the  skin  of  other  parts.  In  Lewiii 
and  Heller's  inono^^Miiph  there  ari'  M.')  eases  of  isolatcil  selerodai-tylism,  and 
!(»(!  eases  in  which  it  was  eond»ini'd  with  scleroderma. 

The  patholof^y  o'  the  disease  is  unknown.  It  is  usually  regarded  as  a 
tropho-iu'urosis,  probably  depen<lent  upon  changes  in  the  arteries  of  the 
skin  leading  to  ecdim'ctive-tissue  overgrowth.  The  thyroid  has  been  fouml 
alrophie(|. 

i?reatment. — The  patients  recpiire  to  be  warndy  clad  and  to  '<e 
guarded  against  exjMJSure,  as  they  are  particidarly  sensitive  to  changes  .  ■ 
the  weather.  Warm  liatlis  followed  by  frictions  with  oil  should  be  sys- 
tematically used.  I  have  tried  the  thyroid  feeding  thoroughly  in  the  dif- 
fuse form  without  success.  In  a  recei  t  ease  of  (juite  exti'Usive  localized 
scleroderma,  after  ten  weeks'  treatment,  the  patches  are  softer  and  the  pig- 
mentation much  less  intense.  Salol  in  ir)-grain  doses  three  times  a  day  is 
stated  to  have  been  successful  in  several  cases. 


TTerc  a  brief  reference  may  bo  made  to  the  remarkable  trophic  lesion 
described  by  Da  Silva  Lima,  which  is  met  witli  in  negroes  in  Brazil,  Africa, 
India,  and  occasionally  in  the  Southern  States.  It  is  confined  to  the  toes, 
usually  the  little  toe,  and  begins  as  a  furrow  on  the  line  of  the  digito- 
])lantar  fold.  This  gradually  deepens,  the  end  of  the  toe  enlarges,  and, 
usually  without  inflammation  or  ])ain,  the  too  falls  olf.  The  process  may 
last  some  years.  Cases  have  been  reported  in  this  country  by  Iloruaday, 
I'ittman,  F.  J.  Sliephcrd,  and  Morrison. 


.  I 

/ 


SECTION  XL 


DISEASES   OF  THE    MUSCLES. 


1.    MYOSITIS. 


Definition.' — Inflammation  of  the  voluntary  muscles. 

A  prijiiary  myositis  occurs  as  an  acute  or  subacute  afTection,  and  if? 
probably  dependent  on  some  iir  known  infectious  agent.  Several  charac- 
teristic cases  have  been  described  of  late  years.  That  of  K.  A\'agner  may 
be  taken  as  a  tyjiical  example.  A  tuberculous  but  well-built  woman  entered 
tlie  hospital,  complaining  of  stilfness  in  the  shoulders  and  a  slight  eedema 
of  the  back  of  the  hands  and  forearms.  There  was  par{\?sthesia,  the  arms 
became  swollen,  the  skin  tense,  and  the  muscles  "elt  doughy.  Gradually 
tlie  thighs  became  atfected.  The  disease  lasted  about  three  months.  Tlie 
post  mortem  showed  slight  pulmonary  tuberculosis;  all  the  muscles  except 
the  glutei,  the  calf,  and  abdominal  muscles  were  stiff  and  firm,  but  fragile, 
and  there  Avere  serous  infiltration,  great  i)roliferation  of  the  interstitial 
tissue,  and  fatty  degeneration.  Similar  cases  have  been  reported  by  Un- 
verricht,  Ilepp,  and  Jacoby,  of  New  York.  In  the  case  reported  by  Jacol)y 
the  muscles  were  firm,  hard,  and  tender,  and  there  Avas  slight  (vdema  of  the 
skin.  The  duration  of  the  cases  is  usually  from  one  to  tiiree  months,  though 
tliere  are  instances  in  which  it  has  been  longer.  The  swelling  and  tender- 
ness of  the  muscles,  the  oedema,  and  the  pain  naturally  suggest  trichinosis, 
and  indeed  ITepp  speaks  of  it  as  a  pseudo-trichinosis.  The  nature  of  the 
disease  is  unknown.  Senator's  case  presented  marked  disorders  of  sensa- 
tion, and  there  is  a  question  whether  the  peripheral  nerves  arc  not  involved 
with  the  muscles.  "Wagner  suggests  that  some  of  these  cases  were  examples 
of  acute  progressive  muscular  atrophy.  The  separation  from  trichinosis 
can  be  made  only  by  removing  a  portion  of  the  muscle.  It  has  not  yet  l)een 
determined  whether  tlie  eosinophilia  descril)ed  by  Thrown  is  peculiar  to  the 
trichinous  myositis.  There  are  septic  cases  in  which  a  diffuse,  puruleni 
infiltration  of  the  muscles  of  different  regions  occurs.  Instances  haA^e  been 
re]iorted  in  A\diich  this  has  been  described  as  the  primary  affection,  the  con- 
dition of  the  muscles  even  passing  on  to  gangrene. 
1148 


MYOTONIA. 


1149 


Myositis  Ossificans  PnooREsgiVA. 

Of  till?  raro  ivnd  rciiiiukaljlu  allVctiou  A2  cases  liave  boon  recorded  (Mat- 
tlies).  The  process  bej^ins  within  the  neck  or  buck,  nsiially  with  avvelling 
of  the  ull'eeted  nniseles,  rednesa  of  the  skin,  and  slight  fever.  After 
snhsiding  an  induration  remains,  which  becomes  i)r()gressively  harder  as 
the  transrormation  into  bone  takes  place.  The  disease  is  very  chronic,  and 
nltimately  may  involve  a  majority  of  the  skeletal  muscles.  .Nothing  is 
known  of  tiie  etiology;  the  condition  has  often  been  associated  with  mal- 
formations. 


'tion,  and  is 
k-eral  charac- 
Wagnev  may 
»man  entered 
light  oedema 
da,  the  arms 
.  Gradually 
lonths.  The 
usclcs  except 
,  bnt  fragile, 
e  interstitial 
irted  by  Un- 

d  by  Jacoby 
edema  of  the 
nths,  though 

and  tender- 
it  trichinosis, 
latnre  of  the 
ers  of  ponsii- 

not  involved 
•ere  examples 
n  trichinosis 

not  yet  lieen 
'culiar  to  the 
use,  pnrnlont 

es  have  l)een 
ion,  the  con- 


II.    MYOTONIA  {.Thomaen'a  Disease). 

Definition. — An  infection  characterized  by  tonic  cramp  of  the  mus- 
cles on  attempting  voluntary  movements.  The  disease  received  its  name 
from  the  physician  who  first  described  it,  in  whose  family  it  has  existed 
for  live  generations. 

While  the  disease  is  in  a  majority  of  cases  hereditary,  hence  the  name 
myotonia  c(mgenita,  there  are  other  forms  of  spasm  very  similar  which  may 
be  ac(piired,  and  others  still  which  are  ipiite  transitory. 

Etiology. — All  the  typical  cases  have  occurred  in  family  groups;  a 
few  isolated  instances  have  been  described  in  which  similar  symptoms  have 
been  present.  The  disease  is  rare  in  this  country  and  in  Kngland;  it  seems 
more  common  in  (iormany  and  in  Scandinavia. 

Symptoms. — The  disease  comes  on  in  childhood.  It  is  noticed  that 
on  account  of  the  stiffness  the  children  are  not  able  to  take  part  in  ordi- 
nary games.  The  peculiarity  is  noticed  only  during  voluntary  movements. 
The  contraction  which  the  patient  wills  is  slowly  accomplished;  the  relaxa- 
tion which  the  ])atient  wills  is  also  slow.  The  contraction  often  persists  for 
a  little  time  after  he  has  dropi)ed  an  object  which  he  has  picked  u[).  Tn 
walking,  the  start  is  difTicult;  one  leg  is  put  forward  slowly,  it  halts  from 
stiffness  for  a  second  or  two,  and  then  after  a  few  steps  the  legs  become 
limber  and  he  walks  witliout  any  difhculty.  The  muscles  of  the  arms  and 
legs  are  those  usually  im])licated;  rarely  the  facial,  ocular,  or  laryngeal  mus- 
cles. Emotion  and  cold  aggravate  the  condition.  In  some  instances  there 
is  mental  weakness.  The  sensation  and  the  reflexes  are  normal.  G.  j\[. 
TTammond  has  reported  three  remarkable  cases  in  one  family,  in  which  the 
disease  began  at  the  eighth  year  and  was  confined  entirely  to  the  arms.  It 
Avas  accom])anied  with  sonu'  slight  mental  feebleness.  Th(>  condition  of  the 
nniscles  is  interesting.  ^Fhc  patients  a])])ear  and  are  muscular,  and  there 
is  sometimes  a  definite  hypertropliy  of  the  mnscles.  The  force  is  scarcely 
proportionate  to  the  size.  Erb  has  described  a  characteristic  reaction  of 
the  nerve  and  muscle  to  the  ehvtrical  currents — the  so-called  myolonic 
reaction,  the  chief  feature  of  whidi  is  fhat  normally  the  contractions  caused 
by  either  current  attain  their  maximum  slowly  and  relax  slowly,  and  ver- 
micular, wave-like  contractions  pass  from  the  cathode  to  the  anode. 

The  disease  is  incurable,  bnt  it  may  bo  arrested  temporarily.  The  na- 
ture of  the  affection  is  nnknown.    In  the  only  antojisy  made  Dejerine  and 


1150 


DISEASES  OF  THE  MUSCLES. 


Sottas  have  found  hypertrophy  of  the  primitive  fibres  with  multiplication 
of  the  nuclei  of  all  the  muscles,  including  the  diaphragm,  but  not  the 
heart.  The  spinal  cord  and  the  nerves  were  intact.  From  Jacoby's  recent 
studies  it  is  doubtful  whether  these  changes  in  the  muscles  are  in  any  way 
characteristic  or  peculiar  to  the  disease.  No  treatment  for  the  condition  is 
known. 

III.    PARAMYOCLONUS    MULTIPLEX 

{Myoclonia), 

An  affection,  described  by  Friedreich,  characterized  by  clonic  contrac- 
tions, chiefly  of  the  muscles  of  the  extremities,  occurring  either  constantly 
or  in  paroxysms. 

The  cases  have  been  chiefly  in  males,  and  the  disease  has  followed  emo- 
tional disturbance,  fright,  or  straining.  The  contractions  are  usually  bilat- 
eral and  may  vary  from  fifty  to  one  hundred  and  fifty  in  the  minute.  Occa- 
sionally tonic  spasms  occur.  They  are  not  accompanied  by  any  sensory 
disturbances.  In  the  intervals  between  the  attacks  there  may  be  tremors  of 
the  muscles.  In  the  severe  spasms  the  movements  may  be  very  violent;  the 
body  is  tossed  about,  and  it  is  sometimes  difficult  to  keep  the  patient  in  bed. 
Gucci  has  described  a  family  in  which  the  affection  has  occurred  in  three 
generations. 

Weiss  has  also  noted  heredity  in  four  generations.  According  to  this 
author  the  essential  symptoms  are  continuous  or  paroxysmal  muscular  con- 
tractions, usually  symmetrical  and  rhythinical,  of  muscles  otherwise  normal, 
which  cease  during  sleep.  There  are  neither  psychical  nor  sensory  disturb- 
ances. The  condition  is  most  common  in  young  males,  and  is  unaffected 
by  treatment.  Raymond  groups  this  disease  with  fibrillary  tremors,  electric 
chorea  (Henoch),  tic  non  douloureux  of  the  face,  and  the  convulsive  tic, 
nnder  the  name  of  myoclonies,  believing  that  it  is  only  one  link  in  a  chain 
of  pathological  manifestations  in  the  degenerate. 


ultiplication 
but  not  the 
oby's  recent 
in  any  way 
condition  is 


INDEX. 


Qic  contrac- 
r  constantly 

llowed  emo- 
sually  bilat- 
mte.  Occa- 
any  sensory 
J  tremors  of 
violent;  the 
lent  in  bed. 
•ed  in  three 

ling  to  this 
isoular  con- 
'ise  normal, 
)ry  disturb- 

unaffeeted 
ors,  electric 
vulsive  tic, 

in  a  chain 


Abasia,  1126, 1186. 

Abdominal  typhua,  1. 

Abducens  nerve  (see  Sixth  Nehve),  1048. 

Aberrant,  thyroid  glands*,  836  ;  ai.renalft,  896. 

Abortion,  in  relapsing  fever,  55 ;  in  small-pox, 

65  ;  in  syphilis,  251. 
Abscess,  atheromatous,  771 ;  of  brain,  1025 ;  in 

appendicitis,  522,  526 ;  in  glanders,  235 ;  of 

kidney  (pyonephrosis),  886 ;  of  liver,  577 ;  of 

lung,  662;  of  mediastinum,  686;  of  parotid 

gland,  447 ;  of  tonsils,  452 ;  perinephric,  900 ; 

cerebral,  1025 ;  pysemie,  163;  retro-pLaryngeal, 

450,  971. 
Acanthooephala,  365. 
Acardia,  765. 

Acarus  scabiei,  A.  folliculorum,  876. 
Accentuated   aortic   second  sound,  in   chronic 

Bright's  disease,  881 ;  in  arterio-sclerosis,  774. 
Accessory  spasm,  1064. 
Acephalocysta  (see  IIvdatid  Cysts). 
Acetontemia,  426. 
Acetone,  424 ;  tests  for,  424. 
Acetonuria,  864. 
Achondroplasia,  841. 
Achromatopsia  in  hysteria,  1116. 
Acliylia  gastrica,  501. 
Acne,  from  bromide  of  potassium,  1101 ;  rosacea, 

882. 
Acromegaly,  1142,  and  gigantism,  1143. 
Actinomycosis,  235 ;  pulmonary,  236 ;  cutaneous, 

237 ;  cerebral,  237. 
Acute  bulbar  paralysis,  933. 
Acute  yellow  atrophy,  551. 
Addison's  disease,  828;  pill,  254;  keloid,  1145. 
Adenie,  809. 

Adenitis  in  scar!'.,  fever,  81. 
Adenitis,  tuberculous,  282,  812 ;  malignant,  191. 
Adenoid  growths  in  pharynx,  454. 
Adherent  pericardium,  696. 
Adhesive  pylephlebitis,  554. 
Adrenals  in  Addison's  disease,  829. 
^gophony,  120,  670. 
Afferent  system,  diseases  of,  920. 
Ageusia,  1060. 
Agoraphobia,  1124, 
Agrapliia,  992. 
Ague,  202. 


Ague  cake  (see  Enlaroed  Spleen),  216. 

Ainhum,  1147. 

"Air-hunger"  in  diabetes,  426. 

Akinesia  algera,  1126. 

Akoria,  503. 

Albini,  nodules  of,  767. 

Albinism,  in  leprosy  (lepra  alba),  341;  of  the 
lung,  656. 

Albumin,  tests  for,  856. 

Albuminous  expectoration  in  pleurisy,  678. 

Albuminuria,  854,  and  life  assurance,  858 ;  cy- 
clic, 855 ;  febrile,  855 ;  functional,  855  ;  in  acute 
Bright's  disease,  870;  in  chronic  Bright's  dis- 
ease, 880  ;  in  diabetes,  424 ;  in  diphtheria,  l.iO ; 
in  epilepsy,  1097  ;  in  erysipelas,  159;  in  gout, 
415;  in  pneumonia,  122;  in  scarlet  fever,  V!), 
80  ;  in  typhoid  fever,  31 ;  in  variola,  64  ;  neu- 
rotic, 855;  physiological,  855;  prognosis  in, 
858. 

Albuminuric  retinitis,  1039. 

Albuminuric  ulceration  of  the  bowels,  513.  . 

Albumosuria,  857. 

Alcaptonuria,  865. 

Alcohol,  oft'ects  of,  on  the  digestive  system,  381 ; 
on  the  kidneys,  382;  on  the  nervous  system, 
381 ;  poisonous  effects  of,  381. 

Alcoholic  neuritis,  1034. 

Alcoholism,  380;  acute,  380;  and  tuberculosis, 
382;  chronic,  380. 

Alexia,  992. 

Algid  form  of  malaria,  215. 

Allantiasis,  391. 

AUocheiria,  924. 

Allorrhythmia,  756. 

AUoxuric  bodies  in  gout,  409. 

Alopecia,  in  syphilis,  241. 

Alternating  paralysis  (see  Crossed  Paralysis). 

Altitude,  effects  of  high,  346. 

Altitude  in  tuberculosis,  259,  334. 

Amaurosis,  hysterical,  1040,  1116  ;  to.xic,  1040  ; 
urtemic,  867,  881 ;  in  hasmatemesis,  496. 

Amblyopia,  1040  ;  tobacco,  1040  ;  crossed,  1044. 

Ambulatory  typhoid  fever,  14,  34. 

Ama'ba  coli  (amceba  dysenteriie),  195 ;  in  liver 
abscess,  195,  577  ;  in  sputa,  201. 

Ama3bic  dysentery,  195. 

Ammouitcmia,  838. 

1151 


1152 


INDEX. 


•  I 


Ariinosin,  miditory,  900  ;  tnctile,  990  ;  visual,  990. 

Aiiiiilioric  breatliiii/^,  a09,  OSJl. 

Aiiiplioric  echo,  30U. 

Amu.siii,  yjl. 

Amyloid  disiMise,  in  phthisis,  298;  in  syphilis, 
%12  ;  of  kidnoy,  8S4  ;  of  liver,  5S(). 

Aiiiyo.sthenia,  1125. 

Aniyotrophio  luteriil  sclerosis,  928, 

Aniumiu,  7H9 ;  bothriocephiilus,  3()7 ;  in  nnehy- 
lostoniiasis,  300  ;  from  Uilhurziii,  352  ;  in 
cliloro.si8,  792  ;  Irom  gastric  ntrophy,  409  ; 
from  liiL'iiiorrhngc,  789 ;  miner's,  300 ;  briuk- 
miiker's,  3(j0  ;  tunnel,  360  ;  from  inanition, 
791;  from  lead,  387;  idiopatliic,  795;  in  gas- 
tric cancer,  489  ;  in  gastric  ulcer,  482  ;  moun- 
tain, 340,  300  ;  in  malarial  fever,  210  ;  in 
rheumatism,  170  ;  in  sypliilis,  240  ;  in  tjphoid 
fever,  19  ;  prinuiry  or  essential,  792 ;  pmgres- 
sive  pernicious,  795;  seeondury  or  symptom- 
atic, 789  ;  of  spinal  cord,  900 ;  splenic,  834 ; 
to.\ic,  791. 

Aniemic  mumuira  (8e«»  H.emic  Murmurs). 

AniBsthesia,  dolorosa,  970 ;  in  hemiplegia,  1005; 
in  liysteria,  1115;  in  leprosy,  342;  in  loco- 
motor ataxia,  924 ;  in  Morvnn's  disease,  975 ; 
in  lailway  spine,  1134  ;  in  unilateral  lesions  oi" 
the  cord,  965. 

Analgesia  in  hysteria,  1115;  in  Morvan's  dis- 
ease, 975;  in  syringo-myeliu,  975. 

Anarthria,  988. 

Anasarca  (see  Dropsy). 

Ancliylostomiasis,  359. 

Anchyloatomum  duodennle,  359. 

Aneurism,  776 ;  arterio -venous,  77S,  788 ;  cir- 
soid, 776  ;  congenital,  788  ;  cylindrical,  776  ; 
dissecting,  770 ;  embolic,  776  ;  false,  776  ;  fusi- 
form, 776 ;  mycotic,  776 ;  of  the  abdominal 
aorta,  786 ;  of  the  branches  of  the  abdominal 
aorta,  787  ;  of  the  cerebral  arteries,  1013 ;  of 
the  c(jeliac  axis,  787  ;  of  heart,  753  ;  of  the  he- 
patic artery,  787 ;  of  the  renal  artery,  787 ;  of 
the  splenic  artery,  787  ;  of  the  superior  mesen- 
teric artery,  787  ;  true,  776. 

Aneurism,  of  thoracic  aorta,  777;  hemorrhage 
in,  781 ;  pain  in,  781 ;  Tufnell's  treatment  of> 
784  ;  uailateral  sweating  in,  782. 

Aneurism,  verminons,  in  the  horse,  359,  777. 

Angina,  Ludovici,  450  ;  simplex,  448  ;  suffoca- 
tiva,  138. 

Anirina  pectoris,  761 ;  pseudo-  or  hysterical,  763: 
toxic,  764  ;  vaso-motoria,  704. 

Angiocholitis,  chronic  catarrhal,  557;  suppura- 
tive and  ulcerative,  557. 

Ansrio-neurotic  axlema,  1140. 

Anirio-sclcrosis.  773. 

An<ruillula  stcrcoralis,  A.  intestinalis,  364. 

Animal  lymph,  72. 

Anisocoria,  1047. 

Ankle    clonus,  in    hysterical    paraplegia,    941, 


1114;    in   spastic    parajilegia,  937;    spurious, 
1114. 

Anorexia  nervosa,  503,  1117. 

Anosmia,  1038. 

Anterior  cerebral  artcr      inbolism  of,  1011. 

Anterior  crural  nerve,  paralysis  of,  1072. 

Anthorayia  canicularis,  378, 

Anthraoosis,  of  lungs,  652  ;  of  liver,  570. 

Anthrax,  224;  bacillus,  224;  in  animals,  224; 
external,  225;  internal,  220. 

Antlirojiopliobia,  1124. 

Antipneumonic  serum,  113. 

Antipneumotoxin,  112. 

Antitoxino  of  diphtheria,  141,  155;  of  pneu- 
monia, 112;  of  tetanus,  233. 

Antityphoid  vaccine,  42. 

Anuria,  850 ;  complete,  from  stone,  850 ;  hys- 
terical, 851.  (, 

Anus,  imperfonite,  533. 

Aorta,  aneurism  of,  777 ;  dynamic  pulsation  of, 
782;  throbbing,  786,  1126;  tuberculosis  of, 
327. 

Aortic  incompetency,  709;  sudden  death  in, 
712. 

Aortic  orifice,  congenital  lesions  of,  767. 

Aortic  stenosis,  715. 

Aortic  valves,  bicuspid  condition  of,  766 ;  in- 
sufficiency of,  709, 

Apex  pneumonia,  123, 

Aphasia,  988 ;  anatomical  localization  of,  992 ; 
ataxic,  991  ;  hemiplegia  with,  991 ;  in  in- 
fantile hemiplegia,  1018 ;  mixed  fonns  of, 
992 ;  motor,  991  ;  of  conduction,  992 ;  in 
phthisi.s,  312 ;  prognosis  of,  993 :  sensory, 
989  ;  in  typhoid  fever,  30 ;  testa  for,  993  ;  trar- 
sient,  in  migraine,  1103  ;  Wernicke's,  992. 

Aphemia  (see  Aphasia). 

Aphonia,  hysterical,  1116;  in  acute  larj'ngitis, 
015;  in  abductor  paralysis,  1061;  in  pericar- 
dial ert'usion,  692. 

Aphthffi  (see  Stomatitis,  Aphthous),  441. 

Aphthous  fever,  347. 

Apoplectic  habitus,  998;  stroke,  1001. 

Apoplexy,  cerebral,  997;  ingravescent,  1001; 
pulmonary,  038. 

Appendicitis,  519;  obliterans,  520;  infective, 
521;  perforative,  520;  relapsing,  527;  ulcera- 
tive, 521. 

Appendicular  colic,  520,  524. 

Appendix  vermiformis,  situation  of,  519;  perfo- 
ration of,  in  typhoid  fever,  10;  ftecal  concre- 
tions in,  519;  foreign  bodies  in,  520;  necrosis 
and  slougliing  of,  521. 

Apraxia,  989. 

Aprosexia,  454,  456. 

Arachnida,  parasitic,  375, 

Arachnitis  (see  Meningitis),  954, 

Aran-Diifhenne  type  of  muscular  atrophy,  929, 
941 ;  in  lead-poisoning,  388. 


937 ;   ppurlous, 


3IU  of,  1011. 
of,  1072. 

vcr,  .570. 

11   niniuuls,   224 ; 


155 ;   of  pneu- 

Jtone,  850 ;  hys- 

riic  pulsntion  of, 
tuberculosis    of, 

dilen    denth    in, 

of,  707. 

ion  of,  766 ;  in- 


lizntion  of,  992; 
h,  991 ;  in  in- 
ii,\cd  fonus  of, 
action,  992  ;  in 
',  993 :  sensory, 
ts  for,  993  ;  trar- 
liclie's,  992. 

neute  laryngitis, 
061 ;  in  pericar- 

ous),  441. 

1001. 
•avescent,    1001 ; 

520 ;    infective, 
ng,  527;  nlcera- 


n  of,  519;  perfo- 
0 ;  foecal  concre- 
in,  520 ;  necrosis) 


4. 

lar  atrophy,  929, 


INDEX. 


1153 


; 


Arch  of  aorta,  aneurism  of,  779. 

AroiiH  Hutiiiis,  750. 

Arijyll  Jicbirlnon  i)Upil,  1047;  in  ataxia,  922. 

Aritliiiioiiiniiia,  10^9. 

Ann,  periplieral  paralysis  of  (seo  Paralysis  or 

HUACIIIAL   I'LKXUHj. 

Arrhythmia,  756. 

Arsenical  neuritis,  1035. 

Arsenical  pigmentation,  390;  in  chorea,  1085. 

Arsenical  poisoning,  390;  paralysis  in,  391. 

Arteries,  diseases  of,  770;  calcification  of,  770; 
degeneration  of,  770 ;  fatty,  770;  hyaline,  770; 
tuberculosis  of,  327. 

Arterio-cnpillary  fibrosis,  770. 

Arterio-selerosis,  770;  ditl'use,  772;  in  lead-pois- 
oning, 389;  in  migraine,  1103 ;  nodular  form, 
771 ;  in  phthisis,  31C;  senile  form,  772. 

Arteritis  in  typhoid  fever,  12,  21. 

Arteritis,  syphilitic,  250. 

Arthralgia  from  lead,  389. 

Arthritides,  post-febrile,  165;  in  gout,  414. 

Arthritis,  173 ;  acute,  in  infants,  173 ;  gonorrlueal, 
256;  in  acute  myelitis,  977 ;  in  cerebro-spinal 
meningitis,  106;  in  chorea,  1080;  in  dengue, 
100;  in  dysentery,  200;  in  haemophilia,  820; 
in  small-pox,  65;  in  tabes  dorsalis,  935;  mul- 
tiple secondary,  173 ;  in  purpura,  815 ;  rheuma- 
toid, 399 ;  in  scarlet  fever,  80 ;  septic,  173. 

Arthritis  deformans,  399 ;  as  a  chronic  infection, 
400;  in  children,  403;  chronic  form,  402;  gen- 
eral progressive  form,  402;  Hthenleii's  nodes 
in,  401 ;  partial  or  mono-articular  form,  403. 

Arthropathies  in  tabes,  925. 

Arthropathy,  hypertrophic  pulmonary,  1144. 

.\scariasis,  352. 

Ascaris  lumbricoides,  352. 

Ascites,  605,  609 ;  chylous,  607 ;  from  cancerous 

.  peritonitis,  605;  from  cirrhosis  of  the  liver, 

672 ;  from  syphilis  of  the  liver,  249 ;  in  cancer 

of  the  liver,  584;  in  tuberculous  peritonitis, 

287  ;  physical  signs  of,  606 ;  treatment  of,  607. 

Ascitic  fluid,  chylous,  607  ;  serous,  607 ;  liicmor- 
rhagic,  607. 

.\spergillus  in  lung,  302. 

Asphyxia,  local,  1137;  denth  by,  in  phthisis, 
317. 

Aspiration,  BoivditcK's  conclusions  on,  677 ;  in 
empyema,  678 ;  in  pericardial  effusion,  695 ;  in 
pleuritic  effusion,  677. 

Aspiration  pneumonia,  642. 

Astasia-abasia,  1126,  1136. 

Asthenic  bulbar  paralysis,  947. 

Asthenopia,  nervous,  1124. 

Asthma,  bronchial,  628;  nasal  affections  in,  629  ; 
sputum  in,  630;  cardiac,  628;  hay,  612;  L(^/- 
deii'a  crystals  in,  631 ;  renal,  867  ;  thymic,  618, 
844. 

Astrophobia,  1124. 

Atavism,  in  hfemophllia,  819  ;  in  gout,  408. 

73 


Ataxia,  cerebellar.  087;  ccrebellar-luriMlo,  O'jD; 
hereditary,  !i4!i ;  in  pr(>grcssi^•e  pare>is,  '.iii-J; 
locomotor,  ',i;iii;  alter  i<mall-pox,  64. 

Ataxic  gait,  923. 

Ataxic  paraplegia,  WH. 

.Atelectasis,  pulmoiuiry,  642. 

Atlieroma  (seo  Aktebio-sclerosis  and  I'iii.kiio- 
sci.Enosis). 

Athetosi.x,  miO;  bilateral  or  double,  U39. 

Athlete's  heart,  710. 

Athyrea,  837,  840. 

Atmospheric  pressure,  effects  of,  969. 

Atremia,  1126. 

Atrophic  cirrhosis,  571. 

Atrophy,  acute  yellow,  of  liver,  551 ;  of  brain, 
dilFusc,  in  general  paresis,  '.ml  ;  of  brain,  uni- 
lateral, 1017;  of  muscles,  various  foruis  nf, 
935;  progressive  muscular,  of  central  origin, 
928  ;  unilateral,  of  face,  1141. 

Attitude,  in  pseudo-hypertrophic  muscular  \rA- 
ralysis,  934;  in  i>aralysis  agitaus,  1077. 

Auditory  centre,  aifectioiis  of,  1056;  nerve,  dis- 
eases of,  1056;  vertigo,  1058. 

Aura,  forms  of,  in  ejiilcpsy,  1095. 

Auto-infection  in  tul>crl•ull'^<is,  273. 

Autouuitisui,  in  iittit  mat,  1097 ;  in  cerebral 
syphilis,  246. 

Autumnal  fever,  3. 

Avian  tuberculosis,  258. 

BaccelWs  sign,  670,  672. 

Bacillus,  anthracis,  224;  of  cholera,  175. 

Bacillus  coli  communis— distinction  from  ty- 
phoid bacillus,  4;  in  bile-pa.ssages,  558;  in 
fiBces  of  sucklings,  508 ;  in  fat  necrosis  with 
colitis,  591;  in  peritonitis,  597. 

Bacillus  diphtheria',  140,  451 ;  value  of,  in  di;ig- 
nosis,  151. 

Bacillus  gas  (B.  aerogenes  eapsulatus)  in  peri- 
tonitis, 597;  in  pneuniaturia,  864:  in  pnemno- 
pcricardium,  698. 

Bacillus  icteroides,  183. 

Bacillus,  Klebs-Loeffler,  140  ;  toxine  of,  141. 

Bacillus,  of  glanders.  233;  of  influenza,  9(i ;  of 
smegma,  238  ;  in  whooping-cough,  \)-l  ;  of 
leprosy,  340  ;  of  plague,  190  ;  of  syphilis,  2.'!8 ; 
of  tetanus,  231 ;  pyoeynneus,  163  ;  strepto-,  in 
typhus  fever,  50. 

Bacillus  mallei,  233. 

Bacillus  pestis,  190. 

Bacillus  pneumoniie.  111. 

Bacillus  proteus  fluorescens,  344. 

Bacillus  smegma,  238. 

Bacillus  tuberculosis,  259,  666;  diagnostic  value 
of,  313;  distribution  of,  261;  in  sputum,  300; 
methods  of  detection,  801 ;  outsiile  the  boily, 
261 ;  products  of  growth  of,  200. 

Bacillus  typhi  abdominalis,  3. 

Bacteremia,  161. 


1154 


INDEX. 


Buutur'm,  protcus  group  in  dinrrhojn,  509 ;  rclatiuii 
to  diurrluua,  fiOS. 

Buctoriuin,  coli   uoiiiiiiunc   (huo  Hai'illts  Com 
CiiM.MiNis);  liK'li.-i  aurogL'iics,  oOS. 

balanitis  in  diabftus,  4ii5. 

lialaiitiiiiuni  coli,  351. 

Uall-tliroiiibus  in  left  auricle,  723. 
JJall-valve  Htoiie  in  common  duct,  506. 

/lantiiii/n  motliod  in  ol)esity,  439. 

"Barbun  diolora,"  31)4. 

Barking  coiigli  of  puberty,  1117. 

Barlow^H  iliscasc,  82.3. 

Barrel-HliaiK'd  clicst  in  einpliy«enia,  658 ;  in  en- 
larged tonsils,  455. 

Jiagvdoiv's  disease,  836. 

Basilar  artery,  embolism  and  thrombosis  of,  1010. 

Baths,  cold,  in  typhoid  fever,  44;  in  hyperpy- 
rexia of  rheumatism,  175  ;  in  scarlet  fever,  84. 

Batophobia,  1124. 

Beaded  ribs  in  rickets,  436. 

Bed-bug,  377. 

Jiednarh  aphtha^  443. 

Bed-sores,  acute,  in  mycHtis,  977, 978  ;  in  typhoid 
fever,  19. 

Becr-driid<ers,  heart  disenso  in,  745. 

BtWs  {Luther)  mania,  1075. 

yA7r.f  palsy,  1051. 

/3oxy-butyric  acid,  426,  865. 

Bcri-bcri,  220  ;  forms  of,  222. 

JU'.-<oin  de  respircr,  346. 

Bieruacki''8  symptom,  963. 

"  Big-jaw  "  in  cattle,  235. 

Bile  coloring  matter,  tests  for,  549. 

Bile-ducta,  acute  catarrh  of,  555;  ascnrides  in, 
560  ;  cancer  of,  559  ;  congenital  obliteration  of, 
501 ;  stenosis  of,  500. 

Bile-pasaages,  diseoses  of,  555. 

Bilharzia  hn;matobia,  352. 

Biliary  cirrliosis  of  liver,  570. 

Biliary  colic,  563. 

Biliary  flstulre,  567. 

Bilious  remittent  fever,  213. 

Birtli  palsies,  938. 

Black  death,  190. 

Black  spit  of  miners.  654. 

Black  vomit,  180  ;  in  dengue,  100. 

Bladder,  paralysis  of,  in  locomotor  ataxia,  922; 
care  of,  in  myelitis,  979 ;  hypertrophy  of,  in 
diabetes  insipidus,  432  ;  tuberculosis  of,  325. 

"Bleeders,"  819. 

Bleeding,  in  arterio-selerosis,  775 ;    in  cerebral 
lia?morrhage,  1012;    in  empliysema,  659;    in 
heart-disease,  731;    in    pneumonia,   135;    in 
sun-stroke,  398 ;  in  yellow  fever,  188. 
Blepharospasm,  1055. 
Jilindncss  (see  Amaukosis). 
Blood  and  ductless  glands,  diseases  of,  789. 
Blood,  characters  of,  in  antemia,  789;  in  cancer 
of  the  stomach,  489 ;    in  chlorosis,  792 ;    in 


cholera,  178;  in  diabetes,  421  ;  in  gout,  410; 
in   Inemophilia,  820;    in    leukiumia,  806;    in 
pernicious    anwmia,    797;    in    pseudo-leukue- 
mia,  llodgkin's  disease,  812;  in  purpura,  814; 
in  secondary  anii'miu,  790 ;  in  typhoid  fever, 
19. 
Blood  scrum    therapy   in    diphtheria,   155 ;    in 
pneumonia,  112;  in  tetanus,  233;  in  typhoid 
fever,  47. 
Blood-vessels  of  liver,  att'ections  of,  553. 
"  Hlue  disease,"  768. 

Blue  line  on  gums  in  lead-poisoning,  387. 
Boils,  in  diabetes,  425;  alter  typhoid  fever,  19; 

after  snudl-pox,  65. 
Bones,  lesions  of,  in  acromegaly,  1142;  in  con- 
genital  syphilis,  244;   in    leukiemia,  608;    in 
rickets,  434;  in  typhoid  fever,  32. 
Borborygmi,  498,  507. 
liothriocephalus  latus,  306  ;  unwniia,  367. 
Botulism,  391. 

Botyroid  liver  in  syphilis,  249. 
Bovine  tuberculosis,  258. 

Bowel,  affections  of  (see  Intestines)  ;  acute  ob- 
struction of,  534  ;  infarction  of,  546. 
Brachial  plexus,  affectioiis  of,  1069. 
Brachycardia  (Bradycardia),  759;    in   typhoid 

fever,  21, 
Brain,  diffuse  and  focal  diseases  of,  979;  absce.ws 
of,  1025;  abscess  of,  in  congenital  heart-dis- 
ease, 708 ;  att'ections  of  blood-vessels  of,  994  ; 
anieniia    of,    995 ;    atrophy  and  sclerosis    of, 
1017;    congestion    of,   994;    cysts    in,    1021; 
echinococcus  of,  374;  liwmorrhage  into,  997; 
syphilis  of,  244,  1020;   glioma  of,  1020;  hy- 
pcra-mia  of,  994 ;  intianmiation  of,  1024 ;  code- 
ma  of,  997;  porencephalus  of,  1017. 
Brain-murmur  in  rickets,  437, 
Brain,  sclerosis  of,  957;  diffuse,  958;  insular, 

959;  miliary,  958;  tuberous,  959. 
Bruin,  softening  of,  red,  yellow,  and  white,  1009. 
Brain,  tubercle  of,  321, 1020. 
Brain,  tumors  of,  1020;  medical  treatment  of, 
1024;  surgical  treatment  of,  1024;  symptoms, 
general  and  localizing,  1021. 
BrainTs  method  in  typhoid  fever,  43. 
Breakbone  fever  (see  Dkngue),  99. 
Breast- pang,  701. 
Breath,  odor  of,  in  diabetic  coma,  426;  foul,  in 

scurvy,  823 ;  fa'tid,  in  enlarged  tonsils,  450. 
Breathing  (see  Respiration)  ;  mouth,  454. 
Bremer's  blood  test  in  diabetes,  427. 
Brick-maker's  anosmia,  360. 
Bright's  disease,  acute,  869 ;  interstitial  form  of, 

870. 
Briglit's  disease,  chronic,  874 ;  interstitial  form  of, 
877  ;  causes  of,  877  ;  cardio-vascular  changes 
in,  880 ;  hereditary  influences  in,  877 ;  paren- 
chymatous form  of,  875. 
BroadbtnVa  sign,  696. 


Mk^ 


I ;  ill  /»out,  410; 
(wiiiiii,  hutj ;    in 

pHfUllo-lfllklt- 

n  purpura,  SU  ; 
1  typlioid  fever, 

tiiuriu,  155;  in 
233;  in  typhoid 

of,  558. 

linj.',  387. 
plioid  fever,  19; 

',  1142 ;  in  con- 
kujiiiiu,  bOS ;  in 
32. 

niia,  367. 


>fE8) ;  acuto  ob- 

;  546. 

69. 

59;    in   typhoid 

of,  979 ;  ni38ce.'<s 
nital  heart-dis- 
■vessels  of,  994  ; 
id  sclerosis  of, 
ysts  in,  1021  ; 
liage  into,  997 ; 
u  of,  1020;  hy- 
1  of,  1024  ;  u>de- 
1017. 

0,  958 ;  insular, 

'9. 

ind  white,  1009. 

1  treatment  of, 
024;  symptoms, 

,43. 

19. 

la,  426;  foul,  in 
tonsils,  456. 
outh,  454. 
27. 

TOtitial  form  of, 

erstitial  form  of, 
iscular  clianges 
in,  877 ;  paren- 


INDEX. 


1155 


"Ilroken-winded,"  742. 

IJromutotoxismus,  391. 

Hroniism,  1100. 

llionchi,  casts  of,  633 ;  diseases  of,  C21. 

linmclilul  asthma,  628. 

lironchiitl  catarrli  (hronchitisl,  621. 

IJronohial  f,']ands,  tuberculosis  of,  283 ;  enlarge- 
ment in  whooping-cough,  94, 684 ;  suppuration 
in,  684. 

Bronchiectasis,  626;  abscess  of  brain  in,  627; 
congenital,  626;  cylindrical,  626;  rlicumatoid 
affections  in,  627 ;  saccular,  626 ;  sputum  in, 
627  ;  universalis,  626. 

Bronchiolitis  exudativa,  628. 

lironchitis,  G21 ;  acute,  621 ;  capillary,  641. 

Hronciiitis,  chronic,  623. 

Bronchitis,  librinous,  632. 

Bronchitis  in  measles,  87;  in  sniall-pox,  64;  in 
typhoid  fever,  27  ;  putrid,  625. 

Bronchocclo  (see  Goitue),  835. 

Bronchophony,  in  pneumonia,  120. 

Broneho-pncumonia,  acute,  641 ;  chronic,  649 ; 
acute  tuberculous,  292. 

Bronchorriiagia,  637. 

Bronchorrhcea,  624  ;  serous,  624. 

Bronze-skin,  in  phthiriasis,  377;  in  Addison's 
disea-se,  830  ;  in  Basedow's  disease,  839;  in  dia- 
betes, 425;  in  Ilodgkin's  disease,  812. 

Brown  atropiiy  of  heart,  750. 

JJrown  induration  of  lung,  635. 

Jirown-SiquanVg  paralysis,  965. 

Jiruit,  d\iiraiti,(\S3  ;  de  cuir  neuf,  690 ;  de  diahle, 
794 ;  depot  file  (see  Ciiaoked-pot  Sound),  309 ; 
de  soupte,  703  ;  a'sophngoal,  460. 

Bubo,  parotid  (see  also  Parotitis),  447. 

Bubonic  plague,  189. 

Buccal  psoriasis,  446. 

BuhVs  disease,  818. 

Bulbar  paralysis,  928,  932;  acute,  938;  asthenic 
form,  947 ;  of  cerebral  origin,  932 ;  progressive, 
928. 

Bulimia,  423,  502. 

Cachexia,  in  cancer  of  the  stomach,  489 ;  mala- 
rial, 208,  216;  periosteal,  825;  saturnine,  387; 
strumipriva,  842  ;  syphilitic,  240. 

Caisson  disease,  969. 

Calcareous  concretions,  in  phthisis,  296;  in  the 
tonsils,  456. 

Calcareous  degeneration,  of  orteries,  770;  of 
heart,  750. 

Culeitication,  annular,  of  arteries,  770. 

Calcification  in  tubercle,  271. 

Calculi,  biliary,  561 :  "  coral,"  892 ;  pancreatic, 
595;  renal,  891 ;  tonsillar,  456;  urinary,  891. 

Calculous  pyelitis,  886. 

Camp  fever,  49. 

Cancer,  of  bile-passages,  559, 583 ;  of  bowel,  583 ; 
of  brain,  1020 ;  of  gall-bladder,  559  ;  green,  809 ; 


of  kidney,  896  ;  of  liver,  582 ;  of  lung,  663 ;  of 
(Psophagus,  461  ;  of  pancreas,  594;  of  perito- 
nieum,  miliary,  6(14  ;  of  stimuich,  486  ;  acute,  493. 

Cancrum  oris,  444  ;  in  measles,  87. 

Canities,  the  result  of  lu^iralgia,  1104. 

Canned  goods,  jioisoning  by,  393. 

Capillary  pulse,  in  aortic  insuflicienoy,  714;  in 
neurasthenia,  112i') ;  in  phthisis,  311\ 

Capsule,  internul,  982;  lesions  of,  983. 

Caput  Meilusie,  606. 

Caput  quatlratum,  in  rickets,  436. 

Carboluria,  865. 

Carbuncle  in  diabetes,  425. 

Cardia,  spasm  of,  499. 

Cardiac,  compensation,  rupture  of,  741 ;  disease' 
(see  Disease  of  IIeakt). 

Cardiac  murmurs,  hainic,  in  chlorosis,  794;  in 
chorea,  1084,  in  idiopathic  unaMiiia,  799. 

Cardiac  murmurs,  organic,  in  aortic  insufficiency,. 
713;  in  aortic  stenosis,  71  <>;  in  congenital  heart 
afl'ections,  769 ;  in  mitral  incompetency,  720 ;. 
in  mitral  stenosis,  723 ;  in  tricuspid  valve  dis- 
ease, 726. 

Cardiac  nerves,  neuralgia  of,  761. 

Cardiac  overstrain,  742. 

Cardiac  septa,  anomalies  of,  766. 

Cardialgia  (see  Gastkaloia). 

Cardioeentesis,  755. 

Canlio-rcspiratory  murmur,  308. 

Cardio-sclerosis,  750. 

Cardio-vascular  changes  in  renal  disease,  880. 

Caries,  vertebral,  970. 

Carinated  abdomen,  278. 

Carotid  artery,  ligature  and  compression  of,  im 
cerebral  hnemorrhage,  1012. 

Carphologia,  29. 

Carpo-pcdal  spasm,  1111. 

Carreau,  288. 

Caseation,  271. 

Caseous  pneumonia,  272. 

Ca.sts,  blood,  of  bronchial  tubes  in  hsemoptysis,. 
638;  in  librinous  bronchitis,  633;  of  pelvis  of 
kidney  and  ureter,  897. 

Cnstsof  urinary  tubules,  872;  epithelial,  871,872; 
fatty,  876  ;  granular,  876,  880;  hyaline,  880. 

Casts,  tube,  in  acute  Bright's  disease,  872;  in 
chronic  Bright's  disease,  876,  880. 

Catalepsy  in  hysteria,  1119. 

Cataract,  diabetic,  427  ;  after  typhoid  fever,  30. 

Catarrh,  acute  gastric,  4(>3  ;  autumnal,  612; 
bronchial,  621 ;  chronic  gastric.  466  ;  dry,  625; 
nasal,  611 ;  simple  chronic  (nasal),  611 ;  suffo- 
cative, 645. 

Catarrhal  bronchitis,  influence  of,  in  tuberculo- 
sis, 269. 

Catarrhe  tec,  625. 

Catarrhus  aistivus,  612. 

Cauda  equina,  lesions  of,  972. 

Cavernous  breathing,  309. 


115(3 


INDEX. 


/ 


Cnvltios,  pulmonary,  phyHical  h'ihiih  of,  309;  qul- 
t'HCfiit,  liU7. 

Ciiyor  lly,  :n\). 

CulliilitiH  of  tlio  nuck,  4.10. 

C'ciitnini  H(!rnioviil(!,  luHioim  of,  081. 

('e|>)iiilul);iii  (Hcu  Mkaiiaciik). 

Cophnlio  tctaniiH,  U.l'i. 

Coplialodyiiiu,  407. 

Curc«iiionuti  intuHtiimlis,  195,  851 ;  C.  hominii), 
S51. 

Ccrcbollnr,  ntiixiu,  050,  987  ;  hcredo-ntaxia,  960 ; 
vertigo,  98«. 

Ccrel)clluiii,  tuinora  of,  986 ;  all'uotions  of,  985. 

Cerebral    arteries,  aneurism    of,   1013;    artorio- 

.  BcleroNia  of,  1014;  eiiiboliBin  of,  1008;  endar- 
teritis of,  10l4;  syphilitic  ondarteritiB  of,  245, 
1014;  thronibosiH  of,  1008. 

Cerebral  cortex,  lesions  of,  980. 

Cerebral  liuoinorrhage,  997 ;  anourisniB,  miliary, 
in,  998;  convulsions  in,  1007  ;  forms  of,  999. 

Cerebral  localization,  907. 

"Cerebral  pneumonia,"  122. 

"  Cerebral  rheumatism,"  171. 

Cerebral  sinuses,  thrombosis  of,  1015. 

Cerebral  softening,  1008. 

Cerebritis  (see  Encephalitis),  1024. 

Cerebro- spinal  meningitis,  epidemic,  100;  anom- 
alous forms  of,  105;  complications  of,  105; 
malignant  form,  103 ;  ordinary  form,  103. 

Cervical  pachymeningitis,  953. 

Cervical  plexus,  lesions  of,  10()7. 

Ccrvico-brachial  neuralgia,  1105. 

Cervico-occipital  neuralgia,  1067,  1105. 

Cestodes,  disease  due  to,  365 ;  visceral,  368. 

Chalicosis,  652. 

Chancre,  239. 

Charb*-      ,24. 

■Charc^    .  joint,  925. 

Charcot- Leyden  crystals,  507,  681,  803. 

'Chattering  teeth,  1051. 

'Check,  gangrene  of,  444. 

Cheese,  poisoning  by,  303. 

Chest  expansion,  diminution  of,  in  Graves'  dis- 
ease, 839. 

Cheijne-Stokes  breathing,  Cheync's  original  de- 
scription of,  751 ;  in  apoplexy,  1001 ;  in  fatty 
heart,  751 ;  in  sun-stroke.  397 ;  in  acute  tuber- 
culosis, 275 ;  in  urmmia,  867. 

Chiasma  and  tract,  att'eotions  of,  1041. 

Chicksn-breast,  436,  455. 

Chicken-pox,  74. 

Child-crowing,  618. 

Children,  constipation  in,  540;  diabetes  in,  425  ; 
tuberculous  broncho-pneumonia  in,  292  ;  pneu- 
monia in,  126  ;  tuberculosis  of  mesenteric 
glands  in,  284,  288 ;  mortality  from  small-pox 
in,  65  ;  rheumatism  in,  1G7 ;  typhoid  fever  in, 
35. 

Chills  (see  Rigors),  in  typhoid  fever,  17. 


Cliloasnia  phthisicorum,  318. 

Cliloro-anuMniH  in  phtiiisis,  311. 

Cliiiiroma,  h09. 

Chlorosis,  792 ;  and  aiiirinia,  sinus  thrombosis  in, 
1015;  dilatation  of  stomach  in,  7m;  Kgyptiiui, 
360;  fever  in,  794;  heart  syinptdiiis  in,  794; 
menstrual  disturbance  in,  795 ;  thrombostH  in, 
794. 

Choked  disk,  1040. 

Cholusmia,  650. 

Cholangitis,  infective,  566;  suppurative,  567, 
678  ;   in  typhoid  fever,  27. 

Cliolecystectomy,  569  ;  indications  for,  569. 

Cholecystitis  acuta,  564. 

Cholecystitis,  acute  infective,  658. 

Choleeyslotomy,  569. 

Cholelithiasis,  561 ;  in  typhoid  fever,  27. 

Cholera,  asintica,  175  ;  bacillus  of,  175;  epidemics 
of,  175;  infantum,  509;  nostras,  180;  sicca, 
179:  typhoid,  179. 

Cliolera  toxine,  176. 

Cholerine,  180. 

Cholestcriemia,  550. 

Cholesterin  in  biliary  calculi,  563. 

Choluria,  865. 

Chondrodystrophia  foitalis,  841. 

Chorea,  acute,  1079;  etiology  of,  1079;  lienrt 
symptoms  of,  1083;  infectious  origin  of,  1080; 
in  pregnancy,  1080:  paralysis  in,  1083;  rheu- 
matism and,  1079;  school-made,  1081. 

Chorea,  canine,  1080 ;  chronic,  1090. 

Chorea,  habit  or  spasm,  1088. 

Chorea,  Huntingdon's  or  hereditary,  1090. 

Chorea,  insaniens,  1083, 1085;  paralytic  form  of, 
1083;  major,  1088;  pandemic,  1088;  post-hemi- 
plegic,  1019;  preheniiplegic,  1001 ;  rhytlimic 
or  hysterical,  1091 ;  senile,  1090;  spastica,  939, 
1080;  Sydenham's,  1079. 

Choroid  plexuses,  sclerosis  of,  1029. 

Choroid,  tubercles  in,  279. 

Choroiditis  in  syphilis,  241. 

Chovstek's  symptom  in  tetany,  1110. 

Chylangiomata,  547. 

Cliylo  vessels,  disorders  of,  547. 

Chylo-pericardium,  698. 

Chyluria,  non-parasitic,  859  ;  parasitic,  361. 

Cicatricial  stenosis  of  bowel,  533. 

Ciliary  muscle,  paralysis  of,  1047. 

Ciliata,  parasitic,  351. 

Cimox  lectularius,  377. 

Circulatory  system,  diseases  of,  688. 

Circumcision,  inoculation  of  tuberculosis  by,  264 ; 
in  hrornophilia,  820. 

Circumflex  nerve,  affections  of,  1070. 

Cirrhosis,  of  kidney,  877 ;  of  liver,  569 ;  of  lung, 
6-49 ;  ventriculi,  467. 

Claudication,  intennittent,  763. 

Claustrophobia,  1124. 

Claviceps  purpurea,  poisoning  by,  394. 


INDEX. 


115' 


until romboHis  in, 

i,Vlt4;  KK}|>tiiui, 
I  in|it(iiiiH  ill,  7114; 
;  tliroMiboitiH  in, 


uiiiiunitive,    507, 
jiiH  for,  669. 


rever,  27. 

f, ITS;  epidemics 
trus,  IbO ;   siocii, 


J3. 


of,  1079;   henrt 
I  origin  of,  1080  ; 
1  in,  1083;  rheu- 
Je,  1081. 
.090. 

tary,  1090. 
inralytic  form  of, 
1088;  post-lienii- 
1001 ;  rliytliniic 
W ;  spastica,  93'J, 

)29. 


110. 


irawitic,  361. 


7. 


688. 

erculoaia  by,  264 ; 

1070. 

■er,  569 ;  of  lung, 


>y,  394. 


Clnvus  liystoriouH,  111(J. 

(Jluw-liiiiul  (iimin  en  grilfu),  930. 

C'liiiiute,  intliK^nco  of,  in  aHtiiiiui,  632;  in  clironic 
HrlKJa'H  (lieti'iiHu,  HMa;  in  lulnTculosis,  !t:i;j. 

('ii)iiux  (Huo  Anklk  Clonih;  ;  jaw,  931. 

ClowniHiii  in  liysteria,  1113. 

('iietiioeum))a,  379. 

Oobttlt  iiiiiiern,  caiicer  ')f  lung  in,  664, 

Coeciiliuiri  oviloniio,  349. 

('uuoyilyiiin,  1106. 

('ocliin-<.'hinu  diarrliom,  365. 

<'a'lia(!  ulfei'tion  in  ciiililren,  611. 

Cog-wiieul  rcspirution,  808. 

<'()in-.soii!ul,  683. 

Cokl  pack,  inctliocl  of  giving,  84. 

(Joliu,  biliary,  503  ;  in  appendicitiH,  520,  524 ;  in 
angid-neurotic  (rduma,  1140;  in  purpura,  816 
lead,  388;  mucous,  544;  ronal,  893. 

Colica  I'ictonuni,  386. 

Culitiii,  diplitliuritic,  512;  mucous,  544;  nimplo 
ulcerative,  513. 

CoUn's  law,  239. 

t'olloid  cancer,  of  lung,  663 ;  of  pcritonreum,  004 ; 
of  stomach,  487. 

Colon,  cancer  of,  533  ;  dilatation  of,  545. 

Colopto.sis,  543. 

Coma,  diabetic,  425;  epileptic,  1096;  from  lieat- 
stroke,  396;  from  muHcular  exertion,  809;  in 
ucute  encephalitis,  1025  ;  in  acute  yellow  atro- 
phy, 552;  in  alcoholic  poisoning,  380  ;  in  ajio- 
plexy,  1001  ;  in  cerebral  syphilis,  240;  in  gen- 
eral paresis,  962 ;  in  multiple  sclerosis,  900  ;  in 
pernicious  malaria,  215 ;  in  thrombosis  of  cere- 
bral sinuses,  1015;  in  typhoid  fovor,  29;  uraj- 
mic,  867. 

(-"oma  vigil,  29. 

Comatose  form  of  malaria,  215. 

Comma  bacillus,  175. 

Common  bile-duct,  obstruction  of,  566. 

Compensation  in  valve  lesions,  708;  periods  in, 
740;  rupture  of,  741. 

Composite  portraiture  in  tuberculosis,  268. 

Compressed  air  disease,  969. 

Compression  and  traction  of  the  bowel,  533.  ■ 

Compression  paraplegia,  970. 

Concretions  (see  Calcaheous). 

Concussion  of  spinal  cord,  1133. 

Confusional  insanity,  30. 

(."ongenital  heart  affections,  705. 

Congenital  stenosis  of  pylorus,  494. 

("ongenital  stricture  of  the  bowel,  533. 

Congenital  syphilis,  242. 

Conjugate  deviation,  in  brain  tumor,  1023 ;  in 
apoplexy,  1002 ;  in  tuberculous  meningitis,  279. 

Conjunctiva,  diplitheria  of,  149. 

Consecutive  nephritis,  886. 

Cons  ipalion,  538 ;  in  adults,  533  ;  in  infants,  540  ; 
spasmodic,  539  ;  treatment  of,  540. 

Constitutional  diseases,  399. 


Consumption  Csco  TrnnnruLosts). 

Contracted  kiilneys,  H77. 

Cdiitracture,  hysterical,  1114;  in  liomiplogia, 
loo,');  of  nursing  women,  1110. 

Cnntusiun  pneumonia,  109. 

('onus  arteriosus,  stenosis  of,  767. 

(Ninus  medullaris,  lesions  of,  972. 

Convahtscence,  fever  of,  16;  from  typhoid  fovcr, 
management  of,  48. 

(,'onvulsions,  epileptic,  1090  ;  hysterical,  1112  ;  in 
acute  yellow  atrophy,  552;  in  alcoholism,  880  ; 
in  aspiration  of  pleural  ellusio  i,  078  ;  in  cere- 
bral huMiiorrhage,  lo(Jl  ;  in  cerchrul  syjihili.s, 
240,  101)9;  in  cerebral  tuiiiors,  1021  ;  im'lironic 
llriglit's  disease,  876. 

(Jotivulsions,  infantile,  1091 ;  relation  to  rickets 
438. 

(Convulsions,  in  general  paralysis,  962  ;  in  he- 
patic colic,  504  ;  in  infantile  hemiplegia,  lOlli; 
in  lead-poisoning,  3S9  ;  in  nu^ningitis,  !)5ri ;  in 
sun-stroke,  397  ;  in  typlioid  fever,  28;  in  uriB- 
niia,  806  ;  Jacksonian,  1098. 

Convulsive  tic,  1088,  1089. 

(Coordination,  disturbance  of,  in  tubes,  923. 

Copaiba  eruption,  88. 

Copper  test  for  sugar,  423. 

Copriumia,  539,  792. 

Coprolalia,  1089. 

Cor  adiposum,  749. 

Cor  bilocularo,  706, 

Cor  bovinum,  711. 

(,'or  villosum,  689. 

Coronary  arteries,  in  angina  pectoris,  702,  703 ; 
obliteration  of,  747. 

Corpora  quadrigemina,  tumors  in,  1023 ;  lesions 
of,  984. 

Corpulence,  439. 

Corpus  callosum,  lesions  of,  981. 

Corrigati's  disease,  709. 

Corrigan  pulse,  714. 

Coryza,  acute,  CIO ;  fcetida,  612 ;  from  the  io- 
dides, 2.">4. 

Costivencss,  538. 

Cough,  barking,  of  puberty,  1117;  liysterical, 
1116;  in  acute  bronchitis,  622;  in  chronic 
bronchitis,  624;  in  pertussis,  93;  in  phthisis, 
300 ;  during  aspiration  of  pleural  effusion, 
077;  in  pneumonia,  118;  paroxysmal,  in 
bronchiectasis,  627  ;  paroxysmal,  in  fibroid 
phthisis,  314  ;  stomach,  469. 

Coup  de  soleil,  395. 

Cow-pox,  08. 

Cracked-pot  sound,  309. 

Cramp,  writer's,  1107. 

Cramps,  in  cholero,  180  ;  in  gout,  415  ;  in  chronic 
Bright's  disease,  882. 

Cranio-selerosis,  437. 

Cranio-tabes,  relation  to  congenital  syphilis, 
430  ;  in  rickets,  430. 


1158 


INDRX. 


til 


,.  .■,.•' 


m 


Crftw-craw,  !)rtl. 

Cn'opliilu,  ;i7H. 

CrctiiiiHni,  uiuli'inio,  840  ;  uponuUo,  R40. 

I'retinoul  cliuii(tu,  MO, 

CriHiiH,  ({ii«tr()-int<!(*liiml,  ill  uiii^io-notirotin  nxlo- 

iim,    IHO;  in   lovoiiuitor   utuxiti,  U'Jt ;  in  piir- 

piiru,  Hltl. 
Criiiiit,  in  pncuniDniii,  117;  in  n^lupxin^  fuvur ; 

54  ;  in  tyi)lui»  I'uvit,  M. 
Croruu'd  ur  ultcrniiliiif;  |iiu-itly>iit«,  UH4,  1004. 
(IrosBcd  ounHory  purui>'Hi»,  yH5. 
Cn)Ui>,  nicinbrunuus,  14H  ;  H()iMnioUic,  GIT. 
CroupoiiH  uiiU'i'itiH,  <>\'i. 
Vn>u\nn\»  piiumnonlu,  108. 
('rum  ccrtibri,  icnions  of,  lt83, 1004. 
Crutch  punilyrtiH,  1070. 
Cnmeilhiir'K  piiUy,  1)29. 
Cry,  fi>ilt'iitiii,   liiytl ;  hyilroccphnlto,   27S ;  hys- 

terioul,  1110;  in  con);enital  Hypiiilio,  243. 
Cryptoj^cnotio  Hoptii'iuriiiii,  lti2. 
Vurna/tmann^H  Miiinilx,  (131,  (134. 
CyunottiH,  in  iieiitc  tuliorculonirt,  'J7(i ;  in  congen- 
ital liourt-tliscitso,  7(18  ;  in  uniphysonin,  057. 
Cydoplogiu,  1047. 
Cynimeho  nmlijtnii,  13S. 
("ynobox  lioliutii-a,  1117. 
Cystic  diaunso,  of  kitlnoy,  808  ;  of  liver,  584. 
Cystic  duct,  ol)struction  of.  505. 
Cyst      reus    ccIIuIomc,    Siis ;    ot-uliir,   309;   sub- 

cu    neous,  309  ;  gencrul,   309  ;  corobro-Hpiniil, 

309. 
Cystine  caJculi,  802,  892. 
Cystinuria,  801. 
Cystitis,  locoiiiotor    ataxia,    925 ;   in  trnnsverso 

myolitis,  978  ;  tuberculous,  320. 
Cytozon,  349. 
Cysts,  cliylous,  of  mesentery,  547  ;  in  kidneys, 

898;  of  brain,   1020;  iwrenceplialic,   1017  ;  of 

bruin,  tlironibotie,  1009  ;  pancreatic,  692. 

Dacryoadonitis  (see  Lachrymal  Glands). 

Dancing  mania,  10S8. 

Dandy  fever  (dengue),  99. 

Davainea  Madagascariensis,  SOG. 

Day-blindness,  1040;  in  scurvy,  824. 

Deaf-mutism  after  eerebro-'  j)inal  fever,  106. 

Deafness,  in  cerebral  tumor,  1023;  in  cerebro- 
spinal meningitis,  100;  in  hysteria,  1110;  in 
Meniere's  disease,  1058 ;  in  scarlet  fever,  81 ; 
in  tabes  dorsalis,  924 ;  nervous,  1057. 

Death,  modes  of,  in  tuberculosis,  317  ;  sudden, 
in  angina  pectoris,  702 ;  in  aortic  insullicioncy, 
712  ;  in  typhoid  fever,  40 ;  in  pleural  effusion, 
071. 

Debility,  nervous  (pee  Neurasthenia),  1122. 

Decubitus,  acute,  1002;  (bed-sores)  in  transverse 
myelitis,  978. 

Degeneration,  reaction  of,  914  ;  in  neuritis,  1036 ; 
in  facial  paralysis,  1054. 


Deglutition,  difficult  (kco  Dviii'itAdtA). 

Deglutition  pneumonia,  i'i42. 

Delayeit  reholutlun  in  pueunioniu,  129. 

Delayed  setiHUtion  ill  talies,  924. 

I»eliriuiii,  acute,  lti75;  acute,  in  lead-]ioiMon!Mg, 
389;  cordis,  41,  755,  757;  expansive,  902;  in 
acute  rlieuinutism,  171;  in  pneumonin,  \-ijl\ 
in  tyi>li()id  fever,  29;  in  typhus  fever,  52; 
tremens,  382. 

Deltoid,  paralysis  of,  UCn. 

Delusional  liiHanity  aft(M'  |ineum(iiiia,  123. 

Delusions  of  grandeur,  902. 

Deiiu^ntia  paralytica,  900;  nlcoliol  us  u  factor  in, 
881  ;  syphilis  and,  242,  24i),  901. 

Demodex  folllculorum,  370. 

Dengue,  99. 

Dentition,  in  congenital  syphilis,  243  ;  iu  mer- 
curial stomatitis,  445  ;  in  rickets,  437. 

Dermacentor  amerlcanus,  370. 

Dermatitis,  exfoliative  form,  82. 

Dermatobia,  878. 

Dermatose  parasitairo,  301. 

l)es(iuaniation,  in  measles,  87;  in  rubella,  89; 
in  scarlet  fever,  79;  in  small-pox,  C2;  in 
typhoid  fever,  17. 

Deviation,  secondary,  1048. 

Devonsliire  colic,  380. 

Dextrocardia,  705. 

Diabetes  insipidus,  432;  licredity  in,  432;  in 
abdominal  tumor,  432 ;  in  tuberculous  peri- 
tonitis, 432. 

Diabetes  mellitus,  418 ;  acute  fonn,  422  ;  bronz- 
ing in,  425:  chronic  form,  422;  coma  in,  425  ; 
diet  iu,  428;  dietetic  form,  422:  gangrene  in, 
425;  hereditary  intluences  in,  418;  in  obesity, 
419;  in  children,  425;  lipogeiiic  form,  422; 
neurotic  form,  422  ;  pancreas  in,  421  ;  pancre- 
atic fonn,  422:  pifajjlegia  in,  427;  })erforatiiig 
ulcer  in,  426  ;  theories  of,  420 ;  urine  in,  423. 

Diabetes,  phosphatic,  802. 

Diabetic,  centre  in  medulla,  419;  cirrhosin.  421 ; 
cointt,  426;  phthisis,  421 ;  tubes,  426. 

Diaeetie  acid,  864. 

Diaphragm,  paralysis  of,  1008;  degeneration  of 
muscle  of,  1008. 

Diarrluca,  505;  acute  dysi>cptic,  509;  albo,  511 ; 
bacteria  in,  508 ;  chronic,  treatment  of,  514 ; 
chylosa,  511;  endemic,  of  hot  countries,  304; 
from  unchylostomiasis,  300  ;  in  children,  treat- 
ment of,  510;  in  cholera,  179:  in  dysentery, 
194,  198,  199;  in  hysteria,  1117:  in  phthisis, 
311;  in  typhoid  fever,  23;  in  urcemiu,  807; 
nervous,  500 ;  of  Cochiu-China,  365 ;  tubular, 
544 ;  lienteric,  507. 

Diathesis,  gouty,  408,  414;  limmorrhagie,  814; 
lithic  acid,  859 ;  tuberculous  or  scrofulous, 
208  ;  uric  acid,  800. 

Diazo-reaction  in  typhoid  fever,  31. 

Dicrotism  of  pulse  iu  typhoid  fever,  13,  20. 


111 


tIAIIU). 

ill,  I'.'D. 

It'iiil-poiHonifijf, 
;|)uiiKivc,  ih;'J;  ill 
iiu:iini()iiin,  l'J2; 
liliiiH   I'uvur,  &2; 

lonin,  123. 

ol  OH  u  t'uctor  in, 
1. 


ift,  243  ;  iu  mcr- 
'Xh,  437. 


in  rul)ellu,  89; 
luil-pox,    G2;    iu 


lity  in,  43'i;  in 
uburculous  j)uri- 

Hiii,  422;  bronz- 
i  ;  coil  in  in,  42') ; 
i2 :  j.'iii>jri'i'i»e  ill, 
418;  in  obesity, 
enic  form,  422; 
in,  421  ;  puiicre- 
427;  jHirlbruting 
,  urine  in,  423. 

• ;  cirrliosis.  421 ; 
8,  420. 

degeneration  of 

509;  albn,  511; 
atiucnt  of,  514; 

countries,  304; 
1  cliildren,  treiit- 
:  in  dysentery, 
17;  in  phtliisis, 
n  unemiu,  807; 
a,  365;  tubular, 

norrliagrie,  814 ; 
or   scrofulous, 

31. 

rer,  13,  20. 


INDK.X. 


u.in 


I)iot,  In  eliror  lo  dyKpopHln,  470 ;  in  conHtipntion, 
fi40;  In  i!<  nvaUwiM'iicti  IVum  typhoid  iVvrr, 
4H;  in  diuli'tcH,  4'JM  ;  in  i^mit,  llO  ;  in  inltiiitilt' 
<liiirrlin;ii,  .»U1;  in  (ihrnity,  4.')',t ;  in  Hciirvy,  Hii2; 
in  tiil)ereiil<»«iH,  335  ;  in  tyjilioid  fever,  42. 

IHttl'n  erlKCH,  H4H. 

l>ivf('ntivi'  HyMt<!iii,  dineaHOd  of,  441. 

Dldctopliyiiie  n'litui*,  304. 

Diphtheria,  138;  ntypiciil  fonim  of,  140  :  of  audi- 
tory nicatUH,  14!*;  of  coiijuiK-tiva,  14'.t;  iind 
crotij),  144;  biieilbm  of,  14ii;  contiitfiousiii'NH 
of,  13H;  heiniplu;^iu  in,  ITiO;  iiniiiunity  from, 
141;  in  aniiimln,  13'.( ;  laryngeal,  148;  latent, 
147;  nephritiH  in,  150;  neuritis  in,  151 ;  iiumuI, 
147;  pharyiiKenl,  14<'> ;  ofukin,  Hit;  Hymptoms 
of,  140;  Hysteiiiio  infection,  147;  aiitiloxine 
treatment  of,  155;  of  wounds,  141*. 

Diphtheritic,  colitis,  512;  inemhrane,  liiHtolojry 
of,  144;  proecHHcs  in  imcuiuoniu,  115;  pro- 
cesses in  typhoid  fever,  33. 

Diphthoritis,  14ii. 

Diphtheroid  intlnininationH,  142. 

Diplc(,'iii,  facial,  lO.Vi ;  in  childnai,  !)."8. 

Diploeoeeiis  intriioclluliiris  meningitidis,  102. 

DiplococcuB  pnouinoniiD  (mieroeoecua  lancoo- 
latus,  pneunioeoecus),  110;  in  cnipycnia,  071 ; 
in  endocarditis,  702;  in  peritonitis,  51(7. 

Diplopia  (sec  Dol'blk  Visio.v),  1049. 

Dipsomania,  380. 

Dipylidiuin  caninum,  300. 

Disinfection  in  diphtheria,  153;  in  typhoid 
fever,  41. 

Dissecting  aneurism,  770. 

Distomiasis,  351. 

Distomum  lanccolntuni,  351 ;  D.  buski,  351 ;  D. 
cndeniicum,  "^51  ;  D.  porniciosuin,  351  ;  D. 
Binensc,  351 ;  D.  felincum,  351 ;  D.  wester- 
manni,  038,  352. 

Dittrichh  plugs,  025. 

Diuresis,  432. 

Diver's  paralysis,  909. 

Diverticula  of  oesophagus,  402. 

Dochmius  duodenalis,  35'J. 

Dorsodynia,  407. 

Dothi6nont6rito,  1. 

Double  heart,  705. 

Double  vision,  1049 ;  in  ataxia,  922 ;  in  chronic 
Bright's  disease,  881. 

Drncontiasis,  802. 

Dracunculus  medinensis,  302. 

Drainage,  and  diphtheria,  138;  and  scarlet 
fever,  70;  and  tonsillitis,  451;  and  typhoid 
fever,  5. 

Dreamy  state  in  epilepsy,  1097. 

Dropsy,  cardiac,  treatment  of,  733 ;  in  annMiiin 
(cudema),  797 ;  in  acute  Bright's  diseanc,  8T0; 
in  aortic  insufHciency,  712;  in  aortic  stenosis, 
717;  in  cancer  of  stomach,  490;  in  chronic 
Bright's  disease,  870 ;  in  mitral  insutlicieucy, 


720;  In  mitral  otononln,  725 ;  In  phfhlHis,  3l!i; 
in  scarlet  Icmt,  ho. 

Mnnf-rashcH,  m;i,  h14. 

Driinki'iincNri,  iliagiKwiR  from  apoplexy,  3ko, 
l(m7. 

Dry  Mouth,  447. 

Diiliu'HM,  luoviiblp,  in  pleural  elTiislon,  009;  In 
])lieiimotlioi'ax,  0H3. 

Dumb  ague,  217. 

Duodenal  idi'cr,  478;  dingnosis  of,  from  gastric, 
4H4. 

Duodenum,  defect  of,  5.'i3  ;  uIcit  of.  47H. 

Dura  mater,  diseases  of,  ii51  ;  hiemaloma  of,  952. 

/>(/;•««</«'*  mixture,  608. 

Ihirdiii'z'n  murmur,  714. 

Dust,  diseases  due  to,  05O,  052;  tuborolo  hneilll 
in,  201. 

DysBcusis,  1057. 

Dysentery,  I'J'l;  nbRcess  of  liver  in,  100,  200; 
acute  catarrhal,  194;  iimieba  coli  in,  195; 
chronic,  199;  diphtheritic,  198;  treatment  of, 
201 ;  tropical  or  niiuibic,  195. 

Dyspepsia,  acute,  403 ;  chronic,  400 ;  nervous, 
497. 

Dysphagia,  hysterical,  1117;  In  cancer  of  the 
<i'sophagus,  4t'il ;  in  hydroplioiiia,  'j-28  ;  in  o>so- 
phagisiiiUK,  459 ;  in  o'sophagitis,  4")S  ;  in  pcii- 
cnrdial  elt'usioii,  O'.t'.' ;  in  tlioriicic  aneurism, 
781  :  in  tuberculous  laryngitis,  019. 

Dyspiiiea,  cardiac,  treatment  of,  733  ;  from  ntii'U- 
risiii,  781  ;  hysterical,  llKi,  ll.'l.'! ;  in  nciite  tu- 
berculosis, 'J75  ;  in  aortic  iusullicieiicy,  712; 
in  cardiac  dilatation,  744;  in  chlorosis,  792; 
in  diabetic  eoma,  420  ;  in  mitral  insiitllcivni'V, 
719;  in  mitral  stenosis,  72.'i ;  in  pericardial 
effusion,  092;  in  pneumonia.  117  ;  in  I'hthisis, 
304;  in  o'dema  of  the  glottis,  017;  in  spas- 
modic laryn^ritis,  018;  uriemic,  8t'i7. 

Dystrophies,  muscular,  933 ;  clinical  forms  of, 
934. 

Kar,  complications  of  scarlet  fever,  81  ;  nifcnions 

of,  in  syphilis,  241,  244  ;  symptoms  simulating 

meningitis,  1027. 
Ebstein^s  method  in  obesity,  439. 
Eehinocoecus  cyst,  tlui<l  of,  371,  373. 
Kchinoeoccus  disease,  370. 
Eehinocoecus,  endogenous,  371  ;  exogenous,  371 ; 

multiloeular,  371,  374. 
Echinorhynchus  gigas  ;  E.  moniliformis,  3G5. 
Echokinesis,  1089. 
Eeholalia,  1089. 
Eclampsia,  1091. 
Ectopia  cordis,  70.5. 
Eczema,  of  the  tongue,  445  ;  in  diabetes,  425 ;  in 

gout,  414. 
Efferent  tract,  diseases  of,  928. 
E/ir/i('h\i  reaction  in  typhoid  fever,  81. 
Elastic  tissue  iu  sputum,  301, 


IKIi) 


INDKX. 


/' 


Klcctili'ftl  ronolloiip,  In  oxi-ipliihalinlo  (fnltro,  8.10  ; 
ill  t'lii'iiil  I'liU.V,  lii.Vl  ;  ill  I,(tnilry'i  imliilyftiH, 
(•17  ;  111  iiiiilti|ilit  iii^ui'ItlH,  lo.'lil ;  ill  iiuriniiioul 
|iiii'iil,vi«iM,  ll.'ii);  ill  |iiilIo-iii^i-ritiH  itiit<'rii>r,  U44; 
111   /7('i//i«<  (/\  (lim'iinr,  111!'. 

Eli'ftrol^vKl*  ill  iiiii'iiiiHiii,  7HB. 

Kli'l>liuiitiui<iN,  ;iil-j. 

Kiiiiu'iuiinii.  ill  iiiiornxlu  lutrvoHn,  1117  ;  in  (rnxtric 
cuiii'cr,  4HII ;  ill   <i>Hiiiiliii^uul  i.-tiiK'ur,  -liil  ;  in 

pIllllirtiK,  .'lOlt. 
Kllll">lio  allKCl'HMCH,    l(!t. 

KmlMilJHm,  mill  iiiifiiriHin,  77*1 ;  in  olinron,  lf>fi2; 

ill  t,viiiini(|  I'uvcr,  'Jl  ;  "f  ci'it'liriil  iirlcricn,  Iimis. 
KiiiliryiH-iii'illa,  757;  in  |int'Uiiioiiirt,  I'Jii;  in  t>- 

|ilii<l(l  li'Vir,  '-'I. 
Kiii|iliyi<i'iim,  li.'il ;  iiciiti'  voMli-ulor,  On<i ;  ntropliic, 

(!.Mi;  coiiiiu'iimitory,  •i').'^;  Iiypurtropiiie,  055; 

inUTstitiiil,  (iiio. 
Kiii|iliysi'iiiii,  Kubciitiinuous,  aftiT  traolieotoiny, 

Ob7  ;  at'tcr  «s[)!..,tion  of  tlio  pU'iira,  ()77  ;  in 

ffMslrio   nliHT,  47'.);    in   plitiiisis,  ai3;  of  tliu 

ini>diimt!iiuin,  flH7. 
Knipro.HtimtDno.s  in  totuiuis,  '2.12. 
Einpyfiim,  '"'71  ;  luii'torioloi^y   of,  071 ;  nuooHMi- 

latis,  iJ.'!7.  *I7'J,  78.'1;  perforation  of  lung  in,  (173. 
KiH'cplialitin,    luuito,    10:i4 ;    iin.'nin).'o-,    t-liroiiic 

tlilViisi',  '.Mio  ;   iiiunitij^o-,  fci'tal,  \)o>i\  polio-,  of 

,S/rihiijhl/,    lol8;    HUppiirativL',    lo;!o ;    nyphi- 

litio,  -Mry. 
EiK'L'plialopathy,  load,  383. 
Enclioiiilroina  of  liinjj,  t)ti.?, 
EiiilarK'ritis  of  «piiuil  oonl,  9ii7. 
Euilooanlitis,  ucutc,  OUS ;  oiironie,  705 ;  chronic 

vfjfi'tat         701;  iliplitiR-ritic,  (i'JO;  in  cliorea, 

(I'.t'.t,  '  lotiou.'j,  (j'jy  ;  ill  the  fu}tus,  707, 

Vi"'  .(L'al,  251 ;  in  pnoiniionia,  700  ;  in 

.Dver,  700  ;  in  rhcimiatisiii,  170,  099  ; 

^-dcnsmin,  700;  in  typlioiil  fovur,  11;  in 

lUiviilosis,  20S,  700;  inali-fiiant,  (i'.t9  ;  nieiiin- 

gitis  ill,  700;  iniuro-orj^anisiiis  in,  702;  mural, 

vol ;  recurring,  (50!) ;  Hclorotic,  707 ;  simple  or 

vcnMU'osc,  000 ;  syphilitic,  2.50 ;  ulcerative,  099. 
Eiiiloplik'l)itis,  774. 

Enteric  fever  (sec  Tvimioid  Fkveu),  1. 
Enteritis,  catarrhal,  f<05  ;  croupous,  512;   dipli- 

theritic,  512;  in  eliildren,  .OOy ;  phlejfinonous, 

512;  ineinbranou.s  or  tubular,  644;  ulcerative, 

512. 
Entero-colitis,  acute,  510. 
Eiiteroclysis  in  cholera,  181, 
EiiU'rolith.s,  519,  5i34 ;  as  a  cause  of  appendicitis, 

519;  in  sacculi  of  colon,  539. 
Entcroptosis,  .541,  847,  1120. 
Eiitozoa  (sec  Ani»-   l  Fauasitks),  349. 
Eosinopliiles  in        kiemia,  800 ;   in  trichinosip, 

357. 
Ependyinitis,  purulent,  277 ;  granular,  in  general 

paresis,  901. 
Ephemeral  fever,  342. 


Kpideinlc  lirrmoiflohinurln,  fil9. 

Kpiduli.ie  roseola,  89. 

Kpidenic  Ktoiiiatitis,  .1(7. 

Kpiiliilyinitis  (see  Oiti  Minn),  2.11,  .12fi, 

Kpll<'i>sia,  larvatii,  lnOM;  nutans,  1000. 

Kpile|isy,  loii!i;  and  aleoholisiii,  1095;  and  nyivhl- 
lis,  1095,  loin);  lieredity  ill,  1094;  in  olin.nio 
ergotism,  394  ;  in  general  paresis,  9ii2;  in  leail- 
polHonliig,  889;  in  /ildi/iiiiitiJ'ii  disease,  1139; 
,/iii'^wi/H((/i,  917, 1098;  iiiaslxed,  1()98;  post-ei)i- 
le[)tio  Myiiiptoiiis  of,  1097;  procursive,  lo9(l;  ro- 
Uex,  1095;  rotatory,  1090 ;  Hpinal,937;  surgieal 
treatment  of,  llol. 

Epileptic  tits,  Htages  of,  1000. 

Epistaxis,  014;  in  ha'iiioplillla,  820;  in  Hourvy, 
823;  i;i  typlmid  fever,  27  ;  "renal,"  852;  vica- 
rious, 014. 

Krb-doldllam's  symptom-eoinplex,  'J17. 

Erb's  syphilitic  spinal  paralysis,  910. 

EiX"tlsiii,  394  ;  convulsive,  394 ;  gaiigretiouH,  394. 

Erosion  of  teeth,  44.5. 

Eructations,  norvous,  403. 

Eruptions  (see  Hasiiks). 

Erysipelas,  157;  ul)seesrt  in,  159;  after  vaccina- 
tion, 71 ;  facial,  158  ;  in  typhoid  fever,  33  ;  mi- 
grans, 159;  puerperal,  157. 

Erythema,  exudativum,  81.') ;  in  pellagra,  395  ;  in 
typhoid  fcvt'r,  17;  in  tniiMillitis,  452. 

Erytiiromelalgia,  llOO,  1139. 

Eschar,  sloughing,  in  heii>l[)legia,  1002, 

Eustrongylus  gigas,  804. 

Exaltation  of  ideas  in  general  parcHis,  902, 

Exanthematous  typhus,  49. 

Exfoliative  dermatitis,  82. 

E.xophtlialmic  goitre,  830  ;  acute  form,  837  ;  dimi- 
nution of  electrical  resistance  in,  839;  pigmen- 
tation in,  839  ;  tremor  in,  839 ;  urticaria  in,  8.39. 

Eye,  motor  nerves  of,  paralysis  of,  1040 ;  spasm 
of,  1047. 

Eye-strain  in  migraine,  1102. 

Eyes,  conjugate  deviation  of,  in  brain  tumor,  1023 ; 
in  apoplexy,  1002;  in  tuberculous  meningitia, 
279. 

Facial,  osymmetry,  1004,  1141;  tliplcgia,  1053; 
lieiniatrophy,  1141;  hemiliypcrtroi)liy,  1142; 
nerve,  paralysis  of,  1051  ;  paralysis  from  coUl, 
1053 ;  paralysis  from  lesion  of  trunk  of  nerve, 
1052 ;  paralysis  from  lesion  of  cortex,  1052 ; 
paralysis,  symptoms  of,  1053. 

Facial  spasm,  1055. 

Faeies,  Ilijipncratic,  598 ;  leontina,  in  leprosy, 
341;  in  mouth-breathers,  45.');  /tirki/inoninn, 
1077  ;  syphilitic,  243;  in  typhoid  fever,  14. 

Ftccal,  accumulation,  534,  539 ;  concretions,  519, 
539  ;  vomiting,  534. 

Ftcces,  bacteria  in,  .508  ;  in  jaundice,  540. 

Fallopian  tubes,  tuberculosis  of,  320. 

Famine  fever  (see  Kelai-sino  Fkvku),  53. 


INDKX. 


iini 


lUliil. 
l<)yr<;un<l(i.vplii- 
lo'.l't ;  ill  clii'oniii 
hIh,  'X,2\  ill  li'tiil- 
n  (liNi'iMii,  llill); 
,  lO'.m;  i>(mt-oiii- 
■ui-Kivi^,  HM»il;  ro- 
lui,  U37;  HUi'i^ioiit 


fl'20;  in  Hpurvy, 
iiiiii,"  8.12;  viou- 

i!.\,  U17. 
UIO. 
giin^i'cnouH,  394. 


;  nftor  vacoinii- 
,d  I'livur,  3.'i ;  iiiL- 

p(!lla};rn,  8'J5;  in 
»,  452. 

.1,  IDO'J. 

rcHiH,  903, 


form,  637 ;  dinii- 
11,  839 ;  piginiiu- 
urtit'iuiii  ill,  S.'tl). 
of,  104(J ;  Hpasm 


ain  tumor,  1023; 
oils  meningitis, 


iliplejfia,  10.i3; 
lortropliy,  1142; 
ly.sis  from  colil, 

trunic  of  nerve, 
of  cortex,  1052 ; 


ina,  in   leprosy, 
;  hirkhiRoninn, 
sill  fever,  14. 
concretions,  519, 

lice,  549. 
o2('.. 
;vek),  53. 


Fitroy,  a-ia  ;  wmto,  2.14  ;  ehronio,  835. 

Kurcy-liuilH,  234. 

Fiirrt'i  tuliureloM,  580. 

l''ai«eiolu  luiputiea,  351, 

I'ut  emlioliwm  ill  iHiiln't'H,  42il. 

I'at  iieerohiK,  !>',)\  ;  of  piiiKniiK,  in  (lial)et<i«,  402. 

Fatty  ileKeiienitioii,  of  arterii'H,  7r<>;  of  lu.linyK, 
H74;  of  livor,  5rt5 ;  of  tim  new-horn  {/ln/i/'n 
(liKciiHc),  H18, 

Fiitty  .leKeneration  of  heart,  749  ;  in  anuimiii,  79(). 

Fatty  utoolB,  590, 

Fehrieula,  342, 

Felirif*,  ourniM,  49  ;  roourronB,  53, 

Fihliiiifd  lest  for  HU|,'ur,  423. 

Fermentation,  tertt  for  rtUi^ar,  424. 

Fetiil  Htomatilis,  442. 

Fever,  aplithoim,  .'Vt7 ;  in  cholera,  170 ;  ontoro- 
nieseiiterie,  1  ;  ephemeral,  342  ;  (Jtastric,  4(i3  ; 
Ulaiulular,  345;  iiy«terieiil,  1119;  pernieioiiH 
malarial,  215;  in  pneumonia,  110;  in  ai;uto 
piieumonie  plitliisis,  2110,  293;  in  lUMite  miliary 
tuherculosiM,  274 ;  in  primary  multiple  neiiri- 
tin,  1033  ;  in  meninjfitic  tuheivulosin,  27H  ;  in 
pulinomiry  tuliereulosiH,  304;  in  pyiemia,  104; 
in  [)yleplilel)itis,  siippunitivo,  580 ;  in  inter- 
mittent fever,  212;  in  ivhip.sin;^  fever,  54  ;  in 
remittent  fever,  213 ;  in  nearlet  fever,  77 ;  in 
Hepticosmia,  102;  in  8miill-i)o.\,  59;  in  sun- 
stroke, 390  ;  in  appondieitis,  524 ;  in  secondary 
Hvpliilis,  240;  in  typhoid  fe,er,  14;  in  yellow 
fuver,  185;  lung,  10s ;  .Malta,  219;  Mediterra- 
nean, 219;  mountain,  34(1;  Neapolitan,  219; 
putrid  malignant,  1  ;  relapHing,  53;  roek,  219; 
ship,  49;  slow  nervous,  1;  splenic,  224;  spot- 
ted, 49,  101;  typlidd,  1;  typho-muluriul,  39, 
214;  typhus,  49  ;  uudulant,  219;  yellow,  182. 

Fever,  idiopathic  intermittent,  103. 

Fever,  intermittent,  in  abscess  of  liver,  .579 ;  in 
ague,  209 ;  in  chronic  ol)struetion  of  hile-pas- 
sages  by  gall-stones,  500;  in  lInilijluii''H  dis- 
ease, 812;  in  pytemia,  104;  in  pyelitis,  888;  in 
Hcpticn?mia,  103;  in  secondary  syphilis,  240;  in 
tuberculosis,  299,  305, 

Fibrinous,  bronchitis,  032  ;  pneumonia,  108. 

Fibroid  disease  of  heart,  747. 

Fibrosis,  arterio-capillary,  770, 

Fih're,  infiammatoire,  397  ;  tijpliolde  a  forme 
renale,  31, 

Fifth  nerve,  paralysis  of,  1050 ;  gustatory  branch, 
lO.'il  ;  tropliic  changes  in  paralysis  of,  lO.'iO. 

Filaria  hominis  sanguinis,  F.  bancrofti,  F.  diurna, 
F.  perstnns,  300 ;  F.  medinensis,  302. 

Filaria  loa,  F.  Icntis,  F.  Inbialis,  F.  hominis  oris, 
F.  bronchialis,  F.  immitis,  304, 

Filariasis,  300, 

Fish,  poisoning  by,  393. 

Fm/ier^s  brain  murmur,  437, 

Fistula  in  ano  in  tuberculosis,  31.5,  320. 

Fistulo,  a'sopliago-pleuro-cutuneous,  402. 


Flutulcnoe,  In  liyntcrin,  1117;  In  n«rri»u«  dyn- 

[H'pMia,  .'lOO  ;  treatment  of,  478. 
Flea,  bite  of,  378, 
FUiit'n  murmur,  71-1,  724. 
Floatlni/  kidney,  512,  mm, 
Florida  fever,  3'j7. 

I'luke,  bronchial,  352;  bloo.l,  359;  llvor,  851, 
Flukes,  dist^ases  caused  by,  351, 
Fo'tal  heart-rhythm,  757. 
Fii'tus,  eiidoearilitis  ill,  7ii7 ;    HVphilis    in,  242; 

tuberculosis    ill,    202;    white    piieuiuunia  of, 

247  ;  typhoid  fovor  in,  30. 
/■'iilii   /lri<j/itii/ii(',  Htllt. 
Follicular  tonsillitis,  451. 

F I  (S(!e  DiKTj. 

Food  poisoning,  391, 

Foot  and  moutli  ilise/iso,  817. 

Foreiiiii  bodies  ill  intestines,  534. 

Fourth  nerve,  lo47  ;  iiaralysis  of,  10-17, 

Fremitus,  vocal,  119,  .3u7  ;  liydatid,  372, 

Friction,    mediastinal,    087;    jiericanlial,    090; 

peritoneal,  Oo-t ;  pleural,  308,  070;  pleuro-peri- 

eardial,  80s. 
Friedreich^  ataxia,  949, 

Frieilrcicft^n  sign  in  adherent  pericardium,  697. 
Frontal  convolutions,  lesions  of,  1022, 
Frontal  sinuses,  pentastoines  in,  375, 
Funnel  breast,  807,  455, 

(ia.t,  ataxic,  923  ;  in  paralysis  agitans,  lo77;  in 
pseu<lo-hypcrtropliie  iiiuseular  jianilysis,  934  ; 
ill  spastic  paraplegia,  937  ;  pseudo-tabetic,  42ii, 
1034  ;  utepjHKje,  in  iieripheral  neuritis,  1014  ; 
in  diabetic  tabes,  420, 

Galuctotoxismus,  393. 

Gall-bladder,  diseases  of,  555 ;  atrophy  of,  500; 
calcitieation  of,  505;  dilatation  of,  5<i5 ;  em- 
pyema of,  505;  forming  abdominal  tumor, 
505;  phlegmonous  inllammation  of,  505. 

Gallo[)-rhytliiii,  757. 

(.Jalloping  consumption,  292, 

Gall-stone  crepitus,  505. 

Gall-stones,  501. 

G.imo-birds,  poisoning  by,  893. 

Ganglia,  basal,  tumors  of,  1022. 

Gangrene,  in  diabetes,  425 ;  in  ergotism,  394 ; 
in  pneumonia,  130;  in  typhoid  fever,  12,  22; 
in  tyidius,  52;  local  or  symmetrical,  113S; 
imilti[>le,  113S;  of  lung,  000;  of  mouth,  444. 

(iansircnous  stomatitis,  444. 

(larrod'K  thread  test  for  uric  acid,  410, 

Gas-bacillus  (see  Bacillus    aeuooenes  cai-su- 

I.ATl'S). 

Gastralgia,  501, 
Gastrcctasis,  474. 
Gastric  catarrh,  acute,  403. 
Gastric,  crises,  484,  501,  i>24  ;  fever,  4C3. 
Gastric  juice,  hyperacidity   of,  484,  500;  sub- 
acidity  of,  501, 


1102 


INDEX. 


•  I 


»■ 


(iustric  spasm,  eongonitul,  495. 

(Jastrii!  uluor,  47H;  c'linii'al  tonus  oT,  482. 

Gastritis,  acute,  4(!.'i ;  acutu  supiiurativo,  4t!4; 
chronic,  40U;  diiihtliurltiu,  4U5 ;  incinbranoiis, 
40,');  inyootie,  4()(!;  parasitic,  4i)t) ;  i)lili'g- 
nionous,  4(!4 ;  polypf)sa,  407;  sclerotic,  407; 
simple,  403  ;  siniplo  elironic,  40(i ;  toxic,  405. 

(iastroiiynia,  501. 

(iastrorrliHj^ia,  4i)5. 

Gastro^      y,  4()iJ. 

(ia'jtroxyiisis,  500. 

(Jencral  paralysis  of  the  insane  (general  jm- 
rcsis),  flOO ;  diagnosis  of  from  sy[iliilis,  ilW, 
J103;  intluenec  of  sypliilis  in,  'J42,  ^-40,  KOI. 

Genito-urinary  system,  tuberculosis  of,  !522. 

Gentles,  379. 

Geograpliieal  tongue,  445. 

Gei'lier''s  disease,  1059. 

German  measles,  89. 

(Jiant  growtli,  1143. 

Giants  and  gigantism,  1143. 

Gigantism  and  acromegaly,  1143. 

Giguntol)lasts,  (-99. 

Gigantorhynehus  gigas,  305. 

(relies  de  la  ToiiretWs  disease,  1089. 

Gin-drinker's  liver  (see  Ciiiuiiosis  of  Liver), 
509. 

Glanders,  233;  acute,  234;  chronic,  234;  diag- 
nosis from  small-pox,  07. 

(Jlandular  fever,  345. 

Gkiiard''s  disease,  541. 

Glioma  of  brain,  1020. 

Gliosis,  975. 

Globulin  in  urine,  857. 

Globus  liystericus,  1112. 

Glomerulo-nephritis,  870. 

Glosso-labio-laryngeal  paralysis,  032. 

Glosso-pliaryngcal  nerve,  atlections  of,  1059. 

Glossy  skin  in  arthritis  deformans,  402. 

Glottis,  oedema  of,  C17  ;  ii)  liright's  disease,  881 ; 
in  small-pox,  04;  in  typlioid  fever,  11. 

Gluteal  nerve,  atlections  of,  1072. 

Glycogen,  formation  of,  420. 

Glycogenic  function  of  liver,  420. 

Glycosuria,  420,  805;  gouty,  415;  lipogenic,  422. 

(fmeliii'g  test,  549. 

Goitre,  835;  exophthalmic,  830;  sudden  death 
in,  836. 

Gonorrhojal  artliritis,  250;  endocarditis,  250; 
septiciemia  and  pyiemia,  255. 

Gonorrhtjcal  infection,  255;  systemic,  255. 

Gout,  407;  acute,  411;  chronic,  413;  Ebstein^s 
tlicory  of,  409;  hereditary  influence  in,  408; 
influence  of  alcohol  in,  408;  influence  of  food 
in,  408 ;  influence  of  lead  in,  408 ;  irregular, 
414;  nervous  theory  of,  409;  retrocedent  or 
suppressed,  413. 

Gouty  kidney,  877. 

von  Grae/Vs  sign,  838. 


Grain,  poisoning  by,  394. 

(irandeur,  delusions  of,  902. 

Grand  nuil,  1094,  lO'.iS. 

(iranular  kidney,  877. 

Granulomata,  infectious,  of  brain,  1020. 

Gravel,  renal,  892. 

Gniven'  disease,  830. 

(ireen  cancer,  809. 

Green-siekness  (see  ("iif.ouosis),  793. 

Green-stick  fracture  in  rickets,  437. 

Grcgariiiidie,  [larasitic,  349. 

(irinder's  rot,  052. 

(irippe,  la,  95. 

Grinbler^a  tumor,  889. 

(Juinea-wonn  diseoso,  302. 

(riilPn  disease,  841. 

Gumnuita,  239;  in  acquired  syphilis,  241  ;  in 
congenital  syphilis,  244;  of  brain  and  spinal 
cord,  244;  of  heart,  250;  of  kidneys,  250;  of 
liver,  248;  of  lungs,  247;  of  rectum,  249;  of 
testis.  251  ;  structure  of,  239. 

Gumuuitous  periarteritis,  250. 

Gums,  black  line  on,  in  miners,  387;  blue  lino 
on,  in  lead-poisoning,  387  ;  in  scurvy,  823  ;  in 
stonuititis,  442;  rod  line  on,  in  pulmonary 
tuberculosis,  311. 

Gustatory  paralysis,  1051. 

Habit  spasm,  1088;  in  nioutii-breathcrs,  456. 

Habitus,  apoplectic,  998  ;  plithisicus,  208. 

Ilicmatemesis,  495  ;  causes  of,  495  ;  in  cirrhosis 
of  liver,  572 ;  diagnosis  from  lireinoiitysis,  497  ; 
in  enlarged  spleen,  210,  495;  in  scurvy,  823. 

Ilreniato-chyluritt,  non-parasitic,  859;  parasitic, 
301. 

Iltematoma  of  dura,  of  brain,  952;  of  cord,  953; 
of  mesentery,  546. 

Ilromatomyelia,  908. 

IIa?matoporphyrin,  805. 

Hiematorrhachis,  907. 

Hrematozoa  of  malaria,  205. 

Iliematuria,  851;  endemic,  of  Egypt,  352;  in 
acute  nephritis,  870  ;  in  chronic  phthisis,  312 ; 
in  psorospermiasis,  350;  in  renal  calculus, 
894 ;  in  renal  cancer,  897 ;  in  tuberculosis  of 
kidney,  325  ;  malariii,  210. 

Ilfemoeytozoa,  205. 

Iliiniioglobin,  reduction  of,  in  clilorosis,  793. 

Iliemoglobiniemia,  854. 

Hremoglobinuria,  852;  epidemic,  in  infants,  243; 
818,853;  in  A'ay««!/(/'A' disease,  1138  ;  paroxys- 
mal, 853 ;  toxic,  853. 

Ilfemo-pericardium,  698. 

Ilremo-peritoneum,  588. 

Iln?mophilia,  819. 

lltemoptysis,  eouses  of,  037  ;  hysterical,  1117  ;  at 
onset  of  phthisis,  299  ;  in  acute  broncho-pneu- 
monic phtliisis,  293;  in  acute  miliary  tubercu- 
losis, 275  ;  iu  aneurism,  637,  781 ;  in  aortic  in- 


1, 1020, 


793. 

137. 


I'pliilis,  241  ;    in 

>raiii  iind  spinal 

kidneys,  250;  of 

rectiini,  241) ;  of 


s,  387;  blue  lino 

scurvy,  823  ;  in 

I  in    pulniouury 


cathers,  456. 
icus,  208. 
95:  in  cirrliofis 
i£einoi)tysis,  497 ; 
n  scurvy,  823. 
,  859;  pnrasitic, 

52 ;  of  cord,  953 ; 


INDEX. 


1163 


Egypt,   352;  in 

lie  plitliisis,  312; 

renal    calculus, 

I  tuberculosis  of 


lorosis,  793. 

,  in  infants,  243  ; 
1, 1138;  paroxys- 


«tcrical,  1117;  at 
e  broncho-pneu- 
miliary  tubercu- 
il ;  in  aortic  in- 


Rufiicicncy,  712  ;  in  nrtlirltlo  subjects,  fiSH  ; 
in  bronoliiectasiH,  027;  in  cirrhosis  of  lung, 
051;  in  cnipliysema,  059;  in  hysteria,  1117; 
in  mitral  insulHcieticy,  720  ;  in  mitral  ste- 
nosis, 725  ;  in  pneumonia,  118  ;  in  pulmo- 
nary gangrene,  002 ;  in  scurvy,  823 ;  spurious, 
1117;  symptoms  of,  038;  treatment  of,  039; 
in  typhoid  fever,  28;  relation  to  tuberculosis, 
037;  parasitic,  352;  periodic,  037;  vicarious, 
037. 

IIa,'morrhage,  broncho-pulmonary,  037  ;  cerebral, 
997  ;  from  mesentery,  540  ;  from  the  stomach, 
405 ;  in  acute  yellow  atrojjhy,  552 ;  in  aniemia, 
79U;  in  cirrhosis  ofthe  liver,  572;  in  contracted 
kidney,  882 ;  in  gastric  cancer,  490 ;  in  gastric 
ulcer,  481 ;  in  hiemophilin,  820 ;  in  hysteria, 
1117,  1118;  in  intussusception,  537 :  in  leukic- 
inia,  805;  in  malaria,  210;  in  nephrolithiasis, 
894 ;  in  tlic  new-born,  818 ;  in  purpura  hujinor- 
rhagica,  816;  in  scarlet  fever,  79;  in  scurvy, 
823 ;  in  small-pox,  02  ;  in  splenic  enlargement, 
210,495;  into  pancreas,  588 ;  into  spimd  cord, 
908  ;  into  spinal  membranes,  907 ;  into  tuber- 
culous pyelitis,  325 ;  in  tuberculosis  of  bowels, 
319;  into  ventricles  of  brain,  999  ;  in  typhoid 
fever,  10,24;  in  yoUow  fever,  180;  pulmonary, 
802, 637. 

Ha;morrhagic  diathesis,  814. 

Ilicmorrhagic  diseases  ofthe  new-born,  818. 

]Iieiiiorrhagic  typhoid  fever,  35. 

Jloemothorax,  674. 

Hair  tumors  in  stomach,  494. 

Hallucinations  in  hysteria,  1119. 

Jdarrisoii's  groove  in  rickets,  436 ;  in  enlarged 
tonsils,  455. 

Harvest-bug,  376. 

Hay-asthma  (hay-fever),  612. 

llaygartli's  nodosities,  401. 

Headache,  from  cerebral  tumor,  1021 ;  in  cere- 
bral sypliilis,  240;  in  mouth-breathers,  450; 
■  1  typhoid  fever,  12,  14,  28;  in  uriBmia,  867  i 
sick,  1102. 

Head-cheese,  poisoning  by,  391. 

Heart,  diseases  <  '",  698  ;  diseases  of,  OerteVs  treat- 
ment of,  752 ;  amyloid  degeneration  of,  750 ; 
aneurism  of,  753  ;  atiilcte's,  710  ;  brown 
atrophy  of,  750;  calcareous  degeneration  of, 
750;  congenital  affections  of,  765;  dilatation 
of,  741  ;  displacement  in  pleuritic  effusion, 
667  ;  displacement  in  pneumothorax,  682 ; 
fatty  disease  of,  749 ;  fragmentation  of  fibres 
of,  748  ;  hydatids  of,  754 ;  hypertrophy  of,  735  ; 
hypertrophy  of,  in  Bright's  dineasc,  8S0 ;  in 
exophthalmic  goitre,  838 ;  irritable,  745,  756 ; 
new  growths  in,  754;  neuroses  of,  755;  palpi- 
tation of,  755;  parenchymatous  degeneration 
of,  748;  rupture  of,  753;  valvular  diseases  of, 
707 :  wounds  of,  754. 

Heart-muscle  in  fevers,  748. 


Heart-sounds,  wcnkiipas  of,  744  ;*  Incrcnscd  loud- 
ness of,  739  ;  audible  at  distance,  724,  h.'ts. 

Heart-valves,  congenital  anomalies  anil  lesions 
of,  706;  rupture  of,  711. 

Httat,  exhaustion,  3'J5;  stroke,  395. 

lliherdi'ii''s  iukU'S,  401. 

Hectic  fevur,  306. 

!leel,  painful,  1106. 

lldler's  test,  856. 

Helminthiasis  (sec  Animal  Parasites),  349. 

Hemeralopia,  1040;  in  scurvy,  824. 

Hemialbumose,  85". 

Hemianiesthesia,  in  cerebral  liu>morri.ngc,  1005; 
in  hysteria,  1115;  in  lesions  of  iiiten.'d  cap- 
sule, 983 ;  in  unilateral  cord  lesions,  '.165. 

Hcmianoi>ia,  heteronymous,  1042;  liomonym.uis, 
1042;  in  migraine,  1102;  lateral,  1042;  nasal, 
1042 ;  significance  of,  1045  ;  temporal,  1042. 

llcmicrania,  1102. 

Hcmioi)ic  pupillary  inaction,  1044. 

Hemiplegia,  1002;  crossed,  ',t84,  lo04. 

Hemiplegia,  infantile,  10l7 ;  aphasia  in,  1018; 
in  diphtheria,  150;  epilepsy  in,  1019;  in  hys- 
tera,  1114;  mental  defects  in,  1018;  post- 
hemiplegic movements  in,  1019  ;  spastica  cere- 
brulis,  1018  ;  in  typiioid  fever,  30. 

Hemii)legie  Unsque,  1000. 

J/enoc/t^s  purpura,  816. 

Hepatic,  abscess,  577  ;  artery,  enlargement  of, 
555;  colic,  503;  intermittent  fever,  560  ;  vein, 
affections  of,  555. 

Hepatitis,  dill'use  syphilitic,  248  ;  interstitial  (see 
CiKKHOsis),  569  ;  suppurative,  577. 

Hepatization,  of  lung,  113;  white,  of  f'cetus,  247. 

Hereditary  form  of  tcdema,  1141. 

Heredity,  in  Bright's  disease,  877  ;  in  diabetes 
insipidus,  4.';: :  in  Fritdrcieli's  ataxia,  949;  in 
gout,  408;  in  hivmopliilia,  819;  in  paramyoclo- 
nus multiplex,  1150  ;  in  spastic  paraplegia, 
940;  in  syphilis.  238  ;  in  tul)erculosis,  202. 

Herpes,  in  trifacial  neuralgia.  1105;  in  cerebro- 
spinal meningitis,  104 ;  in  febricula,  343 ;  in 
malaria,  212;  in  pneumonia.  122  ;  zoster,  1100. 

Hiccough,  1068;  causes  of,  1008;  freotment  of, 
1009;  hysterical,  1110. 

High-tension  pulse,  characters  of,  774,  880. 

Hippocratic  facies,  598;  fingers,  313  ;  succussion, 
683. 

Hippus,  1102. 

IIodi/kin''s  disease,  809;  intermittent  fever  in, 
812. 

Homalomyia  scalaris,  378, 

Horn-pox,  63. 

Hospital  fever,  49. 

Huntiiigdon''s  chorea,  1090. 

Husband  and  wife,  diabetes  in,  418  ;  tuberculosis 
in,  266. 

Hitichinionh  teeth,  243. 

Hyaline  ca.sts  in  urine,  871,  876,  880. 


11G4 


INDEX. 


Hybrid  nionslcs'SO. 

lly<luti(l  itisfiiHo  (.s(!i<  KciiiNornrors). 

llyiliitid  thrill  or  t'n'initus,  .'!7ii. 

II,V(lrarllir<isi»,  cliroiiie-,  2.')7  ;  iiitiTinittcnt,  lllS. 

'•  Ilyilri'iici'iiluiloiil  ooiulition,"  510,  1)!H>. 

llydrintio  tn^atiiioiit  (»oo  IIyouotiikuapt). 

lly<lri)ci'|)liiilus,  lOiiS;  iic<|iiiro(l  olironic,  1021); 
iioiiti',  '-'7ii,  lO'JS  ;  imjfio-iuMirotio,  Id'JH  ;  cliroiiic, 
nrtiT  ec'rel>ro-«j>iiial  incniinfitis,  1('(1 ;  t'(iiij;i;ii- 
itiil,  lO'Jlt ;  idiopathic  iiiti'riial,  lo-js  ;  sinirioiis, 

nio. 

Ilydromyidim,  9M,  '.iT'), 

llydroiiophrosis,  8Sl);  congoiiitul,  8S0;  intcrinit- 
tent,  848,  8!I0. 

Ilydropi'vii'urdium,  007. 

1  ly droperitonaMini,  005. 

]lydropliol)ia,  227. 

llydro-imi'Uinotliornx,  081. 

Hydrops  vc'siou'  tollea;,  505. 

llydrothonix,  030. 

HyiiK'iiolopsi.s  diminuta  ;  II.  nana,  300. 

llyporacidity,  500. 

llyperacu-sis,  1057. 

Ilypera^stliosia,  in  ataxia,  024;  in  liy.stcria,  1115; 
in  rickets,  435  ;  in  unilateral  cord  lesions,  905. 

Ilyperchlorliydria,  500. 

Itypcrosniia,  1038. 

Hyperpyrexia,  hysterical,  1120;  in  rheumatic 
fever,  170  ;  in  scarlet  t'evcr,  78  ;  in  sun-stroke, 
800  ;  in  tetanus,  232. 

Hyporthyrca,  837. 

Hyperthyroidism,  836. 

Hypertrophic  cirrhosis  of  liver,  574. 

Hypnotism  in  hysteria,  1121. 

Hypodermic  syringe  in  diagnosis  of  pleural  ef- 
fusion, 675. 

Hypoglossal  nerve,  diseases  of,  1000 ;  paralysis 
of,  1000  ;  spa-sm  of,  1007. 

Hypophysis,  enlargement  of,  1143. 

Hypostatic  congestion,  of  lungs,  035 ;  in  ty- 
phoid fever,  28. 

Hypotonia,  024. 

Hysteria,  1111;  and  disseminated  sclerosis,  960 : 
contractures  and  spasms  in,  1114;  convulsive 
forms  of,  1112;  cries  in,  1110 :  disorders  of 
sensation  in,  1115;  forms  of  fever  in,  1110; 
ha^noptysis  in,  1117;  insanity  in,  1110;  joint 
atfections  in,  1118  ;  mental  symptoms  of,  lllS; 
metabolism  in,  1110;  metallotherapy  in.  1115; 
non-eonvulsivo  forms  of,  1113;  paralysis  in, 
1113;  special  senses  in,  1110;  stigmata  in, 
815,  1118;  traumatic,  1132;  visceral  manifes- 
tations of,  1110. 

Hysterical  angina  pectoris,  763. 

Hystero-epilepsy,  1008, 111.3. 

Hysterogenic  points,  1116. 

Ice-cream,  poisoning  by,  303. 
Ice,  typlioid  bacillus  in,  4. 


Ichthyosis  lingunla\  446. 

Ichthyotoxiwiiius,  303. 

Ict(!rus  (see  .Iainhk^k). 

Idiocy  in  infantile  hendplcgia,  1010. 

Idiopathic  ana'inia  of  Aildimn^  705. 

Idiopathic  intermittent  fever,  103. 

I leo-ca'cal  region,  in  typlioid  fever,  25;  in  ap- 
pendicitis, 525;  in  primary  tuberculosis  of 
bowel,  320. 

Ileus  (see  STiiANoi!i,ATn)N  ok  Rowki.),  531. 

Ind>ecility  in  infantile  hemiplegia,  1010. 

Imitation  in  chorea,  1081. 

Impetigo,  contagious,  and  ulcerative  Htomatitis, 
442. 

Impotence,  in  diabetCB,  427;  in  locomotor  ataxia, 
022 

Incarceration  of  bowel,  581. 

Incoordination,  of  arms,  023  ;  of  logs,  923. 

Indians,  American,  chorea  in,  1079 ;  consump- 
tion in,  250 ;  snudl-pox  among,  56. 

Indicainiria,  803. 

Indigestion,  403. 

Infantile,  convulfiions,  1091;  paralysis,  942; 
scurvy,  825. 

Infantilism,  24.3,  841. 

Infection,  definition,  100. 

Infectious  diseases,  1  ;  of  doubtful  nature,  342. 

Inflation  of  bowel  in  intussusception,  538. 

Influenza,  05;  complications  of,  07. 

Infusoria,  parasitic,  351. 

Inhalation  pneumonia  (sec  Aspiuation  Pneu- 
monia), 642. 

Inoculation,  against  small-pox,  56,  63 ;  protec- 
tive, in  cholera,  170  ;  preventive,  in  hydro- 
phol)ia,  220;  preventive,  in  plague,  102;  pre- 
ventive, in  pneumonia,  112;  preventive,  in 
yellow  fever,  180  ;  tuberculosis  transmitted  by, 
204. 

Insanity,  post-febrile,  30  ;  in  sniall-pox,  64. 

Insanity,  relation  of  ilrink  to,  381 ;  relations  of 
chronic  phthisis  to,  312;  relation  of  heart- 
di.sease  to,  712. 

Insects,  parasitic,  376. 

Insolation,  305. 

Insular  sclerosis,  059. 

Intention  tremor  (see  Volitional  Tremob). 

Intermittent  claudication,  703. 

Intermittent  fever,  200  ;  forms  of  (see  Fever). 

Intermitten';  liepatic  fever,  506. 

Intermittent  hydrarthrosis,  1118. 

Internal  capsule,  lesions  of,  082,  083. 

Internal  carotid  artery,  blocking  of,  1011. 

Intestinal  casts,  544;  sand,  546. 

Intestinal  coils,  tumor  formed  by,  288. 

Intestinal  obstruction,  531. 

Intestines,  di.seases  of,  505 ;  actinomycosis  of, 
280  ;  dilatation  of,  54.5. 

Intestines,  hsrmorrbage  from,  in  typlioid  fever, 
10,  24;  in  dysentery,  105, 108  ;  in  tuberculosis 


1010. 
7!»5. 
(!3. 

fcvor,  25;  in  np- 
'    tulierciiloniH    of 

HowEi.),  Ml. 
gill,  10U>. 

jrativo  stomatitiH) 

locomotor  ataxia, 


f  lOfrs,  923. 

,  1070 ;  consump- 

g,  50. 


paralysis,    942 ; 


fill  nnture,  342. 
iption,  538. 
,97. 

SPIRATION    1'nKU- 

:,  50,  63 ;  protec- 
ntivc,  in  liydro- 
plague,  192 ;  pre- 
I ;  preventive,  in 
is  transmitted  by, 

iiall-pox,  64. 

381 ;  relations  of 

elation  of  heart- 


AL  Tremor). 

if  (see  Fever). 

i. 

,  983. 

?  of,  1011. 

.y,  288. 

ictinomycosis  of, 

n  typhoid  fever, 
;  in  tuberculosis 


INDEX. 


11(55 


of  bowel,  310;  in  intussuRcoption  of,  537;  in 
ulceration  of,  513. 

intestinow,  infarutlon  of,  54(i ;  intussusception 
of,  532,  537;  invagination  of,  532;  iniseul- 
lanuoiis  aU'eetions  of,  544;  new  ginwllis  in, 
533. 

Intestines,  obstruction  of,  531,  509;  acute,  534; 
by  enteroliths,  534;  by  foreign  bodies,  534; 
by  gall-stonos,  534,  5(!8. 

Intestines,  perforation  of,  in  typhoid  fever,  10. 

Intestines,  primary  tuberculosis  of,  310;  stran- 
gulation of,  531,  536 ;  strictures  and  tumors 
of,  533;  twists  and  knots  in,  538;  ulcers  of, 
512. 

Intoxication,  definition  of,  161. 

Intoxications,  380. 

Intussusception,  532,  537. 

Invagination,  532;  post-mortem,  532. 

Inverse  typo  of  temperature,  in  acute  tubercu- 
losis, 274;  in  typlioid  fever,  16. 

lodiile  eruptions,  254. 

Iridoplegia,  1047;  accommodative,  1047;  reflex, 
1047. 

Iritis,  syphilitic,  241,  244. 

Itcli,  876. 

Itching,  of  feot  in  gout,  415 ;  of  eyeballs  in  gout, 
415;  of  skin  in  Briglit's  disease,  882;  of  skin 
in  jaundice,  549 ;  in  diabetes,  425 ;  in  exoph- 
thalmic goitre,  839, 

Ixodes  ricinus,  376. 

Jacksonian  epilepsy,  917, 1098. 

Jail  fever,  40. 

Jaundice,  548;  black,  540;  catarrlial,  555;  cho- 
luria  in,  549;  from  cirrhosis  of  liver,  572,  575; 
ei)idemic  form  of,  344,  550 ;  febrile,  344 ;  from 
acute  yellow  atrophy,  551 ;  from  cancer  of  liver, 
584;  from  gall-stones,  564,  506;  in  inliuenza, 
97 ;  in  pneumonia,  125 ;  and  purpura,  814,  549  ; 
in  WeWs  disease,  344;  malignant,  551;  of  the 
new-born,  551;  obstructive,  548;  toxoemic, 
550 ;  xautlielasjna  in,  549 ;  in  yellow  fever,  185. 

Jaw  clonus,  931. 

Jigger,  378. 

Joints  (see  Arthritis). 

Jumpers,  1080. 

"  June  cold,"  612. 

Kahler's  disease,  albumosuria  in,  857. 

Kakke,  221. 

Kala-azar,  203. 

Keloid  of  Addison,  1145. 

Keratitis,  in  small-pox,  65 ;  interstitial,  of  in- 
herited syphilis,  244. 

Keratosis  follicularis,  350. 

Keratosis  mucosa;  oris,  446. 

Kidney,  diseases  of,  846 ;  amyloid  or  lardaceous 
disease  of,  884;  cancer  of,  896;  cardiac,  850; 
circulatory  disturbance  in,  849 ;  cirrhosis  of, 


877 ;  congenital  cystio,  808  ;  congestion  of,  840 ; 

contracted,  M77 ;  cyanotic  iiicluralion  of,  h.">(»; 

cystic  disease   of,  MOS ;  echi!U)coccus  of,  374; 

fioating,  846 ;  fused,  846  ;  gouty,  877  ;  granular, 

877;  liorst'siioe,    84iJ;   large    wliite,  874;   iiml- 

formatioiis    (^f,   846;  movable,  841!;   jialjialilc, 

846. 
Kidney,  rhahdo-myoma  of,  K06  ;  sarcoma  of,  K96  ; 

scrofulous,  325.  fiST  ;  small  white  kidney,  »74; 

surgical  kidney,  >*>s7  ;  syphilis  of,  250 ;  liilier- 

culosirt  of,  324  ;  tumors  of,  806  ;  uiisymmetrical, 

846. 
KUbx-LoeJIlcr  bacillus,  140. 
Knee-jerk,  loss  of,  in  ataxia,  924;  in  diphtheria, 

151. 
Kock  treatment  of  tuberculosis,  335. 
K<>[)ftetanus  of  Jione,  232. 
Kreotoxismus,  801. 
Kubisagari,  1009. 

Labyrintliine  disease,  1058. 

Lachrymal  gland  in  mumps,  01 ;  in  Mikulicz's 
disease,  448. 

"Lacing"  liver,  587. 

Lacunar  tonsillitis,  401. 

La  grii>pe,  05. 

Lambliu  iiitcstinalis,  851. 

Laridnfs  paralysis,  046. 

Laparotomy  in  typhoid  fever,  48. 

Larvfc  of  tlies,  diseases  cau.sed  by  (myiasis),  378. 

Laryngeal  crises,  025. 

Laryngismus  stridulus,  617  ;  from  pressure  of  en- 
larged tliymus,  844. 

Laryngitis,  acute,  catarrhal,  615;  chronic,  616; 
a.'dematous,  617;  spasn;odic,  617;  sypliilitic, 
020;  tuberculous,  610. 

Larynx,  diseases  of,  615;  adductor  paralysis  of, 
1061 ;  antpsthesia  of,  1062 ;  liypertcsthesia  of, 
1002;  paralysis  of  abductors  of,  1001  ;  spasm  of 
the  muscles  of,  1062;  unilateral  abductor  pa- 
ralysis of,  1061. 

Latah,  1030. 

Lateral  sclerosis,  primary,  087  ;  amyotrophic,  028. 

Lateritious  deposit,  860. 

Lathvrism,  304. 

Lead,  colic,  888 ;  in  t)ie  urine,  387. 

Lead-palsy,  388  ;  localized  forms  of,  388. 

Lead-poisoning,  886;  acute,  387;  arterio-sele- 
rosis  in,  380 ;  cerebral  symptoms  in,  380  ;  chron- 
ic, 387 ;  convulsions  from,  880 ;  gouty  deposits 
in,  389  ;  treatment  of,  380. 

Lead-workers,  prevalence  of  gout  in,  408. 

Leichen-tubercle,  2154. 

Leontiasis  ossea,  1145. 

Lepra  alba,  341. 

Lepra  mutilans,  341. 

Leprosy,  338  ;  ana?sthetic,  342;  bacillus  lepra;  in, 
340 ;  contagiousness  of,  340 ;  macular  form  of, 
341 ;  tubercular,  341. 


1166 


INDEX. 


/ 


Leptomeningitis,  acute  cercbro-spinul,  954 ; 
chronio,  VST;  itit'iitituin,  'J57. 

Lcptotlirix  in  iiioutli,  'JUiJ. 

LuptUH  iiutuinnuliH,  37U. 

Leucin,  552. 

Leucocytes,  relation  to  uric  acid,  409. 

Leucocy  tosis,  in  anieiuiu,  791, 799 ;  chlorosis,  794 ; 
cerebro-spinal  meuin^'itis,  104 ;  diphtheria, 
147;  empyema,  072;  erysipelas,  109;  Ilodg- 
it/i'«  disease,  812;  lcui<a>inia,  800  ;  malaria,  217  ; 
measles,  88;  pywrnia,  105;  ])ncumunia,  120; 
pleurisy,  070;  rheumatic  fever,  170;  scarlet 
fever,  82  ;  stomach  cancer,  469;  in  trichinosis, 
857;  in  tuberculosis  (acute),  275 ;  in  tubercu- 
losis (clironic  pulmonary),  311 ;  typlioid  fever, 
19,  37  ;  in  whooping-cough,  94. 

Leucoderma,  839,  1140. 

Lcuooujata,  241. 

LeuJiOimia,  802 ;  acute,  808 ;  lymphatic,  808 ; 
blood  in,  800 ;  congenital,  803  ;  deflnition  of, 
802 ;  lieredity  in,  S02 ;  in  animals.  803 ;  in  preg- 
nancy, 802 ;  morbid  anatomy  of,  803 ;  mye- 
logenous, 802  :  prognosis  in,  809 ;  pseudo-,  809 ; 
splcno-mcduliary,  805. 

Leukoplakia  buccalis,  440. 

Lit/dell's  crystals,  031,  634. 

Lienteric  diarrliiea,  507. 

Life  assurance  and  albuminuria,  858  ;  and  syph- 
ilis, 255. 

Lightning  pains  in  ataxia,  922. 

Line*  atropliicic,  19. 

Lingual  corns,  446. 

Lipaciduria,  864. 

Lii>iBmia,  421,426. 

Lipothymia,  599. 

Lips,  tuberculosis  of,  317  ;  chancre  of,  238. 

Lipuria,  804. 

Lithaimia,  859,  800. 

Lithic-acid  diathesis,  859. 

Lithuria,  859. 

Little's  disease,  988. 

Liver,  abscess  of,  577 ;  actinomycosis  of,  236 ; 
acute  yellow  atrophy  of.  551 ;  amyloid,  586 ; 
anicmia  of,  553  ;  angioma  of,  584  ;  cardiac,  554 ; 
anomalies  in  form  and  position  of,  587. 

Liver,  cirrhosis  of,  569 ;  alcoholic,  570 ;  ascites 
in,  572 ;  atrophic,  571 ;  capsular  form,  575 ;  in 
diabetes,  421 ;  fatty,  571 ;  hicmorrhage  from 
8toma;h  in,  572;  hypertropiiic,  574;  syphilitic, 
575;  in  tuberculosis,  320;  in  children,  570; 
jaundice  in,  572 ;  toxic  symptoms  in,  573 ;  with 
cancer.  583. 

Liver,  cysts  of,  584;  fatty,  585;  gummata  of, 
248;  hcpato-phlebotomy  in  congestion  of,  554; 
hydatids  of,  372;  hyperemia  of,  553;  infarc- 
tion of,  554;  melano-sarooma  of,  583;  new 
growths  in,  582  ;  nutmeg,  553 ;  passive  conges- 
tion of,  553 ;  periodical  enlargement  of,  553 ; 
primary  cancer  of,  582;   psoroBpermiasis  of, 


349 ;  pulsation  of,  554 ;  sarcoma  of,  583 ;  sec- 
ondary cancer  of,  583  ;  .sypliilis  of,  248;  tuber- 
culosis of,  320;  in  typlioid  fever,  11,27. 

Liver,  diseases  of,  548. 

Liver  dulness,  obliteration  of,  in  perforative  peri- 
tonitis, 26,  598. 

Liver,  movable,  542,  587. 

Living  skeletons,  930. 

Lobar  pneumonia,  108. 

Lobnttiii's  cancer,  897. 

Localization,  cerebral,  907;  spinal,  905. 

Localized  peritonitis,  522,  000. 

Lock-jaw,  230. 

Lock-spasm,  1108. 

Locomotive  ataxia,  920;  bladder  symptoms  in, 
922  ;  ga.st  ic  cri.ses  in,  924 ;  hemiplegia  in,  925  ; 
paresis  ".i,  925  ;  rectal  crises  in,  924  ;  relation 
of  syphilis  to,  920;  reputed  cures  of,  927. 

Long  thoracic  nerve,  atlections  of,  1070. 

Loose  shoulders,  934. 

Lucilia  macellaria,  378. 

Ludivig^s  angina,  450. 

Lues  venerea  (syphilis),  238. 

Lumbago,  400. 

Lumbar  plexus,  lesions  of,  1072. 

Lumbar  puncture  of  Quincke,  107,  956, 1030. 

Lung,  ab.scers  of,  662;  embolic,  062. 

Lung,  actinomycosis  of,  236;  albinism  of,  656; 
brown  induration  of,  635 ;  cancer  of,  acute,  664 ; 
carniflcation  of,  643 ;  cirrhosis  of,  049. 

Lung,  diseases  of,  634;  stones,  296. 

Lung  fever,  108. 

Limgs,  congestion  of,  634;  hypostatic,  635. 

Lungs,  echinococcus  of,  373. 

Lungs,  gangrene  of,  660  ;  abscess  of  brain  in,  601. 

Lungs,  new  growtiis  in,  603;  in  cobalt-miners, 
664. 

Lungs,  hremorrhagic  infarction  of,  638 ;  oedema 
of,  636;  spienization  of,  635,  643;  syphilis  of, 
247  ;  tuberculosis  of,  289. 

Lupinosis,  394. 

Lymphadenitis,  general  tuberculous,  282  ;  local 
tuberculous,  282;  simple,  684;  suppurative, 
684. 

Lymphadenomn,  general,  809. 

Lympliatic  state,  826. 

Lymph atism,  826. 

Lymph-scrotum,  362. 

Lymph,  vaccine,  72. 

Lymph  vessels,  dilatation  of,  362. 

Lyssa,  227. 

Lyssophobia,  230. 

Macular  syphilides,  240. 

MaUlismus,  395. 

Main  en  griffe,  930,  953. 

Maize,  poisoning  by  (pellagra),  895. 

Malarial  cachexia,  208,  216. 

Malarial  fever,  202 ;  accidental  and  late  lesions 


la  of,  583 ;  sec- 
I  of,  248 ;  tubur- 
r,  11,27. 

perforative  peri- 


1,  905. 


•  symptoms  in, 
liplegiu  ii),  925 ; 
II,  924;  rcliition 
'cs  of,  927. 
",  1070. 


',  956, 1030. 

fi2. 

)ini8m  of,  056 ; 

ir  of,  ueute,  664 ; 

of,  649. 


tatic,  635. 

sf  bruin  in,  661. 
cobalt-miners, 

f,  638;  oedema 
13  ;  syphilis  of, 


0U9,  282;  local 
;    suppurative, 


INDEX. 


1107 


)5. 

Del  late  lesions 


of,  208;  (Bstivo-nutumnal,  213;  al),'id  form  of, 
215;  comatose  form  of,  215;  continuud  and 
remittent  form  of,  213;  description  of  the 
j)aro.\y8m  in,  209 ;  geographical  distribution  of, 
203;  huimorrhagic  form  of,  216;  iiitermittont, 
209 ;  meteorological  conditions  influencing, 
204;  pernicious,  207,  215;  jmeumonia  in,  209; 
quartan,  213;  quotidian,  213;  season  in,  204; 
spccillc  germ  of,  204;  telluric  conditions  intlu- 
cncing,  203;  tertian,  212. 

Malarial  nephritis,  209. 

Malignant  jaundice.  551. 

Malignant  purpuric  fever,  101. 

Malignant  pustule,  226. 

Mallein,  234. 

Malta  fever,  219. 

Manunary  glands,  hypertrophy  in  tuberculosis, 
SI 2  ;  tuberculosis  of,  327. 

Mania  a  p6tu,  382. 

Mania,  BelPs,  1075. 

Marriage,  question  of,  in  hrBmophilia,  821 ;  in 
syphilis,  254;  in  tabes  dorsalis,  927;  in  tuber- 
culosis, 329. 

Marrow  of  bones,  in  sniall-po.\,  58;  in  leukflD- 
mia,  803;  in  pernicious  anwmia,  797. 

Masque  desfemmes  enceintes,  831. 

Massai  disease,  303. 

Mastication,  spasm  of  the  muscles  of,  1051. 

McBiiriiey^s  tender  point,  525. 

Measles,  85 ;  complications  and  sequelos  of,  87 ; 
contagiousness  of,  85;  desqiiiimation  in,  87; 
eruption  in,  86 ;  German,  89  period  of  incu- 
bation in,  86. 

Measly  meat,  examination  of,  367. 

Meat,  poisoning  by,  391 ;  tuberculous  infection 
by,  267 ;  inspection  of,  for  trichinuci,  355. 

MeckeVs  diverticulum,  532. 

Median  nerve,  atTections  of,  1071. 

MediiLstinal  friction,  687. 

Mcdiastino-pcricarditis,  indui'ative,  687. 

Mediastinum,  afteetions  of,  684 ;  abscess  of,  686  ; 
tumors  of,  685 ;  cancer  of,  685 ;  emphysema  of, 
687  ;  pleural  effusion  in,  686 ;  sarcoma  o(,  685. 

Mediterranean  fever,  219. 

Medulla  oblongata,  lesions  of,  984;  tumors  of, 
1028. 

Megalo-cephaly,  1145. 

Megalocytes,  798. 

Mtgastrie,  4i1b. 

Melasna,  in  duodenal  ulcer,  484;  in  typhoid 
fever,  24 ;  in  tuberculosis  of  bowels,  319 ;  ne- 
onatorum, 81 8. 

Melano-sarcoma  of  liver,  583. 

Melanuria,  863. 

Melasma  suprarenale,  831. 

Menihre^s  disease,  1058. 

Meningeal  hemorrhage,  999;  in  birth  palsies, 
938. 

Meninges,  afl'ection  of,  951. 


Meningitis,  acute  ccrebro-spinal,  054;  epidemic 
cer  '>ro-spinal,  100;  in  erysipelas,  158,  159;  in 
gout,  415;  in  typhoid  fever,  12,  14,  28;  occlu- 
sive, 957;  posterior,  of  infants,  957;  serosa, 
1028;  syphilitic,  245;  tuberculous,  276. 

Meningococcus,  102. 

Meningo-encephalitis,  clironic  diffuse,  960;  tu- 
berculous, 277. 

Mercurial,  tremor,  1079  ;  stomatitis,  444. 

Merycismus,  499. 

Mesenteric  artery,  aneurism  of,  546;  embolism 
of,  546  ;  t!  .•ombosis  of,  546. 

Mesenteric  glands,  tuberculosis  of,  283;  tuber- 
culous tumors  of,  288;  in  typhoid  fever,  10. 

Mesenteric  veins,  diseases  of,  547. 

Mesentery,  chykous  cysts  of,  547 ;  affections  of, 
546. 

Metallic  echo,  683;  tinkling,  309,  683. 

Metal  lothcrapy,  1115. 

Metastatic  abscesses,  164. 

Metasyphilitic  all'eetions,  242. 

Mctatarsalgia,  1106. 

Mcteorism  in  typhoid  fever,  25;  treatment  of, 
47. 

Micrococci,  in  dengue,  99;  in  Malta  fever,  219; 
in  vaccine  virus,  70. 

Micrococcus  lanceolatus,  108,  110,  644,  702. 

Micrococcus  mclitensis,  219. 

Microcytes,  793. 

Micromegaly,  1145. 

Micromelia,  841. 

Miildle  cerebral  artery,  embolism  and  throm- 
bosis of,  1011. 

Migraine,  1102;  treatment  of,  1103. 

Miliary  abscesses  in  typhoid  fever,  11. 

Miliary  aneurism,  998. 

Miliary  fever,  346  ;  epidemics  of,  347. 

Miliary  tubercle,  270;  tuberculosis,  acute,  273; 
tuberculosis,  chronic,  295. 

Milk  and  scarlet  fever,  76 ;  and  typhoid  fever, 
6;  products,  poisoning  by,  393;  sickness,  344; 
tuberculous  infection  by,  267. 

Mind-blindness,  990. 

Mind-deafness,  990. 

Miner's,  antemia  or  cachexia,  360;  lung,  652; 
nystagnms,  1047  ;  cancer  of  lung,  664. 

Mitchell^  WeiVy  treatment  in  hysteria,  1121. 

Mitral  incompetency,  717. 

Mitral  stenosis,  721 ;  chorea  and,  721 ;  paralysis 
of  recurrent  laryngeal  in,  725  ;  presystolic  mur- 
nmr  in,  723;  rheumatism  and,  721. 

Moist  sounds,  308. 

MoUuscum  contagiosum,  parasites  in,  350. 

Monophobia,  1124. 

Monoplegia,  cerebral,  916,  980;  facial,  1052;  in 

hysteria,  1114;  in  traumatic  neuroses,  1134, 
.}fn»faif/ne  on  renal  colic,  893. 
Montreal   General  Hospital,  autopsies  in  diph- 
theria, 143;  in  typhoid  fever,  8;  statistics,  of 


1168 


INDEX. 


/ 


apex  IcRionn  in  1,000  autopsicfl,  M2;  of  dy.-cn- 
tory,  193;  of  liwmorrhiiKic  Hiiiall-pox,  (i'j;  of 
pneumonia,  1!U;  of  rlicuiiiatic  fever,  lt',7;  of 
typhoid  fever,  3. 

Montreal  Bniall-pox  epidemic  1885-'80,  05,  73. 

Morbilli  htuinorrlia^iei,  87. 

MorbiiH,  cieruleiw,  7t)8. 

Morlmn,  eoxie  senilis,  401,  403 ;  crrorum,  377 ; 
nineulosus,  814. 

Morbus  maculosus  neonatorum,  818. 

Morpliia  liabit,  384  ;  treatment  of,  385. 

Morpliinism,  384. 

Morpliinomania,  384. 

Morplia>a,  1145. 

Mortality,  in  cerebro-spinal  meningitis,  107;  in 
pneumonia,  131;  in  typhoid  fuvcr,  40;  in 
wlioopiny-cough,  94  ;  in  yellow  fever,  188. 

Morton's  painful  foot,  1106. 

Morvan's  diseiute,  975. 

Mosquitoes,  relation  of,  to  fllaria  disonsc,  861. 

Motor  tract,  discascH  of,  9i28. 

Mountain,  anaemia,  3C0;  fever,  340;  sickness, 
346. 

Mouth-breathing,  454. 

Mouth,  diseuties  of,  441 ;  dry,  447 ;  putrid  sore, 
442. 

Movable  kidney,  542,  840  ;  dilatation  of  stomach 
in,  848. 

Movable  liver,  542,  587. 

Mucous  colitis,  544. 

Mucous  patches,  241. 

Muguet,  443. 

Multiple  gangrene,  1138. 

Multiple  sclerosis,  959. 

Mumps,  90,  447. 

Munich,  reduction  of  typhoid  mortality  in,  41. 

Murmur,  in  aneurism,  780 ;  brain,  437 ;  cardio- 
respiratory, 308 ;  in  chlorosis,  794;  in  congen- 
ital heart-disease,  769;  /Vi«<'«,  713;  in  endo- 
carditis, 703  ;  in  lung  cavity,  309  ;  in  subclavian 
artery  in  phthisis,  308 ;  in  valvular  disease, 
713,716,720,  723,720,727. 

Musca  domestica,  378  ;  M.  vomitoria,  378. 

Muscle  callus  in  sterno-niastoid  in  infant.s,  1004. 

Mu.scle,  diseases  of,  1148 ;  de^neration  of,  in 
typhoid  fever,  12,  33. 

Mu.scular  atrophy,  forms  of,  934;  heredity  in, 
933  ;  atrophic  and  hypertrophic  varieties,  935  ; 
infantile  form,  935 ;  juvenile  type,  935 ;  pro- 
gressive neural  form,  933;  peroneal  type,  933. 

Muscular  atrophy,  progressive  central,  928,  941 ; 
hereditary  influence  in,  929. 

Muscular  contractures  in  hysteria,  1114. 

Muscular  dystrophies,  933. 

Muscular  exftrtion,  coma  after,  869. 

Muscular  exertion  in  heart-disease,  710,  745. 

Muscular  rheumatism,  400. 

Museulo-spiral  paralysis,  1070. 

Musical  faculty,  loss  of,  in  aphasia,  991. 


Musical  murmurs,  710,  709. 

Mu«sel  poisoning,  898. 

Myalgia,  400. 

Myiu-ithciiia  gravis  pseudo-paralytica,  947. 

Mycosis  intestinalis,  226  ;  pulmonum,  220. 

Mycotic  gastritis,  406. 

Myeliciiiia,  802. 

Myelitis,  acute,  970;  acute  central,  977;  acute 
transverse,  978;  comjiression,  970;  in  measles, 
88  ;  rerte.xcs  in,  978  ;  transverse,  of  cervical  re- 
gion, 979  ;  syphilitic,  245,  240. 

Myelocytes,  800. 

Myelogenous  kuksemin,  802. 

Myiasis,  378  ;  of  jiostrils  and  of  cars,  378  ;  of  va- 
gina, 378  ;  cutaneous,  378;  interna,  378. 

Myocarditis,  748;  acute  interstitial,  748  ;  fibrous, 
747;  in  rlieumntism,  171  ;  segmenting,  21,74?  ; 
in  typhoid  fever,  21. 

Myocardium,  discuses  of,  740  ;  lesions  of,  due  to 
disease  of  coronary  arteries,  746. 

Myoclonia,  1150. 

Myoclonies,  1150. 

Myoideina,  308. 

Myopathies,  the  primary,  033. 

Myositis,  1148;  ossificans  progressiva,  1149. 

Myotonia,  1149  ;  congenita,  1149. 

Myotonic  reaction  of  Erb,  1149. 

Myriachit,  1089. 

Mytilotoxin,  393. 

Mytilotoxismus,  393. 

Myxccdenia,  840 ;  acute,  842 ;  congenital  form, 
840 ;  operative,  842. 

Nails,  in  typhoid  fever,  IS;  in  phthisis,  313. 

Nasal  diplithcria,  147. 

Naso-pliaryngeal  obstruction,  454. 

Neapolitan  fever,  219. 

Neck,  cellulitis  of.  450. 

Necrosis,  acute,  of  bone,  1T3;  in  typhoid  fever, 
32. 

Necrosis  in  tuherclc,  271. 

Nematodes,  diseases  caused  by,  352. 

Nephralgia,  1106. 

Nephritis,  ^09;  acute,  809;  after  diphtheria, 
150;  chronic,  874;  clironic  hremorrliagic,  875. 

Nephritis,  chronic  interstitial,  877;  htemor- 
rhages  in,  882;  increased  tension  in,  880;  ma- 
larial, 200;  relation  of  heart  hypertrophy  to, 
879 ;  syphilitic,  250 ;  urine  in,  880 ;  vomiting 
in,  881. 

Nephritis,  chronic  parenchymatous,  875;  con- 
secutive, 880 ;  in  erysipelas,  159 ;  in  malaria, 
209  ;  in  scarlet  fever,  80  ;  in  typhoid  fev«r,  31. 

Nephritis,  lymphomatous,  32;  suppurative,  887. 

Nephrolithiasis,  891. 

Nephro-phthisis  (see  Kidney,  Tuberculosis 
of). 

Nephroptosis,  542.  846. 

Neplirorrhaphy,  649. 


yticn,  H7. 
mum,  220. 


itrnl,  977  ;  ncutc 
970;  in  inenslcw, 
it",  of  ccrvicul  rc- 


enrs,  378  ;  of  va- 
;criiu,  378. 
,inl,  748 ;  fibrous, 
inentiiijr,  21,748 ; 

esions  of,  due  to 
1(3. 


Rsiva,  1149. 


INDEX. 


iioy 


congenital  form, 

hthisin,  313. 

14. 

I  typhoid  fever. 


352. 

fter  diphtheria, 
emorrhagic,  875. 
877 ;  hrcmor- 
ion  in,  880 ;  ma- 
il jpcrtrophy  to, 
,  880;  vomiting 

tou8,  875;  con- 
59 ;  in  malaria, 
^•phoid  fevgr,  31. 
uppurative,  887. 

I    Tuberculosis 


Nephrotomy,  8S0. 

Nejihro-typhut*,  31. 

Nerve-lUirea,  intlammation  of,  1031. 

Nerve-root  HymptoniH,  970. 

'■  Nervo-storms,"  1103. 

Nerves,  diHoases  of  periplicral,  1031 ;  diseases  of 
cerebral,  1038  ;  diHcases  of  spinal,  1007. 

Nerves,  lesions  of  anterior  orural,  1072;  cireutn- 
llex,  1070;  external  popliteal,  1072;  gluteal, 
1072;  internal  popliteal,  1072;  long  tlioraeic, 
1070;  median,  1071;  museulo-spiral,  1070; 
obturator,  1072;  seiatie,  1072;  small  sciatic, 
1072;  ulnar,  1071. 

Nervous  diarrhcea,  500,  1117. 

Nervous  dyspepsia,  497. 

Nervous  system,  diseaacs  of,  901  ;  diffuse,  951. 

Nettle  rash  (see  Uiiticahia). 

Neuralgia,  1104;  cau-ses  of,  1104;  oervico-bra- 
chial,  1105;  cervico-occipital,  1007,  1105;  in- 
fluence of  malaria  in,  1104;  intercostal,  1105; 
lumbar,  llOG;  of  nerves  of  feet,  1100  ;  i)hrenic, 
1105;  plantar,  1100;  red,  1139;  reflex  irrita- 
tion in,  1104;  treatment  of,  1107;  trifacial, 
1105;  visceral,  1100. 

Neurasthenia,  1122;  sexual,  1120;  traumatic, 
1182. 

Neuritis,  1031 ;  arsenical,  1035  ;  fascians,  1032 ; 
interstitial,  1031;  of  infants,  progressive  inter- 
stitial hypertrophic,  951  ;  lipomatous,  1031 ; 
localized,  1031,  1032;  parenchymatous,  1031; 
nmltiplo,  1031,  1033;  alcoholic,  1034;  en- 
demic, 220, 1031 ;  in  diphtheria,  151 ;  in  chronic 
phthisis,  312;  in  the  infectious  diseases,  1034; 
in  typhoid  fevor,  29;  recurring,  1033;  satur- 
nine, 1035 ;  traumatic,  1032 ;  optic,  1040. 

Neuroglioma,  1020. 

Neuroma,  ploxiform,  1037. 

Neuromata,  1037. 

Neuroses,  occupation,  1107;  traumatic,  1132. 

Neutrophiles,  806. 

New-born,  hojmorrhagic  diseases  of,  818. 

New  growths  in  the  bowel,  533. 

Night-blindness,  1040  ;  in  scurvy,  824. 

Night-sweats  in  phthisis,  300;  treatment  of, 
837. 

Night-terrors,  455. 

Nipple,  PageVs  disease  of,  350. 

NiU,  377. 

Nodding  spasm,  1006. 

Nodes,  Heherden's,  401. 

Nodes,  symmetrical,  in  congenital  syphilis,  244. 

Nodi.les,  rheumatic,  172. 

Noma,  444;  in  scarlet  fever,  82;  in  typhoid 
fever,  33,  35. 

Normoblasts,  794,  7f.9. 

Nose,  bleeding  from  (see  Epistaxis),  614. 

Nose,  diseases  of,  610. 

Nummular  sputa  in  phthisis,  300. 

Nurse's  contracture  of  Tronaseau,  1110. 

73 


Nutmeg  liver,  553. 
Nyctalopia,  1040 ;  in  scurvy,  824. 
Nystagmus,  1047;  in  />(<v//Yt(7t'«  ataxia,  9.'')0 ;  in 
insular  sclerosis,  959  ;  of  miners,  1017. 

Obesity,  430. 

Obsession,  1089. 

Obstruction  of  bowels,  631 ;  acuto,  684  ;  clironlo, 
535. 

Obturator  nerve,  affections  of,  1072. 

Occipital  lobes,  tumors  of,  1022. 

Occipito-ccrvical  neuralgia,  1007,  1105. 

Occupation  neuroses,  llo7. 

Ocular  palsies,  treatment  of,  1050. 

Oculo-motor  paralysis,  recurring,  104G. 

Odor,  in  small-pox,  08;  in  typhoid  fever,  18. 

(Edema,  angio-neurotic,  1140;  febrile  purpuric, 
816 ;  hereditary,  1141 ;  of  lungs,  030  ;  of  brain, 
997 ;  in  ura;mia,  806,  997. 

(Edematous  laryngitis,  017. 

OefteVs  method  in  obesity,  439,  752. 

(Esophageal  bruU,  461. 

(Esojihago-plcuro-cutaneous  fistula,  402. 

(Esophagisinus,  459. 

(Esopliagitis,  acute,  458 ;  chronic,  459. 

(Esophagus,  diseases  of,  458 ;  cancer  of,  461 ; 
dilatations  of,  402  ;  diverticula  of,  402;  hicmor- 
rliage  from  in  cirrhosis  of  liver,  572 ;  paralysis 
of,  459 ;  post-mortem  digestion  of,  402 ;  rup- 
ture of,  402  ;  spasm  of,  459  ;  stricture  of,  400 ; 
syphilis  of,  249;  tuberculosis  of,  318;  ulcera- 
tion of,  459 ;  varices  of  veins,  in  cirrhosis  of 
liver,  572. 

Oldium  albicans,  443. 

Olfactory  nerves  and  tracts,  disea-ses  of,  1038. 

Omentum,  tuberculous  tumor  of,  287 ;  tumor  of, 
in  cancer  of  the  peritonojum,  605. 

Omodynia,  407. 

Onomatomania,  1089. 

Onychia,  in  arthritis  deformans,  402;  in  loco- 
motor ataxia,  925;  syphilitic,  241,  243. 

Operation  per  se,  effects  of,  in  epilepsy,  1101. 

Operation,  tuberculosis  after,  270. 

Ophthalmia,  gonorrhoeal,  with  arthritis,  173. 

Ophthalmoplegia,  942,  1049;  externa,  1049;  in- 
terna, 1049. 

Opisthotonos,  cervical,  in  infants,  957;  in  teta- 
nus, 232. 

Opium,  poisoning,  diagnosis  from  urasmia,  868 ; 
habit,  384 ;  smoking,  effects  of,  384. 

Optic  nerve  atrophy,  1041 ;  hereditary,  1041 ; 
primary,  1041 ;  secondary,  1041 ;  in  tabes, 
922. 

Optic  nerve  and  tract,  diseases  of,  1039. 

Optic  neuritis,  1040 ;  in  abscess  of  brain,  1026 ; 
in  brain-tumor,  1021 ;  in  tuberculous  menin- 
gitis, 278. 

Orchitis,  in  malaria,  217  ;  in  mumps,  91 ;  inter- 
stitial, in  syphilis,  251  ;  in  typhoid  fever,  32 ; 


1170 


INDKX. 


•  I 


ill  vai-ii»lii,  .'f^ ;  parotl'lcft,  itl  ;  tulicrculous,  320  ; 

valuu  of,  ill  iliii^iioHiH,  U2)!. 
OrtliotoiKm,  ill  tctiiiiuH,  'J;'J. 
I  )Mt('iti«  (Jcriii'iiiaiis,  1  111. 
()«ti!i>-uitlir'H>utliy,     Iiyportrophio     pulmonary, 

11  U. 
t  )nU'o-inyi'lit'm  siiiiiilntin>f  ncuto  rliouiimtisin,  173. 
otitis-iiu'diu,   ill   tyiiiioiil   tbver,  30;  in  Hcurlot 

tV'vor,  HI ;  in  iiicningitiM,  luO. 
Oviiriort,  tubuivuloHiH  of,  320. 
Over  cxirtion,  licart  alfi'i'tionH  duo  to,  Xl'>. 
Oxuiiitc-iif-linKi  I'lili'iiluM,  M',i2. 
Oxaliiria,  801. 
Oxygen,  inliiilations  of,  in  Uial)i!tic  coma,  4.'31 ;  in 

piu'unionia,  l;i7. 
Oxyiiris  vcrnru'iiliii'is,  .353. 
OyHtcM'.s  mill  tyiilioid  I'evor,  0. 
Oysters,  poisoninj,'  by,  3!)3  ;  iind  typhoid  fovor,  0. 
Ozu'uu,  Gl'2. 

9 

I'acliymeniiisrilis,  O.'l. 

]'a('hynu'niin:itis  corvii-alis  hyportropliioa,  0.')3. 

I'lU'liyiiR'nintfitis  liii'niorrliuj,'i(-'a, of  ooruliraldiirn, 
',)r)2;  of  spiiiiil  (liirn,  ',).'')3. 

I'alutt!.  iiiiralysis  of.  in  cliphthoria,  l')0  ;  in  facial 
paralysis,  1053  ;  perforation  of,  iu  scarlet  fever, 
«2. 

Palate,  tuberculosis  of,  318. 

Palpable  kidney,  840. 

I'dlpitation  of  heart,  7.55. 

Palsies,  cerebral,  of  children,  988,  1017. 

Palsy,  lead,  3SS. 

Paludisin  (sec  M.vi.aiuai.  Fevku"!.  202. 

Pancreas,  cancer  of,  5i>4;  in  diabetes,  421  ;  cysts 
of,  502 ;  hiemorrhagc  into,  588 ;  tumors  of, 
594. 

Pancreas,  diseases  of,  588. 

Pancreatic  absees.-*,  5'JO ;  diabetes,  422 ;  calculi, 
505. 

Pancreatitis,  acute  hremorrhagic,  580 ;  chronic, 
592 ;  fat  necrosis  in,  591 ;  gangrenous,  590 ; 
suppurative,  590. 

Pontnphobia,  1124. 

Papillitis,  1040. 

raiwsthesia  (numbness  and  tingling),  in  neu- 
ritis, 1032;  in  locomotor  ataxia,  924  ;  in  tumor 
of  brain,  1022  ;  in  primary  combined  sclerosis, 
949. 

Parageusis,  1000. 

Paralysis,  acute  ascending,  940 ;  acute  spinal,  of 
adults,  940 ;  acute,  of  infants,  942 ;  agitans, 
1O70  ;  alcoholic,  10.34  ;  anaesthesia,  1035  ;  as- 
thenic bulbar,  047  ;  atrophic  spinal,  942  ;  BeWs, 
1051;  bulbar,  acute,  0-33;  chronic,  933;  of 
bladder,  in  myelitis,  977 ;  of  brachial  plexus, 
1009;  in  chorea,  1083;  of  circumflex  nerve, 
1070  ;  crossed  or  alternate,  984, 1004  ;  "crutcli," 
1070;  (;>MW(?i7A»>/''«,  929 ;  diver's,  009  ;  of  dia- 
phragm, 1003;  after  diphtlicria,  150;  follow- 


ing epilepsy,  1097;  of  facial  nerve,  1051;  of 
llftli  nerve,  1050;  of  fourth  nerve,  1047;  gen- 
eral, of  the  insane,  9ii0  ;  of  hypoglossal  nerve, 
ItiOO;  hysterical,  111.3;  infantile,  942;  lal)io- 
glosso-hiryngeal,  932;  Z(i;«/;-y'«,  940;  of  lar- 
yngeal abiluctors,  lOfll  ;  of  adductors,  1001 ; 
in  lateral  sclerosis,  937;  from  lend,  388;  in 
locomotor  ataxia,  925;  of  long  thoracic  nerve, 
1070 ;  in  meningitis,  278,  950  ;  of  median  nerve, 
1071 ;  of  musculo-spiral  nerve,  1070;  of  oculo- 
motor nerves,  1010;  of  olfactory  nerve,  1038; 
l)eriodical,  1130;  in  progressive  muscular  at- 
rophy, 930;  radial,  1070;  of  rectum,  in  mye- 
litis, 977 ;  of  recurrent  laryngeal  nerve,  1001 ; 
secondary  to  visceral  disease,  1032;  of  sixth 
nerve,  1048 ;  of  third  nerve,  1040  ;  of  ulnar 
nerve,  1071  ;  of  vocal  cords,  1061. 

Paramyoclonus  multiplex,  1150. 

Purapliiisia,  902. 

I'araplegia  llascjue,  041. 

Paraplegi.i,  from  alcoliol,  10.34;  ataxic,  948;  from 
aiuemia  of  si>inal  cord,  9ii0  ;  from  compressiijii 
of  cord,  070;  fiom  hiemorrhage  into  cord,  908; 
liereditary  form  of,  940;  hysterical,  941,  1114; 
in  lathyrism,  304 ;  from  myelitis,  977  ;  in  pel- 
lagra, 305;  spastic,  937;  spastica  cerebralis, 
938;  syphilitic,  940;  from  tumor  of  the  cord, 
974  ;  in  tabes,  025. 

Parasites,  diseases  duo  to  animal,  349. 

Parasitic  gastritis,  400. 

Parasitic  stomatitis,  443. 

Parasyphilitie  affections,  242,  901. 

"  Parchment  crackling"  in  rickets,  435. 

Parenchymatous  nephritis,  875. 

Parieto-occipital  region,  brain  tumors  in,  1022. 

"  Paris  green,"  poisoning  by,  390. 

ParkinKoti'i  disease,  1070. 

Parosmia,  1038. 

Parotid  bubo,  447. 

Parotitis,  epidemic,  90;  deafness  in,  01 ;  delirium 
in,  91 ;  chronic,  447 ;  orchitis  in,  91 ;  specific, 
447. 

Parotitis,  symptomatic,  447  ;  after  abdominal  sec- 
tion, 447;  in  pneumonia,  125;  in  typhoid  fever, 
23;  in  typhus  fever,  52. 

Paro.xysmal  hremoglobinuria,  853. 

Parrofn  ulcers,  443. 

Parry's  discn-^o,  830. 

Patellar-teiul'ii  reflex  (see  Knee-jerk). 

Pathophobia,  1124. 

Pectoriloquy,  S09. 

PedicuU,  370;  relations  of,  to  tachc  bleuatro,  IC, 
377. 

Pediculosis,  370. 

Pcdiculus  capitis,  370 ;  P.  corporis,  377. 

Peliomata,  17. 

Peliosis  rheumatica,  815;  in  chorea,  1085. 

Pellagra,  305. 

Pelvis  of  kidney,  affections  of  (see  Pyelitis). 


1  ncrvo,  1051 ;  of 
nurvo,  1047  ;  geii- 
lypojfloHHiil  norvo, 
iitilo,  '.M2  ;  liil)ii)- 
/•yV,  IIH) ;   of  liir- 

iidduotDl's,  lui'd  ; 
1)111  luiul,  3H8;  ill 
i)jf  tlioriicic  iiorvi', 

of  iiiudian  norvo, 
'0,  1070;  of  ooulo- 
tory  iicrvo,  1038; 
wivu  i)iu«cular  iit- 

roctum,  in  inyi;- 
iguiil  iiurvc,  lOtil ; 
0,  103iJ;  of  Hixtli 
u,  1O40 ;  of  ulnar 
OGl. 
». 


ataxic,  948 ;  from 
from  coinprosnioii 
ii,'o  into  cord,  908  ; 
*tcrical,  941,1114; 

litis,  977  ;  in  pd- 
lastica   ecruijralis, 

nior  of  tho  cord. 


ul,  349. 


101. 

kets,  435. 

1. 

tumors  in,  1022. 

DO. 


ss  in,  91 ;  delirium 
A  in,  91 ;  spocitic, 

tor  abdominal  sco- 
;  in  typlioid  fever, 

553. 


ee-jerk). 

tnche  bleuatrc,  IC, 

)ori8,  377. 
horea,  1085. 
(see  PvELiTis). 


iNi)i:x. 


1171 


Pomplii>{oid  purpura,  815, 

I'iim[)lii|i;uM  nuonutoruin,  242. 

reiituMiomi'H,  875. 

rul)lio  ulcer,  478 ;  dyspepHia  in,  481 ;  hipmor- 
rliagu  in,  481 ;  pain  in,  481 ;  tondernuHH  on 
prim:*ure  in,  4H2. 

IV'ptones  in  tlie  urino,  857. 

I'urforating  ulcer  of  foot  in  tabos,  025;  in  dia- 
betes, 425. 

Tcrforation  of  bowol  in  dysentery,  200;  in  ty- 
plioid  fever,  10,  25. 

I'criarteritis,  gummatous,  250;  nodosa,  788. 

Pericardial  friction,  090. 

I'ericunlitis,  088 ;  acute  plastic,  CSy ;  aphonia  in, 
C92;  chronic  adhesive,  C90 ;  deliriuui  in,  092; 
dyspha>fia  in,  092;  epidemics  of,  089;  epilepsy 
in,  093;  from  extension  of  disease,  089;  from 
foreii^n  body,  088;  in  cliorea,  1084;  in  fa'tus, 
089;  in  gout,  415;  in  rlieumatism,  171;  lucm- 
orrlia^ic,  092 ;  hyperpyrexia  in,  090,  092 ;  men- 
tal .symptoms  in,  092;  primary,  088;  pulsus 
paradoxus  in,  092;  secondary,  088;  with  effu- 
sion, 091. 

Pericardium,  adherent,  090 ;  FriedreieWa  sign  in, 
097. 

Pericardium,  diHea.se8  of,  088;  tuberculosis  of, 
285;  air  in,  098. 

Pei-ichondritis,  laryngeal,  in  typhoid  fever,  27 ; 
in  tuberculosis,  019. 

Perihepatitis,  575,  003. 

Perinephric  abscess,  900. 

Perinuclear  basophilic  granules,  410. 

Periodical  paralysis,  1130. 

Periosteal  cachexia,  825. 

Peripheral  neuritis,  1031. 

Peristaltic  unrest,  498, 1117. 

Peritonneum,  diseases  of,  590. 

Peritoneum,  fluid  in,  005,  009;  cancer  of,  004; 
new  growths  in,  004. 

Peritonrouni,  tuberculosis  of,  286. 

Peritonaeum,  tumor  formations  in  tuberculosis  of, 
287. 

Peritonitis,  acute  general,  522,  520,590;  appen- 
dicular, 520,  0O2 ;  chronic,  002  ;  chronic  lirem- 
orrhagic,  004;  diffuse  adhesive,  003;  hys- 
terical, 599;  idiopathic,  596;  in  infants,  000: 
in  typhoid  fever,  20 ;  leukBomic,  805 ;  local  ad- 
hesive, 602;  localized,  522,  000;  pelvic,  002; 
perforative,  590;  primary,  590;  proliferative, 
003 :  pyicmic,  596 ;  rheumatic,  596 ;  secondary, 
596 ;  septic,  590 ;  subphrenic,  600  ;  tuberculous, 
280,  604. 

Peritonitis,  tuberculous,  effects  of  operation  on, 
609. 

Perityphlitis,  519. 

"  Pedes  "  of  Laennec,  630. 

Pernicious  anicmia,  795. 

Pernicious  malaria,  207,  215. 

Peroneal  type  of  muscular  atrophy,  933. 


Pertussin  (koo  WnoopiNO-oouoit),  92. 

Pcsta  magna,  50. 

IVstis  minor,  191  ;  major,  191;  sidcranB,  101. 

Pctechiie  ill  epilepsy,  1(19";  in  relapsing  fever, 
54;  in  scurvy,  823;  in  small-pox,  02;  in  ty- 
phus fever,  51. 

Petechial  fever,  101. 

i'otit  mal,  1094,  l(i97 ;  in  general  paresis,  902. 

J'ti/cr^n  patchim  in  typhoid  fever,  8 ;  in  measles, 
80;  in  tuberculosis,  319. 

PhagH'ytosis  in  (Tysijielas,  158;  in  malaria,  207; 
in  tuberculosis,  271. 

I'hary ngitis,  448 ;  ucuto,  448 ;  chronic,  449 ;  sicco, 
449. 

Pliarynx,  acute  infectious  phlegmon  of,  450; 
hiomorrliage  into,  448;  hyiicncmia  of,  44« ; 
(edema  of,  448;  paralysis  of,  luOo;  spasm  of, 
luOl  ;  tuberculosis  of,  318;  ulceration  of,  449. 

Pharynx,  diseases  of,  448. 

Piiiladelphia  Hospital,  relapsing  fovor  at,  in  1844, 
53;  typhoid  and  typhus  fever  at,  2;  typhus 
epiilemic  in  1883,  49;  HatiHics  of  cerebro- 
spinal fever,  104  ;  of  delirium  tremens  in,  883. 

PiiiliKlelphiu  Iiiflrniary  for  Nervous  Diseases, 
statlstiai  of  chorea,  1079  ;  of  epilepsy,  1094. 

Philadelphia,  tuberculosis  in  city  wards,  200 ; 
yellow-fever  epidemic  in  1793,  182. 

Phlebitis  of  portal  vein,  577. 

Phlebo-sclorosis,  773. 

Phosphates,  alkaline,  802  ;  earthy,  802. 

Phosphatic  calculi,  892. 

Phosphaturia,  802. 

Phosphorus  poisoning,  similority  of  acute  yel- 
low atropliy  to.  553. 

Pli"     'c  nerve,  affections  of,  1068. 

Phtii.iiasis,  376. 

Phthirius  pubis,  877. 

Phthisical  frame,  Hippocrates'  desc'ption  of, 
208. 

Phthisis,  289 ;  chronic  ulcerative,  294 ;  acute 
pneumonic,  2S0 ;  artcrio-sclorosis  in,  310; 
basic  form  of,  295;  Bright's  disease  in,  312; 
of  coal-miners,  209,  052;  chronic  orthritis  in, 
310;  cough  in,  300;  endocarditis  in,  298,  310  ; 
diagnosis  of,  313  ;  distribution  of  lesions  in, 
294;  erysipelas  in,  315  ;  fatal  hirmorrliage  in, 
317 ;  fever  in,  304 :  forms  of  cavities  in,  290  ; 
gastric  symptoms  of,  311 ;  hromoptysis  in, 
302;  modes  of  death  in,  317;  modes  of  on.set 
in,  298 ;  physical  signs  of,  300 ;  pneumonia 
in,  315;  relation  of  fistula  in  ano  to,  320; 
sputum  in,  300 ;  summary  of  lesions  in,  295 ; 
typhoid  fever  in,  315  ;  vomiting  in,  311. 

Phthisis,  fibroid,  314,  649 ;  florida,  292 ;  renum, 
324;  sypliilitic,  247;  of  stone-cutters,  209, 
652  ;  unity  of,  272  ;  ventriculi,  467. 

Physiological  albuminuria,  855. 

Pi  a  mater,  diseases  of,  9.54. 

Picric-acid  test  for  albumin,  857. 


1172 


INDEX. 


i 


w. 


I'i)^oon-br(!iwt,  in  riokt'tw,  4M  ;  In  mouth-1)ronth- 
crH,  466. 

ril^iiiuntiilion  of  Hkin,  from  nrHcnio,  !<00;  in 
/l(ueilow'i  UimjitHo,  Hi>'J  ;  I'roni  phtiiii-iaHiH,  <'l77  ; 
ill  AdilUon't  (itKciwf,  h:iu  ;  in  ciironio  i>ui- 
nionury  tul>cR-ul<>Hl>t,  ai:!;  in  iiicluiu>i«ii«,  N:il ; 
in  [Ksrituiiuul  tuburuui<jtiitt,  287  ;  in  BulunKiuriiia, 
1140. 

I'i^uiuntution  of  virtconi  in  iX)lla(;ru,  305. 

\'\iif>,  tuboruuloHis  in,  258. 

rin-w(irinH,  353. 

J'ittiii)^  in  Kinull-pox,  01 ;  nioosuros  to  prevent,  07. 

I'ituitnry  Ixnly  in  ucroinegiily,  1148;  in  giguu- 
tistii,  1143. 

I'ityrlnBw  vorwicolor,  Sia. 

I'lujifue,  buljonio,  189. 

I'iiigiiu  («ix>ti«,  1U2. 

IMaqiK'H  jauncB,  1009. 

I'lnstio  bronciiitiH,  0.13. 

i'luura,  diseoHert  of,  065. 

rieuru,  ccliinococcUH  of,  873;  tuborculoBis  of, 
284. 

rieural  olfusion,  BaccelWs  eifjn  in,  670,  072; 
coniproMaion  of  li'.ag  in,  S(J7  ;  hiumorrhngic, 
073  ;  in  bcarlct  fever,  81 ;  position  of  heurt  in, 
008 ;  pseudo-cavenious  nijrns  in,  070 ;  purulent, 
071 ;  Bcrous  ell'usion,  conHtituents  of,  007  ;  sud- 
den dettth  in,  071. 

Pleural  inoiiil>rane.s,  ealeificution  of,  079. 

Pleurisy,  acute,  005 ;  diapiirnjfiiiutic,  074 ;  on- 
eysted,  074 ;  flbrinoiw,  005 ;  interlobar,  674 ; 
in  typhoid  fever,  28 ;  pain  in  side  in,  008 ; 
plastic,  005;  pleural  friction  in,  670;  pulsat- 
ing,  072;  purulent,  071;  8oro-tibrinou»,  006; 
tuberculous,  284,  000,  073. 

Pleuriny,  chronic,  678 ;  dry,  079  ;  primitivo  dry, 
079  ;  voso-niotor  plicnomeiui  in,  080  ;  with  ef- 
fusion, 078. 

Pleurodynia,  407. 

Plcuro-peritoncal  tuberculosis,  284. 

Pleurothotonos  in  tetanus,  232. 

Plexiform  neuroma,  1037. 

Plica  poloniea,  377. 

Plunibisin,  386 :  and  gout,  408 ;  as  a  cause  of 
renal  cirrliosis,  877  ;  paralysis  in,  388. 

Plymouth,  epidemic  of  typhoid  fever  at,  5. 

I'neumatosis,  499. 

Pncumaturia,  424,  804. 

Pneumogastric  auru?,  1096. 

Pneumogastric  nerve,  affections  of,  1060 ;  cardiac 
branches  of,  1062;  gastric  and  oesophageal 
branches  of,  1063  ;  laryngeal  branches  of,  1061 ; 
pharyngeal  branches  of,  1060 ;  pulmonary 
branches  of,  1063. 

Pneumonia,  acute  croupous,  108;  abscess  in, 
130;  acute  delirium  in,  123;  antipneumonic 
serum  in,  135;  bleeding  in,  135 ;  clinical  varie- 
ties of,  126  ;  colitis,  croupous,  in,  ^\h  ;  compli- 
cations of,  123  ;  crisis  in,  117  ;  delayed  resolu- 


tion in,  120;  dlagnoHlR  from  fliMifo  pncnr  >inlo 
phthisis,  'Jill;  tli|iloo<>eeiw  pneuinoniw,  110; 
I'lidrK-iirdiliH  in,  11.');  cngnrgunient  of  lung  in, 
113;  epidemics  of,  112,  127;  tevir  ot;  110; 
gangrene  in,  130;  gray  hepatization  in,  \\.\\ 
huri>es  in,  122;  immunity  from,  112;  in  dia- 
betes, 127  ;  in  infants,  120;  in  intluenza,  128; 
in  old  age,  120;  meningitis  in,  115  ;  mortality 
of,  131  ;  iioricarditis  in,  115;  pseudo-erisis  in, 
117;  purulent  intlltralion  in,  113;  recurrence 
of,  125;  red  he]>ati7.ation  in,  113;  relapse  in, 
125;  resolution  of,  113  ;  ti>.\iitmia  in,  132  ;  trau- 
ma in,  109. 

Pneumonia,  neute  syphilitic,  248;  apex  pneu- 
monia, 126;  aspiration  or  deglutition,  042; 
central,  126;  "cerebral,"  122;  chronic  intersti- 
tial, 649;  chronic  pleurogeiioiis,  080;  contu- 
sion, 109;  double,  126;  other,  129;  epidemic, 
127  ;  fibrinous,  108  ;  hypostatic,  635  ;  in  mala- 
ria, 209;  interstitial,  of  t)ie  root,  in  syphilis, 
247;  in  typhoid  fever,  27 ;  larval,  127;  lol)ar, 
108;  massive,  120;  migratory,  126;  pleurogo- 
nous  interstitial,  649  ;  post  operation,  128  ;  sec- 
ondary, 127;  typhoid  pneumonia,  127  ;  white, 
of  the  fiutus,  247. 

Pneumonitis,  108. 

Pi.euinonokoniosis,  052. 

Pneunio-porieardium,  008. 

Pneumo-pcritona'um,  598. 

Pneuinorrhagia,  037. 

Pneumothorax,  081 ;  after  tracheotomy,  687 ; 
chronic,  083  ;  lIipiX)cratio  suceussion  in,  083  ; 
in  phthisis,  297 ;  from  muscular  ettort,  681. 

Pneumotoxin,  112. 

Pneuino-typhus,  11,  28. 

Podagra,  407. 

Podoilynia,  1100. 

Poikilocytosis,  794,  709. 

Poisoning,  by  food,  891 ;  by  lead,  886  ;  by  meat, 
891 ;  by  sewer-gas,  343. 

Polio-myelitis,  acute  and  subacute,  in  adults,  946. 

Polio-myelitis  anterior,  acute,  942  ;  epiuemies  of, 
942 ;  etiology  of,  942 ;  morbid  anatomy  of,  943 ; 
prognosis  of,  944 ;  symptoms  of,  943. 

Polio-myelitis  anterior  chronica,  928,  941. 

Polyadenomata,  494. 

Polyremia,  608. 

Polyneuritis,  acute  febrile,  1038 ;  rccurrens, 
1033. 

Polyphagia,  423. 

Polysarcia,  439. 

Polyuria  (see  Diabktks  iNsinnus),  432. 

Polyuria,  in  abdominal  tumors,  432 ;  in  hysteria, 
432,  1112. 

Pons,  lesions  of,  984 ;  tumors  of,  1023. 

Popliteal  nerve,  external,  1072  ;  internal,  1072. 

Poreneephalus,  1017. 

Portal  vein,  554;  thrombosis  of,  554;  suppura- 
tion in,  578. 


aoiito  pnctit'  •inio 
|>iu'Uii>on'm>,  110; 
iiiuiit  of  \unK  in, 

;  fiiviT  oi,  111! ; 
ktlzution  in,  ll'l ; 
rum,  112;  in  tliu- 
n  intlui^iizii,  lv!8  ; 
It,  115  ;  niortiility 

I>HuuUu-i'riHiH  in, 

,  llil ;  rucurrcnco 

W'.i ;  r('iii|>HO  in, 

iiiu  in,  lti'2  ;  truu- 

248;  opcx  i)n('U- 
(lu),;lutiliun,  )i42  ; 
;  I'hrouio  iiilcrnti- 
lous,  (iSO;  contu- 
r,  129;  epiiluniio, 
ftc,  635  ;  ill  niiila- 
ri>ot,  in  BypliiiiH, 
iirvul,  127 ;  lobar, 
y,  1 2') ;  pk'urogo- 
>orution,  128 ;  bcc- 
loniu,  127  ;  white. 


ncheotoiiiy,  687 ; 
iccimsion  in,  083 ; 
liir  cttort,  681. 


id,  886  ;  by  meat, 

utc,  in  odults,  946. 
942 ;  epiboniicB  of, 
I  anatomy  of,  943  ; 
of,  943. 
a,  928,  941. 


1033 ;    recurrens. 


)U8),  432. 

;,  432 ;  in  liyBteriB, 

f,  1023. 

;  internal,  1072. 

of,  554;  Buppura- 


INDEX. 


1173 


I'list-cplloptlo  Bymptonm,  1097. 

l'()Nt-lu'iiiiiilf>;ic  I'iiorcu,  IdlU  ;  iipiUipny,  1019, 
1(>',»8;  mipviimoiitH,  li/ll». 

I'lmt-iiiortiMii  iiiuvuiiiintri  in  cholera  boUioB,  178, 

I'lMt-jiiiaryiij^iiMl  almcoHS,  460, 

rost-typlioid,  anioinla,  19;  sluvottona  of  tompora- 
turo,  16. 

yi7r*illHeiwe,  970. 

I'ri'xnani'y,  uml  aciito  yellow  atmpliy,  Tifil  ;  aixl 
chort'R,  1080;  ami  lioart-iliHtiano,  729;  ami 
lihtliiMis,  .'i29;  ami  typlioiil  fever,  85. 

rrusy.stolic  inuniiur,  72;j, 

I'riapiHru  in  luukuMiiia,  805. 

I'ricl-.ly  hcot  (boo  I'iitk^ahia). 

rroceBsiou  catiirpiliur,  ed'ectH  of,  879. 

I'rofuBHidnal  HpaBins,  1107. 

I'roj^lottiH  of  tii'iiia,  .'HiS, 

I'rojjrresHivo  niUHoiiliir  atrophy,  928. 

I'nij^'rosslvo  pernicious  ananiiin,  795;  blood  In, 
797. 

I'rophylaxiB.ngainHt  cholera,  180;  njfainstHcnrvy, 
824;  againrtt  tuberoiiloBiB,  330;  a;,'aiiiBt  tu'iiia, 
8n7  ;  agftinHt  trichina,  3,")9;  agaiiiHt  typhoid 
fever,  41 ;  against  yellow  fovor,  188. 

Prosopalgia,  1105. 

I'roHtato,  tuliereuloHiB  of,  326. 

Protozoa,  diHeasea  caused  by,  849 ;  parasitic,  849. 

Pruno-juico  expectoration,  004. 

Prurigo,  in  Hoil<jk'i,n^«  diHoaso,  812. 

Pruritus  in  diabetes,  425  ;  in  uriiMnia,  807  ;  in  ob- 
structive jaundice,  549;  in  gout,  415;  in 
Graves'  disease,  839. 

Pseudo-angina  pectoris,  763,  1118. 

Pscudo-apoplcctio  seizures  in  fatf  '  licart,  751 ; 
with  slow  pulse,  700. 

Pseudo-biliary  colic,  564. 

Pseudo-bulbar  paralysis,  932. 

Pseudo-cavernous  signs,  309,  670,  675. 

Pseudo-cyesis,  1114. 

Pseudo-diphtheria,  142. 

Pseudo-hydrophobia,  230. 

P.seudo-leukn3iiiin,  809. 

Pseudo-lipoinu,  supraclavicular,  841. 

Pseudo-ptosis,  1046. 

Pscudo-scldrose  en  plaques,  900. 

Pseudo-tuberculosis  hominis  stroptothrica,  262. 

Psilosis,  511. 

Psoriasis,  buccal,  446. 

Psoroapermiasis,  849. 

Ptosis,  forms  of,  1040 ;  hysterical,  1046 ;  in  ataxia, 
922 ;  pseudo-,  1046. 

Ptyalism,  444,  446. 

Puberty,  barking  cough  of,  1117. 

Pulex,  irritans,  377  ;  penetrans,  378. 

Pulmonal-cerebral  abscesses,  1025. 

Pulmonary  (ace  Lungs). 

Pulmonary  apoplexy,  638. 

Pulmonary  artery,  sclerosis  of,  773;  perforation 
of,  782. 


Pulmonary  lui'inrrrhago,  6,17. 

I'uliiionary  orillce,  onngcnltal  le»ion»  of,  767; 
tuliiTcMilnHiH  in,  .'till,  7ii7  ;  valve,  ItHions  of,  727. 

Pulmonary      osteo  arthropathy,      liypertropliid, 
1U4, 

I'lilsatiiig  pleurisy,  672. 

Pulsation,  dynamic,  of  aorta,  782. 

Pulse,  altt^riuite,  757  ;  anastomotic,  774  ;  dlorotlo, 
1.1,20;  under  inlluciice  of  digitalis,  732;  in- 
termittent, 757  ;  irregular,  757  ;  liigeminal, 
7,')7  ;  recurrent,  774  ;  triu'emimil,  7.'>7. 

I'uIbc,  capillary  (see  (!ai'ii,l,\hv;  ;  Co/rij/rtn,  714  ; 
wator-lunnmer,  714. 

Pulse,  slow,  in  tuliereulous  meningitia,  279 ;  in 
jaundice,  519  (s(!e  Hiiaim  vcahiiia,  759). 

I'ulsus  paradoxus,  692,  097,  750. 

I'upil,  Anjyll  h'l'birfnon,  9r.2,  1047. 

Pupillary  imiction,  hemiopie,  1044. 

I'liliils,  une(iuiil,  li»17  ;  in  general  paresis,  902. 

Purpura,  814;  artliritic,  815;  caeheotio,  814; 
fulminans,  817  ;  //e/iocAV,  816;  infectious,  814; 
mechanical,  815  ;  ne\irotic,  SLI ;  peliosia  rheu- 
matiea  in,  815;  luemorrhagica,  810;  i)emphl- 
goid,  815;  simplex,  815;  sym|)tomatio,  814; 
toxic,  814  ;  urticans,  815  ;  variolosa,  02. 

Purpuric  a-dema,  810. 

I'ustulo,  nuilignant,  225. 

I'utrid  sore  moutli,  442. 

Pyiemia,    103;    arterial,  705;    iiNopathie,   163;, 
post  typlioid,  33. 

Pyiumic  al)scess  of  liver,  570,  580. 

Pyelitis,  880  ;  intermittent  fever  in,  888  ;  pyuria 
in,  887  ;  in  typhoiil  fever,  32. 

Pyelonephritis,  880. 

Pylephlebitis  adhesivii,  554. 

Pylephlebitis,  in  dysentery,  200;  in  pymmia,. 
104  ;  supi)urativo,  555,  578. 

Pylorus,  hypertrophic  stenosis  of,  494;  conifoni- 
tal  liypertrophy  of,  494  ;  insuUiciency -of,  500  ;. 
spasm  of,  499. 

Pyoneplirosis,  880. 

Pyo-pncumothorax,  285,  081. 

Pyo-pneumothonix  suliphrenicus,  479,  601,  683. 

Pyuria,  858 ;  in  typhoitl  fever,  11,  32. 

Quarantine  against  yellow  fever,  188 ;   agninat 

cliolera,  180. 
Quartan  ague,  213. 
<^i/iiicke''K  lumbar  puncture,  107,  950. 
Quinine  rash,  77,  83. 
(Juinsy  (see  Tonsillitis,  Suppurative). 
(Quotidian  ague,  21G. 

Rabies,  227. 
Rachitic  hones,  434. 
Rachitis  (see  Rickets),  434. 
Radial  paralysis,  1070. 
Rag-picker's  disease,  226. 
Railway  brain,  1132. 


1174 


INDKX. 


Kullwiiy  Hiiliic,  11.11 

li'iiiney^n  tiilu'H,  941), 

l{ii|>i<l  lii'iirt,  1M, 

Kunlii'K,  I'roiii  ilni(fn,  8H,  81-1;  In  (rlnndoni,  S.l'l ; 

in   iiiuitMlcN,   HI);    Id   rulii|iHin){    tuvvr,  M\    in 

ruliullit,  HU  ;  In  Hcitrlut  fuvur,  77  ;  In  hiiibII-iiox, 

Ml,  1(0  ;  In  HvphUiH,  21(1 ;  In  typliolil  IV!V(!r,  17  ; 

ill  lypliUH  I'cviir,  Til  ;  in  ii>'ii>uiia,  lOl ;  in  vuuui- 

nation,  71 ;  in  variccllii,  74. 
KKf4|iluirry  tonj^uo  In  Mcarlut  fuvur,  7**. 
iCaj-t'iuiKiin  (ai'tinoMiycui*),  230. 
A'(i////<i'((/'/i  (li.Hcasi',  ll.'i7  ;  apliasia  in,  11H',);  nml 

Hcli)ro(lfriiia,  1140;  upilupity  in,  llUK;  liuuino- 

(rlol)inuria  in,  118S. 
Ucaotinn  (>f(!f„funuruti<>n,  ni4,  lo;iil,  KiM. 
IJi'iTutliHctMifi!  ot'li'ViT  in  tyjdio'.il  luvur,  111. 
Kcctiil  crincM  in  tui)fH,  U24. 
IJ.^i'tuin,  irritulilu,  lllH;  utrictnru  of,  249 ;  Kjph- 

iliH  of,  241t ;  tuliurculDMin  of,  ."I'JO. 
liccurrcnt  larjn>,'(^al  norvo,  puralyHia  of,  1001. 
Kueurruiit  piilnu,  77'» 
Ut'uurrin)^  niultiplu  nuuritiH,  1033. 
Kud  Hoftiwiirijf  of  i)rain,  loo'j, 
Itcduplii-atlon  of  iirart-Houndti,  707. 
Koilux  crupitUH,  120. 
Kollcx  cpilcpny,  l(»ii.5, 
Ui'tluxos  in   a.seunding   parn1,VHii«,  ii40;   in  ecro- 

bral    lui-niorrlia^'u,    loo,"),    liKiii ;    in    locomotor 

ataxia,  1124;   in   polio-niyulitis  acuta,  !"44 ;   in 

►paHtic  i>ara]ili'f;ift,  037  ;  in  liynterical  paraplu- 

j.'ia,  mi,  1114;  in  pro^^ruasivu  niusoulur  atrophy, 

lt.31. 
l{i';^urt,'itation,  tricuspid,  725. 
liiich)n(inn''H  ilisca^c,  WQ, 
Kflapsu  in  typiioid  fever,  80. 
liulapsiuj;  fever,  5!) ;  Hpirilluni  of,  54. 
Keiiiittent  fever,  213. 
KudhI  calculus,  801. 
Kenal,  colic,    803 ;    epistaxis,   852 ;    sand,    802 ; 

syphilis,  2.')0  ;  sclerosis,  877. 
Rfndu''s  type  of  tremor,  1115. 
IJen  niobilis,  840. 
IJesohition  in  pneumonia,  129. 
Resonance,  amphoric,  809,  082;  tympanitic,  309, 

OiJO,  082. 
Respiratory  system,  di.oeascs  of,  010. 
Rest  treatment,  1121  ;  in  aneurism,  784. 
Retina,  lesions  of,  1030. 
Retinal  hyporffistlicsia,  1040. 
RctVnitis,  albuminuric,  1039 ;  in  antemia,  1039 ; 

in  malaria,  1030  ;  leukiiMiiic,  1040  ;  pigmentosa, 

1030;  syphilitic,  241,  1030. 
Retraction  of  head  in  meningitis,  278,  955. 
Retro-collic  sjiasm,  1005. 
Retroperitoneal  abscess,  522. 
Retroi)eritona'um,  liaimorrliagc  into,  58. 
Retro-pharyngeal  abscess,  450. 
Retropulsion  in  paraly.sia  agitans,  1078. 
Ruvacciuatiou,  71. 


RliabditiHNie]lyl,n01. 

UhalidMinyonui  of  Kidney,  800. 

Rlialiclonciiia  intiHtimilc,  304. 

RhagailcM,  242. 

Kliuumatic  fever,  100  ;  cerebral  complicationH  of, 
171;  undocurditis  In,  170;  Mbnm.i  nodules  In 
172;  germ  tluMiry  of,  108;  h.  rcility  in.  li;7 
h.vperpynrvia  in,  170  ;  melabolie  tlieory  of,  IOh 
nervous  theory  of,  108;  perieardltU  In,  171 
purpura  in,  172;  sudden  deiifh  in,  172. 

KheiMllutii!  gout  (see  AltTUKI'Ma  DtroUMANl). 

RlKMiiiuttii^  liodides,  172. 

KluMimatism,  elironic,  405. 

Uheunuttlsm,  muscular,  4O0. 

Uheunuitism,  sul>aoutu,  170. 

Rheumatoid    urtiiritis   (sue    AHTHiiiTiit    Deroii- 

MANS). 

Rhinitis,   Oil;    atroi)idca.    Oil;    fibrinosa,   147; 

hypertro]ihiea,  Oil  ;  Hyphilitic,  24'.;. 
Rilis,  resection  of,  in  umi)yuina,  078. 
Rice-water  stools,  170. 
Rickets,  434;  ttcutu,488,  826;  fuital,  841. 
liif/a^n  disease,  442. 
Rigidity,  early,  in  hemiplegia,  1002. 
Rigidity,  late,  in  liemiplegiu,  1005. 
Rigors,  in  al)scess  of  iirain,  1O20;  in  al)soPHs  of 

liver,  579;    in   ague,  209;   in  pneumonia,  1 1.") ; 

in  i)yiemia,  \i'A;  in  jiyelitis,  8H7  ;  in  tuljcreulo- 

sis,  200;  in  tyi)lioid  fever,  17. 
Risus  sardonicus,  232. 
Roek-fever,  210. 
Ji(>iiiliin/n  symptom,  928. 
Root-nerve  symptoms  in  compression  i>arai>lcgia, 

970. 
Rosary,  rickety,  430. 
Roseola  (see  Rose  Rash  ok  TyrnoiD),  17 ;  cii- 

demie,  89. 
"Rose  cold,"  012. 
Rose  rash  in  typhoid  fever,  17. 
Rotation  in  epilei>sy,  lOOO. 
Rotatory  spasm  in  hysteria,  111.5. 
Rotheln,  80. 

"  Rough-on-rats,"  poisoning  by,  890. 
Round-worms,  352. 
Rub  (see  Fuiction), 
Rubella,  80. 
Rubeola  notiia,  89. 
Rumination,  490. 

Running  pulse  in  typhoid  fever,  20. 
Russian  fever,  95. 

I'Suhle  intentinal,  540. 

Saccharomyces  albicans,  443. 

Sacral  plexus,  lesions  of,  1073. 

St.  Vitus's  dance,  1079. 

Salaam  convulsions,  1001, 1115. 

Saline  injections,  intravenous,  in  diabetic  coma 

431  ;  subcutaneous,  in  cholera,  181. 
Saliva,  arrest  of,  447  ;  superseeretiou  of,  446. 


INDEX. 


117B 


)06. 
4. 

)rftl  pnmjtUontlonii  of, 

;   HItkiM   lioduli!'*  Ill, 
H  ;   liirt'ility  in.  Iii7  ; 
tiilxdii'tluMiry  of,  108;' 
iMi'iiiiriUtm  In,  171; 
lU'iiili  in,  ll'i. 
iiiTU  Ukitoumani). 


1     AUTIIHITIH     DkKoU- 

nu  ;    ttlinnomi,   MV  ; 
liilitic,  24^. 
unia,  07H. 

26 ;  fojtal,  841. 

■Kin,  lOO'i. 

till,  1005. 

in,  10211;  in  ubsccHH  of 

I',) ;  in  piiouniDniii,  UT) ; 

itiw,  8S7 ;  in  tubcrculo- 

ur,  17. 


iomprjsBion  piiraiik'i^in, 


ov  Tyi-hoU)),  17 ;  cn- 


t'l-,  17. 

G. 

rill,  1115. 

ing  by,  890. 


id  fever,  20. 


I,  443. 
•,  1073. 


M,in5. 

.-enous,  in  diabetic  comii 
[\  cliolcrii,  181. 
uperseoretiou  of,  446. 


Hollvnry  iflnniU,  dlitenncn  of,  440;  Inflaiiiiimll'Hi 

of,  447. 
Hullvtttlou  (itio   I'TVAi.iHM),  444,  44il;  in  Hiiinll- 

pox,  til;  In  bulbar  |mraiyHiM,  \)'A'i. 
Halpi'iicitlH,  tiibcriMiliiUH,  !I20. 
Saltatory  hpimni,  lo"*!'. 

Annatoria,  treatinuiit  of  tubureuloHln  In,  833. 

■and- Ilia,  ;i7><. 
Sapru'Uiia,  l)!l. 
Haranac  Sanitarium,  333. 
Sarclnn,  veiitrieuli,  475;  in  lun^  cnvltlcH,  803. 
SprcocjstlH  Mlcftchuri,  34U ;  «mroooyntlH  hominls, 
8411. 

Sarcoma,  of  i'.ain,  lOJO;  of  kidney,  806;  of 
llvor,  688;  of  Iuiik,  <W3;  inodliwtinul,  085; 
mobinntic,  of  liver,  5H3. 

HarcoptcH  R('al)iei,  370. 

Saturnine  neuriti-*,  lOScV 

Saturni.Hiii,  3S0. 

Sauxu^u  poisonin;^,  301, 

Scapulodynia,  4o7. 

Scarlatina,  miliarix,  78. 

Scarlatina  nine  eniptionc,  70. 

Scarlatinal  nopliritin,  KO. 

Scarlet  fever,  75 ;  anj^inoHO  form,  80 ;  ntnctic 
form,  70  ;  complicatiotiH  and  Heiiueliv,  hO  ;  eon- 
tngiousncHS  of,  70;  d(>s(iu:imation  in,  70  ;  criii>- 
tion  in,  77  ;  hiemorrhaj,'ic  form,  70 ;  incubiition 
of,  77;  invasion  in,  77;  malif^nant,  70;  puer- 
peral, 70;  nur},'ieal,  70. 

Schistosoma  liiematobium,  852. 

SchiUiki It'll  diHcase,  815. 

School-made  chorea,  1081. 

Schott  treatment  in  myocardial  discnso,  762. 

Sciatica,  1073. 

Sciatic  nerve,  alFcctions  of,  1072. 

Scirrhous  cancer  of  stomach.  487,  488. 

Sclerema  in  cholera  infantum,  510. 

Sclerema  neonatorum,  1145. 

Sclerodaotylie,  1140. 

Scleroderma,  1145. 

ScK'rose  en  plaques,  050. 

Scleroses  of  the  brain,  057. 

Sclerosis,  cerebro-spinal,  057  ;  degenerative,  057  ; 
developmental,  0.')8;  inflammatory,  058;  of 
scurvy,  823  ;  syphilis  as  a  cause  of,  242. 

Sclerosis,  primary,  lateral,  037 ;  insular,  050 ; 
multiple,  050. 

Sclerosis,  posterior  spinal  (sec  Locomotou 
Ataxia),  020;  in  chronic  ergotism,  304. 

Sclerosis,  primary  combined,  040. 

Sclerosis  in  tubercles,  271. 

Sclerosis,  renal,  877. 

Sclerosis,  toxic  combined,  951. 

Sclerostomum  duodenale,  350  ;  S.  equinum,  359. 

Sclerotic  gastritis,  407. 

Scolices  of  echinococcua,  371. 

Scorbutus,  821. 

Scrivener's  palsy,  1107. 


Serofulo,  280;  ullej{cd  protective  inwulutloii  by, 

2hl, 
Scrol'tilous  pneumonia,  272. 
Scurvy,  ^21 ;  infantile,  826 ;  propliylaxln  of,  824 ; 

HoleroslM,  H23. 
Scybala,  5;!0. 
Seanomd   relatione,  of  clinroa,  l'i70;  of  malaria, 

204;  of  pneumonia,  llu;  of  rlnumatiMiii,  107. 
Secomlury  contracture  in  licinipleijciu,  1006. 
Secondary  deviat'on,  ln.|H. 
Secondary  fever  of  wmall-pox,  00. 
Self-limitation  in  tuberculosis,  328, 
Semilunar  space  of  Tnviht'^  COO. 
Semilunar  valves,  aortic,  incompetency  of,  709. 
Senile  empliysfimi,  O.'iO. 
Sensation,    painful,  loss    of,   in   syringomyuiiu, 

076. 
Seiisiiiion,  retardation  of,  in  ataxia,  024. 
Sensory  system,  diseases  ol',  O'jo. 
Septiciemia,  100;    eryi'toginetie,   102;    general, 
102:  goiiorrhieal,  2.'>5 ;  progressive,  102;  post- 
tyi>hoiil,  33. 
Septico-pyiemia,  103. 
Serratus  palsy,  lo70. 
Sovcn-day  fever,  53. 
Sewer-gas  and  tonsillitis,  451. 
Sewer-gas  jioisoning,  etfe<'ts  of,  343. 
Sex,  inttuencc  of,  in  lieart-disease,  720. 
Sexes,  proportion  of,  all'eeted  with  acute  yellow 
atrophy,  551 ;    in  chlorosis,  702 ;    in   chona, 
1070;  in  exophthalmic  goitre,  h;j7  ;  in  general 
paresis,  000;  in  luemophilia,  blO. 
Shaking  palsy,  1070. 
Shell-tish,  poisoning  by,  303. 
Ship-fever,  40. 

Shock  as  a  cause  of  traumatic  neuroses,  1132. 
Shock,  death  from,  in  acute  obstruction,  535. 
Sick  headache,  1102. 
Sickness,  sleeping,  301. 
Siderodromophobia,  1124. 
Siderophobia,  1124 
Siderosis,  052,  054. 

Signal  symptom  (in  cortical  lesions),  080,  1021. 
Singultus  (see  lliccouoii). 

Sinus  thrombosis,  1015;  and  anicmia,  1015;  in 
chlorosis,  704;  autochthonous,  lol5;  pyajmia, 
1015;  secondary,  in  ear-disease,  1015. 
Siriasis,  305. 
Sitotoxismus,  304. 
Sixth  nerve,  jiaralysis  of,  1048. 
Skin,  itciiing  of,  in  uriemi'i,  807. 
SkoiUCs  resonance  in  pleural  elfusion,  Of!0  ;  in 

pneumonia,  110. 
Skull,  of  comrenital   syphilis,   243;    of  hydro- 
cephalus, 1020;  of  rickets,  430  ;  percussion  of, 
1027. 
Sleei)ing  sickness,  301. 
Slow  heart,  750. 
Small  pox,  50;  complications  of,  C4 ;  confiucnt 


1176 


INDEX. 


form,  CI ;  contngiousncss  of,  M ;  discrete  form, 
CO;  eruiitioii  in,  (!0;  liii'iiiorrlinijjie,  02 ;  inocu- 
lation in,  f)6;  vtu'cination  in,  uij. 

Sniiill  sciatic  nurve,  all'cctions  of,  IOT'2. 

Sniull,  ad't'ctions  of  scnHC  of  (see  Olkactohy 
Nehve),  1038. 

Snnke-virus,  purpura  caused  hy,  8U. 

Snutlles,  242. 

Softening  of  brain,  1008. 

Soil,  influence  of,  in  cholera,  177;  in  tubercu- 
losis, 208 ;  in  typhoid  fever,  0. 

Solvent  treatment  of  renal  calculi,  896. 

Soor,  443. 

Sordes,  22. 

Sore  throat,  448. 

iSoi/a  bread,  430. 

Spasm,  congenital  gastric,  495. 

Spasm,  lock,  in  writer's  cramp,  1103. 

Spasmodic  wryneck,  lOiJo. 

Spasms,  in  ergotism,  394 ;  in  hydrophobia,  228 ; 
in  hysteria,  1112;  of  face,  1055;  of  muscles, 
after  facial  paralysis,  1055  ;  professional,  1107 ; 
saltatory,  1089. 

Spa.stic  paraplegia  of  adults,  937;  hereditary, 
940 ;  hysterical,  941 ;  LWn  syphilitic,  940 ;  in 
children,  933 ;  secondary,  941. 

Specific  infectious  diseases,  1. 

Specific  treatment  of  typhoid  fever,  47. 

Spectra,  fortification,  1102. 

Speech  (sec  Aphasia),  988. 

Speech,  in  adenoid  vegetations,  456 ;  in  bulbar 
paralysis,  932;  in  insular  sclerosis,  959;  in 
general  paralysis,  902 ;  in  hereditary  ata.\ia, 
950 ;  in  paralysis  agitans,  1078. 

Speech,  scanning,  in  insular  sclerosis,  959. 

Spes  phthisica,  812. 

Spina  bifida,  involvement  of  eauda  equina  in, 
072. 

Spinal  accessory  nerve,  paralysis  of,  1063. 

Spinal  apoplexy,  908. 

Spinal  concussion,  eft'ects  of,  1133. 

Spinal  cord,  diffuse  and  focal  tliseases  of,  964. 

Spinal  cord,  abscess  r.f,  974;  affections  of  blood- 
vessels of,  966 ;  anwmia  of,  906 ;  chronic  lepto- 
meningitis of,  957 ;  compression  of,  970 ;  con- 
gestion of,  966;  embolism  and  thrombosis  of 
vessels  of,  966  ;  endarteritis  of  vessels  of,  967  ; 
fissures  in,  969;  hromorrliaire  into,  908;  lepto- 
meningitis of,  954 ;  localization  of  functions 
of,  905 ;  juichymeningitis  of,  953 ;  sclerosis, 
primary  combined,  of,  949;  sy[»hilis  of,  244; 
tuberculosis  of,  321 ;  tumors  of,  976 ;  unilateral 
lesions  of,  96.5. 

Spinal  epilepsy,  937. 

Spinal  irritation,  1125. 

Spinal  membranes,  hromorrhage  into,  967. 

Spinal  nerves,  diseases  of,  1007. 

Spinal  ncura-sthenia,  1125. 

Spinal  paralysis,  atrophic,  942. 


Spirals,  Ciinic/t7na>>n\  631,  634. 

Spirillum  of  relapsing  fever,  .54. 

Spirochiete  of  Obermeier,  53. 

Splanchnoptosis,  541. 

Spleen,  amyloid  degeneration  of,  in  Byphilis, 
249;  in  tuberculosis,  298. 

Spleen,  diseases  of,  832;  abscess  of,  834;  infarct 
of,  834 ;  tumors  of,  834. 

Spleen,  enlargement  of,  in  congenital  syphilis, 
242,  244;  in  malaria,  207,  216. 

Spleen,  e.veision  of,  in  hypertrophy,  609 ;  in  leu- 
ktemia,  809. 

Spleen,  floating,  543,  833 ;  excision  of,  809. 

Spleen,  in  ague,  208,  216;  in  anthrax.  226;  in 
eirrhosi.s  of  liver,  572,  575;  in  Jloihjkin's  dis- 
eiuse,  811;  hydatid  of,  372;  in  Icukoemia,  803, 
805 ;  in  rickets,  435, 437  ;  in  acute  tuberculosis, 
270 ;  in  typhoid  fever,  10,  26 ;  in  typhus,  50. 

Spleen,  puncture  of,  40. 

Spleen,  rupture  of,  833 ;  in  malaria,  207 ;  in  ty- 
phoid fever,  11,  26. 

Splenectomy,  statistics  of,  809. 

Splenic  anicmia,  834. 

Splenic  fever,  224. 

Splenization  of  lung,  292,  643. 

Spleno-megaly,  primitive,  834. 

Spondylitis  deformans,  403.  - 

Sporozoa,  349 ;  parasitic,  349. 

Spotted  fever,  49, 101. 

Sprue,  511. 

Sputa,  albuminoid,  after  iwpiration  of  chest,  678; 
alveolar  cells  in,  622,  035  ;  amoeba  eoli  in,  201 ; 
in  cancer  of  lung,  004;  in  influenza,  97  ;  hroma- 
toidin  crystals  in,  580 ;  in  anthracosis,  654  ;  in 
asthma,  630;  in  bronchiectasis,  627;  in  acute 
bronchitis,  622;  in  chronic  bronchitis,  624;  in 
putrid  bronchitis,  025  ;  in  gangrene  of  lung,  661. 

Sputa,  in  phthisis,  300;  in  pneumonia,  118;  in 
acute  pi'lmonary  tuberculosis,  275;  prune- 
juice,  604;  uric-acid  crystals  in,  411. 

Staphylococci,  in  diphtheria,  141 ;  in  endocar- 
ditis, 702;  in  peritonitis,  597;  in  pneuinonia, 
113;  in  pyremia,  108;  in  rheumatic  fever,  168; 
in  septicwmia,  162;  in  tonsilitis,  451. 

Status,  epilepticus,  1097;  hystericus,  1119. 

Status  lymphaticus,  826  ;  sudden  death  in,  827. 

SteUwag'x  sign,  838. 

Stenocardia,  761. 

Stenosis,  of  aortic  orifice,  715;  of  mitral  orifice, 
721 ;  of  pulmonary  orifice,  727,  767 ;  of  tricus- 
pid orifice,  726. 

Steppage  gait,  1034. 

Stercoraceous  vomiting,  534. 

Stercoral  ulcers  in  colitis,  513. 

Stertor,  in  apoplexy,  1001. 

Stiff  neck,  406. 

Stigmata,  in  hysteria,  1118;  in  purpura,  815. 

Stitch  in  side  in  pneumonia,  115;  in  pleurisy, 
668. 


of,  in    syphilis, 

I  of,  834 ;  infarct 

jenital  syphilis, 

)liy,  809 ;  in  leu- 

on  of,  809. 
iinthnix.  'J2C;  in 
1  Jloilijkiit's  iHh- 
1  Icukoeiniii,  803, 
lite  tuberculosis, 
in  typhus,  50. 

aria,  207;  in  ty- 


on  of  chest,  678; 
3el>n  ooli  in,  201 ; 
enza,  97 ;  liroma- 
racosis,  654 ;  in 
627 ;  in  acuto 
nehitis,  624 ;  in 
cne  of  lung,  661. 
umonin,  118;  in 
275 ;  prunc- 
,411. 

in  endocar- 
n  pneumonia, 
atic  fever,  168; 
B,  451. 
eus,  1119. 
death  in,  827. 


f  mitral  orifice, 
767 ;  of  tricus- 


11 


INDEX. 


1177 


iirpurn,  815. 
15;  in  pleurisy, 


Stokes- Adams  syndrome,  760. 

Stoliility  of  face  in  general  paresis,  062. 

Stomach,  acute  cancer  of,  493. 

Stomach,  cancer  of,  480 ;  absence  of  free  IICl  in, 
491 ;  diagnosis  from  gastric  ulcer  and  chronic 
gastritis,  493;  hieniorrhage  in,  490;  vomiting 
in,  490. 

Stomach,  dilatation  of,  474;  tetany  in,  475. 

Stomacli,  diseases  of,  463. 

Stomach,  atrophy  of,  467;  atony  of,  500; 
chronic  catarrli  of,  4f>&  ;  erosions  of,  468  ;  for- 
eign bodies  in,  494;  hiemorrhage  from,  481, 
495;  hair  tumors  in,  494;  neuroses  of,  497; 
non-cancerous  tumors  in,  494 ;  tuberculosis  of, 
819;  ulcer  of,  478;  washing  out  of  (lavage), 
472. 

Stomatitis,  441 ;  acute,  441 ;  aplithous,  441 ;  epi- 
demic, 347  ;  fetid,  442 ;  follicular,  441 ;  gangre- 
nous, 444;  mercurial,  444 ;  neurotica  chronica, 
443;  parasitic,  443 ;  ulcerative,  442;  vesicular, 
441 ;  uraimic,  868. 

Stone-cutter's  phthisis,  269,  652. 

StooLs,  of  acute  yellow  atrophy,  552 ;  of  cholera, 
179;  of  dysentery,  195,  197,  199;  of  typlioid 
fever,  23 ;  in  ha;matomcsis,  497  ;  of  obstructive 
jaundice,  549. 

Strabismus,  1048. 

Strangulation  of  bowel,  581,  536. 

"  Strawberry  "  tongue  in  scarlet  fever,  78. 

Streptococci  in  diphtheria,  141;  in  empyema, 
671;  in  endocarditis,  702 ;  in  pneumonia,  113; 
in  peritonitis,  597 ;  in  pyromia,  163;  in  rheu- 
matic fever,  168;  in  scarlet  fever,  77;  in  septi- 
cccmia,  162 ;  in  tonsillitis,  451. 

Streptococcus  diphtilieritis,  142. 

Streptococcus  erysipclatos,  157. 

Streptococcus  pyogenes  in  erysipelas,  157. 

Streptothrix  aetinomyces,  235. 

Strictures  and  tumors  of  the  bowel,  533. 

Stricture  of  bile-duct,  560. 

Stricture  of  colon,  cancerous,  533. 

Stricture  of  intestine,  633 ;  after  dysentery,  200, 
533;  after  tuberculous  ulcer,  319. 

Stricture  of  esophagus,  460. 

Stricture  of  pylorus,  494. 

Strongyloides  intestinalif 

Strongylus,  359. 

Strumitis,  836. 

Stuttering  in  mouth-breathers,  456. 

Styrian  peasants,  arsenical  habit  in,  301. 

Subclavian  artery,  murmur  in  and  throbbing  of, 
in  phthisis,  308,  309. 

Subphrenic  peritonitis,  600. 

Subsultus  tendinum  in  typhoid  fever,  29. 

Succussion,  Hippocratic,  683. 

Succussion  splash  in  dilated  stomach,  476. 

Sudamina  in  typhoid  .fever,  17. 

Sudden  death,  in  angina  pectoris,  702;  in 
aortic  insufficiency,  712;   in   coronary  artery 


disease,  747;  in  enlarged  thymus,  844;  in  pleu- 
ral eli'usions,  671;  in  status  lymphaticus,  827  ; 
in  typhoid  fever,  40. 

Sudoral  form  of  typhoid  fever,  18. 

Sugar  in  the  urine,  423. 

Sulphocyanidcs  in  exucss  in  saliva  in  rheuma- 
tism, 170. 

Sun-stroke,  395 ;  aftev-effects  of,  d97. 

Suppression  of  urine,  f  50. 

Suppurative  nephritis,  887. 

Suppurative  pylephlebitis;  555. 

Suppurative  tonsillitis,  452. 

Sui)rarenHl  bodies,  diseases  of,  828 ;  hromor- 
rliago  into,  832 ;  tuberculosis  of,  832 ;  tumors 
of,  832. 

Surgical  kidney,  887. 

Suspension  in  compression  paraplegia,  972. 

Sweating  in  acute  rheumatism,  169;  in  ague, 
212;  in  diabetes,  423;  in  phthisis,  £06;  in 
pyoiinia,  164;  in  typhoid  fever,  18;  in  ulcera- 
tive cndocorditis,  704  ;  profuse,  in  rickets,  43i! ; 
unilateral,  in  cervical  caries,  971 ;  unilateral, 
in  aneurism,  782. 

Sweating  sickness,  346. 

^ydenhaui's  chorea,  1079. 

Symmetrical  gangrene,  1138. 

Sympathetic  ganglia,  in  Addison''8  disease, 
829. 

Sympathetic  nerve  fibres  (see  Vaso-motor). 

Symptomatic  parotitis,  447. 

Syncope,  fatal,  in  diphtheria,  151 ;  in  cardiac 
disease,  712,  750;  in  phthisis,  317;  in  pleu- 
ral effusion,  071. 

Syncope,  local,  1137. 

Synovial  rheumatism  (see  Gonorrikeal  Eiiet- 
matism),  256. 

Synovitis,  gonorrho-al,  257. 

Synovitis,  symmetrical,  in  congenital  syphilis, 
244. 

Syphilides,  macular,  240 ;  papular,  240 ;  pustu- 
lar, 240;  squamous,  241  ;  the  late,  241. 

Syphilis,  238;  accidental  infection  in,  238;  ac- 
quired, 240;  amyloid  degeneration  in,  242; 
bono  lesions  of,  244;  congenital,  2i2;  early 
nerve  lesions  in,  245 ;  gummata  in,  239;  hered- 
itary transmission  of,  238 ;  modes  of  infection 
in,  238;  of  brain  and  cord,  244, 1020;  of  circu- 
latory system,  250;  of  digestive  tract,  249;  of 
liver,  248;  of  lung.  247;  orchitis  in,  251 ;  pri- 
mary stage  of,  240 ;  prophylaxis  of,  252 ;  renal, 
250 ;  secondary  stage  of,  240 ;  tertiary  stage  of, 
241 ;  visceral,  244. 

Syphilis  and  dementia  paralytica,  242,  246, 
961. 

Syphilis  and  locomotor  ataxia,  242,  920. 

Sypliilis  hicmorrhagica  neonatorum,  243,  813. 

Syphilitic  arteritis,  245. 

Syphilitic  fever,  240. 

Syphilitic  nephritis,  250, 


ins 


INDEX. 


Syphilitic  phthisis,  247. 
Syringo-inycliii,  975. 

TnbcB,  diabetic,  426. 

Tubes  dorsiilis  (see  Locomotob  Ataxia),  920;  in 
chronic  ergotism,  394. 

Tubes  iloi-salis  spiisnioiliiiue,  937. 

Tubes  nicsunturicn,  '283. 

Tuchc  ecrcbrulc,  18,  278. 

Taclics  blcuitres,  17,  377. 

Tudiycnnlin,  7r)8,  838;  neurasthenic,  1126;  par- 
oxysmal, 758. 

Tactile  fremitis,  in  cniphyacma,  058;  in  pneu- 
monin,  119;  in  plein-al  etl'usion,  008;  in  piieii- 
motliorax,  (i82;  in  pulmonary  tuboreulosis, 
307  ;  at  rij,'ht  apex,  307. 

Tipnia  cchinococcus,  308,  370. 

Tu'nia  elliptica,  T.  cucumcrina,  T.  flavopunctata, 
T.  nana,  T.  Madagascariensis,  T.  confusa,  300. 

Tasnia  saginata  or  mediocanellata,  366. 

Ticnia  solium,  305. 

Tape-worms,  305 ;  treatment  of,  367. 

Taste,  disturbances  of,  1000 ;  tests  for  sense  of, 
1000. 

Tea,  neuritis  caused  by,  1035. 

Techomyza  fusca,  379. 

Teeth,  actinomyces  in,  236 ;  looseness  of,  in 
scurvy,  823 ;  effects  of  stomatitis  on,  445 ;  ero- 
sion of,  445 ;  Ihitchinsoii's,  243,  445  ;  of  infan- 
tile stomatitis,  445. 

Teichopsia,  1102. 

Telegrapher's  cramp,  1108. 

Temperature  sense,  loss  of,  in  syringo-myelia, 
975  ;  in  Morvati's  disease,975. 

Temperature,  subnormal,  in  acute  alcoholism, 
380 ;  in  acute  tuberculosis,  274 ;  in  apoplexy, 
1001 ;  in  heat  exliaustion,  395 ;  in  malaria,  209, 
215;  in  pulmonary  tuberculosis,  306;  in  tu- 
berculous meningitis,  279;  in  uraemia,  866. 

Temporal  lobe,  tumors  of,  1022. 

Temporo-splienoidal  lobe,  centre  for  hearing  in, 
1056. 

Tender  points  in  neuralgia,  1104;  in  neurasthe- 
nia, 1123. 

Tender  toes,  in  typhoid  fever,  30. 

Tendon-re  11  exes  (see  Reflexes). 

Terminal  infections,  105. 

Tertian  ague,  212. 

Testes,  tuberculosis  of,  3-26 ;  syphilis  of,  251  (see 
also  (Jrciiitis). 

Tetanus,  230  ;  bacillus  of,  231  ;  neonatorum,  230. 

Tetanus,  cephalic,  232. 

Tetany,  1109;  after  tliyroidcctomy,  1110;  epi- 
demic.or  rlieumatic,  1109  ;  in  dilatation  of  the 
stomach,  475,  1110;  in  myxoedema,  1110;  in 
typhoid  fever,  30. 

Tetrodon,  poisoning  by,  394. 

Therapeutic  test  in  syphilis,  251. 

Therapy,  8«rum,  in  plague,  193. 


Thermic  fever,  395. 

Thermic  sense,  loss  of,  in  syrlngo-niyelia,  976. 

Tliird  nerve,  diseases  of,  1045. 

Third  nerve,  recurring  paralysis  of,  1046 ;  signs 
of  paralysis  of,  1046. 

Thomseii's  disease,  1149. 

Thoracic  duct,  tuberculosis  of,  274. 

Thorax,  deformity  of,  in  mouth-breathers,  45r  ; 
in  rickets,  430. 

Thorax  in  emphysenui,  658 ;  in  phthisis,  208, 
300. 

Thorn-lieadcd  worms,  365. 

Tliornwaldfs  disease,  457. 

Thread-worm.  353. 

Throbbing  aorta,  786,  1126. 

Thrombi  in  heart,  723;  in  diphtheria,  145;  in 
pneumonia,  114. 

Thrombi  in  veins  in  typlioid  fever,  21. 

Thrombi,  marantic,  1015. 

Thrombosis  of  cerebral  arteries,  1008;  of  cere- 
bral sinuses,  1015;  of  cerebral  veins,  1015;  of 
portal  vein,  554. 

Thrush,  443. 

Thymic  asthma,  618,  844. 

Thymus  gland,  diseases  of,  84.3  ;  tumors  of,  845  ; 
persistence  of,  844  ;  enlargement  of,  844  ;  sud- 
den death  in,  844. 

Thymus  gland,  in  acromegaly,  1143 ;  and  exoph- 
thalmic goitre,  845. 

Thyroid  abscess,  836. 

Thyroid  extract,  administration  of,  843,  1111. 

Tnyroid  gland,  abcrant  or  accessory  tumors  of, 
836 ;  abscess  ol',  836  ;  absence  of,  in  cretins, 
840 ;  adeno-.nata  of,  830 ;  cancer  of,  836 ;  in 
exophthalmic  goitre,  838 ;  in  goitre,  836 ;  in 
niyxcedema,  842 ;  sarcoma  of,  836 ;  tumors  of, 
836. 

Thyroid  gland,  diseases  of,  835. 

Thyroidism.  843. 

Tic  convulsif,  1055,  1089. 

Tic  douloureux,  1105. 

Ticks,  376. 

Tinnitus  aurium,  1057. 

Tintement  metallique,  738. 

Tobacco,  influence  of,  on  the  heart,  764. 

Tongue,  atrophy  of,  1066  ;  eczema  of,  445  ;  geo- 
graphical, 445  :  in  bulbar  paralysis,  932  ; 
spasm  of,  10C7 ;  tuberculosis  of,  318 ;  unilat- 
eral hemiatrophy  of,  1007. 

Tongue,  tremor  of,  in  general  paresis,  962 ;  ulcer 
of  fricnum  in  whooping-cough,  93. 

Tonsillitis,  451 ;  acute,  451 ;  albuminuria  in,  452  ; 
endocarditis  in,  452;  in  the  newly  married, 
451. 

Tonsillitis,  chronic,  454;  follicular,  451 ;  lacunar, 
451 ;  suppurative,  452;  and  rheumatism,  451. 

Tonsils,  abscess  of,  452;  calculi  of,  450  ;  cheesy 
masses  in,  450 ;  enlarged,  454 ;  tuberculosis  of, 
318. 


o-niyelio,  9T6. 
J  of,  1046;  Bigiia 


74. 

i-breathers,  45?  ; 

in  phthisis,  2C8, 


htherift,  145 ;  iii 

^'cr,  21. 

i,  1008 ;  of  cerc- 
1  veins,  1015;  of 


;  tumors  of,  845  ; 
Jilt  of,  844  ;  sucl- 

.143 ;  and  exoph- 


of,  843,1111. 
essory  tumors  of, 
:e  of,  in  cretins, 
iccr  of,  836 ;  in 
I  goitre,  836 ;  in 
836 ;  tumors  of, 


lart,  764. 

nn  of,  445  ;  geo- 

paralj-sis,    932  ; 

of,  318;   uniliit- 

arcsis,  962 ;  ulcer 
li,  93. 

uminuria  in,  452 ; 
newly  married, 

lar,  451 ;  lacunar, 
leumatism,  451. 
,  of,  456  ;  cheesy 
;  tuberculosis  of, 


INDEX. 


1179 


Tonsil.-t,  diseases  of,  451, 

Tophi,  411. 

Topical  diagnosis,  siiinal,  0(!4 ;  cerebral,  979. 

Toronto  Uenerul  liospilul,  statistics  of  typlioid 
fever  at,  3, 

Torticollis,  406,  1064;  congenital,  1064;  facial 
u.syininetry  in,  1064  ;  spasmodic,  1005. 

Toxic  gastritis,  465. 

To.xines,  in  septiciemia,  161, 

Tracheal  tugging,  780. 

Traction  aneurism,  777. 

Trance  in  hysteria,  1113,  1119. 

Traiibe's  semilunar  space,  669. 

Trauma  as  u  factor,  in  delirium  tremens,  382 ; 
in  neurasthenia,  1132;  in  pneumonia,  109;  in 
tuberculosis,  270. 

Trematodes,  diseases  caused  by,  351. 

Trembles  in  cattle,  344. 

Tremor,  alcoholic,  381, 1079  ;  in  Graves'  disease, 
839;  hereditary,  1079;  hysterical,  1079,  1115; 
in  exophthulmic  goitre,  839  ;  lead,  389  ;  in  pa- 
ralysis agitans,  1077;  litndu's  type  of,  1115; 
senile,  1079;  simple,  1079;  toxic,  1079;  voli- 
tional, in  insular  sclerosis,  959. 

Trichina  spiralis,  354;  distribution  of,  355;  sta- 
tistics of,  in  American  hogs,  355 ;  in  Germany, 
355 ;  modes  of  infection,  356. 

Trichiniasis,  354;  epidemics  of,  356;  prophy- 
laxis of,  359, 

Trichocephalus  dispar,  364. 

Trichomonas  vaginalis,  351 ;  T.  hominis,  351. 

Trichter-brust,  307,  455. 

Tricuspid  orifice,  stenosis  of,  726. 

Tricuspid  valve,  disease  of,  725 ;  insutfloiency  of, 
725. 

Trigeminus  (see  Fifth  Nerve). 

Trismus,  neonatorum,  230 ;  hysterical,  1114. 

Trommer's  test,  423. 

Trophic  disorders,  1137. 

Tropical  dysentery,  195. 

Trou8seau''s  symptom,  in  tetany,  1110. 

Tubal  pregnancy,  ruptured,  simulating  peritoni- 
tis, 600. 

Tubercle  bacilli,  259,  301. 

Tubercle,  dilfuse  infiltrated,  272 ;  miliary,  270, 
295 ;  changes  in,  271 ;  structure  of,  270  ;  nodu- 
lar, 270. 

Tubercles,  miliary,  in  chronic  phthisis,  295. 

Tubercula  dolorosa,  1037. 

Tuberculin,  261 ;  test,  258  ;  treatment,  335. 

Tuberculosis,  acute,  273;  general  or  typhoid 
form,  274 ;  meningeal  form,  276 ;  pulmonary 
form,  275. 

Tuberculosis,  258  ;  bacillus  of,  259,  301 ;  changes 
produced  by  bacillus,  270;  chronic  miliary, 
295  ;  of  circulatory  system,  327  ;  conditions  in- 
fluencing infection,  267  ;  congenital,  262  ;  die- 
tetic treatment  of,  335  ;  distribution  of  the  tu- 
bercles in,  270;  duration  of  pulmonary  form 


of,  329 ;  hereditary  transmirision  of,  262  ;  indi- 
vidual prt)phylaxi.-<  in,  330;  infection  by  meat, 
267;  infection  by  milk,  267;  infei^tion  liy  in- 
halation, 26.) ;  inoculation  of,  264  ;  in  infants, 
316;  in  old  age,  316;  medicinal  treatment  of, 
oOO ;  modes  of  death  in  pulmonary,  317  ;  modes 
of  infection  in,  262 ;  natural  or  spontaneous, 
cure  of,  331 ;  of  alimentary  canal,  317  ;  of  brain 
and  cord,  321;  of  Fallopian  tubes,  326;  of 
genito-urinary  system,  322  ;  of  kidneys,  324 ; 
of  liver,  320;  of  lymphatic  system,  280;  of 
numimary  gland,  327  ;  of  ovaries,  326  ;  of  peri- 
cardium, 285  ;  of  peritonicum,  286  ;  of  pleura, 
284 ;  of  prostate,  326  ;  of  serous  membranes, 
284 ;  of  testes,  326 ;  of  ureters  and  bladder, 
325 ;  of  uterus,  326 ;  of  vesieulie  seminales, 
326;  pregnancy,  influence  of,  in,  329;  prophy- 
laxis in,  330  ;  pscudo-,  262  ;  pulmonary,  289  ; 
and  typhoid  fever,  33 ;  and  valvular  disease  of 
heart,  316. 

'I'ufneWs  treatment  of  aneurism,  784. 

Tumors  of  brain,  1020. 

Tunnel  anicmia,  360. 

Twists  and  knots  in  the  bowel,  533. 

Tympanites,  in  intestinal  obstruction,  535 ;  in 
peritonitis,  598 ;  in  tuberculous  peritonitis, 
287  ;  in  typhoid  fever,  25  ;  as  a  cause  of  sud- 
den heart-failure,  545. 

Typhlitis,  519. 

Typhoid  fever,  1 ;  abortive  form,  34 ;  afebrile, 
17,  35;  ambulatory  form,  14,  34;  anaemia  in, 
19  ;  and  tuberculosis,  49  ;  bacillus  of,  3  ;  chills 
in,  17  ;  circulatory  system  in,  19;  diabetes  in, 
33  ;  diarrhrea  in,  23  ;  digestive  system  in,  22 ; 
EhrlicWs  reaction  in,  31;  erysipelas  in,  33; 
grave  form  of,  34 ;  hrcmorrhage  in,  10 ;  hscm- 
orrhagic,  35 ;  historical  note  on,  1  ;  in  the 
aged,  35  ;  in  children,  35  ;  in  the  foetus,  36  ;  in 
pregnancy,  35  ;  laparotomy  in,  48  ;  liver  in,  11, 
27 ;  Maidstone  epidemic  of,  5 ;  rneteorism  in, 
25 ;  mild  form,  34 ;  modes  of  conveyance  of,  5  ; 
nervous  system  in,  12,  28 :  noma  in,  33,  35 ;  os- 
seous system  in,  32  ;  oysters  and,  6  :  parotitis 
in,  23 ;  perforation  of  bowel  in,  10,  26 ;  peri- 
tonitis in,  26,  47 ;  post-typhoid  elevations  of 
temperature  in,  16 ;  prognosis  of,  40  ;  proph- 
ylaxis of,  41;  pyuria  in,  11,  32;  relapses 
in,  36  ;  renal  system  in,  31 ;  respiratory  system 
in,  27 ;  serum  therapy  in,  47  ;  skin  rashes  in, 
17 ;  spleen  in,  26 ;  tender  toes  in,  30 ;  tetany 
in,  30 ;  varieties  of,  33 ;  ^Vidal''8  reaction  in 
typhoid  fever,  38. 

Typhoid  gansfrene,  12,  22, 

Typhoid  septicaMnia,  33. 

Typhoid  spine,  32. 

Typhoid  state  in  obstructive  jaundice,  550;  in 
acute  yellow  atrophy,  552. 

Typho-malarial  fever,  so  called,  39,  214. 

Typhotoxin,  8. 


1180 


INDEX. 


/ 


TyphuB  fovcr,  49 ;  complicntions  and  scqucloo  of, 

52. 
Typhus  Hiderans,  52. 
TyroMin,  552. 
Tyrotoxicon,  898. 
Tyrotoxisinus,  393. 

Ulcer,  concerous,  of  intestine,  513;  gnstric,  478; 
of  duodenum,  478;  of  bowel  in  dysentery,  194, 
196,  199;  in  typhoid  fovcr,  9. 

Ulcer  of  mouth,  442;  in  the  new-born,  443; 
in  nursing  women,  443 ;  of  paltite  in  infants, 
443. 

Ulcer,  peptic,  478;  perforoting,  of  foot,  in  tabes, 
925 ;  in  diabetes,  425. 

Ulcerative  endocarditis,  699. 

Ulcers,  Parrofs,  443. 

Ulnar  nerve,  affections  of,  1071. 

Uncinaria  duodenalis,  359. 

Unconsciousness  (see  Coma). 

Undulant  fever,  219. 

Urasmia,  805;  cerebral  manifestations  of,  8G6 ; 
coma  in,  867 ;  convulsions  in,  86C ;  diagnosis 
from  apoplexy,  808;  dyspnoea  in,  867;  head- 
ache in,  867 ;  in  Bright's  disease,  884 ;  latent, 
851 ;  local  palsies  in,  867 ;  cedema  of  brain  in, 
997  ;  stomatitis  in,  868  ;  theories  of,  865. 

Urate  (lithate)  of  soda  in  gout,  408. 

Urates  in  the  urine,  860. 

Urates  (lithates),  amorphous,  860. 

Ureter,  blocking  of,  850;  mucous  cysts  of,  350; 
obstructed  by  calculi,  893 ;  psorospermiasis  of, 
350 ;  tuberculosis  of,  325. 

Urethritis,  gouty,  415. 

Uric  acid,  calculus,  892;  deposition  of,  860;  in 
gout,  408  ;  in  urine,  860;  "showers,"  415. 

Uric-acid  diathesis  (see  Lith^mia),  860. 

Uric-acid  headache,  415. 

Uric-acid  theory  of  gout,  408. 

Urinary  calculi,  892. 

Urine,  anomalies  of  the  secretion  of,  850. 

Urine,  density  of,  in  acute  Bright's  diseose,  870: 
in  chronic  Bright's  disease,  880  ;  in  diabetes, 
423;  in  diabetes  insipidus,  433. 

Urine,  hremoglobin  in,  852. 

Urine,  in  acute  yellow  atrophy  of  liver,  552 ;  in 
grave  anoDmia,  799;  in  cholera,  179;  in  dia- 
betes insipidus,  433 ;  in  diabetes  mcllitus,  423 ; 
in  diphtheria,  150;  in  erysipelas,  159;  in  gout, 
411,  413,  415;  in  jaundice,  549;  in  melanotic 
sarcoma,  863;  in  pneumonia,  122;  in  acute 
pulmonary  tuberculosis,  312;  in  typhoid  fever, 
81 ;  oxalates  in,  861 ;  pus  in,  858. 

Urine,  quantity  of,  in  chronic  Bright's  disease, 
880 ;  in  diabetes  insipidus,  433 ;  in  diabetes 
mellitus,  423  ;  in  intestinal  obstruction,  535. 

Urine,  retention  of,  in  typhoid  fever,  31. 

Urine,  suppression  of,  850;  treatment  of,  851; 
in  cholera,  179;  in  acute  nephritis,  870;  in 


scarlet  fever,  80;  in  acute  intestinal  obstruc- 
tion, 535;  obstructive  supi)rfssion,  894. 

Urine,  tests  for  i.lbumln  in,  856;  biliary  jdg- 
incnt  in,  549 ;  blooil  in,  852  ;  albumosea  in, 
857 ;  peptones  in,  857. 

Urobilin,  incrcLso  of,  in  pernicious  nnremia,  799. 

Uro-genital  tuberculosis,  322. 

Urticaria,  ofter  tapping  of  hydatid  cysts,  372; 
epidemica,  379;  giant  form  (see  Neukotio 
(Ki)e.ma),  1141:  with  purpura,  815;  in  small- 
pox, 60  ;  in  tyy  old  fever,  18. 

Uterus,  tuberculosis  of,  826. 

Uvula,  oedema  of,  448 ;  infarction  of,  448,  816. 

Voccination,  68 ;  mark,  70 ;  tcclini(iuo  of,  78 ; 
rashes,  71 ;  ulcers,  71 ;  value  of,  73. 

Voccine,  antityphoid,  42. 

Vaccine  lymph,  choice  of,  72. 

Vaccinia,  68;  bacteriology  of,  70;  generalized, 
71. 

Vaecino-syphilis,  71. 

Vagabond's  discoloration,  377,  831. 

Valvular  disease  of  heart,  707 ;  and  tuberculosis, 
816. 

Varicella,  74  ;  hrcmorrhagic,  75. 

Varicella  bullosa,  75 ;  escharotica,  75. 

Varices,  oe80])hugcal,  in  cirrhosis  of  liver,  459. 

Variola,  56;  lii'cmorrliagica,  59,  62,  63;  vera,  59. 

Variola  hromorrliagica  pustulosa,  62,  68. 

Variola  sine  eruptiono,  64. 

Varioloid,  59,  63. 

Va.so-motor  disorders,  1137. 

Vaso-motor  disturbances  in  caries,  971 ;  in 
chronic  pleurLsy,  680 ;  in  exophthalmic  goi- 
tre, 839 ;  in  hemierania,  1103 ;  in  myelitis,  977 ; 
in  neuralgia,  1104. 

Veins,  cerebral,  thrombosis  in,  1015;  diastolic 
collapse  of,  697;  pulsation  in,  311, 1084,  1126; 
sclerosis  of,  773. 

Vena  cava,  inferior,  twist  in,  668. 

Vena  cava,  superior,  perforation  of,  by  aneu- 
rism, 778,  788. 

Venereal  disease,  238. 

Venesection  (see  Bloodletting). 

Venous  pulse,  811, 1084, 1126. 

Ventricles  of  brain,  dilatation  of  (hydrocepha- 
lus), 1028  ;  puncture  of,  1030. 

Ventricular  liojmorrhage,  999. 

Verruca  ncicrogenica,  264. 

Vertebra!,  caries  of,  970 ;  cervical,  caries  of,  971. 

Vertebral  artery,  obstruction  of,  1010. 

Vertigo,  auditory,  1058 ;  cerebellar,  986 ;  in  ar- 
terio-sclerosis,  775 ;  in  brain  tumor,  1021 ; 
gastric,  469;  labyrinthine,  1058 ;  endemic  para- 
lytic, 1059. 

Vesicula;  seminales,  tuberculosis  of,  826. 

Vicarious,  epistaxis,  614;  hojmoptysis,  637. 
Virugfixe,  229. 

Visceroptosis,  541. 


illl: 


;stinal  obstruc- 
ion,  894. 
'i;   biliary  pig- 
ulbumosea  in, 

18  aniemin,  790. 

itid  cyHts,  372; 
(see  Nkukotic 
815;  in  Kmull- 


of,  448,  816. 

Iinique  of,  73; 
;73. 


);  general  izod. 


id  tuberculosis, 


,75. 

of  liver,  459. 
2,  63 ;  vera,  59. 
62,  63. 


iries,  971 ;  in 
phthnlmic  goi- 
a  myelitis,  977 ; 

1015;  dinsttolic 
311,1084,  1126; 


of,  by  aneu- 


(hydrocoplia- 


,  caries  of,  971. 
010. 

ar,  986 ;  in  ar- 

tumor,    1021 ; 

;  endemic  para- 

of,  326. 
lysis,  637. 


INDEX. 


1181 


Vitiligoidca,  549. 

Vocal  fremitus,  119,  668  ;  resonance,  120,  670. 

Voice  (sue  Si'kkoii). 

Voice,  alteration  of,  in  mouth-breathers,  456. 

Volitional  tremor,  959. 

Volvulus,  533,  537. 

Vomica,  296 ;  signs  of,  in  phthisis,  309. 

Vomit,  black,  186  ;  coffee-ground,  490. 

Vomiting,  in  Addison''»  disease,  830 ;  in  Jiritjfifs 
disease,  881 ;  in  cerebral  abscess,  1026  ;  in 
cerebral  tumor,  1021  ;  in  chronic  obstruction 
of  intestines,  535;  in  chronic  ulcerative 
phthisis,  311;  in  gall-stone  colic,  564;  in  gas- 
tric cancer,  490 ;  in  gastric  ulcer,  481 ;  in 
acute  obstruction  of  intestines,  534  ;  in  tuber- 
culous meningitis,  278  ;  in  migraine,  1103;  in 
peritonitis,  598;  in  small-pox,  59;  nervous, 
499 ;  primary  periodic,  499 ;  stercoraceous, 
534;  uraiinie,  867. 

Vulvitis,  ulcerative,  in  measles,  87. 

Wall-paper,  poisoning  by  arsenic  in,  390. 

Wart- pox,  63. 

Warts,  post-mortem,  264. 

Washing  out  stomach,  472,  477. 

Water-hammer  pulse,  714. 

Water,    infection    by,  in    diphtheria,    138 ;    in 

cholera,  177  ;  in  typhoid  fever,  5. 
"  Water  on  the  brain,"  276. 
[Vi^ber,  syndrome  of,  279, 1004,  1023. 
Weil^s  disease,  344. 
Werlhofs  disease,  816. 
Wertdcke's  hemiopic  pupillary  inaction,  1044. 
Wet-pack,  84. 


Wliip-worm,  864. 

White  softening  of  brain,  1009. 

White  thrombi  in  heart,  728. 

Whooping-cough,  92. 

WinckeVs  disease  (see  Ei-iuemio  II.EMOOLoniNf- 

RiA  OK  THE  New-iiokn),  243,  818,  853. 
"Winged  scapula',"  307. 
Wintric/i^g  sign,  309. 
Woillez,  maladie  </«,  634. 
Wool-sorter's  disease,  224,  226. 
Word-blindness,  989. 
Word-deafness,  989. 
Word-dumbness,  992. 
Wormian  bones  in  hydrocephalus,  1029. 
Worms  (see  Pakasites). 
Wounds  of  the  heart,  754. 
Wrist-drop,  1071 ;  in  lead-poisoning,  888. 
Writer's  cramp,  1107. 
Wryneck,  1064  ;  spasmodic,  1065. 

Xanthelasma,  549. 
Xanthine  calculi,  892. 
Xanthomata,  425,  549,  566. 
Xanthopsia,  353. 
Xerostomia,  447. 

Yellow  fever,  182;    bacteriology  of,  183;    epi- 
demics of,  182. 
Yellow  softening  of  brain,  1009. 
Y'ellow  vision,  353. 
J'eo'*  dietary  in  obesity,  440. 

Zona,  1106. 


THE  END. 


/ 


yjgl 


A  New,  Thoroughly  Revised,  and  Enlarged  Edition  of 

QUAIN'S 
DICTIONARY  OF  MEDICINE. 

BV   VARIOUS   WRITERS. 

Edited  by  Sir  RICHARD  QUAIN,  Bart.,  M.  D.,  LL.  D.,  etc., 

Physician  Extraordinary  to  Her  Majesty  the  Queen  ;  C»nsiiltiii}{  Physician  to  the  Hospital  for  Diseases 

of  the  Chest,  Brompton,  etc. 

Assisted  by  FREDERICK   THOMAS   ROBERTS,  M.  D.,  B.  Sc, 

Fellow  of  the  Koyal  Cullege  of  Physicians,  etc. : 

•  And  J.  MITCHELL   BRUCE,  M.A.,  M.  D., 

Fellow  of  the  Royal  College  of  Physicians,  etc. 

With  an  American  Appendix  by  SAMUEL  TREAT  ARMSTRONG,  Ph.D.,  M.  D., 

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IN   TWO  VOLUMES. 


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This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are  fully 
discussed  in  alphabetical  order.  The  description  of  each  includes  an  account  of  its  etioloy;y 
and  anatomical  characters  ;  its  symptoms,  course,  duration,  and  ♦ermination  ;  its  diai^^nosis, 
prognosis,  and,  lastly,  its  treatment.  General  Pathology  comprehends  articles  on  the  origin, 
characters,  and  nature  of  disease. 

General  Therapeutici  includes  articles  on  the  several  classes  of  remedies,  their  modes  of 
action,  and  on  the  methods  of  their  use.  The  articles  devoted  to  the  subject  of  Hygiene  treat 
of  the  causes  and  prevention  of  disease,  of  the  agencies  and  laws  affecting  public  health,  of 
the  means  of  preserving  thi  health  of  the  individual,  of  the  construction  and  management  of 
hospitals,  and  of  the  nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  respective 
headings,  both  in  aggregate  and  in  detail. 

The  American  Appendix  gives  more  definite  information  regarding  American  Mineral 
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.  I 

/ 


REFERENCE-BOOK  OF 
PRACTICAL  THERAPEUTICS. 

BY  VARIOUS  AUTHORS. 
Edited  by  FRANK  P.  FOSTER,  M.  D., 

Editor  of  "  The  Xew  York  .\htHcal  Journal"  and  r/ 
Foster's  "  A'MyclopiViHc  Medical  Dictionary." 


In  two  large  8vo  volumes.     Sold  only  by  subscription. 


This  work  is  intended  as  a  ready  reference  book,  in  which  the 
physician  can  find  tlie  most  recent  information  concerning  the  uses 
and  application  of  remedies  ;  their  indications  and  counter-indica- 
tions ;  the  various  conditions  in  Avhidi  they  are  indicated  ;  the  forms  in 
which  drugs  are  best  used,  their  doses,  and  the  methods  of  adminis- 
tration. 

"It  is  essentially  a  book  for  the  practitioner,  nnd  is  an  up-to-date  work  of  refer- 
ence. Only  so  much  of  the  physiological  properties  of  drugs,  their  cheniicttl,  ininer- 
alogical,  botanical,  and  zoological  relations  as  are  of  direct  bearing  on  their  use  in 
practice  have  been  considered  in  the  compilation  of  this  work.  .  .  .  The  ambitious 
physician  will  be  pleased  with  this  work." — Canadian  Medical  Record. 

"  With  the  second  volume  this  excellent  work  is  completed,  and  is  rendered 
immediately  available,  by  means  of  the  general  index  and  index  of  diseases  and 
remedies,  as  a  book  of  therapeutic  reference.  A  supplement  of  nearly  fifty  pages 
bears  witness  to  the  rapid  strides  in  medical  science,  since  it  is  filled  chiefly  with 
matter  relating  to  knowledge  acquired  since  the  op{)enrance  of  the  first  volume. 
The  work  is  well  printed  and  well  bound,  and  the  brief  articles  on  every  subject 
relating  to  the  treatment  of  disease  are  excellently  written,  and  in  the  main  satis- 
factory as  to  the  information  they  impart." — Medical  Record. 

"  A  cai-eful  review  of  the  second  volume  of  this  valuable  work  shows  that  there 
is  nothing  to  criticise,  and  that  the  same  care  has  been  exercised  by  the  various 
authors  in  their  contributions  that  characterized  those  in  the  first  volume.  The 
editor  has  executed  his  difficult  task  well,  and  has  added  all  the  information 
that  has  been  published  in  the  journals  on  the  different  subjects  since  the  original 
articles  were  written.  So  great  has  been  the  advance  in  therapeutics  that  it  has 
been  necessary  to  add  an  appendix,  thus  making  the  book  thoroughly  up  to  date  in 
3  very  particular." — Medical  Sentinel. 


D.  APPLETON  AND  COMPANY,  NEW  YORK. 


)F 
TICS. 


D., 


criptiou. 


1  which  the 
iig  the  uses 
inter-indica- 
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work  of  refer- 
emical,  miner- 
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Die  ambitious 
d. 

d  is  rendered 
'  diseases  and 
•ly  fifty  pages 
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first  volume. 

every  subject 
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RK. 


